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Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
Osteoporosis new horizons
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Osteoporosis new horizons

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  • Incidence od osteoporotic fractures is more than all combined incidence of breast cancer, stroke and heart attack.it is more then 5.5 times incidence of breast cancer, 4.4 times incidence of stroke and more than twice the incidence fo heart attack , even then we are neither aware of osteoporosis and nor are taking any measures fot timely diagnosis.
  • United States National institute of Health consensus conference modifies this definition as follows: “
  • (Title and text box Appears) The risk factors for osteoporosis are well known. They include being (1 st left -hand bullet Appears) female, (2 nd left -hand bullet Appears) over 50, (3 rd left -hand bullet Appears) having low estrogen, (4 th left -hand bullet Appears) being thin with a body mass index of less than 19 kg/m2, (5 th left -hand bullet Appears) having low bone mass, (6 th left -hand bullet Appears) having a history of fragility fractures in yourself or a family member, (1 st right -hand bullet Appears) having poor nutrition with deficient calcium and vitamin D intake, (2 nd right -hand bullet Appears) smoking, (3 rd right -hand bullet Appears) excessive use of alcohol, (4 th right -hand bullet Appears) having an inactive lifestyle, or (5 th right -hand bullet Appears) having taken steroids or anti-convulsant drugs.1,3
  • Socio economic Over $17 billion annually in direct medical costs Over 430,000 hospital admissions annually Approximately 2.5 million medical visits each year Over 180,000 annual admissions to nursing homes Potential for lost income due to incapacitation, morbidity, and mortality risks
  • With the same BMD at different ages risk of fracture is different e.g -1.5 score at age 50 carries a risk of 5.9 but at age 70 this 10 year probability risk increases to 14.6
  • Transcript

    • 1. OSTEOPOROSIS DIAGNOSIS NEW PARADIGMS Dr.maninder ahuja Ahuja nursing home&infertility centre 526, sector 17 faridabad Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 2. DR.MANINDER AHUJA CHAIRPERSON GERIATRIC GYNE.COMMITTE FOGSI TO DIAGNOSE OSTEOPOROSIS WE HAVE ALWAYS TO KEEP IT IN MIND WHEN TREATING AGING WOMEN ! Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 3. What is changing? <ul><li>The life span of a woman has increased from 23 years in the Roman era to 65 years in India and 80 years in developed countries </li></ul><ul><li>Age of menopause is 46&52 </li></ul><ul><li>1/3rd of a woman’s life is spent after Menopause and no of women in menopause is increasing. </li></ul><ul><li>Source: US Dept of Health and Human Services; 1999;47(28). </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10 Year 1850 1900 1950 2000 0 20 40 80 60 Age (Year)
    • 4. NUMBER OF AGING WOMEN IS INCREASING Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10 1990 2030 World wise population 470million 1.2 billion Developing countries 40% 24% Developed countries 60% 76%
    • 5. New Age Approach--Quality Of Life <ul><li>Early diagnosis and assessment of problems </li></ul><ul><li>Prevention of problems main stay is life style modifications </li></ul><ul><li>New treatment modalities </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 6. Magnitude of problem in India <ul><li>1 out of 3 females in India suffers from osteoporosis, largest affected. </li></ul><ul><li>26 million with the numbers projected to increase to 36 million by 2013.(Osteoporosis Society of India (2003) </li></ul><ul><li>By 2050 1 out of 2 hip fractures would occur in Asia </li></ul><ul><li>A woman’s risk of developing an osteoporosis-related hip fracture is equal to her combined risk of developing breast  uterine and ovarian cancer. </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 7. Osteoporotic Fracture 1,200,000 Heart Attack 513,000 Strokes 228,000 Breast Cancer 1,84,000 1 million > 2.0 x > 4.4 x > 5.5 x OSTEOPOROSIS IN WOMEN : CONCERN Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 8. Osteoporosis – the silent disease Under diagnosed and most common 35 yrs onwards you lose bone mass at 0.5 to 1% per yr(initial quality Imp) Around menopause loss is upto 4-5 % per year You also lose muscle mass from 35 years onwards vitamin D receptor, estrogen receptor, transforming growth factor, interleukin-6, interleukin-1 receptor 2, type I collagen genes, and collagenases are for genetic causes Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 9. Sarcopenia and osteoporosis go hand in hand Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI Beginning in the fourth decade of life, adults lose 3 % to 5% of muscle mass per decade,rate of decline increases to 1% to 2% per year after age 50 years( RED ALERT FAT) N sarcopenia 05/01/10
    • 10. Osteoporosis defined <ul><li>“ A systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue with a resultant increase in fragility and risk of fracture.” </li></ul><ul><li>New definiton: </li></ul><ul><li>A skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. </li></ul><ul><li>Bone strength reflects the integration of three main features: </li></ul><ul><li>Bone density, </li></ul><ul><li>Bone structure </li></ul><ul><li>Bnd bone quality </li></ul><ul><li>Euler’theorem </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI    05/01/10
    • 11. DIAGNOSED BY BMD MEASUREMENTS <ul><ul><li>By DXA SCAN </li></ul></ul><ul><li>BMD is compared to two norms - healthy young adults ( T-score) </li></ul><ul><li>age-matched ( Z-score) </li></ul><ul><li>WHO CLASSIFICATION: </li></ul><ul><li>Normal A T-score within 1 SD (+1 or -1) of the young adult </li></ul><ul><li>Osteopenia A T-score of 1 to 2.5 SD below the young adult mean (-1 to - 2.5 SD) </li></ul><ul><li>Osteoporosis A T-score of 2.5 SD or more below the young adult mean (> - 2.5 SD) </li></ul><ul><li>It takes about 10 years for change of 1 SD </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI For each standard deviation decrease in femoral neck BMD,there is an approximate 2.5-fold increased risk of hip fracture. 05/01/10
    • 12. ADVANTAGES DEXA <ul><ul><li>High Accuracy (Error < 1%) </li></ul></ul><ul><ul><li>Diagnose both osteopenia & osteoporosis </li></ul></ul><ul><ul><li>Predicts risk of fractures </li></ul></ul><ul><ul><li>Evaluates response to therapy </li></ul></ul><ul><ul><li>Low Radiation </li></ul></ul><ul><ul><li>Can assess both central as well as peripheral osteoporosis </li></ul></ul>05/01/10 Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI
    • 13. LUMBAR SPINE <ul><li>AP Lumbar Spine most widely used for evaluation </li></ul><ul><li>BMD value in spine: extent of osteoporosis </li></ul><ul><li>BMD value in hip: </li></ul><ul><li>predicts fracture </li></ul>05/01/10 Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI
    • 14. Other methods of Diagnosis Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 15. Micro and high-resolution MRI <ul><li>Strengths </li></ul><ul><li>Limitations </li></ul><ul><li>A noninvasive approach </li></ul><ul><li>No ionizing radiation </li></ul><ul><li>3-dimensional assessment of cortical and trabecular structure </li></ul><ul><li>Can use clinically available MRI available </li></ul><ul><li>Treatment related effects can be assessed </li></ul><ul><li>Limited to appendicular skeleton </li></ul><ul><li>Reference data limited </li></ul><ul><li>technically demanding </li></ul>05/01/10 Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI
    • 16. Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 300,000 hip fractures 20% die within 6months approximately 10% have a second fracture within a year of the incident hip fracture 60% of those who survive hip fracture do not regain the same level of independence 200,000 broken wrists Limited movement Quality of life impaired <ul><li>Most of time undiagnosed 500,000 spinal fractures,compression or wedge fractures, </li></ul><ul><li>Losing height .>2cms </li></ul><ul><li>Back pain </li></ul><ul><li>Kyphosis,inc.mortality &morbidity </li></ul><ul><li>In extreme cases chest compression </li></ul><ul><li>Abdominal space reduced and problems of eating and digestion </li></ul>COMMON SITES OF FRACTURES 05/01/10
    • 17. Dental health and osteoporosis <ul><li>A correlation between lower BMD and/or postmenopausal osteoporosis and parameters of periodontal disease, such as alveolar crestal bone height, tooth loss and, to a lesser degree, gum recession . </li></ul><ul><li>Hormone replacement therapy has been associated with reduced tooth loss in several observational studies. </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 18. In Diabetics <ul><li>&quot;In type 2 diabetes mellitus patients, impaired bone quality may </li></ul><ul><li>result from the deterioration of microarchitecture rather than a </li></ul><ul><li>decrease in bone mass, </li></ul><ul><li>In Diabetics BMD by QUS is lower and by DXA higher </li></ul><ul><li>Still fracture rate is higher </li></ul><ul><li>Guang Ning and colleagues from Shanghai Jiao-tong University School of Medicine, China </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 19. Risk factors <ul><li>Female </li></ul><ul><li>Over 50 years old </li></ul><ul><li>Low estrogen </li></ul><ul><li>Body mass index<19kg/m 2 </li></ul><ul><li>bone mass low </li></ul><ul><li>History of fragility fractures in self or family </li></ul><ul><li>Poor nutrition (with deficient calcium and vitamin D intake) </li></ul><ul><li>Smoking,active and passive </li></ul><ul><li>Excessive alcohol use>3 drinks /day </li></ul><ul><li>sedentary lifestyle </li></ul><ul><li>Rheumatoid arthritis </li></ul>Sources: Chan, KM, Anderson M, Lau EM. Exercise interventions: defusing the world’s osteoporosis time bomb. Bulletin of the World Health Organization 2003;81:827-830. National Osteoporosis Foundation: Fast Facts. Available at: www.nof.org/osteoporosis/disease facts.htm . . Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 20. Medications causing ostoeoporosis <ul><li>Glucocorticoids>5mg /day predenisolone for > 3months </li></ul><ul><li>Long acting progestins/inj depoprovera </li></ul><ul><li>Aromatase inhibitors </li></ul><ul><li>GnRh agonists </li></ul><ul><li>Anticonvulsants </li></ul><ul><li>Cytotoxic drugs </li></ul><ul><li>Long term anticoagulation </li></ul><ul><li>Lithium </li></ul><ul><li>Proton pump inhibitors </li></ul><ul><li>SSRIs </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 21. Heridity or genetics Is very Imp. <ul><li>Up to 80% of the variability in peak bone density might be attributable to genetic factors. </li></ul><ul><li>Female children of women who have osteoporotic fractures have lower BMD </li></ul><ul><li>First-degree relatives (ie, mother, sister) of women with osteoporosis also tend to have lower BMD than those with no family history. </li></ul><ul><li>In one large study of postmenopausal women from five ethnic groups (white Americans, African Americans, Asian Americans, Hispanic Americans, and Native Americans),African Americans had the highest BMD, while Asian Americans had the lowest. </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 22. Effects of osteoporotic fractures <ul><li>Psychological trauma </li></ul><ul><li>Physical disabilities </li></ul><ul><li>Morbidity </li></ul><ul><li>Huge costs of treatment </li></ul><ul><li>So to diagnose and prevent we have to keep it in mind. </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 23. Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI <ul><li>90% - 95% of patients go home without a bone density test </li></ul><ul><li>Fragility Fracture Patients Are Rarely Evaluated for Osteoporosis </li></ul><ul><li>Counselling should be done whenever you get an opportunity </li></ul><ul><li>Aim is to assess by risk factors so that first fracture is prevented </li></ul><ul><li>After first fracture treat her so that you can prevent a second fracture!! </li></ul>FACTS 05/01/10
    • 24. NOF 2008 Recommendations for BMD Testing <ul><li>All women ≥ 65 years and all men ≥ 70 years, </li></ul><ul><li>Postmenopausal women < 65 and men aged 50 to 70 with a concerning clinical profile </li></ul><ul><li>Perimenopausal women with a particular risk factor </li></ul><ul><li>Anyone under consideration for osteoporosis medication </li></ul><ul><li>Any adult taking high-risk medication or who has a high-risk condition for bone loss </li></ul><ul><li>Any adult >50 years who sustains a fracture </li></ul><ul><li>Postmenopausal women who are coming off estrogen </li></ul><ul><li>Anyone in whom knowledge of low BMD would lead to pharmacotherapy </li></ul><ul><li>To monitor effectiveness for those on treatment </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 25. 10-year Probability of Fracture in Women by Age and FN T-Score- ”age and BMD are independent predictors”   Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 26. A new paradigm -FRAX <ul><li>10-year risk for hip and other major fractures. The model, called &quot;FRAX,&quot; incorporates BMD, age, sex, body-mass index, and seven other risk factors, family H/O fragility fracture, rheumatoid arthritis, alcohol intake ,smoking, glucocorticoids, secondary osteoprosis </li></ul><ul><li>Model does allow the identification of those in the low BMD range (T-score –1 to –2.5) who have the highest risk of fracture and would benefit for treatment,but they should not be on treatment for osteoporosis </li></ul><ul><li>This model can be seen at following web site. </li></ul><ul><li>http://www.shef.ac.uk/FRAX . </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 27. Prior fracture <ul><li>A prior fracture has been associated with an 84% increased risk of a future fracture. For example, a prior wrist fracture has led to a 50% greater risk of a future hip fracture. </li></ul><ul><li>Roux C. Joint Bone Spine. 2009;76:1-3. </li></ul><ul><li>FRAX ® WHO Fracture Risk Assessment Tool. Available at: http://www.shef.ac.uk/FRAX. Accessed June 2, 2009 </li></ul>05/01/10 Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI
    • 28. Risk should be >3%for hip#&>20% for all major # Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 29. Bone turnover markers (For determining response to treatment) <ul><li>Bone formation(serum) </li></ul><ul><li>Osteocalcin(OC) </li></ul><ul><li>Bone specific alk.phosphotase(BAP) </li></ul><ul><li>Amino-terminal type 1 collagen(PINP) </li></ul><ul><li>Carboxy terminal type1 collagen(PICP) </li></ul><ul><li>increase when response to anabolic agents </li></ul><ul><li>Bone resorption(urine) </li></ul><ul><li>Pyridinoline(pvr) </li></ul><ul><li>Deoxypyridinoline(Dvd) </li></ul><ul><li>Aminoterminaltelopeptide(NTx) </li></ul><ul><li>Carboxyterminal telopeptide(CTx) </li></ul><ul><li>decrease when response to antiresorptive agents, </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 30. OTHER BIOCHAEMICAL TESTS <ul><li>For Secondary osteoporosis </li></ul><ul><li>fasting serum calcium, </li></ul><ul><li>24-hour urinary calcium, </li></ul><ul><li>serum 25-OH-D (vitamin D). </li></ul><ul><li>Anti-tTG (tissue TransGlutaminase) antibodies. An anti-tTG test is the most sensitive lab test for celiac disease </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Complete blood count; </li></ul><ul><li>Measurement of phosphorous, </li></ul><ul><li>alkaline phosphatase, </li></ul><ul><li>Thyroid-stimulating hormone, </li></ul><ul><li>Hepatic enzyme levels </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 31. Role of Vit D <ul><li>Serum 25 D should be 80 nmol/L or higher </li></ul><ul><li>Low levels of vitamin D are highly prevalent </li></ul><ul><li>Vitamin D plays a key role in normalizing PTH levels </li></ul><ul><li>Vitamin D deficiency is associated with increased risk of falls and fractures, </li></ul><ul><li>vitamin D intakes much higher than are currently recommended are quite safe. </li></ul><ul><li>Raising serum 25(OH)D from 50 to ~80 nmol/L improves Ca absorption, raises BMD, and reduces both fall and fracture risk </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 32. Vit D Def & Risk Of Falls Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 33. Genetic Tests in near future <ul><li>Two variants — one in a protein governing bone formation ( LRP5 ), and another in a receptor involved in bone resorption ( TNFRSF11B ) — were linked to increased risk for osteoporosis or a history of clinical low-impact fractures. </li></ul><ul><li>“ Can be measured with near-perfect precision ... years before the age at which fractures tend to occur — which could provide ample lead-time for preventive measures.&quot; </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 34. Conclusion <ul><li>Dexa scan is Gold standard for diagnosis </li></ul><ul><li>Fracture risk is now calculated by FRAX MODEL </li></ul><ul><li>Age and BMD are independent risk factors </li></ul><ul><li>Biochemical markers have place in determining response to treatment. </li></ul><ul><li>We should always assess by risk factors </li></ul><ul><li>Aim is to avoid first fracture </li></ul><ul><li>After first fracture treat and prevent second fracture. </li></ul><ul><li>Role of calcium 1200-1500 mg/day and Vit 800 IU is undisputed </li></ul>Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 35. Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10
    • 36. Acknowledgements <ul><li>Dr.Sonal Bathla </li></ul><ul><li>Dr.shekhar Agarwal </li></ul>05/01/10 Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI
    • 37. Dr.ManinderAhuja chairperson geriatric gynecology committe FOGSI 05/01/10 CHAIRPERSON GERIATRIC GYNAECOLOGY COMMITTEE (FOGSI ) [email_address]

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