OSTEOPOROSIS

dr. Leonardo Sp.PD-KGEH

Bagian Penyakit Dalam

FK NOMENSEN - Medan
 EPIDEMIOLOGY

Osteoporosis is a major public health problem, and

postmenopausal osteoporosis constitutes as a major part
of the problem.
Claus Christiansen, Am J Med 1993

Hip fractures will increase sharply in the next half

century, especially in Asia, making osteoporosis a truly
global issue.
WHO 1998
Introduction
Osteoporosis is a disease characterized
by low bone mass and microarchitectural
deterioration of bone tissue, leading to
enhance bone fragility and a consequent
increase in fracture risk

(WHO)
Osteoporosis is a skeletal disorders
compromised bone strength,
predisposing in an increase risk
of fracture
Rigg and Nelson divided into :

A/. Primary osteoporosis

1. Post menopause osteoporosis
2. Senile osteoporosis
B/. Secondary osteoporosis
Osteoporosis due to other condition
of disease such as metabolic,
endocrine or malignancy
Post menopausal osteoporosis
• Most common in woman 15 – 20 year after menopause
• Mostly affects trabecular bone, increasing patient
susceptibility to vertebral compression fractures,
distal radial fractures and intertrochanteric fractures.
• Esterogen deficiency plays a primary role
Senile Osteoporosis
Occurs in men and women over the age of 70 years
with female to male ratio of 2:1
It affects : cortical and trabecular bone equally,
predisposing patient to multiple wedges vertebral and
femoral neck fractures
Aging and long-term calcium deficiency is more
important.
Primary osteoporosis mostly are old and
elderly people complaining of mild
backache but may also a sudden pain with
only a mild injury due to a compression
fractures of the vertebrae.
Before it reaches the threshold of fractures,

usually the height of patient reduces beside

deformity (kyphotic deformity)

It is a silent disease, meaning there is
no significant signs and symptoms
caused by osteoporosis
 Etiology :
General factor predictive of osteoporosis :
1. Peak bone mass at maturity :
General / familial
Nutritional
Physical (activity status, exercise, etc)
Life style (alcohol, cigarettes, caffeine)
Medical (chronic disease, hypogonadal states, etc)
Iatrogenic (corticosteroid, anticonvulsant, etc)
Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889
 Bone Mass Development

Peak Bone Mass Bone Loss

male
Bone Mass

Menopause

female

20 40 60 80
Age (year)
age
2. Post menopausal bone loss
Accelerated trabecular bone loss for 3
to 10 years post menopausal
Due to increased bone resorption
secondary to estrogen loss
Loss of normally 1 to 2% per year to
a maximum of 10%

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Age-related (involutionall) bone loss
Starts at age 35 – 40 years in both sexes,
continues for 30 to 40 years
Subtle uncoupling of rates of bone formation
and resorption
Both cortical and trabecular bone affected
Loss normally less than 0.5% per year to a
maximum of 20 %

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Risk factors
Genetic, life style, Medical, Iatrogenic

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Risk factors for bone loss :

1. Genetic :
- Female sex
- Caucasian / Asian ethnicity
- Family history of osteoporosis

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

2. Life Style :
- Low calcium intake
- Excessive alcohol use
- Cigarette smoking
- Excessive caffeine use
- Extreme or insufficient athlecity
- Excessive acid ash diet (high protein /
soft drink intakes)

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Medical :
- Early menopause
- Gonadal hormone deficiency states
- Eating disorders
- Chronic liver / kidney disease
- Malabsorption syndrome

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Iatrogenic :
- Corticosteroids
- Excessive thyroid hormone
- Chronic heparin therapy
- Radiotherapy to skeleton
- Long-term anticonvulsants
- Loop diuretics

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Bone is the most dynamic tissue.
Metabolism of catabolism and anabolism
as the activity of osteoclast and osteoblast
as a process of bone remodeling or
bone turn over
Degeneration occurs as an aging process

where the activity of osteoclast is not able

to compensate by the activity of osteoblast.

As a result bone mineral density decrease

The main problem of osteoporosis
lies in the effectiveness of intervention-
prevention and treatment
Osteoporosis is preventable if prevention
starts during the childhood and adolescence
when bone reaches maturity at the end
of 3rd decade to achieve maximum
Peak Bone Mass
After the 3rd decade all organ include skeletal /
bone will degenerate, the speed of
degeneration, differs for different organ.

In general organ will loose function

1% every year (the rule of 1% of Andreas
and Tobin)
Diagnosis should include differential diagnosis of
primary and secondary osteoporosis by :
o Taking a good history

o Physical examination

o Laboratory examination

o Imaging examination
DIAGNOSIS
History :
o ras, sex and age
o health status
o life style (alcohol, smoking)
o physical activity (sports)
o history of previous disease including administration of
o drugs, previous fracture.
Physical Examination :
oBody weight and height (BMI)
oExtremities and spine including :
deformity, MMT and ROM
Laboratory findings :
o blood serum
o hormone
o Urine
LABORATORY FINDINGS :
Routine:
- Serum :
- Complete blood counts
- Electrolytes, creatinine, blood urea, nitrogen calcium
- Phosphorus, protein, albumin, alkaline phosphatase,
liver enzyme
- Protein electrophoresis
- Thyroid function tests
- Testoterone (men only)
- 24 hours urine :
- calcium
- Pyridinium cross-links
LABORATORY FINDINGS :
Spesial :
- Serum:
- 25 hydroxyvitamin D3
- 1,25 hydroxyvitamin D3
- intact parathyroid hormone
- osteocalcium (bone Gla protein)
- Urine :
- Immunoelectrophoresis
- Bence-Jones protein
IMAGING :
Radiology : plain X-ray
(especially the spine, hip and wirst)
The spine : - the ballooning disc
- deformity of vertebral body
(wedge, fish tail)
The Hip : - Singh Index
The Wirst : - Porotic / thinning cortex
The general diagnostic categories
established in woven : (WHO working group)

Normal : Bone Mass Density (BMD) or

Bone Mineral Content (BMC)
-1 SD from T Score of the young
adult reference mean
Osteopenia : BMD or BMC –1 SD to –2.5 SD
Osteoporosis : BMD or BMC –2.5 SD

(severe osteoporosis when there is followed a fracture)

 Prevention and Treatment
T-score
T-score Fracture
Fracture risk
risk Teatment
Teatment
>> +1
+1 very
very low
low •• no
no treatment
treatment
•• densitometry
densitometry with
with indication
indication
-1
-1 s/d
s/d 00 low
low •• no
no treatment
treatment
•• densitometry
densitometry after
after 55 years
years
-- 11 s/d
s/d +1
+1 low
low •• no
no treatment
treatment
•• densitometry
densitometry after
after 22 years
years
-1s/d
-1s/d -2,5
-2,5 midle
midle •• prevention
prevention
•• densitometry
densitometry after
after 11 years
years
<< -- 2,5
2,5 high
high •• osteoporosis
osteoporosis treatment
treatment
no
no fracture
fracture •• continue
continue prevention
prevention
•• densitometry
densitometry after
after 11 years
years
<< -- 2,5
2,5 very
very high
high •• osteoporosis
osteoporosis treatment
treatment
With
With fracture
fracture •• continue
continue prevention
prevention
•• surgery
surgery with
with indication
indication
•• densitometry
densitometry after
after within
within
66 month
month –1
–1 years
years
Prevention
 Aging process is a natural process of a person
getting old

 3 steps of osteoporosis prevention :

I. Up to the end of 3rd decade
where Peak Bone Mass should be achieved
II. After the 3rd decade up to menopause /
Andropause
III. Senile, prevent from minor injury / accident
Goal of Osteoporosis Prevention
Optimising skeletal development
Nutrition
Physical activity
Life style changes
Minimize medical / iatrogenic factors

Minimize postmenopausal bone loss

Early identification of patients at risk
Reduced risk factors
Hormone replacement therapy (HRT)
Other agents pre-emptively if HRT contraindicated
raloxifene, alendronate

Minimize age-related bone loss

Identification of patients at risk
Reduce risk factors
Full prevention and exercise program (physical
therapy)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
1st Prevention :
 Good nutrition

 Life style and physical exercise

To achieve maximum Peak Bone Mass

2nd Prevention
 Early diagnose of osteoporosis
 The same prevention as 1 prevention
st

 In female patient after menopause with HRT

 Prevention of the use of medication

consist steroid etc

3rd Prevention
 Prevent from accident
(minor injury could cause fracture)
 Care giver especially after fracture
 Operative intervention and bracing
Treatment
Nowadays there is a lot of medication
For osteoporosis such as :
- calcium and vitamin D
- calcitriol
- calcitonin
- bisphosphonate : generation : I – III
such as (clorodronate, alendronate, and
risedronate (actonel))
- hormone : - anabolic
- sex hormone
- SEMs (Selective Modulator)
- SERM (Selective Estrogen Reseptor
Modulator : Raloxifene
(analogue of tamosifene)
SURGERY
Calcium : 1500 mg / day
Vitamin D : 500 mg / day
Calcitonin (myacalcic : Nasal spray: 200 mg / daily)
HRT : establish approach for osteoporosis prevention
and treatment.
But what after WHI report ????

SERM : Raloxifene : Evista : 60 mg/daily

- the goal is to increase bone benefits and decrease
deletterious affects on breast and endometrim.
- decrease breast cancer : 76 %
- 60 % women, 2 years : BMD increase 1-2 %

Dr. C. Deeply
 DIET CUKUP KALSIUM DAN VIT. D
4 SEHAT 5 SEMPURNA
KEBUTUHAN KALSIUM

 Balita 400  700 mg / hari

 Remaja 1000  1500 mg / hari
 Dewasa 750  1000 mg / hari
 Hamil 1500 mg / hari
 Menyusui 2000 mg / hari
 Sebelum menopause 800  1000 mg / hari
 Selama menopause 1000  1200 mg / hari
 Setelah menopause 1200  1500 mg / hari
 BAHAN MAKANAN
Per Ons Teri nasi mengandung 1000 mg Kalsium
Per Ons Kepiting 210 mg
Per Ons Kerang 133 mg
40 gr Dencis kaleng 200 mg
Per Ons Kuning telur ayam 147 mg
Per Ons Tempe 129 mg
Per Ons Tahu 124 mg
er Ons Emping 100 mg
Per Ons Bayam merah 347 mg
Per Ons Kacang panjang 347 mg
Per Ons Daun singkong 165 mg
1 gelas Susu kental manis 275 mg
1 gelas Susu segar 380 mg
1 gelas susu krim penuh 290 mg
1 gelas Susu non fat 480 mg
1 gelas yurgort 200 mg
20 gr keju 100 mg
PREPARAT KALSIUM YG TERSEDIA DI PASARAN
No.Jenis Kalsium Nama Dagang Kalsium(mg)
1. Kalsium karbonat Ca-C 100 Sandoz 327
Calsan 1250
Caxon-F 250
Calsium Sandoz 300
Epocaldi 400
2. Kalsium Laktas Ca-C 1000 Sandoz 1000
Calcidin 100
Calsium Sandoz 2940
3. Kalsium fosfat Calcidin 200
Calcalcin 800

Catatan : Kalsium karbonat mengandung 40 % kalsium

Kalsium laktas mengandung 13 % kalsium
Kalsium fosfat mengandung 25 % kalsium