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Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
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Osteoporosis

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  • 1. Osteoporosis
  • 2. Osteoporosis - Hx <ul><li>Symptoms: pain (bone, toe), proximal muscle weakness (these can happen in osteomalacia, characterised by defective bone mineralisation in adults – due to Vit D deficiency, must exclude malabsorption). </li></ul><ul><li>Fractures: wrist, hip, humerus and ribs, and vertebral compression fractures (esp. T12) – with minimal stress (risk increases from age 55). </li></ul><ul><li>Risk factors: menstrual history, age of onset of menopause, symptoms of thyroid excess or thyroid hormone replacement (thyroxine), symptoms or a history of anaemia (coeliac disease). </li></ul><ul><li>Previous investigation: X-ray </li></ul><ul><li>Drug history: alcohol, heparin, steroids, thyroxine-overreplacement, anticonvulsants (by affecting Vit D metabolism), and cyclosporin. </li></ul><ul><li>Life style: a low-fat diet (limits calcium intake), inadequate sun exposure (NH resident), renal disease, phenytoin use (all risk factors for osteomalacia), exercise (preserves bone mass), smoking (decreases bone mass). </li></ul><ul><li>Complications: falls, fractures (PE/nosocomial infection) </li></ul><ul><li>Social impact: immobility, pain, fear of falling. </li></ul>
  • 3. Osteoporosis – physical examination <ul><li>Bone tenderness and proximal muscle weakness (osteomalacia), thoracic kyphosis, bowing of the legs (rickets) </li></ul><ul><li>Thyroid disease/Cushing’s syndrome </li></ul><ul><li>Weight and general nutritional status </li></ul>
  • 4. Osteoporosis - investigations <ul><li>Blood tests: calcium, AP results </li></ul><ul><ul><li>FBE, ESR (?myeloproliferative disease) </li></ul></ul><ul><ul><li>EUC, LFTs (exclude renal, hepatic disease) </li></ul></ul><ul><ul><li>TSH (rule out thyrotoxicosis) </li></ul></ul><ul><ul><li>Men: testosterone level </li></ul></ul><ul><ul><li>if severe osteoporosis ( serum EPG to rule out multiple myeloma ) </li></ul></ul><ul><ul><li>Osteoporosis – normal calcium, normal AP </li></ul></ul><ul><ul><li>Osteomalacia – increased AP, also check 25-OH vitamin D levels (if risk of osteomalacia) </li></ul></ul><ul><ul><li>Vitamin D deficiency – low 25-OH vitamin D levels </li></ul></ul><ul><ul><ul><li>Vitamin D malabsorption </li></ul></ul></ul><ul><ul><ul><li>Chronic liver disease </li></ul></ul></ul><ul><ul><ul><li>Lack of sun exposure (NH resident) </li></ul></ul></ul><ul><ul><li>DDx for elevated AP: </li></ul></ul><ul><ul><ul><li>Osteomalacia </li></ul></ul></ul><ul><ul><ul><li>Paget’s disease </li></ul></ul></ul><ul><ul><ul><li>Metastatic malignancy to bone </li></ul></ul></ul>
  • 5. Osteoporosis - investigations <ul><li>Skeletal x-rays: </li></ul><ul><ul><li>Spine: loss of trabecular bone in the vertebral body, accentuatoin of the vertebral endplates, more prominent vertebral trabeculae with the loss of horizontal trabeculae. Collapse, anterior wedging and the codfish deformity. </li></ul></ul><ul><ul><li>Osteomalacia – </li></ul></ul><ul><ul><ul><li>decrease in bone density, coarsening of trabecular and blurring of the margins. </li></ul></ul></ul><ul><ul><ul><li>Looser’s zones (pseudo fractures) in the long bone shafts, ribbon-like zones of rarefaction </li></ul></ul></ul><ul><ul><ul><li>Triangular pelvis and biconcave collapsed vertebrae. </li></ul></ul></ul><ul><ul><ul><li>If there is secondary hyperparathyroidism present with osteomalacia, then bone cysts, erosion of the distal ends of the clavicles and subperiosteal resorption in the phalanges may be seen. </li></ul></ul></ul>
  • 6. Osteoporosis - investigations <ul><li>Bone densitometry – dual-energy X-ray absorptiometry (DEXA) – T score </li></ul><ul><ul><li>Lumbar spine </li></ul></ul><ul><ul><li>Proximal femur </li></ul></ul><ul><ul><ul><li>Osteopenia – 1-2.5 SD below peak bone mass </li></ul></ul></ul><ul><ul><ul><li>Osteoporosis - &lt;2.5 SD below peak bone mass </li></ul></ul></ul><ul><ul><li>What is T score – the number of standard deviations by which the measured bone density falls below the average for a young normal person of the same sex. </li></ul></ul>
  • 7. Osteoporosis - investigations <ul><li>In difficult cases: an iliac crest bone biopsy with double tetracycline labelling can help distinguish osteoporosis from osteomalacia. </li></ul><ul><li>If secondary causes are suspected – search for the cause </li></ul>
  • 8. Osteoporosis - treatment <ul><li>Goal – prevention, correct secondary causes, prevent complications </li></ul><ul><ul><li>Life style – stop smoking, avoid excess alcohol consumption, fall prevention (consider hip protector), prescribe regular weight-bearing exercise. </li></ul></ul><ul><ul><li>Calcium – absorption decreases with age, age &gt;65 (have 1200-1500 mg of calcium daily is advisable) </li></ul></ul><ul><ul><li>Vitamin D supplementation – </li></ul></ul><ul><ul><ul><li>Moderate to severe vitamin D deficiency (serum 25-OH D &lt; 25 nmol/L) </li></ul></ul></ul><ul><ul><ul><ul><li>High dose Vit D of 3000-5000 IU/day for 6-12 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Then 1000 IU/day from then on </li></ul></ul></ul></ul><ul><ul><ul><li>Elderly women in NH who have inadequate intake should receive supplementation of Vit D 800IU/day and calcium 1200 mg/day (reduce non-vertebral fracture risk). </li></ul></ul></ul>
  • 9. Osteoporosis - treatment <ul><li>Bisphosphonates (risedronate and alendronate): </li></ul><ul><ul><li>Benefits: </li></ul></ul><ul><ul><ul><li>Increase bone mineral density in postmenopausal women with osteoporosis and </li></ul></ul></ul><ul><ul><ul><li>Reduce the risk of fracture for postmenopausal women with osteoporosis by 50%. </li></ul></ul></ul><ul><ul><li>If cannot tolerate oral agents: </li></ul></ul><ul><ul><ul><li>Infusion once every 3 months or </li></ul></ul></ul><ul><ul><ul><li>Once a year (zolendronic acid) </li></ul></ul></ul><ul><ul><ul><li>S/E: </li></ul></ul></ul><ul><ul><ul><ul><li>Oesophageal ulceration (presents with odynophagia, 1-2 months after starting the treatment) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Osteonecrosis of the jaw – more likely with IV formulations with dental infections. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Indications: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>&gt;70 y.o. with a T score of &lt; -3 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>A fracture after minimal trauma </li></ul></ul></ul></ul></ul>
  • 10. Osteoporosis – treatment (PBS criteria for long-term steroid treatment ) <ul><li>Treatment as the sole PBS-subsidised anti-resorptive agent for corticosteroid-induced osteoporosis in a patient currently on long-term ( at least 3 months ), high-dose (at least 7.5 mg per day prednisolone or equivalent) corticosteroid therapy with a Bone Mineral Density (BMD) T-score of -1.5 or less. The duration and dose of corticosteroid therapy together with the date, site (femoral neck or lumbar spine) and score of the qualifying BMD measurement must be documented in the patient&apos;s medical records when treatment is initiated. </li></ul>
  • 11. Osteoporosis – treatment (PBS criteria for osteoporosis without fracture) <ul><li>Treatment as the sole PBS-subsidised anti-resorptive agent for osteoporosis in a patient aged 70 years of age or older with a Bone Mineral Density (BMD) T-score of -3.0 or less. The date, site (femoral neck or lumbar spine) and score of the qualifying BMD measurement must be documented in the patient&apos;s medical records when treatment is initiated. </li></ul>
  • 12. Osteoporosis – treatment (PBS criteria - osteoporosis in patients with fracture due to minimal trauma ) <ul><li>The fracture must have been demonstrated radiologically and the year of plain x-ray or CT-scan or MRI scan must be documented in the patient&apos;s medical records when treatment is initiated. A vertebral fracture is defined as a 20% or greater reduction in height of the anterior or mid portion of a vertebral body relative to the posterior height of that body, or, a 20% or greater reduction in any of these heights compared to the vertebral body above or below the affected vertebral body. </li></ul><ul><li>Anti-resorptive agents in established osteoporosis include alendronate sodium, risedronate sodium, denosumab, disodium etidronate, raloxifene hydrochloride, strontium ranelate and zoledronic acid. </li></ul>
  • 13. Osteoporosis – treatment (alternative) <ul><li>Strontium ranelate – for people who cannot tolerate bisphosphonate. </li></ul><ul><li>Effective in vertebral and rib fractures but the effect is not established in hip fracture yet. </li></ul><ul><li>It should be taken at bed time at least 2 hours after eating. </li></ul>
  • 14. Osteoporosis – treatment <ul><li>Oestrogen – HRT </li></ul><ul><ul><li>Prevent loss of cortical and trabecular bone in postmenopausal women. </li></ul></ul><ul><ul><li>Most effect if started earlier in menopause as bone loss is most rapid then. </li></ul></ul><ul><ul><li>S/E of Oestrogen </li></ul></ul><ul><ul><ul><li>Increases the risk of endometrial cancer, so combination with progesterone is important unless pt had hysterectomy </li></ul></ul></ul><ul><ul><ul><li>Increases breast cancer </li></ul></ul></ul><ul><ul><ul><li>Increases DVT/PE risks </li></ul></ul></ul><ul><ul><ul><li>Increases CVS risks (hence the use in post-menopausal women has declined) </li></ul></ul></ul>
  • 15. Osteoporosis – treatment <ul><li>Selective oestrogen receptor modulators: </li></ul><ul><ul><li>Raloxifene (closely related to tamoxifen) </li></ul></ul><ul><ul><ul><li>Reduces the risk of spine fractures </li></ul></ul></ul><ul><ul><ul><li>Increases the risk of DVT </li></ul></ul></ul><ul><ul><ul><li>Lowers the risk of breast cancer </li></ul></ul></ul><ul><ul><ul><li>Not associated with an increase in endometrial cancer. </li></ul></ul></ul><ul><ul><li>Tamoxifen (a mixed oestrogen receptor antagonist and agonist that prevents bone loss) </li></ul></ul><ul><ul><ul><li>Increases the risk of endometrial cancer </li></ul></ul></ul>
  • 16. Osteoporosis – treatment <ul><li>Parathyroid hormone peptide – very effective for osteoporosis but very expensive. </li></ul><ul><li>Calcitonin (s/c or intranasal): </li></ul><ul><ul><li>Inconsistent results </li></ul></ul><ul><ul><li>Any effect is smaller than with other therapies </li></ul></ul><ul><ul><li>S/E: nausea, flushing, and inflammation. </li></ul></ul>
  • 17. Osteoporosis – treatment <ul><li>Men with osteoporosis: </li></ul><ul><ul><li>Check testosterone level: if low then androgen replacement (unless history of prostatic carcinoma) </li></ul></ul><ul><ul><li>If secondary hypogonadism, human chorionic gonadotrophine or pulsatile gonadotrophin-releasing hormone may be worthwhile. </li></ul></ul><ul><ul><li>Bisphosphonates and teriparatide (PTH) are efficacious in men </li></ul></ul><ul><ul><li>The role of raloxifene is not clear. </li></ul></ul>
  • 18. Osteoporosis – treatment <ul><li>Steroid-induced osteoporosis: </li></ul><ul><ul><li>Measures to prevent bone loss are important from the time steroids are begun, particularly in postmenopausal women or when high doses are needed. </li></ul></ul><ul><ul><li>Co-administration of bisphosphonates is of value here. </li></ul></ul><ul><ul><li>Calcium and 25-OH vitamin D in combination have also been shown to be effective. </li></ul></ul><ul><ul><li>These drugs have been shown to reduce fracture risk for patients on steroids. </li></ul></ul>
  • 19. Osteoporosis – treatment (surgical) <ul><li>Assessment of anaesthetic risk </li></ul><ul><li>Pain management </li></ul><ul><li>Prevent prolonged bed rest if possible. </li></ul><ul><li>Injection of bone cement into the vertebral body (vertebroplasty) is a new treatment that may relieve pain and possibly has other benefits. </li></ul>

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