Osteoporosis-pathogenesis, diagnosis, management and prevention

Osteoporosis-pathogenesis, diagnosis, management and prevention for clinical practice

1. Osteoporosis Dr.S.Sethupathy 1

2. Defining Osteoporosis “Progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk ” True Definition: bone with lower density and higher fracture risk WHO: utilizes Bone Mineral Density as definition (T score <-2.5); surrogate marker

3. Who Gets Osteoporosis? Age Estrogen deficiency Testosterone deficiency Family history/genetics Female sex Low calcium/vitamin D intake Poor exercise Smoking Alcohol

4. Who gets osteoporosis? Low body weight/anorexia Hyperthyroidism Hyperparathyroidism Prednisone use Liver and renal disease (think about vit d synthesis) Low sun exposure Medications ( antiepileptics , heparin) Malignancies (metastatic disease; multiple myeloma can present as osteopenia!) Hemiplegia s/p CVA/ immobility

5. SYMPTOMS Back pain, which can be severe if fractured or collapsed vertebra Loss of height over time, with an accompanying stooped posture Fracture of the vertebrae, wrists, hips or other bones

6. Hypogonadal states Turner syndrome, Klinefelter syndrome, Kallmann Syndrome, anorexia nervosa, hypothalamic amenorrhea, hyperprolactinemia. Nutritional and gastrointestinal disorders malnutrition, parenteral nutrition, malabsorption syndromes, gastrectomy, severe liver disease (especially biliary cirrhosis), pernicious anemia. Hematologic disorders/malignancy multiple myeloma, lymphoma and leukemia, mastocytosis, hemophilia, thalassemia. Etiology Endocrine disorders Cushing's syndrome, hyperparathyroidism thyrotoxicosis, insulin-dependent diabetes mellitus, acromegaly, adrenal insufficiency

7. Drugs associated with increased risk of osteoporosis - Glucocorticoids - Cycosporine - Cytotoxic drugs - Anticonvulsants - Excessive alcohol - Excessive thyroxine - Heparin - Lithium 7

8. WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis , 1998. T-Score World Health Organization (WHO) Osteoporosis Guidelines 1.4 1.3 1.2 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 20 30 40 50 60 70 80 Age BMD Mean – 2 SD Consider preventive intervention Consider therapeutic intervention Mean Lumbar Spine BMD: Decades 3 to 9 of a Woman’s Life Bone Mineral Density Values

9. Osteoporosis PATHOGENESIS 1. Peak bone mass : about 20 years old - genetic, hormone, nutrition, life style 2. Rate of bone loss : after age 30-45, bone resorption (osteoclast)> formation (osteoblast) and become exaggerated after menopause (50 years old) 3. Bone remodeling : keep balance at 20-30 years old, after that become negative balance 9

10. Mechanism

11. Osteoporosis Type 1 Type 2 Type 3 Postmenopausal Senile secondary Age 55 -70 years 70-90 years all Sex(F/M) 6:1 2 :1 1:1 Fx site vertebrae vertebrae vertebrae distal forearm hip hip distal forearm The threshold for Fx is reduced for osteoporotic bone 11

12. Risk factor for osteoporosis fracture Potentially modifiable 1. Cigarette smoking 2. Low body weight ( < 58 kg.) 3. Estrogen deficiency : early menopause (<45 years) 4. Low calcium intake, high salt and protein diet 5. Alcoholism 6. Inadequate physical activity 7. Poor health 12

13. Lab Investigations CBC ESR Serum calcium (8.6 – 10.4 mg/dl) Serum phosphorus (3.00 – 4.5 mg/dl) Children 4-6 mg/dl Serum alkaline phosphatase (44 – 147 Iu /lit.) Children 1.5 -2.5 times more Liver function tests Renal function tests T3,T4, TSH Para thyroid hormones Vitamin D 25 (25 – 80 ng /ml) Protein electrophoresis (M band) Anti endomysial antibody ( Coeliac disease)

14. Osteoporosis Treatment: Calcium and Vitamin D Fewer than half adults take recommended amounts Higher risk: malabsorption, renal disease, liver disease Calcium and vit D supplementation shown to decrease risk of hip fracture in older adults 1000 mg/day standard; 1500 mg/day in postmenopausal women/osteoporosis Vitamin D (25 and 1,25): 400 IU day at least; Frail older patients with limited sun exposure may need up to 800 IU/day

15. Osteoporosis Treatment: Calcitonin Likely not as effective as bisphosphonates 200 IU nasally/day (alternating nares) Decrease pain with acute vertebral compression fracture

16. Osteoporosis Treatment: Bisphosphonates Decrease bone resorption Multiple studies demonstrate decrease in hip and vertebral fractures Alendronate, risodronate IV: pamidronate, zolendronate (usually used for hypercalcemia of malignancy, malignancy related fractures, and multiple myeloma related osteopenia) Ibandronate (boniva): once/month Those at highest risk of fracture (pre-existing vertebral fractures) had greatest benefit with treatment

17. ESTIMATED DAILY CALCIUM INTAKES RECOMMENDED DAILY INTAKE OF VITAMIN D

18. Milk equivalents containing 300 mg of calcium per serving

19. 98% of a woman’s skeletal mass is acquired by age 20 Optimal strategies for building strong bones occurs during childhood and adolescence A study of disease management in a rural healthcare population demonstrated that a preventive program was able to reduce hip fractures and save money. A balanced diet rich in calcium and vitamin D Weight-bearing and resistance-training exercises A healthy lifestyle with no smoking or excessive alcohol intake Talking to one’s healthcare professional about bone health Bone density testing and medication when appropriate Five Steps Toward Prevention

20. THANK U… Thank you