OSTEOPOROSIS KARENA STEROID

NAJIRMAN
SUBBAGIAN REUMATOLOGI, BAGIAN ILMU PENYAKIT DALAM
FK UNAND/ RSUP DR M.DJAMIL
PENDAHULUAN
Tulang manusia : 220 bh 15% BB
Kortikal 80%
Trabekular 20%
Penderita OP : AS 52 juta 2010
61 juta 2020
Dunia 200 juta
70% dari 1,3 juta Fraktur di AS OP
Total biaya : 17 miliyar dolar
60% hip fraktur
50 th Resiko Fraktur : Vertabrae 32%
Hip 15%
Lengan bawah 16%
 Kalsium
MINERAL Phosphorous (as hydroxyapatite
Ca10(PO4)6(OH)2)

90% of bone matrix:

Kolagen TERUTAMA KOLAGEN TIPE I
KOMPOSISI
TULANG

NON 10% of matrix:

Osteonectin, Proteoglycans,
KOLAGEN
fibronectin, osteopontin,
 MARKER BONE TURN OVER
Osteocalcin
BONE Bone-specific alkaline phosphatase
FORMATION Type I collagen C- and N-propeptide (PICP and PINP)

Free pyridinoline and deoxypyridinoline

Pyridinoline cross-linking telopeptides
(C- and N-telopeptides, CTx, NTx, ICTP)
BONE Tartrate-resistant acid phosphatase 5b
RESORPTION Bone sialoprotein

Pyridinoline crossliinks (pyridinoline and

deoxypyridinoline)
Pyridinoline cross-linking telopeptides
(C- and N-telopeptides, CTx, NTx, ICTP)
URINE Osteocalcin fragments
Hydroxyproline
Calcium
Bone turnover
 Steps of remodelling trabecular bone

Resorption, 20 days
Formation, 100 days
Control of bone turnover
OSTEOPOROSIS
-Kelainan skeletal sistemik
-Penurunan massa tulang
-Perubahan mikroarsitektur jar. Tulang
-Fragilitas tulang meningkat
-Mudah fraktur

Pembagian
Osteoporosis Primer : Tipe I
Tipe II
Osteoporosis sekunder : - Penyakit dasar
- Obat-obatan Steroid
Risk factors for osteoporosis and fracture
 RESIKO FRAKTUR PADA OSREOPOROSIS
Ada riwayat fraktur sebelumnya
Post menopause
Menopause prematur ( < 45 thn)
Hipogonadisme Kejadian fraktur
Pria usia > 65 tahun pada penggunaan
Pemakaian steroid > 6 bulan steroid jangka
BMI < 20 Kg/m2 panjang 30-50%
Riwayat hip fracture usia < 60 thn
Alkoholisme
Penyakit yang beresiko untuk osteoporosis
- RA
- hiperparatiroid
- Hipertiroid, dll
 Faktor endokrin
Defisiensi estrogen
Ras produksi androgen Hipercalciuria
Faktor genetik Defisiensi calcitonin gagal ginjal
Kelamin wanita kronis

Obat-obatan
STEROID Inaktivitas fisik/
Antikonvulsan OSTEOPOROSIS immobilisasi
Antasida lama

Defisiensi vit. D Penyakit hati

Diet tidak seimbang Defisiensi kalsium
Rokok-cafein
Gangguan absorbsi Alkoholik
Malabsorbsi kalsium Diet tinggi protein
Aklorhidria
 Equiva Glucocorti Mineralo Protein Half life Biologic
lent coid corticoid binding in half life
dose activity activity plasma (hours)
(Hours)
Short acting
Cortisone 25 0,8 0,8 - 0,5 8-12
Cortisol 20 1 1 ++++ 1,5-2 8-12

Intermediate
acting
Metil prednisolon
Prednisolon 4 5 0,5 - > 3,5 18-36
Prednison 5 4 0,6 ++ > 2,1- 18-36
Triamsinolon 5 4 0,6 +++ 3,5 18-36
4 5 0 ++ > 3,4- 18-36
3,8
> 2->5
Long acting
Dexamethsone 0,75 20-30 ++ 36-54
Betamethasone 0,6 20-30 ++ 36-54
 EFEK BERBEGAI JENIS STEROID
Efek terhadap
Jenis steroid Efek anti inflamasi
keseimbangan cairan
Fludrokortison + ++++
Kortison ++ +++
Hydrokortison +++ ++
Prednisolon ++++ +
Metil prednisolon ++++ +
Triamsinolon ++++ +
Beklometason ++++ +
Terminology of glucocorticoids dose for use in Rheumatology

Low dose < 7,5 mg prednison or equivalent per day

Medium dose > 7,5 mg prednison, < 30 mg prednison or
equivalent per day
High dose > 30 mg prednison, < 100 mg prednison or
equivalen per day
Very high dose > 100 mg prednison or equivalent per day
Pulse therapy > 250 mg prednison or equivalent per day for
one or few days
 Osteoblast differentiation
& activity Bone formation
Apoptosis

Negative Ca balance Bone resorption BMD

Osteocyte apoptosis
Bone architecture & RISK OF
Oral GCs quality FRACTURE

Oestrogen &
testoterones

Muscle weakness & Propensity to fall

atrophy

Bone resorption
Underlying disease Systemic inflammation BMD
Bone formation

Pathophysiology of glucocorticoid induced fractures

 MECHANISM OF GC BONE LOSS
OSTEOBLAST
Apoptosis
Protein synthesis
FORMATION

OB PRECURSOR
Proliferation

OSTEOCYTES NET LOSS

Viability

GLUCOCORTICOIDS ADRENAL & TESTIS

Androgens
RESORPTION
OPG

GI TRACK
Ca absorption PARATHYROID
PTH
RENAL TUBULE
Ca reseorption

Schematic diagram of effects GCs

on bone metabolism
Effects of glucocorticoids on bone metabolism
Effects of glucocorticoids on bone
Dual-energy x-ray absorptiometry = DXA
ALGORITMS TATA
LAKSANA
OSTEOPOROSIS EC
STEROID
Management algorithm for glucocorticoid osteoporosis.
Recommendations on counseling for lifestyle modification and assessment of
patients starting glucocorticoids at any dose with an anticipated duration
>3 months
Pharmacologic recommendations for postmenopausal women
and men age >50 years starting glucocorticoid therapy with an
anticipated duration of >3 months, or prevalent glucocorticoid
therapy of a duration of at least 3 months
The grading of evidence: a scheme for the hierarchy of evidence for
developing recommendations in guidelines
PROSES IMUNOLOGIS PADA OA
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