Dra. Juarez osteoporosis y osteopenia

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  • In its simplest form, osteoporosis can be defined as a metabolic disorder of the bones causing them to become weaker and more susceptible to fracture.
  • Hip fractures are the most serious complication of osteoporosis, requiring hospitalization for nine out of 10 sufferers. Costly and painful, they result in permanent disability in more than 30 percent of patients and more than 50 percent are unable to return to independent living. Sadly, up to 20 percent of hip fracture patients die within one year of fracture.
  • Did you know, that the incidence of osteoporotic fracture in women is far greater than that of heart attack, stroke and breast cancer combined? In light of the staggering statistics, it is important for physicians and patients to understand that osteoporosis should be managed as aggressively as other diseases.
  • Osteoporosis is characterized by low bone mass, the deterioration of bone tissue leading to fragility and a heightened risk of fracture. Bones usually stop growing in your late teens, but they continue to increase in density until about age 35. Increasing your bone mass before age 35 can help to prevent osteoporosis as you age. Once you have started to lose bone tissue, the condition cannot be reversed, only slowed down.  
  • Once weekly dosing with alendronate can be considered as a potential alternative treatment regimen based on the biology of bone remodeling and the knowledge that alendronate remains at the bone surface, where it is active, for up to several weeks after dosing. Bone remodeling occurs in discrete remodeling units or sites. At any point in time, most bone surface is inactive, and lining cells cover the surface during the resting stage. The first step in remodeling is activation of resorption; the lining cells retreat, and osteoclasts then resorb the exposed mineralized tissue. Resorption proceeds for approximately 2 weeks at each remodeling site. For this reason, an antiresorptive agent, administered up to every 2 weeks, but not less frequently, would be anticipated to affect all active remodeling sites. Once the resorption phase is completed, osteoblasts migrate to the resorption pit and refill it with new osteoid matrix, which becomes well mineralized within 1-2 weeks of deposition; a subsequent further increase in the density of mineralization occurs over the following 4-6 months. Initiation of new remodeling sites occurs continuously and asynchronously throughout the skeleton. Thus, there are remodeling sites at various stages of bone resorption and formation at any point in time.
  • Osteoporosis is characterized by low bone mass, the deterioration of bone tissue leading to fragility and a heightened risk of fracture. Bones usually stop growing in your late teens, but they continue to increase in density until about age 35. Increasing your bone mass before age 35 can help to prevent osteoporosis as you age. Once you have started to lose bone tissue, the condition cannot be reversed, only slowed down.  
  • For those diagnosed with osteoporosis, the AACE medical guidelines recommend a comprehensive follow-up examination that included a patient history and physical examination. The physical exam will include: an assessment of risk factors for fractures, laboratory tests such as, blood and urine samples, and an assessment of the patient’s reliability, understanding, and willingness to accept available interventions. Adding an endocrinologist to your osteoporosis management team is also strongly suggested.
  • For those diagnosed with osteoporosis, the AACE medical guidelines recommend a comprehensive follow-up examination that included a patient history and physical examination. The physical exam will include: an assessment of risk factors for fractures, laboratory tests such as, blood and urine samples, and an assessment of the patient’s reliability, understanding, and willingness to accept available interventions. Adding an endocrinologist to your osteoporosis management team is also strongly suggested.
  • Low bone density is a major, consistent characteristic of osteoporosis. There is a strong inverse relationship between a person’s bone density and their future risk of fracture. Your bone density is the best indicator of your fracture risk. However, it is important to realize that patients may fracture at different bone density levels. Measuring your bone density provides your medical team with the information needed to make a clinical decision about next steps in your osteoporosis management and care.
  • For those diagnosed with osteoporosis, the AACE medical guidelines recommend a comprehensive follow-up examination that included a patient history and physical examination. The physical exam will include: an assessment of risk factors for fractures, laboratory tests such as, blood and urine samples, and an assessment of the patient’s reliability, understanding, and willingness to accept available interventions. Adding an endocrinologist to your osteoporosis management team is also strongly suggested.
  • Although there currently is no cure for osteoporosis, there are several preventive measures and treatments available. The goals for treatment are to prevent fractures,maximize physical function, and halt progressive deformity. The ability to achieve these goals depends on the commitment to therapy of both the patient and his or her medical team, and the potential for the chosen therapeutic program to produce positive results. Often, a patient’s therapy includes a combination of treatments.
  • The progression of osteoporosis can be delayed through a number of preventive measures. Effective prevention strategies are important for all people, particularly children and adolescents who are still in the “bone-building” years. A balanced diet high in calcium (1,000 to 1,500 mg/day) and vitamin D (400 to 800 IU/day) helps retain healthy bone mass. Weight-bearing exercises, such as walking, dancing and biking, enhance bone development and may slow bone loss linked to the lack of activity in the elderly. Maintaining a healthy lifestyle, and avoiding smoking and excessive alcohol consumption may also offer modest preventive benefits. It is also important to add bone density testing to your regular check up once you turn 45 or feel you might be at risk.
  • Lack of calcium is known to lead to the development of osteoporosis, but calcium also plays an important role in the proper function of the heart, muscles and nerves and also in the clotting of blood. Nutritional surveys indicate that young girls and women consume less than half of the recommended amount of calcium need to grow and maintain healthy bones. Your recommended daily calcium intake ranges from 1,000 mg to 1,500 mg. In addition to dairy products, certain vegetables (broccoli, turnip greens), canned fish (sardines), tofu, corn bread, eggs and calcium fortified foods are good sources of calcium.
  • Los efectos sobre el esqueleto del complemento de calcio no son claros por completo. 1 Los resultados de estudios aleatorizados, prospectivos no son concluyentes; sin embargo, la mayoría de los datos indica que el complemento de calcio no previene la pérdida ósea en mujeres posmenopáusicas en los primeros años. Este estudio doble ciego, controlado con placebo, aleatorizado, evaluó el efecto de 2 formas de calcio sobre la pérdida ósea en la columna vertebral y cuello en mujeres que habían sido posmenopáusicas durante 5 años o menos. 2 Después de 2 años, todos los grupos experimentaron reducciones significativas en la DMO. Además, comparado con placebo, no hubo diferencias significativas en la pérdida ósea en ninguno de los grupos de calcio. Así, en la mayoría de las mujeres posmenopáusicas en los primeros años pudiera ser necesario el tratamiento contra la resorción para prevenir la pérdida ósea. 1 American Association of Clinical Endocrinologists. American Association of Clinical Endocrinologists 2001 medical guidelines for clinical practice for the prevention and management of postmenopausal osteoporosis. Endocr Pract . 2001;7:293-312. 2 Dawson-Hughes B, Dallal GE, Krall EA, Sadowski L, Sahyoun N, Tannenbaum S. A controlled trial of the effect of calcium supplementation on bone density in postmenopausal women. N Engl J Med . 1990;323:878-883.
  • Vitamin D, which aids in the absorption of calcium, is not widely found in natural food sources. It is primarily found in fish oils, some vegetables, and fortified milks, cereals, and breads. You can also receive vitamin D through your skin following direct exposure to sunlight. 10-15 minutes of sun exposure two to three times a week is usually enough to satisfy your body’s vitamin D requirement. As you age, your ability to absorb vitamin D through your skin decreases and you might need to take a multi-vitamin to increase your vitamin D consumption. Too much vitamin D can be harmful, so consult your doctor before you start taking any supplements.
  • Although there currently is no cure for osteoporosis, there are several preventive measures and treatments available. The goals for treatment are to prevent fractures,maximize physical function, and halt progressive deformity. The ability to achieve these goals depends on the commitment to therapy of both the patient and his or her medical team, and the potential for the chosen therapeutic program to produce positive results. Often, a patient’s therapy includes a combination of treatments.
  • Alendronate and Risedronate, medications from the bisphosphonates class of drugs, are effective alternatives to estrogen replacement therapy for treating postmenopausal osteoporosis in women who cannot or will not take estrogen. They have been approved for use in steroid-induced osteoporosis that occurs in men and women. Calcitonin is a hormone made by the thyroid gland which prevents the cells that break down bone from working properly, improving the action of bone building cells. Calcitonin is particularly effective immediately following fractures because of its pain suppressing effect. Estrogen replacement therapy is the most common treatment for osteoporosis. In the United States, oral and transdermal forms of estrogen are approved for the prevention of bone loss in newly menopausal women. Estrogen therapy may be continued for a lifetime. Direct evidence suggests that bone loss recurs after estrogen treatment is discontinued. SERMs or selective estrogen receptor modulators are a new generation of synthetic hormones, which have estrogen-like effects in some parts of the body but not others. They prevent bone loss in the spine, hip and total body.
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • For most osteoporosis sufferers, an endocrinologist is a valuable member of the treatment team. We are physicians who specialize in your body’s glands and hormones, with a specific concentration on metabolic bone disease. By training, endocrinologists are the experts in osteoporosis management, as we also have a thorough understanding of the underlying causes of the disease. If you have been diagnosed with osteoporosis, you may wish to consult with an endocrinologist. Endocrinologists also are an important resource for primary physicians treating bone disease.  
  • To effectively manage osteoporosis, physicians must first identify the underlying cause of the disease. Without this critical information, effective therapy is unlikely. Specifically, AACE recommends that you should see an endocrinologist when: your osteoporosis is unexpectedly severe or has unusual features; you have very low bone density; you are young (premenopausal if female) yet have osteoporosis; you fracture easily despite borderline or normal bone mass density results; [continued on next slide]
  • Dra. Juarez osteoporosis y osteopenia

    1. 1. Osteoporosis y Osteopenia. Controversias en el tratamiento Dra. Xiomara Emely Juarez M. Dra. Xiomara Emely Juarez M.Medicina Interna y EndocrinologiaMedicina Interna y Endocrinologia
    2. 2. Osteoporosis es … Una alteración metabólica de los huesos que causa que ellos se hagan débiles y suceptibles a fracturas.
    3. 3. Fracturas de cadera: Una malacaídaMueren por 20complicacionessIncapacidad permanente 30Incapacidad para llevar 50una vida independienteRequiere hospitalización 90 0 20 40 60 80 100 AACE Medical Guidelines for Clinical Practice for the Prevention and Management of Postmenopausal osteoporosis
    4. 4. La fracturas osteoporoticas son más comunes en mujeres que los infartos, accidentes vasculares cerebrales, y cáncer de mama combinados 1-3 2,000,000Incidencia annual de enfermedades comunes 1,500,000 1,500,000 * 300,000 cadera 1,000,000 250,000 antebrazo 250,000 otros sitios 513,000 500,000 ** 228,000 184,300 700,000 vertebrales † ‡ 0 Fracturas Infarto AVC Cancer de mama Osteoporóticas* annual incidence allages 1. Riggs, B.L., and Melton, L.J. III, Bone 17(5)(Suppl.):505S-511S, 1995** annual estimate 2. Heart and Stroke Facts: 1996 Statistical Supplement, American Heartwomen 29+ Association† annual estimate 3. Cancer Facts & Figures—1996, American Cancer Societywomen 30+
    5. 5. Resistencia del huesoResistencia ósea = DMO + Calidad ósea • Arquitectura • Masa ósea pico • Recambio óseo • Cantidad de masa ósea • Daño acumulado • Mineralización
    6. 6. El Proceso de Remodelación Osea Estado de descanso Remodelación Iniciación terminada Resorción Osteoclasto (~proceso de 2 semanas) OsteoblastosFormación Fase de reversión Bone HG, et al. Clin Ther. 2000;22:15-28.
    7. 7. Osteoporosis se caracteriza por ♦ Masa ósea baja ♦ Deterioro y fragilidad del tejido óseo ♦ Riesgo aumentado de fractura por fragilidad ósea
    8. 8. Factores de riesgo♦ Sexo femenino.♦ Raza blanca.♦ Edad avanzada.♦ Historia personal de una fractura.♦ Historia familiar de osteoporosis / fractura en un familiar de primer grado.♦ Hábito corpóreo pequeño / bajo peso (<127 lbs).♦ Estilo de vida sedentaria / pobre actividad física.♦ Uso de tabaco.♦ Ingesta alcohólica excesiva (> 2 bebidas al día)
    9. 9. ♦ Insuficiente ingesta de calcio o vitamina D.♦ Excesiva ingesta de cafeína.♦ Menopausia temprana (<45 años) – Falla ovárica prematura. – Menopausia médica o quirúrgica.
    10. 10. ♦ Los estudios sobre Densidad Osea muestran que hay pérdida del hueso en la mandíbula al aumentar la edad. Esto ocurre con mayor frecuencia en las mujeres que en los hombres, y la pérdida de dientes puede ser un signo de osteoporosis.
    11. 11. PÉRDIDA ÓSEA DESPUÉS DE LAMENOPAUSIA Adaptado de Wasnich RD et al. Osteoporosis: Critique and Practicum, Honolulu, Banyan Press, 1989, pp. 179-213.
    12. 12. Resistencia a insulina/DM DislipidemiaInflamación Hipertensión vascular
    13. 13. Causas de osteoporosis secundaria♦ Trastornos endocrinos ♦ Trastornos metabólicos /♦ Trastornos genéticos / de la nutricionales colágena ♦ Enfermedades pulmonares♦ Trastornos GI / hepáticos ♦ Trastornos renales♦ Trastornos hematológicos ♦ Trastornos reumatológicos♦ Enfermedades infecciosas ♦ Medicamentos
    14. 14. Trastornos endocrinos♦ Acromegalia♦ Amenorrea primaria o secundaria de cualquier causa♦ Sd de Cushing / hipercortisolismo♦ Diabetes Mellitus tipo 1♦ Hiperparatiroidismo♦ Hiperprolactinemia♦ Hipertiroidismo♦ Hipogonadismo (primaria o secundaria)♦ Porfiria
    15. 15. Trastornos genéticos / de la colágena ♦ Ehlers-Danlos ♦ Enfermedades de depósito de glucógeno ♦ Homocistinuria ♦ Hipofosfatasia. ♦ Osteogénesis imperfecta.
    16. 16. Trastornos GI / hepáticos ♦ Esprue celiaco ♦ Enfermedad hepática colestásica crónica ♦ Condiciones de malabsorción crónica ♦ Cirrosis ♦ Bypass gástrico / gastrectomía ♦ Hemocromatosis ♦ Enfermedad intestinal inflamatoria
    17. 17. Trastornos hematológicos ♦ Amiloidosis ♦ Leucemia / linfoma ♦ Mastocitosis ♦ Mieloma múltiple
    18. 18. Enfermedades infecciosas ♦ HIV / SIDA
    19. 19. Trastornos metabólicos / nutricionales ♦ Alcoholismo ♦ Heperhomocistinemia ♦ Hipocalcemia ♦ Deficiencia de vitamina D
    20. 20. Trastornos pulmonares ♦ EPOC
    21. 21. Trastornos renales ♦ IRC. ♦ Acidosis tubular renal.
    22. 22. Trastornos reumatológicos ♦ Espondilitis anquilosante ♦ Artritis reumatoidea
    23. 23. Medicamentos♦ Aluminio♦ Ciclosporina♦ Dilantin♦ Glucocorticoides♦ Agonistas de gonadotropina (ej. Lupron)♦ Heparina (uso prolongado)♦ Metotrexate♦ Fenobarbital♦ Fenotiazinas♦ Inhibidores de proteasa♦ Tiroxina (reemplazo excesivo)
    24. 24. Problemas frecuentemente encontrados en el tratamiento de la osteoporosis1. Sub-diagnóstico2. No hay políticas claras para la Prevención3. Preparar al médico para ofrecer tratamiento adecuado4. Falta de seguimiento a largo plazo
    25. 25. A quiénes evaluar?♦ Todas las mujeres mayores de 65 años♦ Todas las mujeres adultas con historia de fractura no causada por trauma severo♦ Mujeres posmenopáusicas más jovenes que tengan factores de riesgo – Bajo peso (menos de 57.6 kilos) – Historia familiar de fractura de cadera o columna
    26. 26. Cuando se sospecha la osteoporosis serecomienda ♦ Evaluación clínica completa ♦ Determinar la densidad mineral ósea ♦ Evaluar la confiabilidad y entendimiento del paciente y su deseo de aceptar los tratamiento disponibles
    27. 27. Exámen físicoApariencia generalEstaturaDeformidadesPruebas de laboratorioHemogramaQuímica sanguínea (proteínas, enzimashepáticas, fosfatasa alcalina, creatinina,electrolitos)Urinalisis, incluyendo pH y calciuriaEvaluación adicionalTSH, PTH, 1-25 hidroxivitamina D,cortisol, marcadores de resorción ósea
    28. 28. National Osteoporosis Foundation♦ Mujeres arriba de 65 años, independientemente de los factores de riesgo.♦ Mujeres postmenopáusicas más jóvenes, con uno o más factores de riesgo además del sexo, raza y estado postmenopáusico.
    29. 29. U.S. Preventive Services Task Force ♦ Todas las mujeres >65 años, independientemente de los factores de riesgo. ♦ Mujeres entre los 60-65 años de edad, con riesgo incrementado de fracturas, basado primariamente en peso bajo (<70kg) o falta de terapia de reemplazo hormonal.
    30. 30. American College of Obstetricians and Gynecologists♦ Todas las mujeres >65 años, independientemente de los factores de riesgo.♦ Mujeres postmenopáusicas <65 años con factores de riesgo adicionales.
    31. 31. ♦ La densidad ósea baja es la principal característica de la osteoporosis♦ La medida de la densidad ósea ayuda en: – Diagnóstico de la osteoporosis – Determina su severidad – Determina el riesgo de fractura – Monitorea la respuesta al tratamiento
    32. 32. “Las máquinas no mienten, pero no existe máquina alguna capaz de decirnos toda la verdad.”G K Chesterton (1874-1936)
    33. 33. ♦ RX convencional NO detecta osteoporosis a tiempo♦ Se sospecha al perderse 30 a 40% de la DMO
    34. 34. Rayos-xRadiogrametría Fotodensitometría Absorciometría Tomografía Morfometría Metacarpal Radiológica de Fotón Cuantitativa Radiológica SPA DPA pQCT Radiogrametía AbsorbimetríaDigital de Rayos-X Radiológica SXA LVA/ IVA DXA pDXA OSTEOGRAM SPA: Fotón simple DPA: Fotón Dual SXA: Rayos x- Simple DXA: Rayos-x Dual
    35. 35. Evaluación de la densidad mineral ósea . ♦ DEXA central y periférica. ♦ TAC cuantitativa. ♦ USG periférica.
    36. 36. Pruebas periféricas de Tamizaje♦ Son pruebas para detectar población en riesgo♦ Se requiere entrenamiento especializado♦ Falsos positivos y falsos negativos♦ NO hay criterios diagnósticos establecidos♦ Decisión de pasos a seguir dependen del médico especialista♦ NO se utilizan para seguimiento de la osteoporosis
    37. 37. DXA• Técnica más utilizada.• Separa hueso y otros tejidos• Puede medir en sitios relevantes de fractura (cuerpo entero,cadera, antebrazo, columna lumbar)• Rapidez, (20 a 30 minutos).• Precisión alta (< 1 % error)• Exactitud alta (< 3% error).• Dosis baja radiación (1 a 5 uSv)• Buena correlación con Riesgo de Fracturas.
    38. 38. Indicaciones para elDiagnóstico y el Tratamiento ¿Qué lugar y qué criterios? ?
    39. 39. Criterios diagnósticos de osteoporosisDiagnóstico Criterio de DMONormal DMO dentro de 1 DS del promedio de adultos jovenesOsteopenia DMO -1 DS y - 2.5 DS por debajo del promedio adulto jovenOsteoporosis DMO - 2.5 DS por debajo del promedio adultoDMO = densidad mineral ósea; DS = desviasión estandardreferencia
    40. 40. Clasificación OMS para DXACentral
    41. 41. . Hueso normal Osteopenia OsteoporosisDempster DW, et al. A simple method for correlative light and scanning electron microscopy ofhuman iliac crest bone iopsies: Qualitative observations in normal and osteoporotic subjects. JBone Miner Res 1986;1(1):15-21.
    42. 42. Evaluación de laboratorio♦ Evaluar causas secundarias de osteoporosis.♦ La Fundación Nacional para la Osteoporosis: – TSH – PTH – Niveles de vitamina D – Electroforesis de proteínas séricas – Calcio y cortisol en orina de 24 horas.
    43. 43. Otros tests a considerar: ♦ Función renal. ♦ Función hepática. ♦ Evaluación de testosterona, LH y FSH.
    44. 44. Marcadores séricos y urinarios derecambio óseo ♦ Marcadores de formación ósea: – Fosfatasa alcalina. – Osteocalcina. ♦ Marcadores de resorción ósea: – Hidroxiprolina urinaria. – Telopéptidos colágeno termial N y C.
    45. 45. ♦ 20-50% del hueso se debe haber perdido para hacerse evidentes cambios en las radiografías.♦ Rayos X de columna lumbosacra puede considerarse.
    46. 46. Prevención de la osteoporosis Optimizar el desarrollo esquelético y maximizar el pico de masa ósea Prevenir las causas secundarias de pérdida ósea y las relacionadas con la edad Preservar la integridad estructural del esqueléto Prevenir fracturas
    47. 47. Tx farmacológico♦ Todos los adultos con fracturas osteoporóticas de cadera o columna.♦ Adultos con score T <= -2.0 SD que no tienen factores de riesgo específicos para osteoporosis.♦ Adultos con score T <= -1.5 SD que tienen factores de riesgo para osteoporosis.
    48. 48. Mantener huesos fuertes – Previene la osteoporosis♦ Buena nutrición♦ Una dieta adecuada en calcio (2 to 3 vasos de leche al día)♦ Ingesta adecuada de vitamina D♦ Ejercicio regular (caminata/bicicleta)♦ Evitar uso de tabaco o ingesta excesiva de licor
    49. 49. Alimentos ricos en calcio* 1 taza de leche descremada 302 mg 1 taza de yogurt desgrasado 306 mg 1 onza de queso Cheddar 183 mg 1/2 taza de yogurt congelado 154 mg 2 onzas de sardines con hueso 217 mg 1 taza de broccoli 42 mg 1 taza de garbanzos 80 mg* Alimentación en Osteroporosis
    50. 50. El Calcio Solo no Previene la Pérdida Ósea Posmenopáusica Temprana Columna Vertebral Cuello femoral Citrato de Carbonato Citrato de Carbonato Placebo calcio de calcio Placebo calcio de calcio (n = 14) (n = 25) (n = 28) (n = 11) (n = 24) (n = 23)Cambio en DMO Después de 2 Años (%) 0 0 -1 -1 -2 -2 -3 -3 -4 * -4 * * Complemento de calcio = 500 mg/día. *P < .01 contra la basal. Dawson-Hughes B, y col. N Engl J Med. 1990;323:878-83.
    51. 51. Vitamina D ♦ Recomendaciones diarias 400-800 IU por día ♦ Fuentes De la dieta Del sol
    52. 52. METAS DEL TRATAMIENTO DE LAOSTEOPOROSIS  Prevenir fracturas futuras  Maximizar la función física  Detener las deformidades
    53. 53. Expectativas de un Medicamento para elTratamiento de la Osteoporosis♦ Consistencia en objetivos de eficacia♦ Aumento de la DMO en todos los sitios♦ Reducción consistente de fractura – Fracturas vertebrales (morfométricas y clínicas) – Fracturas no-vertebrales – Fracturas de cadera♦ Resultados reproducibles y consistentes en – Subgrupos – Múltiples estudios – Diferentes poblaciones♦ Eficacia y seguridad establecida a largo plazo
    54. 54. Medicamentos: Qué es lo que hay?♦ Bisfosfonatos Todos estos agentes : – Alendronato • Suprimen la resorción ósea – Risedronato • Mejoran la DMO♦ Calcitonina • Reducen riesgo de fracturas♦ Estrógenos La tibolona no se incluyó pues♦ Raloxifeno no ha sido aprobada para el tratamiento de la osteoporosis por la FDA
    55. 55. Recomendaciones de ACCE♦ Primera prioridad – Agentes aprobados por FDA para la prevención de la osteoporosis♦ Segunda prioridad * – Agentes que no son aprobados por la FDA pero que tienen niveles de evidencia 1 o 2 de eficacia y seguridad * Se usarían en caso de que los primeros no puedan ser empleados por alguna razón
    56. 56. Agentes aprobados por FDA para la prevención de la osteoporosis Nivel 1 Nivel 2 Existe evidencia de eficacia en Existe evidencia de eficacia antifractura de nivel 2 para: reducción de fracturas vertebrales Bisfosfonatos Calcitonina Raloxifeno EstrógenosSolo los bisfosfonatos demostraron reducción de fracturas de cadera yde otros sitios
    57. 57. Bisfosfonatos♦ Alendronato – Es un bisfosfonato que contiene un grupo nitrógeno♦ Indicaciones – Prevención de osteoporosis – Tratamiento de osteoporosis pos menopáusica – Tratamiento de osteoporosis inducida por glucocorticoides♦ Presentaciones – Tabletas de 10 y 70 mg♦ Dosis – Tableta 10 mg una vez al día; tableta 70 mg una vez por semana, debe tomarse con un vaso grande de agua pura con el estómago vacío, 1/2 hora antes del desayuno; el paciente no debe acostarse después de tomar el medicamento
    58. 58. ♦ Eficacia : En estudios clínicos controlados, doble ciego, comparado contra placebo: – Previene la pérdida del hueso y aumenta la DMO en columna y cadera entre el 5 a 10 %, previene la pérdida de hueso en el antebrazo (Nivel 2 de evidencia) – Reduce el riesgo de fracturas vertebrales y no vertebrales hasta en un 40 a 50 % (Nivel 1 de evidencia) – Los efectos sobre la DMO en columna y cadera se mantienen por lo menos después de dos años de haber sido descontinuado en mujeres de edad avanzada – Ha demostrado se efectivo para el tratamiento de osteoporosis inducida por glucocorticoides
    59. 59. Remodelamiento Oseo
    60. 60. Terapia de reemplazo estrogénico
    61. 61. Efectos Sistémicos de los estrógenos
    62. 62. Moduladores selectivos de los receptores estrogénicos♦ Activan los receptores estrogénicos en órgano blanco y producen efectos estrogénicos variables en los tejidos que responden a esas hormonos.♦ Aprobados por FDA para el tratamiento de la osteoporosis posmenopáusica y la prevención de la pérdida de hueso en mujeres menopáusicas de reciente diagnóstico.♦ Disponible como tabletas de 60 mg.♦ Dosis 60 mg diarios
    63. 63. ♦ Eficacia: – Estudios de 36 meses de duración con raloxifeno (60 y 120 mg diarios) redujo las fracturas vertebrales en un 30 a 50 % (Nivel 1 de evidencia) – No reduce fracturas no vertebrales y aumenta la DMO en la columna en un 2.7 % y en la cadera en un 2.4% comparado contra placebo.♦ Efectos no esqueléticos – Reduce el colesterol total y el Col LDL, el efecto cardiovascular de raloxifeno no se conoce. – En el estudio MORE se observó una reducción del 76% en el cáncer de mama y una disminución del 90% de los cánceres de mama sensibles a estrógenos
    64. 64. ♦ Efectos secundarios – Riesgo tres veces mayor de tromboembolismo venoso – Calores en la cara – Calambres en las piernas – Edema periférico – Acumulación de líquido endometrial♦ Contraindicaciones – Embarazo – Tromboflebitis o enfermedad tromboembólica o antecedentes de tromboembolismo – Hipersensibilidad♦ Duración del tratamiento – La eficacia y seguridad se ha determinado hasta por 40 meses
    65. 65. Otras terapiasHormona paratiroideaFitoestrógenosCalcitonina
    66. 66. PUNTOS CLAVE♦ Las consecuencias clínicas de la osteoporosis están principalmente relacionadas con las fracturas por fragilidad, que se presentan más frecuentemente en columna, cadera y muñeca.♦ La parte clave de evaluación en pacientes que se sospecha osteoporosis es evaluar su densidad ósea por DEXA (dual energy x-ray absorptiometry).
    67. 67. ♦ Osteoporosis y osteopenia se definen como scores T > 2.5 y 1-2.5 SDs por debajo de la media de referencia para el joven adulto.♦ Todos los pacientes con fracturas osteoporóticas, un score T <-2.0, o un score T < -1.5 con factores de riesgo adicionales deberían tratarse para osteoporosis.♦ Es vital asegurar que todos los pacientes con osteoporosis tengan una adecuada ingesta de calcio y vitamina D, lo cual usualmente requiere suplemento.
    68. 68. ♦ Bifosfonatos (alendronato, risedronato) son generalmente los agentes de primera línea en el tratamiento de la osteoporosis, ya que son la única opción terapéutica que ha probado reducir el desarrollo de fracturas de cadera y vertebrales.♦ Terapia de reemplazo con estrógenos y terapia de reemplazo hormonal pueden prevenir el desarrollo de fracturas osteoporóticas, pero este beneficio debe valorarse contra el riesgo incrementado de muchos resultados adversos.
    69. 69. Prevención y tratamiento de la osteoporosis Mejor calidad de vida Menos fracturas Menos gastos en servicios médicos

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