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Epidemiology, Management,

Osteoporosis is a progressive,

systemic skeletal disorder

characterized by compromised
bone strength that increases the
risk of bone fragility and
susceptibility to fracture.

Bone strength primarily reflects the

integration of bone density and bone


Epidemiology -Worldwide
Osteoporosis is estimated to affect 200

million women worldwide

One-tenth of women aged 60,
One-fifth of women aged 70,
Two-fifths of women aged 80
Two-thirds of women aged 90

Osteoporosis causes more than 8.9

million fractures annually, resulting in an

osteoporotic fracture every 3 seconds

Epidemiology -Worldwide
Worldwide, 1 in 3 women over

50 will experience osteoporotic

fractures, as will 1 in 5 men
A prior fracture is associated

with an 86% increased risk of

any fracture

Epidemiology Of Osteoporosis in KSA

50-59 yrs : 33.4% osteopenia

24.3% osteoporotic
60-69 yrs : 27% osteopenic
62% osteoporotic
70-80 yrs : 21.5 osteopenic
73.8% osteoporotic
Osteoporosis in postmenopausal Saudi women using dual x-ray
bone densitometry . MahmoudI. El-Desouki,

Epidemiology Of
Osteoporosis in KSA
483 post menopausal Saudi women in

Riyadh with an average age of 55 yrs

( range 52-62 yrs):
42% had normal BMD
34% had osteopenia
24% had osteoporosis

El-Douski,Saudi Med J

Osteopenia and osteoporosis

are common among

postmenopausal Saudi women
and should be considered as a
matter of public health.
The prevalence of osteoporosis
is far more common in the
country than its Western


Shape and structure of bone are

continuously renovated and modified by the
processes of modelling and remodelling

Bone modelling
Begins with the development of the
skeleton during fetal life and continues until
the end of the second decade

Bone remodelling
Occurs from fetal life through to skeletal
It maintains the mechanical integrity of the
skeleton by replacing old bone with new.
This constant process of turnover enables

In the adult skeleton, approximately 510%
of the existing bone is replaced every year
through remodelling
The maintenance of a normal, healthy,
mechanically competent skeletal mass
depends on keeping the process of bone
resorption and formation in balance.
Failure to match bone formation with bone
resorption results in net bone loss.
This is what occurs in osteoporosis, as a

Risk Factors of Osteoporosis:

Risk Factors of osteoporosis:

:Risk Factors of osteoporosis

Gain of bone Peak bone mass

The peak bone mass is the amount of

bone tissue present at the end of skeletal
It is the difference between the amount
accumulated at maturity and that lost with
It is a major determinant of the risk of
fracture due to osteoporosis.
There is, therefore, considerable interest in
exploring ways to increase peak bone

Determinants of peak bone mass

Endocrine factors (gonadal sex
hormones and adrenal androgens
Exposure to risk Factors

Disorders impairing peak bone

Anorexia nervosa
Exercise-associated amenorrhoea
Delayed puberty

Clinical manifestations and

Complications of Osteoporosis
Symptoms: may include Back pain, loss
of height, kyphosis
However, osteoporosis is a silent disease,
as bone loss occurs without symptoms.
There are no warning signs until a fragility
fracture occurs.
A fragility fracture is defined as any
fracture that occurs as a result of minimal
trauma or no identifiable trauma

Clinical manifestations and

Osteoporosis- related fractures may occur
in any bone but are most likely to occur at
sites of low bone mass.
The most typical sites of osteoporosis
related fractures are the vertebrae, distal
radius, proximal femur, and ribs.
The morbidity of osteoporosis comes
mainly from fractures and their potential

Clinical manifestations and

Vertebral compression fractures are
associated with pain, deformity, disability,
and increased mortality.
The most serious consequences, are
those associated with hip fractures.
An average of 24 % of patients aged > 50
years die within one year after their
fracture, and approximately half of the
survivors will have a disability
necessitating long- term care.

Optimal evaluation consists of:
Establishing the diagnosis of
osteoporosis on the basis of bone
mass assessment
Establishing the fracture risk
Determining the need for
instituting therapy.
History and a physical examination to
evaluate fracture risks; should
include assessment for loss of height
and change in posture.

Osteoporosis Diagnosis:
The Dual-energy X-ray
Absorptiometry (DXA) report
provides Bone Mineral content
in a given area of Bone
This gives BMD in grams per
square centimeter(g/cm2)

World Health Organization

Diagnostic Categories of BMD
Normal bone mass

BMD within 1 standard deviation of the reference mean

for young adults (T-score 1.0)
Low bone mass (osteopenia)
BMD of > 1.0 to < 2.5 standard deviations below the
mean for young adults (T-score < 1.0 and > 2.5)
BMD 2.5 standard deviations below the mean for
young adults (T-score 2.5)
Severe or established osteoporosis
BMD 2.5 standard deviations below the mean for
young adults in the presence of one or more fractures

Establishing the fracture

WHO fracture assessment
tool (FRAX)
The FRAX is a simple clinical tool

developed by the WHO to evaluate

fracture risk in patients
The FRAX comprises of variables/risk

o Screening:

Is the systematic application of the

test when it is assumed that people
have no symptoms.

Recommendations for Osteoporosis screening:

- Osteoporosis is common, costly associated with high morbidity and
- Easily detectable and highly treatable
- DXA is safe screening test
- Patients can be started on treatment and counselled regrading lifestyle changes

Osteoporosis screening at

High risk or selective


All Men and Women > 60 years

Postmenopausal women
Men 50-59 years
With one or more of the following:
Fragility fracture after age 40
Vertebral fracture or low BMD
identified on X-ray
Parental hip fracture
High alcohol intake
Current smoking
Low body mass index (less than
18.5 kg/m2)
High risk medication use: i.e.
prolonged glucocorticoid use)
Rheumatoid arthritis
Other disorders that lead to bone

Men and women <

50 years
With one or more of the

Fragility fracture
High risk medication use
Rheumatoid arthritis
Chronis inflame conditions
Cushing disease
malabsorption syndrome
Primary hyperthyroidism
for DXA
with rapid
bone loss/

Determining the need for instituting therapy


An important goal in the

management of osteoporosis is to
prevent the first fracture.
A. Non- pharmacologic measures.
Change lifestyle risk factors.
Prevent falls
Maintain or improve mobility
Increase weight bearing

B. Pharmacologic measures.
Treat secondary causes of osteoporosis, and associated

Treat pain, discomfort and other associated morbidity
Increase bone mass.
Drugs for osteoporosis primarily reduce bone turnover
by inhibiting osteoclast activity.
The selection of any of the drugs used for osteoporosis
should be individualized based on the patient
characteristics, efficacy, and health economics.
There is no agent that is suitable for all patients, and
clinical judgment should always be exercised.
Referral for expert opinion is warranted

1. Calcium and Vitamin D:
Should not be used as the sole treatment of

osteoporosis, but rather as adjuncts to therapy.

Improve bone density in postmenopausal women.
Reduce risk of fractures in elderly women.
Most effective in subjects with low calcium and
vitamin D.
Premenopausal, men <50 yr and pregnant
women (1000 mg/d)
Postmenopausal, men >50 yr (1500 mg/d)

Premenopausal, men <50 yr and

pregnant women (600 IU/d)

Postmenopausal, men >50 yr (1000
An alternative to supplementation
would include exposure to the sun for
1015 minutes every day, 23 times/

2. Alendronate [ Drug Class:
Bisphosphonates] Approved for prevention and treatment of

osteoporosis, including steroid induced

osteoporosis, and osteoporosis in men.
Improves BMD at spine and hip
Reduces vertebral fractures and non-vertebral
Reduces hip fractures.
Once weekly dose of 70 mg is as effective as
daily dose of 10 mg.

Fall Prevention and Hip

Non-pharmacologic interventions directed at
preventing falls and reducing their effect on
Using hip protectors to absorb or deflect
the impact of a fall
Removing any obstacles that may result in
Withdrawal of psychotropic medications

Initiatives should be directed at the following
Optimize nutrition in the youth to achieve high
peak bone mass.
Encourage adequate intake of calcium and
Vitamin D.
Identify and treat subjects with Vitamin D
deficiency, especially children, females in the
reproductive age group, and the elderly.
Recommend regular weight bearing exercise.
Avoidance of tobacco smoking and excessive
alcohol intake.

Assess every postmenopausal woman for

risk of osteoporosis, and determine the

need for diagnostic tests and
prevention /treatment.
Early treatment of causes of osteoporosis
[e.g. thyrotoxicosis, smoking,
hyperparathyroidism, others].
Prevention and early treatment of
osteoporosis of patients who are receiving
high dose steroid therapy, or other drugs
that contribute to osteoporosis.

International Osteoporosis Foundation
Saudi Guidelines for Osteoporosis Prevention
and Treatment 2014
Guidelines for Prevention and Management of
Osteoporosis in Adults at KFSH&RC -2003
2015 Guidelines for Osteoporosis in Saudi
Arabia: Recommendations from the Saudi
Osteoporosis Society. Ann Saudi Med 2015;
35(1): 1-12