OSTEOPOROSIS SIGMA 2016 LATEST ABRIDGED.ppt

osteoporosis

1. OSTEOPOROSIS

2. •Incidence 4 times that of stroke
•Mortality as common as that of breast
cancer
•It is an “orphan” disease…….
…………………....neglected

3. •Each year, there are an estimated :
- 5 lac spinal fractures,
- 3 lac hip fractures,
- 2 lac broken wrists, and
- 3 lac fractures of other bones
 
•About 80% of these fractures occur from
relatively minor falls or accidents

4. A woman’s risk of developing an
osteoporosis-related hip fracture is
equal to her combined risk of
developing breast,
 
uterine and ovarian
cancer

5. MEN BEWARE!!
•Prevalence of osteoporosis in men is higher
than previously thought
•One in three hip fractures and one in five
vertebral fractures occur in men
•The lifetime risk of an osteoporotic fracture in
men (over age 50) is similar to the lifetime risk
of developing prostate cancer

6. •There are about 300 million people with
osteoporosis in India
•80% of these are women
•WHO figures  1 out of every 8 males and
1 out of every 3 females in
India suffers from
osteoporosis
•Makes India one of the largest affected
countries in the world

7. •35% of post-menopausal women in India have
osteoporosis
•One in every two women(over 50) and one in every
eight men (over 50) are expected to suffer an
osteoporotic fracture in their lifetime
•Fractures related to osteoporosis result in :
 Dependency,
 Limited mobility
 Pain, and
 Fear of further injury

8. •Evidence indicates that there may be
a 50 per cent increase in the number
of people with osteoporosis in India in
the next 10 years
• So, this “SILENT EPIDEMIC” is a
huge problem in India

9. Osteoporosis
(Osteon-bone, Pore- passage/tiny hole)
•It defined as a “progressive (often), systemic (commonly)
and skeletal disease characterized by overall low bone mass
(quantitative) predominated by microarchitectural
(qualitative) deterioration of bone tissue that results in
increased bone fragility, and hence susceptibility to
fracture”.
•Newer definition of osteoporosis considers it to be a
skeletal disorder characterized by low bone strength and
increased risk of fracture
•Usually affects all the bones of the body.
•Most common metabolic bone disease.

10. •Peak adult bone mass reaches at about the
age of 35 years
•accumulated from age of 8 years till the end
of 2nd decade.
•Subsequently declines with aging at the rate
of 0.3–0.5% per year in both men and women.
•At menopause the loss of bone mass
accelerates an average of 1% initially to 5%
over the decade which then again slows

11. Riggs and Melton Classification of
osteoporosis
PRIMARY SECONDARY
Type 1
Postmenopausal
Hormonal: Hypogonadism, thyrotoxicosis, Cushing’s,
hyperprolactinemia and diabetes mellitus
Type 2
Senile or involutional
Drugs: Steroids, phenobarbital, anticonvulsants,
anticoagulants, cytotoxic agents
Type 3
Postclimacteric
Nutritional: Calcium deficiency, vitamin C and vitamin D
deficiency, malabsorption, alcohol intake and malnutrition
Metabolic diseases: Osteogenesis imperfecta,
homocystinuria, Marfan’s syndrome
Chronic liver and renal disease
Miscellaneous disorders: Multiple myeloma, rheumatoid
arthritis, mastocytosis, thalassemia, Wilson’s disease,
hemochromatosis

12. postmenopausal
osteoporosis
senile osteoporosis
Age > 50 years Age > 75 years
Female to male ratio around 5:2 Female to male ratio around 2:1
Usually high turnover
osteoporosis
Usually low turnover osteoporosis
Involves mainly trabecular
bone
involves both trabecular
and cortical bone
Predominantly vertebral
fractures
Predominantly proximal femoral
Fractures
PTH normal to low PTH increased
Estrogen withdrawal main
etiology
Age related reduced bone turnover is
the main cause

13. ORGANIC 40% INORGANIC 60%
BONE CELLS MATRIX
OSTEOBLASTS
OSTEOCYTES
OSTEOCLASTS
COLLAGEN (Type I) 95%
TENSILE STRENGHT
NON-COLLAGENOUS
PROTEINS 5%
Hydroxyapatite
95%
COMPRESSIVE
STRENGHT
+
small amounts of
Mg, Na, K, Fl, Cl
CONSTITUTION OF BONE

14. Osteoblasts serve the purpose of bone
formation (osteogenesis), while osteoclasts are
mainly
accountable for bone resorption; their combined
action
contributes to progressive mineralization and
remodeling.
The osteocytes maintain the milieu of bone and its
homeostasis through vast network of canalicular
system
that communicates with external environment
through
Haversian system.

15. •They produce the organic component of bone matrix— the osteoid by synthesizing and
secreting type I collagen along with proteoglycans or glycosaminoglycans.
•Osteoblasts facilitate subsequent mineralization of osteoid by secreting matrix vesicles.
They create a conducive milieu for deposition of calcium and
phosphate in the organic matrix. Osteocalcin secretion is at its peak during
mineralization.
•Production of non-collagenous proteins including the osteocalcin, osteopontin, bone
sialoprotein and osteonectin that takes part in bone mineralization and
Maintenance
•Regulating bone metabolism- through receptors for (PTH) and 1, 25-dihydroxy vitamin
D3 present on mature cells
•Differentiation of osteoclasts—this is now considered a primary function with
increasing understanding of osteoporosis. The osteoblasts secrete receptor activator of
nuclear factor kappa B (RANK) ligand to regulate the activation and differentiation of
osteoclasts that then effect remodeling.
•Alkaline phosphatase enzyme levels and activity is increased with osteoblast activity,
The non-collagenous proteins are expressed uniquely during osteoblast differentiation.

17. IMPORTANCE OF CALCIUM
•Macrominerals account for 4-5% of total body
weight
•Approximately half of this weight comes from
calcium
•CALCIUM IS THE MOST ABUNDANT MINERAL IN THE
HUMAN BODY
•The teeth & bones contain 99% of the body’s
calcium; the remaining 1% is in the ECF and blood

18. CALCIUM
•This 1%, however, is required for basic regulatory
functions including :
- Contraction & relaxation of muscle (including
normal heart beat)
- Coagulation of blood
- Transmission of nerve impulses
- Activation of enzyme reactions
- Stimulation of hormone secretions
- Integrity of intracellular cement substances

19. REGULATORY MECHANISMS
•So important is this 1% of circulating Ca to life itself,
that special regulatory mechanisms are present to
maintain its levels, often at the expense of the other
99%
•If the serum levels of Ca fall below normal, the body
reacts as follows :
1) It may increase intestinal absorption
2) It may decrease urinary excretion
3) It may increase release of Ca from bone

20. •Factors monitoring these
activities :
- Parathyroid hormone (PTH)
- Vitamin D
- Calcitonin

21. •All 3 increase Ca and decrease P levels in the serum
- PTH : acts on Kidney increases renal excretion
of P(phosphaturia)
increases resorption of
Ca
Bone increases mobilisation of
Ca
- Vit D : acts on GIT increases absorption of
Ca & P
Bone increases mobilisation of
Ca
- Calcitonin : ” Kidney decreases urinary
excretion of Ca
Bone decreases mobilisation
of Ca

22. THE CYCLE OF “RESORPTION” & “FORMATION”
•Bone continually undergoes a process of remodeling, which
entails resorption and formation
•During resorption, osteoclasts attach to the bone surface and
break it down, releasing calcium into the blood stream and
leaving trenches in the bone
•Osteoblasts release collagen into these troughs and
eventually evolve into structural bone cells or osteocytes
•These cells combine with calcium and other minerals to form
a cement-like substance known as hydroxyapatite,
completing the formation of new bone

23. NORMAL BONE

26. •The continuous remodelling cycle serves to supply
the body with the calcium it needs and maintains
the skeleton’s structure and strength by replacing
old bones with new ones
•Weekly recycling of bone mass is 5% to 7%
•Every 4 years your spongy bone is replaced
and every 10 years your compact bone is
replaced completely!!

27. •When formation exceeds resorption, the bone
mass increases
•When resorption exceeds formation, there is a
loss of bone mass
•Continued excessive bone loss leads to
osteoporosis

28. BONE FORMATION & RESORPTION
A net uncoupling of these can cause osteoporosis
a)Increased Bone Turnover :
1) Severe uncoupling : ↓ BF + ↑ BR  net decline in
bone mass
e.g : chronic glucocorticoid excess
2) Normal BF + ↑ BR  Post-Menopausal OP(Type I)
3) ↑ BF + ↑ BR , but rate of BR >> BF  net loss of
bone mass
e.g : - Hyperthyroidism
- Hyperparathyroidism
- Chronic dietary Ca deficiency
b) Decreased Bone Turnover : ↓ BF + Normal BR 
Senile(age-related)OP
(Type II)

29. GENERAL FACTS AND
DEFINITIONS

30. •The commonest metabolic bone disease
•Most common skeletal disorder in the world,
second only to arthritis as a cause of skeletal
morbidity in the elderly
•It is a generic term referring to a state of decreased
bone mass per unit volume (density)of normally
mineralised bone

31. •The WHO Working Group defines
osteoporosis according to measurements
of bone mineral density (BMD) using
dual-energy
X-ray absorptiometry (DEXA)
•Osteoporosis is defined as a bone
density T score at or below 2.5
standard deviations below normal peak
values for young adults

32. •The WHO definition of osteoporosis only takes into
consideration measurement of bone density, with no
component of bone quality
•A clinical definition of osteoporosis :
“Osteoporosis is defined as a skeletal
disorder characterised by compromised
bone strength predisposing a person to
an increased risk of fracture”
•This definition takes the microarchitecture of bone into
consideration

34. With bone loss, the outer shell of a bone becomes thinner
and the interior becomes more porous
Normal bone (A) is strong
and flexible
Osteoporotic bone (B) is
weaker and subject to
fracture

36. OSTEOPOROSIS (COMMON TYPES)
POST MENOPAUSAL
(TYPE I)
AGE-RELATED
(TYPE II)
Age 55 -75 >70 (F); >80 (M)
Sex Ratio (F:M) 6 :1 2 :1
Pathogenesis of
uncoupling
Osteoclast activity
RESORPTION
Osteoblast activity
FORMATION
Net bone loss Mainly TRABECULAR Cortical & trabecular
Rate of bone loss Rapid / short durationSlow / long duration
S/S : fracture sitesVertebrae (crush)
Distal forearm
Hip (intracapsular)
Vertebrae (multiple
wedge)
Proximal humerus & tibia
Hip (extracapsular)

37. CAUSES
•In any given patient, several factors may be
operative simultaneously
•Commonest factor :

- In males  Senility
- In females  Menopause

38. GENERALISED OSTEOPOROSIS
(CAUSES)
 Senility
 Post-immobilisation e.g : a bed-ridden
patient
 Post-menopausal
 Protein deficiency 
- Inadequate intake (old age; illness)
- Mal-nutrition
- Malabsorption
- Excess loss (3rd degree burns; CRF,
etc)

39. GENERALISED OSTEOPOROSIS (CAUSES)
 Endocrinal 
- Cushing’s disease(pituitary dependent…adenoma)
- Cushing’s syndrome(prolonged exposure to
corticosteroids)
- Hyperthyroid state
 Drug-induced 
- Long term steroid therapy (asthma, RA, psoriasis)
- Phenobarbitone therapy
- Diuretics
- Heparin
- Aluminium containing antacids

40. MAIN RISK FACTORS
(NON-MODIFIABLE)
•Female gender
•Caucasian or Asian race
•Advanced age
•Family history of osteoporosis
•History of a fracture in a first degree relative
•Personal history of fracture particularly over age 50
•Early menopause (younger than 45 years of age) or
surgically induced menopause
•Absence of menstrual periods for an extended period
(more than 6 months)
•Thin or small body frame

41. MAIN RISK FACTORS
(MODIFIABLE)
•Low calcium intake over one’s lifetime
•Deficiency in vitamin D
•Low physical activity or being sedentary
•Cigarette smoking and / or excessive alcohol
intake
•Use of oral corticosteroid therapy (oral
steroids) for more than 3 months
•Use of certain other medications (such as
anticonvulsants)

42. CLINICAL FEATURES

43. IF HYPERTENSION IS A SILENT KILLER,
OSTEOPOROSIS IS A SILENT THIEF
(not obvious)
DIFFICULT TO CATCH (diagnose)
CAUGHT ONLY WHEN IT BREAKS THE HOUSE
(fractures)
IF CAUGHT, DIFFICULT TO PUNISH (treat)

44. CLINICAL FEATURES
•The thief insidiously robs the skeleton of its banked resources
(for decades) until it is so weak i.e., bone mass is so
compromised that the skeletal framework can no longer
withstand mechanical stresses of everyday living
•Patient presents commonly with complications :
- Compression fractures of vertebral bodies (D-L spine
most frequent)
- Fractures of ribs, hip, humerus & Colles’  with
minimal trauma

45. EARLY SYMPTOMS
1)Earliest symptom is acute PAIN
In the middle to low thoracic or high lumbar
regions  either at rest or during routine
daily activities (not stressful enough to cause
# in a patient with normal bone mass)
Onset  sudden; localised;
Increases with sitting / standing, coughing,
sneezing, straining
Relieved with recumbency

46. EARLY SYMPTOMS
2)Spine MOVEMENT— decreased severely
3)Incremental loss of height
4)Thoracic kyphosis
5)Appendicular fractures : Proximal femur / distal
radius

47. SIGNS
•In the early stages following an acute thoracic compression
fracture :
- Marked discomfort on sitting / standing
- Gait — slow but normal
- Spine movements greatly reduced : Flexion restricted
more than extension
- Dowager’s hump (thoracic kyphosis due to previous
anterior compression #s)
- Axial height diminishes
- Spasm & tenderness in para-vertebral muscles

50. A persistent low backache, or sudden localized pain,
could be a warning sign of compression fractures in the
vertebrae of the spine

51. OSTEOPOROTIC VERTEBRA

52. SIGNS
•Most patients are totally PAINFREE during intervals
between compression #s; some have chronic, dull-
aching, postural pain
•With each episode of segmental vertebral collapse &
progressive kyphosis  patient’s height reduces 2-4
cm; this stops when the lower ribs come to rest on
the iliac crest

54. LONG TERM (DISTURBING) SIDE-EFFECTS OF VERTEBRAL
COMPRESSION FRACTURES
•These occur because of DECREASE IN SIZE OF THORACIC &
ABDOMINAL CAVITIES
a) Decreased exercise tolerance
b) Feeling of fullness & bloating after ingestion of small
amounts of food
c) Abdominal protrusion, secondary to severe lumbar
vertebral collapse

55. RADIOLOGICAL FEATURES
Radiological evidence of decreased bone
mass is more reliable …
BUT…
about 30% of bone mass must be lost
BEFORE it becomes apparent on
X-rays

56. •Radiological Features :
- Loss of vertical height of a vertebra due to collapse
- Cod-fish appearance  disc bulges into adjacent
vertebral bodies so that disc becomes bi-convex
- Ground glass appearance of bones, seen in bones like
the pelvis
- Singh’s index  grading of OP into 6 grades on the
basis of trabecular pattern of femoral
neck
- Metacarpal index & vertebral index  other methods of
quantification of
OP

57. General osteoporosis  There is reduced radiographic density
(osteopenia), with reduction in the number of trabeculae, which may
be destroyed completely, and the bone cortex becomes thinned, as
evident in the lateral radiograph of the calcaneus

58. Common osteoporotic fractures
Colles’ fracture

59. Common osteoporotic fractures
Vertebral fractures

60. Common osteoporotic fractures
Fracture neck femur

61. PATTERNS OF TRABECULAR BONE
LOSS IN THE SPINE

62. Lateral radiograph of an osteoporotic spine, showing
compression fractures in the L1 and L3 vertebral bodies

63. •The earliest feature of
spinal osteoporosis is
prominent vertical striations
due to loss of secondary
horizontal trabeculae

64. •Vertebral fractures are the
most common osteoporotic
fractures
•Multiple vertebral fractures
in the lumbar spine of
varying types and grades
•Top vertebra : (moderate)
wedge fracture;
•Mid vertebra : (mild) upper
end plate fracture;
•Lower vertebra : (severe)
crush fracture

65. OTHER INVESTIGATIONS
1)Biochemistry :
- Serum Calcium, Phosphates & Alkaline phosphatase
are normal
- Total plasma proteins & albumin may be low
2)Densitometry : method to quantify OP
- Absorption of photons emitted from gamma emitting
isotopes by the bone calcium is measured
- Two types : Ultrasound based & X-ray based

66. DEXA
•The diagnosis of osteoporosis is made on measuring the
bone mineral density (BMD)
•The most popular method is  Dual Energy X-ray
Absorptiometry (DXA or DEXA)
•DEXA scan : is an X-ray based bone densitometry
•DEXA is considered the gold standard for the diagnosis of
osteoporosis
•Osteoporosis is diagnosed when the bone mineral density is
less than or equal to 2.5 standard deviations below that of a
young adult reference population. This is translated as a T-
score

67. BMD
•The World Health Organization has established the following
diagnostic guidelines :
•T-score : -1.0 or greater is "normal"
•T-score between -1.0 and -2.5 is "low bone mass" (or
"osteopenia")
•T-score -2.5 or below is osteoporosis
•When there has also been an osteoporotic fracture (also
termed "low trauma-fracture" or "fragility fracture"), defined
as one that occurs as a result of a fall from a standing height,
the term "severe or established" osteoporosis is used

70. Bone density tests are usually done on bones in the
spine (vertebrae), hip, forearm, wrist, fingers and heel

71. During a DEXA test, you lie on a padded platform while an
imager – a mechanical arm-like device - passes over your
body.

72. T- SCORE
•Your T-score is your bone density compared
with what is normally expected in a healthy
young adult of your sex
•Your T-score is the number of units - standard
deviations (SD) - that your bone density is
above or below the standard

73. Z- SCORE
•Your Z-score is the number of standard deviations above or
below what's normally expected for someone of your age,
sex, weight, and ethnic or racial origin
•This is helpful because it may suggest you have a secondary
form of osteoporosis through which something other than
aging is causing abnormal bone loss
•A Z-score less than -1.5 might indicate these other factors are
to blame

74. INDICATIONS FOR BONE
DENSITOMETRY
•Low trauma fracture (fall from standing height or less)
•Clinical features of osteoporosis (height loss, kyphosis)
•Osteopenia on plain X-ray
•Corticosteroid therapy (> 7.5 mg prednisolone daily for >
3 months)
•Family history of osteoporotic fracture
•Low body weight (body mass index < 19)
•Early menopause (< 45 years)
•Diseases associated with osteoporosis
•Assessing response of osteoporosis to treatment

75. OTHER INVESTIGATIONS
3) Neutron activation analysis :
Here, Ca in bone is activated by neutron bombing & its
activity is measured
4) Bone biopsy (trans-iliac) :
Site  2 cm posterior & 2 cm caudad to the ASIS

76. PREVENTION
IS
BETTER
THAN CURE ..

77. SKELETON
•A dynamic mineral reserve bank which stores
calcium & phosphorus in a metabolically STABLE and
structurally USEFUL way
•Osteoporosis results when the ASSETS of the bank
fall below the normal for :
- body size
- age
- sex
- race

78. •During the early years of life, formation is greater
than resorption and the bone mass increases
•Maximum or peak bone mass is reached around the
age of 30 in a healthy adult
•After that, resorption is faster than formation and
the bone mass decreases
•While gradual bone loss is normal to aging, it is those
who fail to achieve optimal peak bone mass and/or
those with accelerated bone loss who are at the
greatest risk of osteoporosis

79. •Under normal conditions (proper diet &
activity) NET DEPOSITS cannot be made to the
bone bank after the age of 35
•It is important to eat foods high in calcium
while you're young
•You only have until age 20 or 30 to build the
bone tissue and store the calcium you will
need in later years

80. •Around the age of 30, bone mass stops increasing. At
this point, peak bone mass is reached and the goal
becomes to maintain the level of bone mass
•The rate of bone loss in women increases (1% of
their bone mass per year) for several years after
menopause
•Thereafter, the depletion of bone slows down but
does not stop completely

81. Bone density levels can be compared with a
savings account :
accumulate as much bone mass as
possible early on to generate highest
levels of peak bone mass…assets
so… you will have more bone density to
"spend" as your bones regenerate more
slowly with age…liabilities
………………………………..SO……….

83. PREVENTION OF OSTEOPOROSIS
•FIRSTLY, the aim is to maximize peak bone mass up
to the age of about 30
•SECONDLY, the aim is to minimize the rate of bone
loss,
•Goals :
- Maintaining bone strength long-term
&
- Preventing fractures

84. DUS KADAM
OR
DUS KA DAM

85. TEN STEPS FOR PREVENTING
OSTEOPOROSIS
• Five steps to maximizing peak bone mass
during the bone forming years and
• Five steps to minimizing bone loss,
especially after menopause
• One step alone is not enough !!
• All steps need to be addressed together!

86. FIVE STEPS FOR MAXIMIZING YOUR PEAK BONE
MASS
•Most important for women who have not yet reached
their maximum peak bone mass (age ≤30 )
•Step 1 : Get your daily recommended
amounts of calcium and
vitamin D

How much calcium you need depends of your stage of life

87. RECOMMENDED CALCIUM INTAKES (mg/day)
AGE mg/day
Birth – 6 months 210
6 months – 1 year 270
1-3 500
4-8 800
9-13 1300
14-18 1300
19-30 1000
31-50 1000
51-70 1200
70 or older 1200

88. STEP 1
The best way to get enough
calcium is by eating at least
three servings of low-fat dairy
foods per day

90. FOOD & DRINKS WITH HIGH LEVELS OF CALCIUM
FOOD Calcium (in mgs)
Milk ( 8 oz ) 300
Yogurt ( 6 oz ) 250
Orange juice ( 8 oz ) 300
Tofu (soya milk) – ½ cup 450
Cheese ( 1 oz ) 195-335
Beans – ½ cup, cooked 60-80
Dark, leafy, green vegetables50-135
Almonds ( 24 whole) 70
Orange ( 1 medium ) 60
Gingelly seeds ( 100 g ) 1450
RAGI ( 100 g ) 344

91. STEP 1
•Vitamin D is said to be the `key' that unlocks the door to the
body to let calcium in
•Without vitamin D, the body cannot use calcium well even if it
gets enough of the mineral
•Experts recommend 800 International Units (IU) of vitamin D
to be consumed each day
•The best way to ensure adequate vitamin D levels is from
exposure of face, arms, hands, or back (without sunscreen)
to sunlight for 10 to 15 minutes at least twice per week

93. STEP 2
•Step 2 : Perform regular weight-bearing exercises
•Regular weight-bearing and muscle-strengthening exercises
are important in order to maximize your bone strength and
reduce bone loss
• Weight-bearing exercises, for example, jogging,
walking, dancing, and soccer force your bones and
muscles to work against gravity
•Swimming and bicycling are not weight-bearing

94. Studies show that exercises requiring muscles to pull
on bones (resistance exercise) cause the bones to
retain and possibly gain calcium (density)

95. STEP 3
Avoid smoking and excessive alcohol
intake
Smoking and moderate-to-excessive
alcohol consumption can cause
bones to become weaker

96. STEP 4
Talk to your healthcare
professional about
your risk factors

97. STEP 5
• When appropriate, have a bone mineral
density test and take medication
• Especially if any major risk factors are present :
- a family history,
- if you are underweight, or
- if you have had a fracture as an adult
BMD will assess the need for medication in these cases

98. FIVE STEPS TO MINIMIZING BONE LOSS ESPECIALLY
AFTER MENOPAUSE
•Women beyond the age of their peak bone mass
should follow the five steps below, especially if they
are postmenopausal
•Step 1 : Commit to a balanced diet and regular
exercise program
The three most important things that will help minimize bone
loss :
- An adequate intake of calcium in your diet
- Regular sunlight exposure, and
- A weight-bearing exercise program

99. •Step 2 : Stop smoking and reduce your
alcohol consumption
•Step 3 : Get a risk factor assessment
and screening test

100. STEP 4 : IF REQUIRED, TAKE MEDICATION FOR
OSTEOPOROSIS PREVENTION
Indications for medication in prevention of OP :
- Bone mineral density test T-scores below -2
with no other risk factors
- Bone mineral density T-scores below -1.5 (but
not below -2) with one or more major risk
factors
- A previous fracture of the hip or vertebral
bones

101. MEDICATION FOR PREVENTION OF OSTEOPOROSIS
•Bisphosphonates are probably the most commonly
prescribed medication for preventing osteoporosis in
those at high risk
•Bisphosphonates are available in daily, weekly, or
once-a-month tablets and once-a-year infusions
•Hormone therapy medications for prevention are
usually prescribed only when there are other
menopausal symptoms such as hot flashes, that need
managing OR the patient has troublesome side
effects from oral bisphoshonates

102. MEDICATION FOR PREVENTION OF
OSTEOPOROSIS
Bisphosphonates for osteoporosis prevention
•Alendronate - daily or once-a-week tablet
•Risedronate - daily or once-a-week tablet
•Ibandronate - once-a-month tablet
•Zolindronate - once-a-year infusion(5mg/15min)
•All bisphosphonates help reduce bone loss, increase
bone density, and reduce the future risk of
developing osteoporosis-related fractures

103. MEDICATION FOR PREVENTION OF
OSTEOPOROSIS
Selective Estrogen Receptor Modulator (SERM) :
Raloxifene
•Like bisphosphonates, these medications can help reduce
bone loss and reduce the risk of certain future osteoporosis-
based fractures
•These drugs are not estrogens but can mimic some of the
effects of estrogen on bone
•Currently, SERMs are not thought to have the same potential
adverse effects on breast and uterine tissue as estrogens have
•Side effects of SERMs include hot flashes and venous
thromboembolism

104. MEDICATION FOR PREVENTION OF OSTEOPOROSIS
Hormone Therapy for Prevention of Osteoporosis
•Women with a uterus must not take estrogen alone and
should take progestin either in a separate preparation or as
an estrogen/progestin combination preparation
•Oral estrogen
•Estrogen skin patches (transdermal estrogen)
•Oral progestin
•Combined oral estrogen/progestin
•Combined estrogen and progestin skin patches
•Currently, hormone therapy is prescribed mainly for the relief
of menopausal symptoms such as hot flashes, night sweats,
vaginal dryness, and urinary symptoms

105. STEP 5
AVOID CERTAIN MEDICATIONS
(as they have potential to accelerate bone loss)
- Corticosteroid medications
- Heparin
- Vitamin A
- Certain antiepileptic drugs (for example, phenytoin
[dilantin], carbamazepine, primidone, phenobarbital,
and valproate)

106. Summary of Osteoporosis Prevention
for All Women

107. TREATMENT (punishing the “thief”)
•Difficult because :
- Aetiology is multi-factorial
- Diagnosis is usually delayed
•No set pattern of treatment
•Principle objectives of treatment :
- Alleviation of PAIN
- Prevention of FRACTURES

108. TREATMENT
NON-MEDICATION BASED TREATMENT :
1)Good nutrition
In particular, calcium and vitamin D are needed for strong
bones

2) Regular exercise
- Exercise, particularly weight-bearing physical activity
is an important part of an osteoporosis treatment
program
- Exercise not only improves bone strength but it
increases muscle strength, coordination, and
balance, and leads to better overall health as well as
a reduced risk of frailty and falls (a major problem in
the elderly)

109. NON-MEDICATION BASED TREATMENT
- Benefits of exercise are quickly lost if you stop
exercising,therefore, choose an exercise regimen that
you really enjoy to ensure long-term continuity of your
program
- Try different exercises to find out what you enjoy most
- On the other hand, excessive exercise should be
avoided because it can lead to weight loss and
amenorrhea (loss of menstrual periods), which may in
turn increase bone loss

110. NON-MEDICATION BASED TREATMENT
3) Sunlight exposure
- Getting at least 15 minutes of sunlight
exposure twice a week to your face,
arms, or legs is one of the best ways to
get vitamin D
4) Stop smoking
- Smoking cigarettes accelerates bone loss,
therefore, quitting is beneficial for keeping your
bones as strong as possible

111. NON-MEDICATION BASED TREATMENT
5) Preventing falls
•By maximizing certain physical attributes including balance,
flexibility, and strength
•Recurrent falls are particularly common in the elderly, a
population at high risk of osteoporosis and fractures
•Sometimes an undiagnosed medical condition, such as
cardiovascular or neurological disease, can be the underlying
cause, and if treated, may stop accidentally falling over

112. MEDICATION BASED TREATMENT

113. TREATMENT OBJECTIVES
Osteoclast
Inhibition of resorption
Osteoblast
Stimulation of formation

114. DRUG TREATMENT OF OSTEOPOROSIS
Inhibitors of bone
resorption
•Bisphosphonates
–Alendronate
–Risedronate
–Ibandronate
–Zolendronate
•Calcitonin
•Estrogen ± progestin
•SERMs
–Raloxifene
Stimulators of bone
formation
•(Fluoride)
•Parathyroid hormone
Mixed mechanism of
action
•Vitamin D active
metabolites
•Strontium
Calcium and vitamin D  Recommended for all women
at risk for osteoporosis

115. MEDICATION BASED TREATMENT
1)Bisphosphonates :
Oral bisphosphonates
•Alendronate : daily or weekly tablet (10mg a day
or 70mg once a week)
•Risedronate : daily or weekly tablet (5mg a day
or 35mg once a week)
•Ibandronate : once monthly tablet

116. MEDICATION BASED TREATMENT
2) Selective estrogen receptor modulator (SERM)
•Raloxifene tablet
•This medication is prescribed less commonly than
bisphosphonates
•It is approved for osteoporosis only in women, it is
not currently approved for use in men
•Side effects of raloxifene include hot flashes and
thromboembolism

117. MEDICATION BASED TREATMENT
3) Salmon calcitonin
•Salmon calcitonin (intranasal or injectable) is an alternative to
HRT or bisphosphonates
•Salmon calcitonin can help maintain and increase bone
mineral density
•Calcitonin nasal spray reduces the incidence of vertebral
fractures by 25-35% at a daily dose of 200 IU
•Significantly improves bone pain in vertebral fractures

118. MEDICATION BASED TREATMENT
4) Teriparatide
•Teriparatide is a form of human parathyroid hormone
•It is used mostly for patients with established osteoporosis
(who have already fractured), have particularly low BMD or
several risk factors for fracture or cannot tolerate the oral
bisphosphonates
•Teriparatide is only available as a daily injection given just
under the skin with the use of a pen-type injection device,
and, as with insulin, the patient can learn to inject himself

119. Parathyroid hormoneParathyroid hormone (PTHPTH)
PTH binds to cell surface G protein-coupled receptor
Decreased apoptosis
of osteoblasts
Stimulates differentiation
of bone lining cells and
preosteoblasts to osteoblast
Net increase in number & action of bone forming osteoblasts
20 ug teriparatide s/c daily for 2 yrs

120. Effect of Teriparatide onEffect of Teriparatide on
Skeletal ArchitectureSkeletal Architecture
Patient treated with teriparatide 20µg
Baseline Follow-up

121. Vitamin D derivatives
Calcitriol, the active metabolite of Vitamin D,
has some stimulatory effects on the
osteoblasts, the bone forming cells
Calcitriol reduces the risk of vertebral fractures
in postmenopausal osteoporosis

122. VITAMIN K 2
•Recently, Vitamin K2 (menaquinone) has been shown
to exert a powerful influence on bone-building,
especially in osteoporosis, and has been cited as one
of the most frequently prescribed treatments for OP
in Japan
•It is associated with increased bone formation and
decreased bone resorption
•Recommended in daily dose of 45-90 mcg/day

123. CONCLUSION
•Given the magnitude of the problem, it is
important that the government recognises
osteoporosis as a priority disease
•In the West, there is a growing awareness of
bone diseases. Australia, for instance, has put
osteoporosis on its list of national priority
diseases

124. The number of patients of osteoporosis in
India nearly equals….
double the entire population of Australia!!!
India needs to wake up and recognise it as a
priority disease

125. START EARLY!!