Osteoporosis Seminar

1. OSTEOPOROSIS

2. • “Osteo” means bone, and “porosis” means
something that has holes in it, like a sponge.
• Osteoporosis is a progressive disease which
causes bone to become more porous,
gradually making it weaker, more brittle and
likely to break.

3. Osteoporosis
A disease characterized by:
– low bone mass
– micro architectural deterioration of the bone tissue
Leading to:
– enhanced bone fragility
– increase in fracture risk
Normal bone Osteoporotic bone
Bone Strength = Bone Mass + Bone Quality

4. Normal bone

5. Osteoporotic bone

6. Defining Osteoporosis
• National osteoporosis foundation-“Systemic
skeletal disease characterized by low bone
mass and microarchitectural deterioration of
bone tissue, leading to enhanced bone fragility
and a consequent increase in fracture risk”

7. What is Osteoporosis?
• Loss in total mineralized bone
• Disruption of normal balance of bone breakdown
and build up
• Bone mass -peak by 3rd decade of life
• Major mechanisms:
–Slow down of bone build up: osteoporosis seen in
older women and men (men after age 70)
–Accelerated bone breakdown: postmenopausal

8. Osteoporosis
• A major public threat for more than 28 million
Americans. 80 % are women.
• One in 2 women and One in 8 men over 50 will
have an osteoporosis related fracture.
• 50% of Indians >50 yrs have osteopenia
• The estimated cost for osteoporotic and associated
fractures is 38 million a day.

9. Most common sites of fracture
–Vertebrae (Spine)
–Distal Radius (Wrist)
–Proximal femur/Pelvis (Hip)
Bones become fragile and more likely to break.

10. • Hip fractures almost always require surgery and hospitalization.

11. • Spine fractures have serious consequences
such as loss of height, severe back pain, and
deformity.

13. 163 million in
2001
230 million in
2015

14. Classification
Primary:
Type 1:
Postmenopausal
osteoporosis
Type 2:
Senile Osteoporosis
Secondary:
Systemic diseases
Drugs

15. Classification of Osteoporosis
• Primary osteoporosis
Loss of bone mass that is not connected to another
disease
• Secondary osteoporosis
Loss of bone mass that is related to another illness or
to the use of drugs

16. Risk Factors
• Primary osteoporosis
1) Female Gender
–3X more likely to have hip or vertebral fracture
than men
–6X more likely to have forearm fracture
2) Smoking
3) Low Body Weight (less than 58 kilos)

17. Risk Factors (cont’d)
4) Sedentary Lifestyle
5) Excessive Alcohol Intake
6) Old age
7) Family history of osteoporosis

18. • Secondary osteoporosis
1) Long term glucocorticoid or immunosuppressive
therapy
2) Anticonvulsant therapy-phenytoin
3) Malabsorptive disorders
4) Calcium and Vit.D deficiency
5) Hypogonadism
6) Chronic renal disease
7) Hyperthyroidism
8) Hyperparathyroidism
9) Sudeck’s osteodystrophy(localised osteoporosis)

19. Genetic factors
• Bone density of the spine and hip are more similar in identical
twins than in nonidentical twins.
• Genetic factors may involve structural genes, such as those
that affect collagen, or regulatory genes, or those control bone
turnover.
• Increased risk for the development of osteoporosis in
individuals who have a family history of the disease.
• Ethnic differences in bone mass and fracture incidences have
pointed to race as a risk factor for osteoporosis. Data have
shown that blacks in both Africa and North America appear to
be less vulnerable to hip fractures.

20. Osteoporosis
• Average female bone mineral density peaks at
age 35, slow decline thereafter
• Density loss is accelerated post-menopausally

21. Menopause / Estrogen deficiency
• Gonadal failure at the time of
menopause causes bone loss.
• Estrogen replacement therapy
decreases the risk of osteoporotic
fracture.
• Removal of the ovaries prior to
natural menopause causes a
complete loss of estrogen.
Therefore, oophorectomy carries a
significant risk (estimated at 50%)
for osteoporosis.
Menopause effect- 25 years

22. Calcium
• The role of calcium intake as a risk factor in
osteoporosis is controversial.
• Calcium supplements given to postmenopausal
women have usually shown a protective effect on
the rate of cortical bone loss
• However, this effect is less than that seen with
estrogen therapy.
• Although calcium by itself will not counteract the
effects of menopausal estrogen deficiency, a
reasonable intake of calcium may remove the
threat of bone loss exacerbation due to calcium
deficiency.

23. Physical activity
• The level of physical activity is related to lifestyle – rural or
urban, active or sedentary.
• An urban lifestyle characterized by physical inactivity is
associated with osteoporosis, whereas a rural lifestyle,
mobility, and outdoor activity are associated with a lower
fracture risk.
• Patients recuperating from hip fractures have reduced
levels of physical activity and increased bone resorption
rates.
• Being bedridden may also induce low vitamin D levels,
which in turn, can affect the parathyroid glands and induce
resorption.

24. Other Risk Factors
• High levels of alcohol consumption and cigarette smoking.
Fractures from falls and poor nutrition are two contributions
of alcohol abuse.
• Alcohol may affect the remodeling cycle by reducing the rate
at which osteoblasts form bone matrix. Cigarette smoking
has an adverse effect on bone mass in women.
• Thinness or a small body build has been found in most
studies to be associated with an increased risk for
osteoporosis. This may be attributed to lower levels of
circulating estrogen in thinner women than in obese or
heavy women
• Women who have never had a child may have an increased
risk for osteoporosis as compared to women who have had
at least one child

25. The Diagnosis of Osteoporosis Can be
Made Clinically By
• Fragility fracture
– Often defined as a fracture occurring with a fall
from standing height or less
Vertebrae are larger in size in Caucasians as compared to Asians.
Hence, higher BMD is seen in them
http://qjmed.oxfordjournals.org/content/97/2/95.full

26. Routine Procedures
• Routine
– History and physical examination
– Blood cell count, sedimentation rate, serum calcium,
albumin, creatinine, phosphate, alkaline phosphatase
and liver transaminases
– Lateral radiograph of lumbar and thoracic spine
– Bone densitometry (DXA)
• Other procedures
– X-ray – vertebral fracture assessment
– Markers of bone turnover, when available

27. Medical History
• Symptoms
– Osteoporosis symptoms: none
– Fracture symptoms: variable
•Pain and deformity (hip, spine, forearm, etc.)
•Frequently no symptoms (vertebral fractures)-
1.Asymptomatic fracture-- H/o LBP few months back.
2. If LBP+ Point tenderness Do X ray to Diagnose fracture
• Risk factors
– Risk factors for osteoporosis
– Risk factors for fracture

28. Amanda D. Green. JAMA 2001 vol.292(23)
Physical Examination

29. Laboratory Investigation
Test parameter Associated diseases
Differentiated blood count Hematological pathology
ESR or C-reactive protein (D) Differential diagnostics of inflammatory causes of spinal
deformities
Serum calcium (B) ↑ Primary hyperparathyroidism or other causes of
hypercalcemia
↓ e.g. secondary hyperparathyroidism, malabsorption
Serum phosphate ↓ Secondary hyperparathyroidism, malabsorption
Alkaline phosphatase (AP) ↑ Osteomalacia
Gamma-GT Helpful in discriminating AP increases of skeletal origin
from those of hepatic origin
Serum creatinine and eGFR (C) ↑ Renal osteopathy
Serum protein electrophoresis (C) Multiple myeloma, MGUS (monoclonal gammopathy of
uncertain significance)
(A-D: evidence level)
DVO Guidelines, Osteology 2011:55-74

30. Laboratory Investigation
(A-D: evidence level)
DVO Guidelines, Osteology 2011:55-74
Test parameter Associated diseases
TSH (B) < 0.3 mU/L endogenous or caused by excessive thyroxine
treatment (risk factor for fracture)
25-(OH)-D Vitamin deficiency
Intact PTH
in Hypo-, Hypercalcemia
Differentiation of primary HPT, secondary HPT,
hypercalcemia of malignancy
Testosterone in men Hypogonadism
Tryptase (evt.) Mastocytosis
Bone resorption marker Evaluation of bone turnover
Four important basic tests to differentiate OP from other causes
•Serum Calcium
•Alkaline Phosphatase
•CBC with ESR
•RFT

31. Diagnosis of osteoporosis
• Imaging studies
1) Plane X-ray-30 to 80 percent loss required to be
identified on X-ray
2) Dual-energy x-ray absorptiometry (DEXA)- BMD
T-scores—Represent the no. of SD from mean body
density in healthy young adults
Z-scores—Represent the no. of SD from the normal
mean value for age and sex matched control
3) Quantitative CT – For spine
4) Ultrasound- Calcaneum

32. Interpreting T-scores (WHO)
-1.5

33. Screening Options
• Single Photon absorptiometry
–Can only be used at radius or calcaneus
• Dual Photon absorptiometry
–Can be used at deeper sites (spine,hip)

34. Management
 Non-pharmacological:
1. Lifestyle modification
2. Adequate intake of calcium &
Vit D
3. Regular weight bearing &
muscle strengthening exercises
4. Avoidance of tobacco
5. Treatment of alcoholism
6. Fall prevention
 Pharmacological:
1. Bisphosphonates
2. Calcitonin
3. Calcium & Vit D
4. Raloxifene
5. HRT
6. Teriparatide
7. Fluoride
8. Strontium

35. Prevention
• Building strong bones in childhood and
adolescence is the best defence.
• A balanced diet rich in calcium and Vitamin D
• Weight bearing exercise
• A healthy lifestyle with no smoking or
excessive alcohol intake.
• Bone density testing and medication when
appropriate.

36. Calcium
• Is needed for heart muscles, and nerves to
function properly.
• Inadequate amounts contribute to osteoporosis.
• Appropriate calcium intake falls between 1000
and 1300 mg a day
How to get Calcium:
• Consume calcium rich foods such as, low-fat
milk, cheese, broccoli, and others.
• Calcium supplement, if dietary calcium
consumption is inadequate

37. Recommendations: Calcium
• Bone forming EAR RDA
– Infancy 500 – 800mg 700- 1000mg
– Growth spurts 800 -1000mg 1000 – 1200mg
• Bone maintenance
– Male 800 – 1000mg 1000 – 1300mg
– Female
• Pregnancy
• Lactation
• Menopause
• Bone decay
– Above 65 1000mg 1300mg
– Osteoporosis

38. Calcium Summary
• Evidence suggests that calcium supplementation reduces
bone loss and fractures
• Some studies suggest that calcium supplements may increase
vascular disease risk
• Effects on vascular disease are controversial and expert
opinion is divided
• Calcium is a simple first step in promoting bone health, but
excessive amounts could have adverse health effects
• CCM is better soluble and more bioavailable hence absorbed
more into the body.

39. Vitamin D
• Is needed for your body to absorb calcium.
• Comes from 2 sources : the sun and
Fortified dairy products, egg yolks, saltwater
fish, and liver.
• Need 400-800 IU a day.

40. Vitamin D - One outfit for All
• Anti aging,
• Anti cancer,
• Anti diabetes,
• Anti infective,
• Anti depressant,
• Anti hypertensive,
• Cardiac protective

41. National Osteoporosis Foundation
Vitamin D Recommendations
• Deficiency is when 25-hydroxyvitamin D blood
level of below 10 ng/ml (25nmol)
• Insufficiency is defined as a 25-hydroxyvitamin
D blood level between 10 ng/ml - 30 ng/ml
• Sufficiency is defined as a 25-hydroxyvitamin D
blood level of 30ng/ml or higher

42. Age Male Female Pregnancy Lactation
0–12 months*
400 IU
(10 mcg)
400 IU
(10 mcg)
1–13 years
600 IU
(15 mcg)
600 IU
(15 mcg)
14–18 years
600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
19–50 years
600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
51–70 years
600 IU
(15 mcg)
600 IU
(15 mcg)
>70 years
800 IU
(20 mcg)
800 IU
(20 mcg)
* Adequate Intake (AI)
Recommended Dietary Allowances (RDAs) for Vitamin D [1]

43. • Ultraviolet (UV) B radiation with a wavelength
of 290–320 nanometers penetrates uncovered
skin and converts cutaneous 7-
dehydrocholesterol to previtamin D3, which in
turn becomes vitamin D3.
• Season, time of day, length of day, cloud cover,
smog, skin melanin content, and sunscreen are
among the factors that affect UV radiation
exposure and vitamin D synthesis.
Sun Exposure

44. Sun Exposure
• Approximately 5–30 minutes of sun exposure
between 10 AM and 3 PM at least twice a
week to the face, arms, legs, or back without
sunscreen lead to sufficient vitamin D
synthesis.
• Minimal Erythrismal Dose.
• White skin synthesis more vit D than
Black/Brown during short time exposure.

45. Recommendations:
NICE,NOGG,CKS, NHS
• Due to a lack of supporting evidence, vitamin
D supplementation for active people younger
than 65 years of age is not recommend.
• People older than 65 years of age and those at
risk of vitamin D deficiency should aim for a
daily vitamin D intake of 10 - 20 micrograms
(400 -800 units).

46. Recommendations:
NICE,NOGG,CKS, NHS
• Evidence suggests that vitamin D alone is not
effective in reducing fractures in older people
(when compared with placebo),
• It can reduce the risk of falls in people 60 years of
age and older living in institutionalized care or in
the community.
• For elderly people who are housebound or living
in a nursing home, a higher dose of 20
micrograms (800 units), along with a daily dose of
1.0 g to 1.2 g calcium, is recommended to reduce
the risk of fractures.

47. Suggestions
• Supplementation of Vitamin D & Calcium
should be considered on clinical suspicion.
• Aches & pain, cramps, restless legs in night,
frequent muscle pulls, knee pain.
• Clinically deep bone tenderness – shin tender.
• Proximal muscle weakness.
• Low serum calcium + high Alk PO4, low Vit. D,
high PTH + Urinary excretion of Ca + P.

48. Summary: Calcium and Vitamin D
• Low calcium intake and vitamin D deficiency should be corrected in
all patients
• Hip fractures occur often in patients aged > 75-80 years and this
population is particularly prone to calcium and vitamin D deficiency
• In patients with low calcium intake, calcium alone induces small
increases in bone mineral density and possibly reduces fracture
incidence
• Low-dose vitamin D (400 IU/d) alone did not reduce fracture
incidence in a free living population
• Calcium and vitamin D supplementation in women living in nursing
homes decreases hip fracture incidence
Serum Vitamin D needs to be done in patients in whom
Bisphonates or Teriparatide has to be prescribed

49. Adverse outcome of high dosage

50. Exercise
• Physical activity increases bone mass, density,
quality and strength.
• Exercising regularly in childhood and adolescence
can ensure that you will reach peak bone density.
• Need to participate in weight bearing exercise. For
example, walking, dancing, jogging, stair climbing,
racquet sports and hiking.

51. Hip Protectors
• Padding that fits under clothing
• Multiple studies demonstrate effectiveness at
preventing hip fractures
• Likely cost effective
• Problem: adherence!

52. Prevention of Falls
• Correct visual and
hearing impairment
• Optimize medications
• Bathroom grab-bars and
nonskid mats
• Avoid throw-rugs and
slippery mats
• Keep electric and
telephone cords away
• Reduce clutter from
walking areas
• Nightlight in bedroom
and bathroom
• Handrails on steps and
stairs
• Walking aids, if needed
• Exercise for strength
and balance

53. Thank You

54. Bisphosphonates
• I generation:
Etidronate, Clodronate, Medronate
• II generation:
Alendronate, Pamidronate
• III generation:
Risedronate, Zoledronate

55. Osteoporosis Treatment:
Bisphosphonates
• Decrease bone resorption
• Multiple studies demonstrate decrease in hip and
vertebral fractures
• Alendronate, risodronate
• IV: pamidronate, zolendronate (usually used for
hypercalcemia of malignancy, malignancy related
fractures, and multiple myeloma related
osteopenia)
• Ibandronate (boniva): once/month
• Those at highest risk of fracture (pre-existing
vertebral fractures) had greatest benefit with
treatment

56. Treatment
• Bisphosphonates- most appropriate initial
treatment for women with osteoporosis
1)Alendronate (10 mg/day or 70 mg weekly),
• best when taken on empty stomach with
water, standing upright for 30 minutes,
risk of esophagitis
• Suppresses bone turnover in 6-12 weeks
• contraindicated in patients with active
upper GI disease
2)Risedronate (5 mg/day or 35 mg weekly)
• less apparant GI risk than alendronate

57. Treatment
3) Ibandronate (150 mg once a month oral or 2 mg i.v)
• 2,10 and 50 times more potent than risedronate,
alendronate and pamidronate respectively.
• Available in oral and i.v. form
4) Zoledronate
• Most potent bisphosphonate
• Used in malignant hyercalcemia, Paget’s disease
• Administered as infusion over 15 min.

58. Treatment
• Selective estrogen receptor modulator(SERM)
-Decreases bone turnover and reduces urinary
calcium
1)Raloxifene--best data among 2 in class, approved
for both prevention and treatment of
osteoporosis.(60mg/day)
2)Tamoxifen—not FDA approved, but some data to
suggest bone benefit

59. Treatment
• PTH (Teriparatide)-daily s.c.injections(50
micrograms). Stimulates differentiation of
bone lining cells and preosteoblasts to
osteoblasts
• Currently limited to those at very high fracture
risk or those unresponsive to bisphosponate
therapy due to high cost ($20/day) and risk of
osteosarcoma.

60. Treatment
• Calcitonin-acts as endogenous inhibitor of bone
resorption by suppressing osteoclasts
• Calcitonin from non-mammalian species is more
potent than human calcitonin(salmon calcitonin)
• nasal spray(100,200,400 IU). Less effect on bone
than bisphosphonates, risk of tachyphylaxis.

61. Treatment
• Estrogen / Progestin therapy
–No longer first line, but still an option in women
who may be contraindicated from or intolerant to
bisphosponates or raloxifene.
• Combination therapy- there are demonstrable gains
in using bisphosponates in combination with
SERMs, and estrogen therapy if no contraindications
and less than desired benefit on single osteoporosis
therapy

62. Strontium Ranelate
• As an alkaline earth element, strontium is similar to calcium in its
absorption in the gut, incorporation in bone & renal elimination
• Naturally present in trace amounts around 100 µg /g of bone
• Treatment simply makes more strontium available for
incorporation into bone.
• Short term: strontium atoms adsorbed on to the surface of
hydroxyapatite crystals
• Long term: some strontium exchanges with calcium in the bone
mineral
• . After 3 years' treatment, bone tissue contains 1strontium atom
for every 100 calcium atoms.

63. Emerging therapies
• Factors acting on receptors for osteoclasts
attachment.e.g.RANKL,osteoprotegerin,cathepsin
• Denosumab(6 mg/3months) s.c. injection
• Cytokines,Cathepsin and others are under clinical
trials.

64. Principles of surgical treatment
• Use of load sharing implant
• Biological fixation
• Impaction and compression
• Wide buttresses
• Long splintage
• Bone augmentation

65. Methods of fixations in osteoporotic
bones
• Hydroxyapatite coated pins
• PMMA cement augmentation of screws
• Locked plates-angular stability between screw and
plates
• Four cortex fixation
• Wider nails to be used
• Cancellous bone grafting-stimulation of healing
• Vertebroplasty and kyphoplasty-under trial

66. Ray Moynihan, journalist, Iona Heath, general
practitioner, David Henry, professor of clinical pharmacology.
BMJ 2002;324:886-891
• The social construction of illness is being
replaced by the corporate construction of
disease.
• A lot of money can be made from
healthy people who believe they are sick.
• A lot of money can be made by
telling healthy people that they are sick.

67. Thank You