Hinduja hospital conducts regular webinars and tweetinars for online users where they can seek advice from expert doctors of hinduja hospital for free. Above is the webinar conducted by hinduja hospital on Osteoporosis where issues like osteoporosis symptoms, osteoporosis prevention, osteoporosis treatment were discussed successfully by Spine Consultant, Dr. Uday Pawar. To know more about such upcoming webinars and tweetinars from hinduja hospital, visit http://www.hindujahospital.com/communityportal/

1. Osteoporosis
Dr. Uday Pawar
Junior Spine Consultant
DNB Orthopaedic
Hinduja Hospital, Mahim, Mumbai
http://www.hindujahospital.com/dr-uday-pawar/

2. With age comes wisdom………..
and Osteoporosis

3. What is osteoporosis ?
Normal Osteoprosis

4. Jargon buster………
• Softening of bones …….
• A reduction in the quantity and quality of
bones

5. What is osteoporosis
• A condition rather than a disease
• Silent until complications arise
• Spine, hip & wrist fractures

6. WHO criteria for diagnosis of
Osteoporosis
Kanis et al. J Bone Miner Res 1994; 9:1137-41
T-score
Normal - 1.0 and above
Osteopaenia - 1.0 to - 2.5
Osteoporosis - 2.5 and below
Severe (established)
osteoporosis
- 2.5 and below, plus one
or more osteoporotic
fracture(s)

8. Food for thought…..

9. 1. Osteoporosis ≠ Calcium deficiency
• So, calcium is NOT the treatment of
osteoporosis
• Bone mineral v/s bone mass

10. 2. Osteoporosis is a generalized disease
• affects all the bones

11. 3. Treating osteoporosis
• Prevention is the only treatment of
osteoporosis
• Hence early diagnosis is the most important
step in treating osteoporosis !

12. Size of the Problem in India
• 26 million (2003) 36 million by 2013
• 1 out of 8 males and 1 out of 3 females suffers from osteoporosis
• The high incidence among men and the lower age of peak incidence
compared to Western countries
• Peak incidence of osteoporosis
– Western countries-70-80 years of age
– India –50-60 years
International Osteoporosis Foundation

13. The Magnitude Of The Problem
In women > 50 years, the lifetime risk of:
• Vertebral fracture is 1/3
• Hip fracture is 1/5
NICE guidance 160 October 2008

14. Osteoporotic Fractures in Women:
Comparison with Other Diseases
1 500 000*
0
500
1000
1500
2000
Osteoporotic
Fractures
*
annual incidence all ages
†
annual estimate women 29+
‡
annual estimate women 30+
§
1996 new cases, all ages
513 000†
228 000‡
184 300§
750 000
vertebral
250 000
other sites
250 000
forearm
250 000
hip
Heart
Attack
Stroke Breast
Cancer
Annualincidencex1000
Riggs BL, Melton LJ. Bone 1995
Heart and Stroke Facts, 1996, American Heart Association
Cancer Facts & Figures, 1996, American Cancer Society

15. Osteoporosis affects entire skeleton
• Osteoporosis is responsible for >1.5 million vertebral and
non-vertebral fractures per year
• Spine, hip, and wrist fractures are most common

16. Morbidity associated with Fractures

17. Osteoporosis: Classification
• Primary Osteoporosis
Type 1- Post menopausal osteoporosis
Type 2- Senile/Age related osteoporosis
• Secondary Osteoporosis
Secondary to various causes
17

18. Consequences
Reduced quality of life

19. How is osteoporosis diagnosed
Diagnosis is made on the basis of-
• Detailed medical history
• Examination
• Blood and other tests

20. Early diagnosis of Osteoporosis
• Clinical parameters
– ‘at risk’ subject
– Bone pains
– Generalized tiredness
– Progressive kyphosis
• Investigations
– Radiographs
– DEXA
– QCT, MRI, Bone scan
– Blood markers

21. Clinical Risk Fractures (CRF)
Predictors of low bone mass-
• Female
• Advanced age
• Low bone mineral density
• Gonadal hormone deficiency ( estrogen or testosterone )
• White race
• Low body weight & BMI
• Family history of osteoporosis
• Low calcium intake
• Smoking / excessive alcohol intake
• Low level of physical activity
• Chronic glucocorticoid use
• Prior fragility fracture
National Osteoporosis Foundation (NOF)

22. Clinical Presentation
• Severe backache after minor injury
• Pain worse on sneezing, coughing , standing
erect, changing positions.
• Limited to wheelchair
• Stooped Posture
• Weakness in legs

23. X-rays
• Osteopenia
• Loss of height of vertebral
body
• Wedging

24. Osteoporosis – RadiographicOsteoporosis – Radiographic
Differential DiagnosisDifferential Diagnosis
• Osteomalacia
• Hyperparathyroidism
• Hypercortisolism
• Hyperthyroidism
• Renal insufficiency
• Chronic immobilization

25. • Osteogenesis imperfecta
• Hepatic insufficiency
• Diabetes mellitus
• Multiple myeloma
• Metastatic disease
• Drug induced
Osteoporosis other causesOsteoporosis other causes

26. Assessment of bone mineral density by DXA
Current gold standard for diagnosis of osteoporosis
BMD (g/cm2
) = Bone mineral content (g) / area (cm2
)
Diagnosis based on comparing patient’s
BMD to that of young, healthy individuals
of same sex

29. • Blood count , CRP
• Calcium, Phosphate, Alkaline
Phosphatase (AP)
• Kidney function studies
• Basal Thyroid and parathyroid.
• Protein-immunoelectrophoresis.
• Vit D (25 and 1.25)
Laboratory tests*
NOTES:
- * These are in addition
to routine labs tests.
- These are screening
labs, more may be
indicated based on these
results

30. Preventing Osteoporosis
alciumalciumCC
DDVitaminVitamin
xercisexerciseEE
FFPreventPrevent allsalls
ain weightain weightGG
StopStop mokingmokingSS

31. Modifiable Risk Factors
Vit D
Calcium
Exercise
Quit Alcohol Quit Smoking

32. Non-modifiable Risk Factors
• Older age
• Female gender
• Ethnic background
• Small bone structure
• Family history of osteoporosis or osteoporosis-related fracture in a parent
or siblings
• Previous fracture
• Menopause/hysterectomy
• Some medicines like steroids, anti-epileptics
• Rheumatoid arthritis
• Reduced levels of Gonadal hormones in men

33. Treatments of osteoporosis
• Calcium and vitamin D
• HRT
• SERMs (raloxifene)
• Calcitonin
• Bisphosphonates
– ibandronateibandronate
– etidronateetidronate
– alendronatealendronate
– risedronaterisedronate
• PTH (1–34)
• Fluoride
• Strontium ranelate
• Combination
Hormonal agentsHormonal agents
Anti-resorptiveAnti-resorptive
agentsagents
Anabolic agentsAnabolic agents
Dual mechanism ofDual mechanism of
actionaction
SERMs = selective oestrogen receptor modulatorsSERMs = selective oestrogen receptor modulators
PTH = parathyroid hormonePTH = parathyroid hormone

34. How much and which Calcium??
• 1000-1500mg “elemental calcium”
Type of calcium Elemental Calcium
Calcium carbonate 40%
Calcium gluconate 9%
Calcium lactate 13%
Calcium citrate 20-30%
Calcium acetate 30%
Micro cryst HA complex 100%
◦ May be difficult to attain those levels.
◦ To try a combination of diet and medicines
◦ Can’t give more than 500mg elemental calcium as tabs at a single dose

35. Bisphoshonates
• Etidronate, Alendronate, Risendronate,
Ibandronate, Zolendronate
– Anti resorptive agents
– Reduce osteoclasis

36. Bisphoshonates
• Induce apoptosis (self destruction) in the osteoclasts
• Thus it reduces bone resorption

37. Bisphoshonates
• On this ‘preserved’ lattice – mineralization takes
place
• Thus ‘better mineralized’ bone is formed and
DEXA improves

38. Teriparatide (PTH)
• In small / pulse doses, is a powerful stimulant for
bone formation
• The only drug that can induce osteogenesis

39. Teriparatide
• Teriparatide stimulates formation of new bone
matrix / framework

40. Teriparatide
• On this denser, better structured matrix,
mineralization takes place giving rise to an
overall stronger bone

41. BoneStrength
(Mass+Quality)
Time
Effect of Anabolic vs Anti-resorptives
on Bone Strength
Anabolic
‘Laying down new bone’
Anti-resorptive
‘reducing bone resorption’

42. Treatment with PTH
(woman 69 years)
Dempster DW et al, J Bone Miner Res, 2001;16:1846-1853
Before CtTh: 0.32 mm
CD: 2.9 mm3
After CtTh: 0.42 mm
CD: 4.6 mm3
1 5 10
1520
25 30
Ser Val Ser Glu Ile Gln Leu Met His Asn
Leu
Gly
LysHisLeuAsnSerMetGluArgValGlu
Trp
Leu
Arg Lys Lys Leu Gln Asp Val His Asn Phe

43. Take home points…
• No longer a problem of the WEST
• Awareness essential amongst general public
• Prevention is the best treatment
• Moms and grandmoms vulnerable group

44. OPD Schedule: Tue- 1500 to 1600 hours, Thu- 0900 to 1100
hours, Sat- 1100 to 1300 hours
Appointment Helpline: 022-39818181/67668181/24451515
For any Queries, please write us on: info@hindujahospital.com
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