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Osteoporosis Osteoporosis Presentation Transcript

  • Definition A systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue leading to bone fragility and susceptibility to fracture
  • Who Gets Osteoporosis? Immobilization Hypogonadal states Endocrine disorders Malnutrition, parenteral nutrition and malabsorption rheumatologic disorders Renal insufficiency Hematologic disorders Several inherited disorders
  • Osteoporosis Mechanisms causing osteoporosis  Imbalance between rate of resorption and formation  Failure to complete stages of remodeling Types of osteoporosis  Type I  Type II  Secondary
  • Osteoporosis - Types Postmenopausal osteoporosis (type I)  Caused by lack of estrogen  Causes PTH to overstimulate osteoclast Age-associated osteoporosis (type II)  Bone loss due to increased bone turnover  Malabsorption  Mineral and vitamin deficiency
  • Classification Primary  Postmenopausal  Bone loss – 2-3% per year of total bone mass  Most common fx: vertebral, distal forearm  Age related – 3rd decade of life starts slow decline in bone mass at rate of 0.5-1% per year  Most common types of fx: hip and radius  F>M Secondary
  • Secondary OsteoporosisDisease states Acromegaly  Multiple myeloma Addison’s disease  Multiple sclerosis Amyloidosis  Rheumatoid arthritis Anorexia  Sarcoidosis COPD  Severe liver dz, esp. Hemochromatosis PBC Hyperparathyroidism  Thalessemia Lymphoma and  Thyrotoxicosis leukemia Malabsorption states
  • Secondary OsteoporosisDrugs Aluminum Anticonvulsants Excessive thyroxine Depo Provera (decreased bone mass reversible after stopping medication) Glucocorticoids GnRH agonists Heparin Lithium
  • Diagnosing Osteoporosis Outcome of interest: Fracture Risk! Outcome measured (surrogate): BMD  Key: Older women at higher risk of fracture than younger women with SAME BMD!  Other factors: risk of falling, bone fragility not all related to BMD
  • Prevalence of osteoporosis Osteopenia Osteoporosis Female 37-50% 13-18% Age > 50 year Male 28-47% 3-6% Age > 50 year
  • Incidence of osteoporotic Fx
  • Incidence of osteoporotic Fx
  • Diagnosis of Osteoporosis Physical examination Measurement of bone mineral content• Dual X-ray absorptiometry (DXA)• Ultrasonic measurement of bone• CT scan• Radiography
  • Physical examination Osteoporosis Vertebral fracture Height loss Arm span-height Body weight difference Kyphosis Wall- occiput Humped back distance Tooth loss Rib-pelvis distance Skinfold thickness Grip strength
  • Physical examination
  • Physical examination No single maneuver is sufficient to rule in orrule out osteoporosis or vertebral fracturewithout further testing
  • Diagnosing Osteoporosis Laboratory Data  Limited value in diagnosis  Markers of bone turnover (telopeptide) more useful in monitoring effects of treatment than in diagnosis  Helpful to exclude secondary causes  Hyperthyroidism  Hyperparathyroidism  Estrogen or testosterone deficiency  Malignancy  Multiple myeloma  Calcium/Vitamin D deficiency
  • Work-upScreen for secondary causes  Serum calcium, phosphorus, alk phos  PTH if calcium is high (hyperparathyroidism)  25-hydroxyvitamin D if low ca, low phos and high alk. phos (osteomalacia)  Thyroid function tests (thyrotoxicosis)  SPEP, UPEP (multiple myeloma)  24-hour urinary calcium (hyper or hypo calciuria)  Serum testosterone (hypogonadism)
  • Methods to evaluate for osteoporosis Quantitative Ultrasonography Quantitative computed tomography Dual Energy X-ray Absorptiometry (DEXA)  ?”gold standard”  Measurements vary by site  Heel and forearm: easy but less reliable (outcome of interest is fracture of vertebra or hip!)  Hip site: best correlation with future risk hip fracture  Vertebral spine: predict vertebral fractures; risk of falsely HIGH scores if underlying OA/osteophytes
  • Dual X-ray absorptiometry 2-dimensional study BMD = Amount of mineral Area Accuracy at hip > 90% Low radiation exposure Error in Osteomalacia Osteoarthritis Previous fracture
  • How to interpret the BMD T score: standard deviation of the BMD from the average sex matched 35-year-old Z score: less used; standard deviation score compared to age matched control For every 1 decrease in T score, double risk of fracture 1 SD decrease in BMD = 14 year increase in age for predicting hip fracture risk Regardless of BMD, patients with prior osteoporotic fracture have up to 5 times risk of future fracture!
  • Dual X-ray absorptiometry BMD compare with T score young adult femaleNormal < 1 SD below >/= -1Low bone mass ( Osteopenia ) 1-2.5 SD below < -1 > -2.5Osteoporosis >/= 2.5 SD below </= -2.5Severe osteoporosis >/= 2.5 SD below PLUS Fracture
  • Dual X-ray absorptiometry WHO criteria - Hip BMD Normal Low bone mass (Osteopenia) Osteoporosis Severe osteoporosis
  • Osteoporosis Can Be Assessed byDXA Relative Risk of Fracture DXA-assessed content is a per SD Decrease in BMD proven effective method for 3 assessing osteoporosis 2.5 related fracture risk. Relative Risk 2 Population surveys and Forearm 1.5 Hip research studies demonstrate 1 Spine a decrease in bone density 0.5 measured by DXA predicts 0 fracture at specific sites. m l p s ra ite Hi ar b lS re rte Fo Al Ve
  • Ultrasonic measurement Broad-band ultrasound attenuation No radiation exposure Cannot be used for diagnosis Preferred use in assessment of fracture risk
  • The calcaneus is the most common skeletal site for quantitative ultrasound assessment because -It has a high percentage of trabecular bone that is replaced more often than cortical bone, providing early evidence of metabolic change. -Also, the calcaneus is fairly flat and parallel, reducing repositioning errors.
  • The McCue CUBA: UltrasonometryTechnology That Can Assess Osteoporosis
  • Heel BUA is Significantly Lower inSubjects With Future Hip Fracture. 60 BUA (dB/sq MHz) 50 40 30 20 10 0 Fracture No FractureSubjects who developed hip fracture showed significantly (p<0.001) lowerheel BUA results.
  • CT scan True volumetric study Quantitative Computed Tomography (QCT) utilizes CT technology to detect low bone mass and monitors the effects of therapy in patients undergoing treatment. It is a fast, non-invasive exam that detects low bone mass earlier and more accurately than other bone density exams
  • QCT in a 62-year-old female patient
  •  The trabecular BMD is indicated as the most important parameter, and interpreted using the Felsenberg classification, based on the following cut-off values: Normal BMD > 120 mg/cc Osteopenia < 120 mg/cc Osteoporosis < 80 mg/cc Very high fracture risk < 50 mg/cc
  • Advantages over DXA: Ability to separate cortical and trabecular bone Provides true volumetric density in units of mg/cc No errors due to spinal degenerative changes or aortic calcification
  • Clinicians and researchers favor DXA because-scanners are readily available and relativelyinexpensive.-The radiation dose is negligible-The T-score scale, defined by the WHO specifically forDXA, provides a standardized classification.
  • Plain radiography Low sensitivity High availability Subclinical vertebral fracture is a strong risk factor for subsequent fractures at new vertebral site and other sites
  • The main radiographic features of generalizedosteoporosis are cortical thinning and increasedradiolucency
  • Singh Index The Singh index describes the trabecular patterns in the bone at the top of the thighbone (femur). X-rays are graded 1 through 6 according to the disappearance of the normal trabecular pattern. Studies have shown a link between a Singh index of less than 3 and fractures of the hip, wrist, and spine.
  • Assessment of fracture risk DXA and quantitative ultrasound Clinical risk factors Markers of bone turnover Bone formation Bone resorption
  • Assessment of fracture risk DXA Risk of fracture = 1.5-3.0 for each SD decrease in BMD Low sensitivity ( comparable to BP in predicting stroke ) Screening is not recommended Quantitative ultrasound Risk of fracture = 1.5-2.0 for each SD decrease in BMD
  • Assessment of fracture risk Markers of bone turnoverBone formation markers Bone resorption markers Alkaline phosphatase Hydroxyproline Bone isoenzyme AP Pyridinium crosslinks & Osteocalcin associated peptides Procollagen propeptides of type I collagen
  • Assessment of fracture riskMarkers of bone turnover Associated with osteoporotic fracture independent of bone density 2-Fold increase in fracture risk ? Combined approach with BMD to increased sensitivity
  • Assessment of fracture riskClinical risk factors for fracture Low bone mass History or falls Impaired cognition ( plus medication adverse effect ) Low physical function Presence of environmental hazards Long hip axis length Chronic glucocorticoid use Existing fracture Chronic use of seizure medications Renal, hepatic, thyroid, parathyroid, malabsorptive disorder, vitamin D deficiency, MM and local neoplasia to be ruled out National Osteoporosis Foundation 1998
  • Assessment of fracture riskPredictors of low bone mass Female Advanced age 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 acitivity Chronic glucocorticoid use History of fracture National Osteoporosis Foundation 1998
  • When to Measure BMD inPostmenopausal Women All women 65 years and older Postmenopausal women <65 years of age:  Ifresult might influence decisions about intervention  One or more risk factors  History of fracture
  • When Measurement of BMD Is NotAppropriate Healthy premenopausal women Healthy children and adolescents Women initiating ET/HT for menopausal symptom relief (other osteoporosis therapies should not be initiated without BMD measurement)