osteoporosis and its management; traditional and recent

1. RECENTADVANCESINT/TOF
OSTEOPOROSIS
DR SOURYA MOHAPATRA
1ST YR PGT
DEPT OF PHARMACOLOGY

2. INTRODUCTION
Osteoporosis is a condition characterized by deterioration of bone mass and
microarchitecture of bone resulting in increased bone fragility and propensity
to fracture .
A/T TO WHO: T SCORE : < -2.5,DEFINES OSTEOPOROSIS.
SEX INCIDENCE:Women-30-5O%, Men -15-30%.
AGE INCIDENCE: women >=45yrs, Men >60-70 yrs.
SITES INVOLVED: Vertebral bodies ,distal radius ,proximal femur .But
generalized fragility occurs and fractures at Ribs and long bones are
common.
# incidence increases with age and spine and hip # a/w bad prognosis.

5. PATHOPHYSIOLOGY OF OSTEOPOROSIS

7. TYPES OF OP
1) PRIMARY :
A)Type 1: loss of trabecular bone owing to estrogen lack.
B)Type 2: loss of cortical and trabecular bone in men and women due to
long term remodelling insuff,dietary in adequacy .
2)SECONDARY

9. PHARMACOTHERAPYOF OSTEOPOROSIS

13. CALCIUM
 The crystalline bone is made of 99% Calcium (of total body calcium)
along with p04.(hydroxyapatite)
 Ca.Is essential for normal bone development and its
maintainance through all stages of life.
 Normally Ca.rich milue is essential to impregnate the
osteoid (organic matrix) laid down by osteoblasts.
 In osteoporosis suppresses bone turnover and
incr.Bmd.
PREP. AVAILABLE:
 CA.CARBONATE: M/C USED-1000mg/d.
 IF >50 YRS- 1200mg /d

14.  Given along with Calcium.
 Increases Ca. absorption from
intestine ,suppresses bone
remodelling and increases BMD
in individuals with marginal or
deficient vit D status.
 Also decreases the fracture
incidence in individuals.
PREPARATIONS AVAILABLE:
 Calciferol(D2)- oily solution in
gelatin capsules -25000/50000
IU caps wkly once.
 Cholecalciferol(D3)- ORAL AND
IM INJ given 3-4 wk interval.
 Calcitriol : 0.25 -1mcg orally on
alt.days.
 Alfacalcidol :prodrug –rapidly
hyrolysed to calcitriol in liver .
Dose:1-2 mcg/day.
VIT -D

17. CONT:
At tissue level:
bone turnover due to decr.in bone resorption.
net positive whole body bone balance,Thus reduces risk of vert.# by
, 70% ,non vert # by 25% and hip # by 40%.
At cellular level:
osteoclast recruitment ,adhesion,depth of resorption site,release of
cytokines in macrophages.
osteoblast no.and differentiation.

18. CONT
 Alendronate,Risedronate ,Ibandronate ,Zolendrenic acid-approved
for post menopausal OP.
 Alendronate ,Risedronate ,Zolendronic acid –for T/T OF steroid
induced OP.
 Risedronate and Zolendrenic acid for prevention of steroid
induced OP.
 Alendronate ,Risedronate,Zolendronic acid for t/t of OP in men.

19. CONT:
PREP AVAILABLE:
 Alendronate: oral
Dose: 10mg OD or 70 mg once wkly.
Prevention: 5mg OD or 35mg once wkly for 2yrs.
Decreases vert# risk by 50%,and multiple # by 90% and hip # upto 50%. .
Given in the morning with full glass of water and pt.is advised not to lay down for
30mins.
 Ibandronate: oral ,i.v
Oral: 2.5mg OD or 150mg once a mn.
Iv: 3mg every 3mn.
Vert# decreased by 40%.
 Resedronate: oral
IR: 5mg OD or 35mg once wkly or 150mg once a mn.
DR: 35mg once wkly.
Vert #risk decreased by 40-50% over 3yrs.
 Zolendronic acid: iv
INJ 5mg once a yr. reduces vert #risk by 70% ,hip # by 40% and non vert # by 25%.

20. SERM:SELECTIVE ESTROGEN
REUPTAKE INHIBITORS
 Osteoblasts express ER alpha and beta receptors .
 Estrogen inhibits osteoclast action directly.
 All SERMS bind to ER and decrease bone resorption and osteoclastic
activity.
PREP AVAILABLE:
 RALOXIFENE:FDA APPROVED IN POST MENO.OP.
DOSE:60MG/D ,DECRE.VERT#BY 30-50% IN POST
MENOPAUSAL WOMEN.
 LASOFOXIFENE:3RD GEN SERM ,increases bmd and decrea. in bone
turnover in post meno.op.
 BAZEDOXIFENE:FDA APPROVED IN 2013 FOR POST MENO.OP.
DOSE :20MG WITH 0.45MG CONJUGATED ESTROGEN.

22. CALCITONIN
 Inhibits osteoclastic bone resorption and inc. bone mass in pts
.with OP ,most prominently in pts.with high intrinsic rates of bone
turnover.
 In OP,reduces the incidence of vertebral compression # by about
40% in postmenopausal women.
Prep available:
 Calcitonin nasal spray :200U /d. in alt.nostril every day.

23. PTH AND RELATED COMPOUNDS:

24. TERIPARATIDE
 Recombinant Form of PTH .FDA approved in OP.
 It is an OSTEO ANABOLIC HORMONE,the only drug causing bone
formation.
INDICATIONS:
 Postmenopausal women with OP at high risk of # or previous h/o
OP #.
 Men with primary or hypogonadal OP at high risk of #.
 Steroid induced OP.
 Pts.With high risk of # or who have failed or intolerant to other
osteoporotic T/T.

25. CONT
MOA:
 OSTEOBLAST FUNC.
 INCREASES GI CA ABSORPTION,
 INCR. RENAL TUBULAR REABSORPTION OF CA.,
 BMD (by9-13%) ,BONE MASS AND STRENGHT.
 Decreased vertebral fracture by 65-69%.
PREP AVAILABLE:
 Inj FORTEO : 20mcg s/c daily for 2 yrs. Given along with anti resorptive
therapy.
 The use of teriparatide is limited to 2 years in any life span, and this is
because of the development of OSTEOSARCOMA in pre-clinical animal
studies and the decrease of effects to increase BMD.
 Recently Denosumab and Teriparatide Administration (DATA) study
indicated that the combination of denosumab and teriparatide produced
a more prominent effect on BMD than each drug did alone .

26. OTHERS
 Strontium ranelate :previously used but now withdrawn
due to cardiac events and thromboembolism.
 Thiazides: decreases urinary Ca excretion .

28. DENOSUMAB
 Fully human monoclonal IGG2 ab that inhibits RANKL.
MOA:
 RANK-L is member of TNF and expressed on osteoclasts.
 RANK-L binds to RANK and promotes osteoclast proliferation and
differentiation of OC.
 Denosumab inhibits the RANK AND RANK-L interaction and thus
inhibits bone resorption in osteoporosis.
 In June 2010 FDA approved its use for postmenopausal op.

29. CONT
PREP AVAILABLE:
 Inj 60 mg S/C once every 6MN.
 Supplement with Ca 1000mg/d and Vit D 400IU/D.
 S/E: BACK PAIN,HEADACHE, OSTEONECROSIS OF JAW

30.  Humanized monoclonal ab against Sclerostin and is under clinical
development.(PHASE 3)
 Sclerostin, a glycoprotein selectively secreted from osteocytes is an inhibitor of Wnt
signaling and potently inhibits bone formation.
 A phase 3 study demonstrated that Romosozumab was shown to markedly
increase the BMD of lumbar spine by 13.3% and proximal femur by 6.8% in just 12
months and prevent vertebral and clinical fractures in postmenopausal women with
osteoporosis .
 Mouse and human genetic data indicate that canonical Wnt–β-catenin signaling
enhances osteoblastic bone formation and inhibits bone resorption via direct and
indirect mechanisms.
ROMOSOZUMAB

31.  Abaloparatide is a synthetic analog of PTH-related protein (PTHrP) .
 Abaloparatide is currently under development, most of its clinical data
come from a phase 3 clinical study (Abaloparatide Comparator Trial in
Vertebral Endpoints [ACTIVE]).
 IT increased BMD and reduced vertebral and non-vertebral fractures in
postmenopausal women with osteoporosis over 18 months . The
reduction of non-vertebral fractures by abaloparatide was significant
when compared with placebo.
 The superior anti-fracture effects, especially on non-vertebral fractures
may render abaloparatide a safe and effective anabolic agent when
approved for the treatment of osteoporosis.
ABALOPARATIDE

32. ODANACATIB
 Cathepsin –K inhibitor.
 Cathepsin –K is a protease expressed in osteoclasts which degrades
the collagen type 1 in the bone matrix.
 Odanacatib inhibits cathepsin –k and thus dissolution of matrix
,bone resorption and thus improves BMD in postmenopausal op.
 But development of drug was withdrawn recently due to its serious
side effects(e.g stroke and atrial fibrillation)

33. IGF-1 AND BONE
 GH and IGF-1 are fundamental in achieving a normal longitudinal bone
growth and mass during the postnatal period and, in association with sex
steroids, play a major role in bone growth and development .
 IGF-1 is considered essential for longitudinal bone growth, skeletal
maturation, and bone mass acquisition not only during growth but also in
the maintenance of bone in adult life .
 Lower serum IGF-1 levels in women are strongly associated with low
BMD and an increased risk of osteoporotic fractures.
 In bone IGF-1 Is PTH dependent .Circulating IGF-1 Contributes to cortical
bone integrity.
 In future can serve to maintain the bone integrity in anorexia nervosa pts.

34. INTEGRIN ANTAGONISTS
 Integrin mediates cell and cell matrix interactions.
 Osteoclast adhesion to the bone surface imp.for bone
resorption.
 Integrin inhibitors inhibit this interaction and thus inhibit
bone resorption and incr. BMD.
 STILL UNDER STUDY.

38. OTHERS
Biomaterials:
 Chitosan biopolymers
 Strontium –modified calcium phosphate cement.
 Titanium-coated with ca.phos.
 Coated with collgen type 1
Gut serotonin inhibitors: Studies on rat models indicated that SSRIs like
fluoxetine and venlafexine positively or negatively affected the bone loss
in rats with periodontitis.

41. REFERENCES
1)13th edition GG.
2)KATZUNG BOOK.
3)19th edition Harrison.
4)APLEY”S ORTHOPAEDICS BOOK.
5)Pub med articles and journals.