Osteoporosis dr. mmp

971 views

Published on

Published in: Health & Medicine, Technology
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
971
On SlideShare
0
From Embeds
0
Number of Embeds
354
Actions
Shares
0
Downloads
14
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Parathyroid glands in man were discovered more than 120 years ago. Parathyroid hormone (PTH) was initially recognized as the major hormonal regulator of calcium homeostasis, a catabolic agent to stimulate osteoclastic bone resorption. By 1929 scientists were beginning to accumulate evidence that PTH could also have anabolic effects on the skeleton. PTH research lay relatively dormant for the next 30 years awaiting technological developments in purification and fractionation procedures that would make possible the sequencing of PTH.
    The intriguing question is how can a single hormone have such opposing actions, both mediated by osteoblasts? The answer is found in the method of delivery. When the skeleton is continuously exposed to exogenous PTH, the result is an increase in bone resorption. When PTH is delivered intermittently, bone formation is stimulated.
    At present, the agents approved by the Food and Drug Administration (FDA) for the treatment of osteoporosis are anti-resorptive agents, that is, they reduce bone turnover and result in small but significant increases in bone mass. An agent that would increase bone mass substantially, strengthen bone mass, and restore bone architecture would have to be an anabolic agent. Some clinical research scientists suggest that parathyroid hormone may fill that role.
    Aurbach GD, Potts JT Jr. Parathyroid hormone. Am J Med. 1967;42:1-8.
    Dempster DW, Cosman F, Parisien M, Shen V, Lindsay R. Anabolic actions of parathyroid hormone on bone. Endocr Rev. 1993;14:690-709.
    Whitfield JF, Morley P, Willick GE. The bone-building action of the parathyroid hormone. Implications for the treatment of osteoporosis. Drugs & Aging 1999;15:117-129.
    Cosman F, Lindsay R. Is parathyroid hormone a therapeutic option for osteoporosis? A review of the clinical evidence. Calcif Tissue Int. 1998;62:475-480.
  • Parathyroid glands in man were discovered more than 120 years ago. Parathyroid hormone (PTH) was initially recognized as the major hormonal regulator of calcium homeostasis, a catabolic agent to stimulate osteoclastic bone resorption. By 1929 scientists were beginning to accumulate evidence that PTH could also have anabolic effects on the skeleton. PTH research lay relatively dormant for the next 30 years awaiting technological developments in purification and fractionation procedures that would make possible the sequencing of PTH.
    The intriguing question is how can a single hormone have such opposing actions, both mediated by osteoblasts? The answer is found in the method of delivery. When the skeleton is continuously exposed to exogenous PTH, the result is an increase in bone resorption. When PTH is delivered intermittently, bone formation is stimulated.
    At present, the agents approved by the Food and Drug Administration (FDA) for the treatment of osteoporosis are anti-resorptive agents, that is, they reduce bone turnover and result in small but significant increases in bone mass. An agent that would increase bone mass substantially, strengthen bone mass, and restore bone architecture would have to be an anabolic agent. Some clinical research scientists suggest that parathyroid hormone may fill that role.
    Aurbach GD, Potts JT Jr. Parathyroid hormone. Am J Med. 1967;42:1-8.
    Dempster DW, Cosman F, Parisien M, Shen V, Lindsay R. Anabolic actions of parathyroid hormone on bone. Endocr Rev. 1993;14:690-709.
    Whitfield JF, Morley P, Willick GE. The bone-building action of the parathyroid hormone. Implications for the treatment of osteoporosis. Drugs & Aging 1999;15:117-129.
    Cosman F, Lindsay R. Is parathyroid hormone a therapeutic option for osteoporosis? A review of the clinical evidence. Calcif Tissue Int. 1998;62:475-480.
  • See the weakening in bone architecture as the disease is progressing to severe osteoporosis
  • In the osteoporotic patient, the entire skeleton is susceptible to fracture, resulting in significant disability, limited physical activity, and mortality
    Whereas the entire skeleton is at risk for fracture, vertebral fractures are the most common, accounting for approximately 46% of all osteoporosis-related fractures, followed by the hip (19%), wrist (16%), and nonvertebral fractures (19%).8 Fractures of the hip and spine – most frequently observed throughout the postmenopausal period – are associated with significant morbidity and increased mortality.3,4
    Because the entire skeleton is at risk for osteoporosis, osteoporotic fractures have widespread adverse effects on the body, including the gastrointestinal, respiratory, genitourinary, and craniofacial systems, although exact prevalence rates are unknown.3
  • The incidence of ostéoporoses is very high in women & more than 30% of women succumb to one or more vertébral fractures over the age of 50
  • Asia by 2050 will have the maximum no. of osteoporotic hip fractures by 2050
  • Vertebral fractures remain undetected in clinical practice and are a major cause of mortality and morbidity
    Almost 20% of patients with a prevalent vertebral fracture experience an additional fracture within a year
    Early detection is critical
    Vertebral fractures are frequently asymptomatic – many are only discovered by chance – and less than one third are actually diagnosed.9 Fracture of the spine may lead to crowding of internal organs and intestinal dysfunction or restrictive lung disease. Increased mortality and morbidity are associated with limited physical activity, back pain, skeletal deformity, height loss, and kyphosis. Vertebral fractures are associated with an increased risk for additional vertebral fractures and are predictive for the future development of nonvertebral fractures.9
  • Fractures occur at numerous sites over the entire skeleton (referred to as “nonvertebral fractures” in this presentation)
    Nonvertebral fractures impose significant limitations on a patient’s daily physical activities
    According to recent studies, undiagnosed vertebral fractures increase a patient’s risk for nonvertebral fractures, placing the entire skeleton at risk.9 Typical fracture sites include the hip, spine, wrist, and ribs, although all bones are susceptible to fracture.8
    Like vertebral fractures, certain nonvertebral fractures (eg, wrist fractures) are underdiagnosed and undertreated. According to a retrospective study of 1162 women 55 years of age or older, only 2.8% underwent a bone mineral density (BMD) scan, and 22.9% actually received treatment.11
  • Hip fracture is the most devastating consequence of osteoporosis, with a high rate of morbidity and mortality
    Although hip fracture is easily detected, less than 5% of patients are actually referred for medical evaluation and treatment
    Hip fractures are the most serious complication of osteoporosis.10 One in 5 patients dies within a year of fracture, and more than half fail to regain prefracture mobility and independence; experts estimate that almost one third of hip fracture patients require placement in a nursing home due to permanent disability.1,3 The profound effects of hip fracture are underscored by the fact that 80% of women over 75 years of age preferred death to the consequences of a hip fracture.3
  • Postmenopausal women with low BMD and an existing fracture after age 50 are the most at risk for fracture
    Identification of all other risk factors is critical for early diagnosis
    A wide range of risk factors is associated with an increased risk for fracture in all postmenopausal women.10 The main question is: what are the most important risk factors? A recent study of 7782 women aged 65 years and older evaluated the predictive value of low BMD and key risk factors for bone fracture (data were obtained from the Study of Osteoporotic Fractures [SOF]).19 The FRACTURE Index assessment tool comprised a set of 7 variables – age, BMD T-score, fracture after age 50, maternal hip fracture after age 50, body weight less than or equal to 125 lb (57 kg), smoking status, and the use of arms to stand up from a chair. This index was predictive for hip, vertebral, and nonvertebral fractures, indicating that the 7 risk factors identified in the FRACTURE Index delineate the most important characteristics of women at risk for osteoporotic fractures.19 The FRACTURE Index has since been validated by the EPIDOS fracture study (a multicenter prospective study on risk factors for hip fracture performed in 7575 elderly women living at home, aged 75 to 95 years).20 The FRACTURE Index can also be used with and without BMD in older postmenopausal women to predict their 5-year risk for osteoporotic fractures.19
    The importance of high-dose glucocorticoid therapy as a cause of osteoporosis should not be overlooked. Glucocorticoid therapy (prednisolone at or above 7.5 mg/day or equivalent doses of other glucocorticoids) is associated with significant bone loss within 3 to 6 months and an increased fracture incidence of 15% at 1 year. Fracture rates as high as 30% to 50% have been documented in patients on long-term glucocorticoid therapy.21
    Other secondary causes of osteoporosis include hypogonadism, anorexia nervosa, type 1 diabetes, pregnancy, hyperparathyroidism, acromegaly, chronic liver disease, alcoholism, and rheumatoid arthritis.1
  • The morbidity & disability index with the disease is very high & it is said that atleast 20% of patient who suffer from an hip fracture die within a year
  • The incidence of osteoporotic fractures is highest in women compared to any other diseases
  • Osteoporosis dr. mmp

    1. 1. OSTEOPOROSIS Prof. Dr. M. M. Prabhakar Medical Superintendent, Director Government Spine Institute, Prof. & Head Department of Orthopaedics, B. J. Medical College, Ahmedabad.
    2. 2.  Osteoporosis, which literally means “porous bone”, is a disease in which the density and quality of bone are reduced.  Bones become more porous and fragile  The risk of fractures is greatly increased  The loss of bone occurs “silently” and progressively  Often there are no symptoms until the first fracture occurs.
    3. 3.  Compact bone consists of closely packed cylindrical units called osteons.  The osteon consists of a central canal called the Haversian canal, which is surrounded by concentric rings (lamellae) of matrix.  Between the rings of matrix, the bone cells (osteocytes) are located in spaces called lacunae.
    4. 4. • Spongy bone consists of lattice of fine bone plates (trabeculae) that has small, irregular cavities containing red bone marrow. • The canaliculi connect to the adjacent cavities, instead of a central Haversian canal, to receive their blood supply.
    5. 5.  The bone tissue is composed of a hard matrix of minerals (mostly calcium and phosphorus) that is deposited around protein fibers (collagen). › Osteogenic cells – are precursor cells for all forms of connective tissue. › Osteoblasts – are responsible for bone formation that secret the organic substances and mineral salts used in ossification process. › Osteocytes – are osteoblasts that have stopped laying down new bone, but play a role in the maintaining the cellular activities of the bone tissue. › Osteoclasts – are cells found on the surface of the bone that are responsible for bone resorption.
    6. 6.    Bone resorping cells Use acids or enzymes to dissolve calcium and collagen of old bone Dissolved calcium reenters blood stream and is carried to various parts of the body
    7. 7.     Osteoblasts are cells that build bones. Produce collagen Then coat the collagen with a protein "glue" that holds the calcium in place. Calcium from the bloodstream then automatically adheres to the collagen, forming new bone material.
    8. 8.   Bone cells These maintain bones by maintaining the concentration of calcium
    9. 9.  The terms osteogenesis and ossification are often used synonymously to indicate the process of bone formation.  Osteoblasts, osteocytes and osteoclasts are the three cell types involved in the development, growth and remodeling of bones.  Bone formation occurs by three co-ordinated processes: initially osteoblasts deposit collagen rapidly, without mineralization, producing a thickening osteoid layer.
    10. 10.  The ossification process can occur by two ways: › Intramembranous ossification - involves the replacement of sheet-like connective tissue membranes with bony tissue. › Endochondral ossification involves the replacement of hyaline cartilage models with bony tissue.
    11. 11.  During childhood and the early years of adulthood, while the epiphyses are still open, the skeleton grows in length (growth), and the bones expand in diameter and achieve their external shape (modeling).  During bone modeling, osteoblasts and osteoclasts work independently of each other and on different bone surfaces - often over large surface areas.  The net balance is positive (i.e. there is increased bone mass) and bones reach their final external form and high bone density during this period.
    12. 12.  Both the growth and the modeling processes are controlled by hormones and by mechanical forces mechanical usage.  Around the age 20-25 years, peak bone mass is achieved as a result of these processes. Subsequently, there is continuous revision of bone through resorption and formation, a process known as remodeling.  Remodeling allows for the degradation of worn out bone from damaged and/or unused regions and for the deposition of minerals in regions of greater stress.
    13. 13.  Activation : Activation: via recruitment of osteoclasts by cytokines like IL-1, IL-6  Resorption: via proteo-lytic enzymes & acids secreted by osteoclasts  Coupling: recruitment of osteoblasts & secretion of matrix  Mineralization: deposition of Ca & phosphorous
    14. 14. The Bone Remodeling Cycle Osteoclast Osteoblast Osteoblast Recruitment Resorption Mineralization Osteoid Deposition
    15. 15. ► High Remodeling   Hyperparathyroidism  Hyperthyroidism  ► Hypogonadal (including post-menopausal) Others Low Remodeling  Involutional (Aging)  Glucocorticoids (high dose) HIV 
    16. 16. Normal Remodeling Osteoclast Overactivity Hypogonadal States Parathyroid and Thyroid Osteoblast Dysfunction Involutional (Aging) Glucocorticoids HIV
    17. 17.    To supply Calcium throughout our body To replace old bones Regeneration ensures bone remains strong and flexible
    18. 18.  Calcium Regulating Hormones  Glucocorticoids  Growth Factors  Tumor Necrosis Factors
    19. 19.  1, 25 (OH)2 Vit D (Calcitriol)  Calcitonin  Parathyroid Hormone (PTH)
    20. 20. Calcitriol Absorbs Ca from intestine Calcitonin Calcitonin α serum Ca PTH PTH α 1 / Serum Ca Bone formation Bone resorption Ca absorption from intestine Ca absorption from intestine Ca reabsorption from urine Ca reabsorption from urine
    21. 21. Aging  From 40s onwards bone mass starts declining gradually  Bone formation <Bone resorption  Bones become weak and danger for osteoporosis sets in
    22. 22. Normal Osteoporosis Osteopenia Osteoporosis Severe
    23. 23.   Osteoporosis is responsible for >1.5 million vertebral and non-vertebral fractures annually Spine, hip, and wrist fractures are most common 15 % 19 % 19 % Other Vertebral Hip Wrist 46 % NIH/ORBD (www.osteo.org), 2000
    24. 24. • Osteoporosis : Almost 50 % of post menopausal women over 50 years. Affects 200 million women worldwide Osteoporotic fractures • Approximately 30% of women over the age of 50 have one or more vertebral fractures • Approximately one in five men over the age of 50 will have an osteoporosis-related fracture in their remaining lifetime
    25. 25.  Osteoporosis is highly prevalent in India.  An estimated 61 million people in India are reported to be affected.  Life span of an average Indian has also increased and this also contributes to the increased incidence of osteoporosis.  Recent data indicate that Indians have lower bone density than their North American and European counterparts  Reported that osteoporotic fractures occur 10-20 years earlier in Indians as compared to Caucasians
    26. 26. 0523 Projected to reach 3250 million in Asia by 2050 926 1950 2050 1950 2050 1950 2050 001 Total number of hip fractures: 1950 = 1.66 million 2050 = 6.26 million 006 873 004 247 866 Projected number of osteoporotic hip fractures worldwide 1950 2050 Estimated no of hip fractures: (1000s) Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289
    27. 27.  Spine fractures (vertebral compression fractures) can cause intense back pain, and may eventually result in a gradual loss of movement and the inability to carry out daily chores. Arrr……hh ..Ouch
    28. 28.  They can lead to loss of height, and in severe cases the spine may curve to form what is termed a “hump”.
    29. 29.  Most common fractures (46%)  Insidious  Progressive  Often unrecognized  Associated with › Deformity, height loss, back pain › Morbidity and mortality  Predict future vertebral and nonvertebral fractures
    30. 30.  Entire skeleton can be involved › › › › › ›  Wrist Ankle Pelvis Humerus Rib Others Associated with significant disability
    31. 31. Hip Fracture   Most serious clinical event Morbidity is high › 50% do not regain independence › 50% do not regain previous mobility  Mortality is high › 1 in 5 patients die within 1 year  Patients not treated for osteoporosis
    32. 32.  Hip fractures almost always require surgery and in about a third of patients, result in loss of independent living.
    33. 33. Risk of Fracture All postmenopausal women with the following:         Low BMD Fracture after 50 years Age ≥65 years Maternal history of fracture after 50 years Low body weight (≤125 lb) Smoking Corticosteroid use Other secondary causes
    34. 34. Patients (%) Unable to carry out at least one independent activity of daily living r an afte : ear ture ne y frac O Unable to walk hip independently Death within one year 20% Permanent disability 30% 40% 80%
    35. 35. Annual incidence x 1000 2000 annual incidence all ages 1500 1000 1 500 000 250 000 hip 250 000 forearm 250 000 other sites 500 0 annual estimate women 29+ 513 000 annual estimate women 30+ 750 000 vertebral Osteoporotic Fractures 228 000 Heart Attack Stroke 1996 new cases, 184 300 all ages Breast Cancer The incidence of osteoporotic fractures is highest in women and more than heart attack, stroke and breast cancer put together
    36. 36. Non-modifiable If you are beyond 50 years of  age Caucasian /Asian race And feel you have more than  Advanced age onerisk factors  Female sex  Premature menopause (<45 years) Or Modifiable  Cigarette smoking  Excessive alcohol intake  Inactivity  Low body weight  Poor general health  Prolonged immobilization had a broken a bone after a minor bump or fall Need to consult immediately
    37. 37.     Initial physical examination X-ray. Laboratory blood tests. Bone densitometry (Bone Mineral Density-BMD).
    38. 38.  As osteoporosis has no obvious symptoms other than a fracture when the bone is already significantly weakened, it is important to go to the doctor if any of the risk factors apply to you.
    39. 39.   A number of different types of BMD tests are available, but the most accurate is DXA (dual energy X-ray absorptiometry). DXA is a low radiation X-ray capable of detecting quite low percentages of bone loss. It is used to measure spine and hip bone density.
    40. 40.    The World Health Organization has defined a number of threshold values for osteoporosis. The reference measurement is defined as healthy bone density in a young female of around 25 years. ‘ T- score’ is number that indicates whether or not bone loss has occurred -1 T score > -2.5 Normal bone mass Osteopenia Low bone mass - 2.5 Osteoporosis
    41. 41.  If the results of your BMD test show osteopenia or osteoporosis it does not automatically mean that you will have a fracture.  There are a number of therapies available that your doctor might prescribe that slow down the rate at which bone loss occurs and help prevent fractures.  In addition, there are important nutritional and lifestyle changes that you can make to help reduce your risk of fracture.
    42. 42.  Encourage good general nutrition  Promote a diet with adequate calcium content  Promote adequate vitamin D intake  Regular weight-bearing exercise  Avoid smoking and alcohol  Prevention of falls
    43. 43. 1. Exercise is not just important to generalhealth, it helps build bone mass in youth and slows down bone loss in adults Weight-bearing exercise in particular is good for bone health. This type of exercise includes walking, jogging, tennis and similar sports, aerobics and dancing.
    44. 44.  Both calcium and vitamin D are essential to maintain healthy bones. As we grow older we absorb calcium from food less efficiently. This means that over time we need higher amounts of calcium Milk and other dairy products like cheese and yogurt are the most readily available dietary sources of calcium. Other good food sources include Tofu, soya bean, Apricots, Almonds, fishes and fruits like Orange Good dietary sources of vitamin D include oily fishes, fortified dairy foods and egg yolks Avoid : caffeine , high salt diet, alcohol – which increase calcium loss
    45. 45. Take an additional measure to reduce the risk of fractures by fall-proofing your home.       Reduce clutter at floor level Wear well-fitting shoes or slippers Make sure surfaces are slip-proof: rugs should have a skid-proof backing Have grab rails installed in the bathroom and toilet Make sure that lighting is bright enough. Have regular eye checkups –vision is crucial in judging distances and detail.
    46. 46.  Calcium and Vitamin D supplementation is basic requirement before any other treatment is begun. Recommended daily dietary allowance (RDA) › Vitamin D (RDA : 400 – 800 IU) › Calcium (RDA : 1200 – 1500 mg/day)
    47. 47. Treatment Options Prevent Resorption  Hormone Replacement Therapy (HRT) Build New Bone  Parathyroid hormone (PTH) - Teriparatide  Raloxifene  Bisphosphonates • There is no cure, but several medications have been approved • Each stops or slows bone loss, increases bone density, and reduces fracture risk.
    48. 48.   Oral : Alendronate – daily or weekly dose Risedronate – daily or weekly dose Ibandronate – monthly dose IV › Intravenous Ibandronate – inj. once in 3 month › IV Zolendronate – inj. once a year All biphsphonates have been shown to act quickly (within one year), to maintain bone density and to reduce the risk of having fractures They differ in their degree of reduction of risk
    49. 49.     Health professionals Osteoporosis patient support groups Practical tips Get the information regarding treatments available lessening the feelings of isolation and depression experienced by many patients with severe osteoporosis

    ×