3. β 73 year old man presented with recent onset
of back pain and weight loss.
β X-rays showed multiple vertebral fractures.
β PMH AF controlled with amiodarone.
β Non smoker, little alcohol.
β Differential diagnosis?
Case 1
4. β FBP
β Admission profile, bone profile, PSA
β ESR / CRP
β PPE, Bence Jones
β Testosterone
β TFTs, 24hr urinary cortisol
β Coeliac screen
Case 1 Investigations
5.
6.
7.
8.
9. β T4 96.9 pmol/L
β TSH < 0.02 mu/L
β Hyperthyroidism secondary to
amiodarone
Case 1 Diagnosis
10. β Increased frequency of bone remodelling
β Shortened cycle with bone formation
shortened more than resorption
β Leads to loss of bone with each cycle
β relative increased Ca -- decreased PTH--
decreased 1-25 Vit D -- decreased Ca
absorption and increased Ca excretion
Hyperthroidism and Bone
11. β Increased fracture rate
X 3 to 4 increased rate & only in part related
through BMD.
Hyperthyroidism and Fracture
12. β BMD increases on average 4% in first year.
β BMD returns to normal range within 3-5 yrs.
β But there remains an increased fracture rate
for up to 5 years.
β Therefore in severe osteoporosis use
antiresorptive therapy for 3-5 years.
Correction of Hyperthyroidism
Bone response
16. β 51 year old man # elbow after fall off bicycle,
March 2017
β Keen club cyclist
β Previous #s in falls off bike
β Hip 2007
β Pubic ramus 2013
Case 2
17.
18.
19. β FBP
β Admission profile, bone profile, PSA
β ESR / CRP
β PPE, Bence Jones
β Testosterone
β TFTs, 24hr urinary cortisol and calcium
β Coeliac screen
β All normal
Case 2 Investigations
20.
21. β Sherk et al. (2014)14 cycling (F)>1 year of competition history26β41Longitudinal (1 year) BMD of the hip decreases 1β2% after a
year of training and competition.
β GΓ³mez-Bruton et al. (2013) 20 cycling19 control (M)10 h/wk16.4
Cross-sectional Lower BMD of young cyclists in some places.
β Guillaume et al.(2012)29 cycling (M)25,000β30,000 km/year26β5 Descriptive ND between groups on calcium and vitamin D
intake
β Nichols et al.(2011)19 cycling
18 control (M)11.1 h/wk
4.5 h/wk50β57Longitudinal (7 years) Cycling has not demonstrated positive effects on BMD. High rate of
osteopenia/osteoporosis in cyclists (84.2% and 89.5% after seven years)
β Abe et al.(2014) 14 cycling (masters)13 moderately active youngsters (M)17 years of training 20β71 Cross-sectional BMD lower
in femoral neck of cyclists versus control. ND in BMD of lumbar spine.
β Olmedillas et al. (2011)21 cycling
23 control (M)10 h/wk 4 h/wk15β21 Cross-sectional Lower BMD of the hip, leg and pelvis of cyclists versus control
β Campion et al. (2010)30 cycling
30 control (M)22β25 h/wk
<1 h/wk29 Β± 3 28 Β± 4 Cross-sectional Professional cycling affected negatively BMD (femoral neck: β18%)
β Penteado et al.(2010)31 cycling
28 control 21 h/wk20β30 Cross-sectional ND in BMD versus control
β Barry et al.(2008)14 cycling (M)>450 h/y27β44 Two groups: low and high doses of calcium supplementation during one year
Both groups decreased BMD of the hip and sub-regions, regardless of calcium intake
β Rector et al.(2008) 27 cycling 18 marathon (M)β₯6 h/wkβ₯6 h/wk20β59 Cross-sectional 63% of cyclists had lumbar spine
osteopenia and were 7-fold times more likely to have osteopenia
Cycling and BMD
22. β Is low BMD in cyclists associated with higher
fracture rate?
β Why low BMD?
β Effect of Skeletal loading on osteocyte
β Lazy Bones may be right !
β Advise weight bearing exercise
Cycling and Fracture
24. β 68 year old man presented with tiredness
after small CVA.
β PMH of AF.
β Lower thoracic back pain
Case 3
25.
26.
27.
28. β FBP
β Admission profile, bone profile, PSA
β ESR / CRP
β PPE, Bence Jones
β Testosterone
β TFTs, 24hr urinary cortisol and calcium
β Coeliac screen
β Testosterone 2.8 (6.7-25.7)
Case 3 Investigations
29. β Very aware of postmenopausal bone loss. but
hypogonadism in men?
β Studies suggest up to 50% of osteoporosis in men is
secondary.
β Alcohol probably accounts for half of this and
hypogonadism ? a quarter.
Hypogonadism and Osteoporosis
30. β Testosterone(T) has direct effect on bone cells
through androgen receptor.
β T has indirect effect through peripheral
conversion of T to oestrogen via aromatase in fat
tissue.
β Stronger correlation between oestrogen and
BMD and fractures than T in men.
β Low T could be linked to increased fracture rate
through reduced muscle strength and falls
Testosterone and bone
31. β Treat hypogonadism in men when it is
symptomatic.
β Treat osteoporosis with bisphosphonates
(Denosumab) as per guidelines.
β Treat osteoporosis with testosterone
replacement when there is no alternative
therapy available.
Treatment
32. β Aromatase inhibitors
β Treat when T score is less than -2.0
β Androgen deprivation therapy
β Treat with bisphosphonates ( oral, iv)
β Denosumab licensed USA
Iatrogenic
34. β 45 year old man presented with acute mid
thoracic back pain.
β Keen runner up to marathon level.
β Fatigue recently, not running and weight gain.
β No past medical history.
β X-rays showed 3 thoracic vertebral fractures
Case 4
35. β FBP
β Admission profile, bone profile, PSA
β ESR / CRP
β PPE, Bence Jones
β Testosterone
β TFTs, 24hr urinary cortisol and calcium
β Coeliac screen
β Urine Cortisol 4020 (<210) and subsequent CT
showed adrenal carcinoma
Case 4 Investigations
36.
37.
38.
39.
40. β Endogenous is very rare compared with
exogenous corticosteroids.
β Complex effect on bone metabolism.
β Direct bone cell effects with initial rapid
increase in bone resorption followed by long
term decrease in bone formation.
β Indirect effects through Vit D and calcium,
growth hormones, IGF and hypogonadism.
Glucocorticoid Induced Osteoporosis
(GIO)
41. β Standard relationship between BMD and
fracture risk does not apply.
β In GIO apply higher threshold for treatment
( T score -1.5).
β Bone microstructure is important.
β Trabecular bone is affected most.
β Vertebral fractures are often asymptomatic.
GIO and Fracture
42. β Lifestyle, weight bearing exercise.
β Calcium (1000mg) and Vit D (800iu).
β Depending on fracture risk
β Bisphosphonates oral (IV)
β Denosumab if C/I to bisphosphonates.
β New ACR guidelines
β Pred dose 2.5mg for > 3 months or 5 gm total
β Based on fracture risk and age < or > 40yrs.
Management of GIO