Treatment of Osteoporosis

Deske Muhadi
Internist – Rheumatology
University of Sumatera Utara
Problems in management of osteoporosis
• Problem in diagnosis of osteoporosis : role of
bone density, bone marker, and risk factor?
• Poor compliance to treatment.
• Different specialties background work in
osteoporosis and treatment options for
osteoporosis.
Parameters for treatment
decision?
 Risk factor
Risk for osteoporosis /
BMD testing Risk for fall
• Age • Age
• Female • Female
• Low body mass index • Anxiety, depression
• Glucocorticoid • Arrhytmias
• Rheumatoid arthritis • Dehydration
• Family history • Malnutrition
• Smoking • Medication
• Alcohol intake • Poor vision
• Orthostatic hypotension
• Environment

National Osteoporosis Foundation,2008

 BMD and T-score

T-score is still considered to be major determinant

for treatment decision
Risk fracture assessment
Non-pharmacologic treatment
 Exercise

Weight-bearing exercise memberikan stimulus pada osteocyte.

Exercise dapat mengurangi risk of fall.
 Fall prevention

Home environment for fall prevention

 Nutrition and calcium

Good nutrition including adequate protein, calcium and vitamin D intake is

general recommendation for treatment of osteoporosis
 Vitamin D

Adequate vitamin D is associate with decreased fracture risk on spine, improved

muscle strength, and decreased risk of fall.
 General Recommendation

Recommendation : Grade A : evidence levels Ia and Ib

Grade B : evidence levels IIa, IIb, and III
Grade C : evidence level IV

National Osteoporosis Guideline Group,2000

Pharmacologic treatment
 Current treatment
• Calcium
• Vitamin D

Anti-resorptive Anabolic agent

• Alendronate • Fluoride
• Risedronate • Parathyroid hormon
• Ibandronate • Strontium
• Zoledronate
• Raloxifene
• Calcitonin
• Hormonal replacement therapy

Summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocrine Reviews, 2002

Anti-osteoporotic drug action

The site of action of anti-resorptive agent

and anabolic agent
 Pharmacologic Treatment

Recommendation : Grade A : evidence levels Ia and Ib

Grade B : evidence levels IIa, IIb, and III
Grade C : evidence level IV

National Osteoporosis Guideline Group,2000

 Treatment Guidelines
Summary of recommendations for pharmacologic therapy according to T-score from
the National Osteoporosis Foundation (NOF) and the American Association of Clinical
Endocrinologists (AACE)

Patient Profile T-score

NOF AACE

No Risk Factors Less than -2.0 -2.5 or less

Risk Factors† Less than -1.5 -1.5 or less

† Fragility fracture, family history of fracture, cigarette smoking, low body weight
(<127 lbs.), etc.
National Osteoporosis Foundation 1998.
American Association of Clinical Endocrinologists 2001.
 Bisphosphonates are internalised by
osteoclasts during bone resorption
Intracellular
bisphosphonate Resorption pit

Side view

Bisphosphonate (bone surface)

Osteoclast membrane and nuclei
Cytoskeleton

Courtesy of Dr Fraser Coxon, University of Aberdeen

How long is bisphophonate
treatment?
 Future therapies
New antiresorptive agent
• Human monoclonal antibody to RANKL (Denosumab)
• Cathepsin K inhibitors

New anabolic agent

• Parathyroid hormone
• Antisclerostin monoclonal antibodies

Pierre D Delmas. 17th IOF Advanced Training Course on Osteoporosis. Lyon,France. January 29-
31,2008.
 SUMMARY
• Decision to treat osteoporosis can be based on BMD
measurement or risk fracture assessment.
• General recommendation for osteoporosis treatment
including good nutrition, regular exercise, risk factor
modification, and adequate calcium and vitamin D
intake.
• Recommended pharmacotherapy for osteoporosis
bisphosphonate, SERM, strontium ranelate,
calcitonin, PTH.

“ Terima kasih, semoga bermanfaat “