Osteoporosis

2,953 views
2,797 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,953
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
206
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • 147
  • Children need calcium/vitamin D because their bones are growing fast ( growing in both length and strength ). Teens need calcium/vitamin D because bones are still growing fast and this is the time to maximize bone mass. About 90% of adult bone mass is laid down by age 18 in most people. Young adults need calcium/vitamin D to make sure they maximize bone mass while they can. Adults need to continue to consume enough calcium/vitamin D to keep their maximum bone mass and to slow bone loss that starts when older ( during menopause for women; usually in 60s or older in men ).
  • Children need calcium/vitamin D because their bones are growing fast ( growing in both length and strength ). Teens need calcium/vitamin D because bones are still growing fast and this is the time to maximize bone mass. About 90% of adult bone mass is laid down by age 18 in most people. Young adults need calcium/vitamin D to make sure they maximize bone mass while they can. Adults need to continue to consume enough calcium/vitamin D to keep their maximum bone mass and to slow bone loss that starts when older ( during menopause for women; usually in 60s or older in men ).
  • Children need calcium/vitamin D because their bones are growing fast ( growing in both length and strength ). Teens need calcium/vitamin D because bones are still growing fast and this is the time to maximize bone mass. About 90% of adult bone mass is laid down by age 18 in most people. Young adults need calcium/vitamin D to make sure they maximize bone mass while they can. Adults need to continue to consume enough calcium/vitamin D to keep their maximum bone mass and to slow bone loss that starts when older ( during menopause for women; usually in 60s or older in men ).
  • Osteoporosis

    1. 1. Prevention of Osteoporosis: The Role of The Gynecologist www.freelivedoctor.com
    2. 2. The Nightmare Of Post-menopause Osteoporosis www.freelivedoctor.com
    3. 3. Pathophysiology www.freelivedoctor.com
    4. 4. Lifetime Changes In Bone Mass 50% of cancellous &35% of cortical bone mass are lost over a lifetime www.freelivedoctor.com
    5. 5. Bone Remolding Osteoblasts deposit new lamellar bone. Osteocytes are osteoblasts trapped in the matrix Osteoclasts resorb matrix www.freelivedoctor.com
    6. 6. Determinants Of Peak Bone Mass Peak Bone Mass Physical activity Gonadal status Nutritional status Genetic factors www.freelivedoctor.com
    7. 7. Peak Bone Mass <ul><li>The peak bone mass attained is a major determinant of subsequent bone mass and fracture risk in later life. </li></ul>Johnston, et al.. N Engl J Med 1992;327:82 – 7. Bonjour ,et al. J Clin Invest 1997;99:1287 – 94. www.freelivedoctor.com
    8. 8. Osteoporosis: Definition <ul><li>Osteoporosis is a progressive, systemic disorder characterized by: </li></ul><ul><li>Low bone mass </li></ul><ul><li>Micro-architectural deterioration of bone tissue </li></ul><ul><li>Increase in bone fragility and susceptibility to fracture. </li></ul>National Institute for Clinical Excellence (NICE) guidance 160 October 2008 WHO 1994 www.freelivedoctor.com
    9. 9. Normal bone Osteoporosis Microarchitectural deterioration Low bone density www.freelivedoctor.com
    10. 10. Osteoporosis: Sites <ul><li>Osteoporotic fractures can occur at any site. </li></ul><ul><li>The most common sites are: </li></ul><ul><li>Lumbar & thoracic spines </li></ul><ul><li>Proximal femur . </li></ul><ul><li>Distal radius </li></ul>www.freelivedoctor.com
    11. 11. Incidence Rates for Vertebral, Wrist & Hip Fractures in Women after Age 50 <ul><li>Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999 </li></ul>www.freelivedoctor.com 50 60 70 80 40 30 20 10 Vertebrae Hip Wrist Age (Years) Annual incidence per 1000 women
    12. 12. The Magnitude Of The Problem <ul><li>In women > 50 years, the lifetime risk of: </li></ul><ul><li>Vertebral fracture is 1/3 </li></ul><ul><li>Hip fracture is 1/5 </li></ul>NICE guidance 160 October 2008 www.freelivedoctor.com
    13. 13. <ul><li>5–20% mortality within 1 year </li></ul><ul><li>20% severely impaired mobility, requiring long-term nursing care </li></ul><ul><li>50% do not regain previous mobility </li></ul>Consequences of Hip Fractures www.freelivedoctor.com
    14. 14. What is the technical standard for measuring BMD ? <ul><li>D ual- E nergy X -ray A bsorptiometry (DEXA) is the technical standard Why?? </li></ul><ul><li>It measures at important sites of osteoporotic fractures. </li></ul><ul><li>It has high precision and accuracy. </li></ul><ul><li>It is relatively inexpensive and has modest radiation exposure . </li></ul>ACOG Guideline : January 2004 www.freelivedoctor.com
    15. 15. DEXA It employs two x-ray beams of different energy levels www.freelivedoctor.com
    16. 16. DEXA www.freelivedoctor.com
    17. 17. 1 DEXA www.freelivedoctor.com
    18. 18. <ul><li>T score ≥ -1 </li></ul><ul><li>T score -1 to -2.5 </li></ul><ul><li>T score < -2.5 </li></ul>Normal Osteopenia Osteoporosis WHO Classification of BMD using (DEXA) scan <ul><li>T score < -2.5 </li></ul><ul><li>+ H. of fracture </li></ul>Severe Osteoporosis T score represents the number of SD a patient is above or below the mean BMD of a young adult. www.freelivedoctor.com
    19. 19. The Role of Densitometry Normal Ostopenia Osteoporosis www.freelivedoctor.com
    20. 20. <ul><li>Quantitative ultrasonography . </li></ul><ul><li>Single-energy x-ray absorptiometry. </li></ul><ul><li>Peripheral DEXA </li></ul><ul><li>Peripheral quantitative computed tomography. </li></ul>Tests Other Than DEXA Peripheral bone densitometry devices www.freelivedoctor.com
    21. 21. Quantitative Ultrasound for the Assessment of Osteoporosis www.freelivedoctor.com
    22. 22. <ul><li>They are less expensive and have low radiation exposure, however : </li></ul>Tests Other Than DEXA Peripheral bone densitometry devices <ul><li>They have low precision and accuracy. </li></ul><ul><li>They measure peripheral bone only. </li></ul><ul><li>Cannot replace DEXA scans . </li></ul>ACOG Guideline : January 2004 www.freelivedoctor.com
    23. 23. What Is The Role of The Gynecologist ? <ul><li>I- At Adolescent & Adult Age </li></ul><ul><li>To achieve a peak bone mass </li></ul><ul><li>II- At Peri-menopause </li></ul><ul><li>To prevent osteoporosis in high risk group </li></ul><ul><li>III-At Late Post-menopause? </li></ul><ul><li>To prevent age related osteoporosis (>65y) </li></ul><ul><li>Usually it is an orthopedic role </li></ul>www.freelivedoctor.com
    24. 24. Determinants Of Peak Bone Mass Peak Bone Mass Physical activity Gonadal status Nutritional status Genetic factors www.freelivedoctor.com
    25. 25. www.freelivedoctor.com
    26. 26. Role of Gynecologist <ul><li>I- At adolescent & Adult age </li></ul><ul><li>A-To achieve a peak bone mass in susceptible group. </li></ul><ul><ul><ul><li>Late menarche </li></ul></ul></ul><ul><ul><ul><li>Menstrual interruptions/irregularities </li></ul></ul></ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul><ul><ul><ul><li>Lactation </li></ul></ul></ul>www.freelivedoctor.com
    27. 27. Role of Gynecologist <ul><li>I- At adolescent & Adult age </li></ul><ul><li>A-To achieve a peak bone mass in susceptible group. </li></ul><ul><li>B-To reduce bone loss secondary to drugs. </li></ul>www.freelivedoctor.com
    28. 28. www.freelivedoctor.com
    29. 29. Female Athlete Triad <ul><li>Disordered Eating </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Osteoporosis </li></ul>Adolescent Girls www.freelivedoctor.com
    30. 30. Turner Syndrome <ul><li>- 90% of women had osteopenia or osteoporosis </li></ul><ul><li>- Length of estrogen treatment and BMI showed a positive association with bone mineral density. </li></ul>Emans et al. Obstet Gynecol 1990;76:585. Emans et al. Pediatric & Adolescent Gynecology, 5th Edit.2005 www.freelivedoctor.com
    31. 31. Role of Gynecologist <ul><li>I- At adolescent & adult age : </li></ul><ul><li>B- To reduce bone loss secondary to drugs: </li></ul><ul><ul><ul><li>Gn Rh Analogue. </li></ul></ul></ul><ul><ul><ul><li>Dopamine Agonist </li></ul></ul></ul><ul><ul><ul><li>Glucocortocoied </li></ul></ul></ul><ul><ul><ul><li>Depo-provera?? </li></ul></ul></ul>www.freelivedoctor.com
    32. 32. GNRH Agonist For Endometriosis Can BMD loss be prevented by using ‘ add-back ’ therapy? <ul><li>The use of a GnRH agonist with ‘ add-back ’ (oestrogen + progestagen) therapy protects against bone mineral density loss at the lumbar spine during treatment and for up to 6 and 12 months after treatment, respectively. </li></ul>ESHRE Guideline 2005 & RCOG 2006 Grade A www.freelivedoctor.com
    33. 33. <ul><li>GnRH agonist + ‘ add-back ’ therapy for at least 6 months: BMD was significantly higher compared to a GnRH agonist alone </li></ul><ul><li>Hypoestrogenic side effects were significantly less with ‘ add-back ’ . </li></ul><ul><li>Progestagen only ‘ addback ’ is not protective; </li></ul><ul><li>There is insufficient evidence regarding calcium-regulating agents. </li></ul>GNRH Agonist For Endometriosis Can BMD loss be prevented by using ‘ add-back ’ therapy? Sagsveen M et al , Cochrane Database Syst Rev 2003;(4):CD001297. Level 1a www.freelivedoctor.com
    34. 34. Role of Gynecologist <ul><li>II- At Peri-menopause. </li></ul><ul><li>To Prevent osteoporosis in high risk group: </li></ul><ul><li>1-Screening </li></ul><ul><li>2-Managment </li></ul>www.freelivedoctor.com
    35. 35. www.freelivedoctor.com
    36. 36. <ul><li>Testing of BMD is justified when there is: </li></ul><ul><li>One major risk factor for osteoporosis or </li></ul><ul><li>Tow minor risk factors for osteoporosis </li></ul>The Society of Obstetricians and Gynaecologists of Canada.(SOGC) Clinical Practice Guideline2009 www.freelivedoctor.com
    37. 37. <ul><li>Age >65 years </li></ul><ul><li>Early menopause (< 45 Years) </li></ul><ul><li>Hypogonadism (Spontaneous or iatrogenic) </li></ul><ul><li>Vertebral compression fracture </li></ul><ul><li>Fragility fracture after age 40 Ys </li></ul><ul><li>Family history of osteoporotic fracture </li></ul><ul><li>Glucocorticoid therapy for 3 months </li></ul><ul><li>Malabsorption syndrome </li></ul><ul><li>Primary hyperparathyroidism </li></ul><ul><li>Propensity to fall </li></ul><ul><li>Osteopenia apparent on radiograph </li></ul>Risk Factors For Osteoporosis Major Risk Factors SOGC Clinical Practice Guideline2009 www.freelivedoctor.com
    38. 38. <ul><li>Rheumatoid arthritis </li></ul><ul><li>History of clinical hyperthyroidism </li></ul><ul><li>Long-term anticonvulsant therapy </li></ul><ul><li>Low dietary calcium intake </li></ul><ul><li>Smoking </li></ul><ul><li>Excessive alcohol intake </li></ul><ul><li>Excessive caffeine intake </li></ul><ul><li>Weight < 57 kg </li></ul><ul><li>Weight loss: 10% of weight at age 25 years </li></ul><ul><li>Long-term heparin therapy </li></ul>Minor risk factors SOGC Clinical Practice Guideline2009 www.freelivedoctor.com
    39. 39. When Is Treatment Indicated?? <ul><li>T score < -2 & No fractures </li></ul><ul><li>T score < -1.5 in with a history </li></ul><ul><li>of fracture or other risk factors </li></ul><ul><li>T score < -0.5 in women with </li></ul><ul><li>a history of fracture and other risk factors. </li></ul><ul><li>T score 1 unit higher in patients receiving glucocorticoid drugs. </li></ul>Board of Osteoporosis New Zealand 2004 ACOG Guideline : January 2004 www.freelivedoctor.com
    40. 40. Treatment <ul><li>Exercise </li></ul><ul><li>Diet </li></ul><ul><li>Drugs </li></ul>www.freelivedoctor.com
    41. 41. THE ROLE OF EXERCISE <ul><li>Studies have shown that weight-bearing exercise and increased muscle mass lead to the development of increased bone mass. </li></ul>ACOG Guideline : January 2004 www.freelivedoctor.com
    42. 42. Calcium & Vitamin D (At Any Age) <ul><li>Adequate calcium and vitamin D supplementation is key to ensure prevention of progressive bone loss. </li></ul>Canadian Task Force on Preventive Health Care 2004 The Society of Obstetricians and Gynaecologists of Canada.(SOGC) Clinical Practice Guideline2009 www.freelivedoctor.com
    43. 43. Calcium & Vitamin D (At Any Age) <ul><li>For postmenopausal, intake of 1500mg of elemental calcium & 800 IU/d of vitamin D are recommended. </li></ul>The Society of Obstetricians and Gynaecologists of Canada.(SOGC) Clinical Practice Guideline2009 Grade B www.freelivedoctor.com
    44. 44. Calcium & Vitamin D (At Any Age) <ul><li>Calcium and vitamin D alone are insufficient to prevent fracture in those with osteoporosis. </li></ul>The Society of Obstetricians and Gynaecologists of Canada.(SOGC) Clinical Practice Guideline2009 Grade B www.freelivedoctor.com
    45. 45. What are the pharmacotherapy ? <ul><li>Medications available for osteoporosis </li></ul><ul><li>1- Calcium & Vitamin D </li></ul><ul><li>2- Estrogen (& progesagen) </li></ul><ul><li>3- Bisphosphonates </li></ul><ul><li>Alendronate (Fosamax) </li></ul><ul><li>Risedronate (Actonel) </li></ul><ul><li>5- Selective estrogen- receptor modulators (SERM) </li></ul><ul><li>Raloxifene. (Evista) </li></ul><ul><li>Tibolone. (Livial) {STEAR Selective Tissue Estrogenic Activity Regulator } </li></ul><ul><li>6- Calcitonin (Miacalcic) </li></ul><ul><li>7- Parathyroid Hormone </li></ul>4- Strontium Ranelate(Protelos, 2g) www.freelivedoctor.com
    46. 46. Spine Hip 50% 50% 50% 40% 30% 30% HRT/Tibolone >35% >30% > 30% Raloxifene: Evista 60 mg /d 34% 21% Parathyroid Hormone Fort é o 20micg/d for 2y 65% 45% National Osteoporosis Foundation.; 2003 & The Medical Journal of Australia 2004 Drugs used for prevention & treatment of osteoporosis Alendronate :Fosomax 5mg/d or35mg/w Calcitonin (Miacalcic 100IU/d IM .sc or 200IU/d nasal Other non spine Strontium Ranelate (Protelos, 2g) 30% 30% 30% Risedronate: Actonel 5mg/d or 35mg/w www.freelivedoctor.com
    47. 47. Osteoporosis: Problem Solving Cases www.freelivedoctor.com
    48. 48. A 53-year-old G6P4 woman complains of Amenorrhea 11 months with 10-15 hot flushes/day. She is afraid as her mother has died 9 months after fracture neck femur at the age of 67 years BP 120/75, weight 74 kg , height 171cm (BMI 25kg/m2) Breast, abdominal &pelvic examinations revealed no abnormal findings. www.freelivedoctor.com
    49. 49. <ul><li>T score -2 </li></ul>Osteopenia The result of DEXA is – 2 what is the treatment option of choice? www.freelivedoctor.com
    50. 50. As the patient has significant hot flushes and has no contraindication : HRT may be the option of choice What Is The Treatment Option Of Choice? www.freelivedoctor.com
    51. 51. As the patient has significant hot flushes and has no contraindication : HRT may be the option of choice What Is The Treatment Of Choice? www.freelivedoctor.com
    52. 52. So far there are false perceptions regarding the use of HRT -even in big authorities - due to: 1- Old data 2-Incomplete analysis of the data (subgroup) Discussion www.freelivedoctor.com
    53. 53. False Perceptions <ul><li>HRT should not be used for bone protection because of its unfavorable safety profile. </li></ul><ul><li>HRT is not as effective in reducing fracture risk as other products, e.g. bisphosphonates. </li></ul>www.freelivedoctor.com
    54. 54. False Perceptions <ul><li>Official recommendations by some health authorities as Agency for the Evaluation of Medicinal Products (EMEA) &FDA limit the use of HRT to </li></ul><ul><li>1- Symptomatic women </li></ul><ul><li>2- A second-line alternative when other medications: </li></ul><ul><li>F ailed </li></ul><ul><li>Are contraindicated </li></ul><ul><li>Not tolerated </li></ul>www.freelivedoctor.com
    55. 55. What Is The Recent Evidence ? <ul><li>Overall, HRT is effective in the prevention of all osteoporosis-related fractures. [A] </li></ul><ul><li>There is no evidence to suggest that bisphosphonates or any other antiresorptive therapy are superior to HRT . </li></ul>International Menopause Society ( Z ü rich Summit )2008 www.freelivedoctor.com
    56. 56. What Is The Recent Evidence ? <ul><li>It is therefore suggested that, in 50–59 -year-old postmenopausal women, HRT is a cost-effective first-line treatment in the prevention of osteoporotic fractures. </li></ul>International Menopause Society ( Z ü rich Summit )2008 www.freelivedoctor.com
    57. 57. What Is The Recent Evidence ? <ul><li>Even lower than standard-dose preparations maintain a positive influence on bone indices such as bone mineral density. [A] </li></ul><ul><li>HRT has a positive effect on osteoarthritis and the integrity of intervertebral disks. </li></ul>International Menopause Society ( Z ü rich Summit )2008 www.freelivedoctor.com
    58. 58. <ul><li>A 45-year-old P2 woman complains of amenorrhea one year with 15-20 hot flushes/day . </li></ul><ul><li>She has a history of L. radical mastectomy for breast cancer 7 years ago with complete cure. </li></ul><ul><li>BP 130/85, weight 60 kg. height 163cm, Right Breast, abdominal & pelvic examinations revealed n o abnormal findings. </li></ul><ul><li>Fasting sugar 95 mg/dl & within normal lipid profile </li></ul>Case 2 www.freelivedoctor.com
    59. 59. HRT is not recommended for cases with cured cancer breast even after 5 years except in some exceptional condition for a very short time under strict follow up There are other 2 lines of therapy What is The Treatment of Choice? www.freelivedoctor.com
    60. 60. 1-Venlafaxine = (Effexor) <ul><li>Venlafaxine (Effexor) S elective S erotonin R euptake I nhibitor (SSRI) 75mg/d </li></ul><ul><ul><li>A newer antidepressant used to reduce hot flushes and improve mood at menopause. </li></ul></ul><ul><ul><li>Although venlafaxine resulted in modest and acute reductions in hot flushes with few side effects, it may not be tolerable to some patients for long-term . </li></ul></ul>Carpenter et al Oncologist 2007 Jan;12(1):124-35.RCT(Doub.blinde) Evanc et al Obstet Gynecol. 2005 Jan;105(1):161-6. RCT www.freelivedoctor.com
    61. 61. Tibolone (Previous view) <ul><li>Tibolone alleviates the severity and reduces the frequency of hot flushes .It has been shown to be effective for vaginal dryness . </li></ul><ul><li>The potential harms (cv & Breast cancer of treatment have not yet been thoroughly assessed with long-term randomized (>2 years) trials. </li></ul>New Zealand Guidelines Group March 2004 (Grade A) Use of tibolone may be associated with an increased risk of breast cancer . Million Women Study 2003 www.freelivedoctor.com
    62. 62. <ul><li>Tibolone has been demonstrated to prevent postmenopausal bone loss and increase BMD, however, currently no trials have evaluated whether tibolone decreases the risk of fracture. </li></ul>Tibolone (Previous view) Australian Family Physician Vol. 33, No. 3, March 2004 www.freelivedoctor.com
    63. 63. <ul><li>Tibolone reduces the risk of osteoporotic fractures similar to other treatments such as HRT, bisphosphonates and raloxifene </li></ul><ul><li>Tibolone reduces the risk of invasive breast cancer similar to raloxifene and tamoxifen </li></ul>Tibolone in Breast Cancer (Recent View ) Long-Term Intervention on Fractures with Tibolone (LIFT Study) N Engl J Med 2008;359:697 – 708 (RCT 4538 women 60 - 85 years) www.freelivedoctor.com
    64. 64. Tibolone <ul><li>Tibolone should be used with caution in elderly women (> 70 years ). </li></ul><ul><li>That is the age at which hormone therapy is critical, as was also shown in the Women’s Health Initiative (WHI) studies with the effects of conventional HRT </li></ul>Long-Term Intervention on Fractures with Tibolone (LIFT Study) N Engl J Med 2008;359:697 – 708 (RCT 4538 women 60 - 85 years) www.freelivedoctor.com
    65. 65. <ul><li>There were more cancer recurrences in those taking tibolone compared with those on placebo ( 15% v 10%), causing the trial to close early. </li></ul><ul><li>Overall mortality, cardiovascular events and gynaecological cancers were no different but the breast cancer recurrence rates make it unsafe to use tibolone in these circumstances. </li></ul>Tibolone in Breast Cancer (Recent View ) Kenemanas et al Lancet Oncol. 2009 Feb;10(2):135-46. Multicenter (3098 ptients)245 centres in 31 countries double-blind RCT But www.freelivedoctor.com
    66. 66. For hot flushes 1-Venlafaxine = (Effexor) 2-Tibolone very short time under strict follow up for hot flushes For prevention of osteoporosis : 1- Bisphosphonates Or 2-Strontium Ranelate What is The Treatment of Choice? www.freelivedoctor.com
    67. 67. Raloxifene <ul><li>Raloxifene is not recommended as a treatment option for the primary prevention of osteoporotic fragility fractures in postmenopausal women. </li></ul>NICE October 2008 www.freelivedoctor.com
    68. 68. Lower Higher -2.5 BMD (T-score) Bisphosphonates Or Strontium Ranelate Osteoporosis Therapy Algorithm Postmenopausal Women 50 55 60 65 70 75 80 85 90 www.freelivedoctor.com Raloxifene PTH Calcitonin HRT HRT During Hot Flushes Post Vasomotor Symptoms Pre fracture Post Fracture Risk of Fracture AGE At Risk/Osteopenia Osteoporosis Severe Osteoporosis STAGE
    69. 69. Lower Higher -2.5 BMD (T-score) Bisphosphonates Or Strontium Ranelate Osteoporosis Therapy Algorithm Postmenopausal Women 50 55 60 65 70 75 80 85 90 Tibolone www.freelivedoctor.com Raloxifene PTH Calcitonin HRT HRT During Hot Flushes Post Vasomotor Symptoms Pre fracture Post Fracture Risk of Fracture AGE At Risk/Osteopenia Osteoporosis Severe Osteoporosis STAGE

    ×