OSTEOPOROSIS -MUST KNOW DISEASE INFORMATIONS
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OSTEOPOROSIS IMPORTANCE OF BONE BALANCE IN HUMAN BODY
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OSTEOPOROSIS -MUST KNOW DISEASE INFORMATIONS
- 1. A.Arputha Selvaraj APMP IIM Calcutta
- 2. 2 Bone Remodeling Bone Strength Tissue Properties • Mineralization • Collagen (structure, cross-links) • Micro damage Micro- architecture Mass (Size, Geometry)
- 3. 3 High Bone Turnover Leads to Development of Stress Risers and Perforations Lining Cells Bone Osteoclasts Stress Risers Perforations
- 4. 4 4 NormalNormal22 OsteoporosisOsteoporosis22 ““Osteoporosis is a skeletal disorder characterized byOsteoporosis is a skeletal disorder characterized by compromised bonecompromised bone strengthstrength predisposing a person to anpredisposing a person to an increased risk of fractureincreased risk of fracture.”.”11 1. Consensus Development Conference, JAMA 2001; 285: 785-95; 2. Dempster DW et al, JBMR 1986; 1: 15-21.
- 5. Increased mineralization in existing bone Increased bone tissue per unit of bone volume: Filling in resorption space Widening existing trabeculae Creating new trabeculae Increased bone size 5
- 6. Reflected in DXA Measurements: Bone size Trabecular volume and cortical thickness Amount of mineralization in bone and surrounding tissues Not Reflected in DXA Measurements: Trabecular connectivity and number Collagen quality Microscopic damage (e.g. microcracks) Bone geometry 6
- 7. According to the National Osteoporosis Foundation (NOF): “Osteoporosis (porous bone) is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist.” In common practice osteoporosis is seen as disease of compromised bone strength. BONE STRENGTH= Bone Quality + Bone Mineral Density 7
- 8. The most common type of fractures in men and women is vertebral, followed by hip fractures. Vertebral fractures are associated with Acute and chronic pain Height loss and spinal deformity Decreased mobility and work capacity Diminished self confidence. Vertebral, hip and forearm fractures are strong signals for increased risk of additional osteoporotic fractures. 8
- 9. 9
- 10. Factors that can affect the rate of bone loss: thinness. inactivity. calcium intake. vitamin D. smoking. alcohol. corticosteroids. 10
- 11. Lumbar spine region most prone to osteoporosis 11
- 12. Vertebral Fractures: Osteoporotic crush fractures of the vertebrae may occur in various forms. The vertebral body may be: Compression fracture – compressed only in the center leading to endplate concavities. Wedged fracture – collapsed anteriorly causing kyphosis. Collapse fracture – uniformly compressed. Collapsed posteriorly (uncommon). 12
- 14. 14 • Kyphosis • Loss of height • Bulging abdomen • Acute and chronic pain • Breathing difficulties, reflux and other GI symptoms • Depression REDUCED QUALITY OF LIFE
- 15. Initial indications: • Spinal X-ray, Chest X-ray or Bone Mineral Densitometry leads to suspicion of Osteoporosis, but not confirmation. • As Low BMD or fractures are not only due to Osteoporosis, physicians consider the differential diagnosis of causes of low BMD or fracture before concluding that the patient has osteoporosis. 15
- 16. X-rays: X-Rays usually pick up bone loss when it’s more than 40% (X-Ray Films look more bright) However, X-rays give some important diagnostic clues like: Presence of fractures. Pathologic findings such as cancer metastatic to bone. Deformities indicating disease states other than osteoporosis (e.g. osteomalacia). 16
- 17. 17 Kanis JA et al, J Bone Miner Res, 1994;9:1137-1141 T-Score Normal - 1 SD and above Low bone mass - 1 SD to -2.5 SD Osteoporosis < -2.5 SD Established osteoporosis < -2.5 SD and one or more Osteoporotic fractures
- 18. Dual energy X-ray absorptiometry (DXA): •Two X-ray beams with differing energy levels are aimed at the patient's bones. •When soft tissue absorption is subtracted out, the BMD can be determined from the absorption of each beam by bone. •Dual energy X-ray absorptiometry is the most widely used and most thoroughly studied bone density measurement technology 18
- 20. Surgical Non Surgical NSAIDS BRACING BED REST PHARMACOLOGICAL TREATMENT 20
- 21. Anterior cortex fixation important Pedicle is the strongest point for Fixation 21
- 24. Prevention and Treatment methods include: • Supplemental calcium and Vitamin D • Hormone replacement therapy (HRT) • Selective estrogen receptor modulators (SERMs) • Bisphosphonates • Calcitonin • Parathyroid hormone 24
- 25. Inhibitors of Bone loss •Estrogen •Selective Estrogen Receptor Modulators •Bisphosphonates •Calcitonin Formation of Bone •Teriparatide( rhPTH 1- 34) 25 Mixed Mechanism of Action Strontium Ranelate
- 26. Hormone Replacement Therapy (HRT): • Estrogen Replacement therapy (ERT) has been used successfully to arrest bone loss in post menopausal women • However Estrogen therapy increases Risk of Breast Cancer Breast Tenderness, nipple tingling, Bloating Risk of DVT and Pulmonary Embolism 26
- 27. Selective estrogen receptor modulators (SERMs): • SERMs act as estrogen agonists on bone and cardiovascular system, but act as estrogen antagonists on endometrial and breast tissues. • Two commonly Used SERMs TAMOXIFENE: Used in breast cancer, not in osteoporosis RALOXIFENE: Approved in Osteoporosis and management of Breast cancer 27
- 28. Bisphosphonates: • Bisphosphonates have strong affinity towards bone surface and eventually get incorporated into the bone crystal • Nitrogen containing bisphosphonates inhibit the enzyme Farnesyl diphosphate synthatase • As a result Osteoclasts are unable to resorb the bone and undergo apoptosis • In early osteoclast precursor cells this results in inhibition of their development into osteoclasts 28
- 29. Non Nitrogen containing •Etidronate •Clodronate •Tiludronate Nitrogen Containing •Alendronate: Osteofos •Risedronate: Actonel •Ibandronate: Bonviva •Zolendronate: Aclasta 29
- 30. Bone formation Markers BSAP( Bone specific alkaline Phosphatase) PINP( Amino terminal propeptide of Type 1 collagen) PICP (Carboxy terminal propeptide of Type 1 collagen) Osteocalcin Bone resorption Markers •NTX (N-terminal Telopeptide of Collagen Cross Links) •CTx (c-terminal telopeptide of collagen cross links) 30
- 31. Enquiry email : arputhaselvaraj@gmail.com 31
Editor's Notes
- Note that stress risers are NOT microfractures or microcracks. Stress risers are only points of critical mechanical compromise in the bone structure, at which the application of a significant mechanical stress (strain, torsion, etc) makes this area as very susceptible to sustaining a fracture.
- The textbook definition of osteoporosis is of a disease which decreases bone strength and therefore increases the risk of fracture. As you look at these visuals, you can see that the healthy (normal) bone is comprised of thick, inter-linking trabeculae, while the osteoporotic bone is thin and some of the connectors are broken. Importantly, the disease is no longer considered as just a low bone mineral density problem. There are multiple factors affecting the strength of bone and therefore fracture risk – including BMD and bone architecture. You can relate this to a steel bridge. A high quality bridge is not one with just a lot of steel. Both the steel and the way in which it is structured combine to make a bridge strong. The same could be said about bone mineral density and bone architecture. One of the first thing you have to consider in osteoporosis is its consequences, mainly due to the fractures that can occur quickly with the time. The typical physical image of osteoporosis spiral is the cascade of fractures from the first, very early peripheral fracture to the first vertebral fracture and then, to the hip fracture. The progression of the disease from the first vertebral fracture to many subsequent vertebral fractures can be a fast one. References: 1. Consensus Development Conference: Osteoporosis prevention, diagnosis, and therapy, JAMA 2001; 285: 785-95. 2. Dempster DW et al., A simple method for correlative light and scanning electron microscopy of human iliac crest bone biopsies: qualitative observations in normal and osteoporotic subjects, JBMR 1986; 1: 15-21.
- Bone mineral density reflects the amount of mineral content found in a specified region of bone. Areal bone density (which is what is measured with a typical DXA machine) reflects the amount of mineral (in grams) per projected area of bone (in centimetres squared). Volumetric bone densities reflect the amount of mineral (in grams) per volume of bone (in centimetres cubed). An increase in bone mineral density can occur with increased amount of bone tissue, increased mineral content (example: increased secondary mineralization seen with antiresorptives), or increased bone size.
- This slide describes some features of bone quality and strength, and demonstrates that not all important characteristics of bone are reflected in standard DXA measurements. DXA measurements are affected by the size of the bone, and the amount of mineralization present in the bone (and in the surrounding tissues). However, DXA measurements do not reflect the shape of the bone, nor microscopic architectural issues such as number, alignment, and connectivity of trabeculae; quality of the collagen matrix; or amount (and repair) of microscopic damage such as microcracks in the trabecular struts.
- This definition emphasizes the observed changes in bone mass (as opposed to bone fractures) and indicates that the fractures are late manifestations of the disease.
- Kyphosis: curvature of the spine as viewed from the side; hunchback.
- Cyclically – last 12 days of the cycle during which a normal menstrual period should occur.
- The non-nitrogenous bisphosphonates(disphosphonates) are metabolised in the cell to compounds that replace the terminal pyrophosphate moiety of ATP, forming a nonfunctional molecule that competes with adenosine triphosphate (ATP) in the cellular energy metabolism. The osteoclast initiates apoptosis and dies, leading to an overall decrease in the breakdown of bone N-containing bisphosphonates: Pamidronate (APD, Aredia) - 100 Neridronate - 100 Olpadronate - 500 Alendronate (Fosamax) - 500 Ibandronate (Boniva) - 1000 Risedronate (Actonel) - 2000 Zoledronate (Zometa, Aclasta) - 10000