Osteoporosis is characterized by low bone mass and deterioration of bone tissue, leading to fragile bones that fracture easily. It results from an imbalance where bone resorption exceeds bone formation. Key factors include decreased estrogen in women after menopause and increased age. Symptoms typically only occur after fractures, with common sites being the vertebrae, leading to pain and loss of height or mobility. Prevention relies on adequate calcium, vitamin D, exercise and avoiding risk factors like smoking.

1. 1
Prof Sriram Chandra Mishra
Kayachikitsa Department
VYDS Ayurved Mahavidyalaya, Khurja

2. ASTHI KSHAYA
• Kshaya means loss , decline, decay, diminution or waning.
• Asthi kshaya is mentioned as an independent condition which can be
correlated with “decrease in the bone tissue”.
• Dalhana has aptly defined kshaya as ‘Swapramanhaani’ (S. Su.
15/24) whereas Chakrapani dutta describes it as
“Swagunakriyanasat“(Ch. Su. 17/63-72).
2

3. ASTHI SOUSHIRYA
• Various terms such as asthi-soushirya, asthi-daurbalya, asthi-shieeran, asthi-
laghav, asthi-shunyata/riktata and asthi-mardava (Osteomalacia) appear in
Ayurveda texts to describe asthi-kshaya.
• Asthi soushirya is not mentioned as a separate condition but in Majjakshaya
symptoms Vagbhatta elaborate about the term ‘Soushirya’.
• Hemadri commented ‘Saushirya’ as ‘SARANDHRATVAM’ which means
“with pores”. (Asthi soushirya means ‘porous bones’)
अस्थ्नां सौषिर्ये - सरन्ध्रत्वम ् ॥ (हेमाद्रि - आयुर्वेद रसायन on A.H.Su. 11/19 )
• The porosity of bone is due to Vayu and Aakash amongst other factors (C.
Chi. 15/33) (Aashrayaashrayee bhava)
(A.H.Su. 11/19)
3

4. SYMPTOMS OF ASTHI KSHAYA
(SU. Su. 15/9)
(A.H. Su. 11/19)
(Cha. Su. 17/67)
4
• दन्त – नख भंग (brittleness of teeth and nails), शदन या गगरना (falling)
• अस्थितोद / अस्थिशूल (pain in bones)
• क
े श (hairs), लोम (body hairs), श्मश्रु या दाढ़ी (beard) पतन या गगरना (falling)
• श्रम अिाात् शऱीर में िकार्वट (lassitude)
• सस्न्ियों में शशगिलता (laxity of joints)
• त्र्वचा में रूखापन (roughness of skins)

5. MANAGEMENT OF ASTHI KSHAYA
5
• Treatment principle
अस्स्िसांक्षर्यनत् ।
जनतन्् क्षीरघृतैस्स्तक्तसांर्युतैर्बस्स्तभिस्तिन ।। (अ. हृ. सू. 11/31)
अस्थिक्षयजन्य वर्वकारों की गचककत्सा क्षीर (milk) एर्वं घृत (ghee) तिा ततक्त िव्यों
(pungent drugs) से युक्त बस्थतयों (enema therapy) से करनी चाद्रहये ।
• Nidana parivarjanam
Avoid Steroids, sedentary life style, smoking etc.
• Medication
 Calcium containing drugs – Sudha varga dravyas
 Drugs Helpful in Osteogenesis – Aswagandha, Shatavari, Amalaki

6. • Proper nutrition with Agni Deepan
 Adequate Dietary Calcium - MASHA (black gram), TILA (sesame seeds), milk, milk
products, banana, pear, apple and other dietary articles rich in calcium,
 Adequate vitamin D
 Skin exposure to sunlight
 Natural sources like Oily fish / Fish oils, Butter, Eggs (yolk – vitamins, minerals,
Proteins)
• Vata Shamana with various measures
 Abhyanga (Ksheerabala, Murivenna oil etc)
 Swedana
 Pizichil
 Sasthikasali Pinda sweda
 Panchatikta ksheera basti etc
• Yoga – Pranayama, Vrikshasana, Trikonasana, Virabhadrasana, Ustrasana, Savasana
• Physiotherapy - Rehabilitation, strengthen of bone and muscles 6

7. 7
SUDHA VARGA DRAVYAS (Calcium containing drugs)
Badarashma, Vamshalochana, Swetanjana, Hastidanta

8. 8
Medication
• Pravala Pisti • Mukta Pisti • Godanti Bhasma
• Kukuttanda twak bhasma • Kurmapristha Bhasma • Shringa Bhasma
• Ajasthi Bhasma • Khatika • Churnodaka
• Asthisrinkhala / asthisamharaka (Cissus quadrangularis) churna
• Laksha Churna
• Sudhashataka yoga (Pravala Bhasma, Mukta Bhasma, Shankha Bhasma, Kapardika Bhasma,
Kurmapristha Bhasma, and Godanti Bhasma) - (250 mg-1000mg) along with cow milk
• Madhu malini vasanta rasa - Shuddha Hingula, Kukkutanda, Shweta Marich, Priyangu,
Kachora and Dadim, Nimbu
• Lakshadi Guggulu - Ashwagandha, Guggulu, Nagbala, Asthisamhari, Arjuna and Laksha
• Praval Panchamrut bhasma - Pravala, Mouktik, Shankha, Shouktik,, Kapardika
(Some medicines may not suitable for vegetarian peoples)

9. 9
• Shuktadi Yoga (Shukti Bhasma, Godanti Bhasma, Yashada Bhasma and Trikatu)
• Guggulu Tiktaka Ghritam
• Panchatikta Ksheera Kwatha
• Trayodasanga Guggulu
• Gadha tailam
• Lakshadi tailam
• Balaswagandhadi Taila
• Dhanwantara Taila
• Tila Rasayanam
• Narasimha Rasayanam

10. 10
Vyavasthapatra
(SAMPLE PRESCRIPTION)
• Madhu malini vasata Rasa – 125 mg
+ Guduchi satva – 500 mg
+ Praval panchamrita – 62.5 mg
……………………………………..
1 dose twice daily with honey
• Lakshadi guggulu – 1 tab
• Gadha tailam – 1 cap/10 drops
……………………………………..
1 dose twice daily with L.W. Water
• Aswagandhadi churna
……………………………………..
5gm twice daily with Milk
• Ahyanga – Dhanwantara tailam
• Yoga & Physiotherapy

11. Definition
• OSTEOPENIA - A medical condition in which the protein and mineral
content of bone tissue is reduced, but less severely than in
osteoporosis.
• OSTEOPOROSIS - Osteoporosis, which literally means porous
bone, is a systematic skeletal disease characterized by low bone
mass and micro architectural deterioration of bone tissue, with a
consequent increase in bone fragility and susceptibility to fractures.
(API)
W.H.O. – A bone mineral density ≤ −2.5 standard below the
young normal men.
11

12. W.H.O. definition
of Osteoporosis and
Osteopenia
Bone Mineral Density (BMD)
Category
T-score range
Expressed in grams per cm2 (g/cm2)
Normal ≥ −1.0
Osteopenia −1.0 to −2.5
Osteoporosis ≤ −2.5
Severe osteoporosis ≤ −2.5 with fragility fracture
12

13. Physiology of Bone
• Bones consist of living cells embedded in a mineralized organic matrix.
• This matrix consists of
1. Organic components, mainly type I collagen (40%).
2. Inorganic components, primarily hydroxyapatite and other salts
of calcium and phosphate (60%).
• The collagen fibers give bone its tensile strength, and the interspersed
crystals of hydroxyapatite give bone its compressive strength.
• Each bone constantly undergoes modeling during life to help it adapt to
changing biomechanical forces, as well as remodeling to remove old,
microdamaged bone and replace it with new, mechanically stronger bone to
help preserve bone strength.
13

14. Types of Bone cells
• Osteoprogenitor cells (stem cells of mesenchymal origin) - Osteoblasts and
osteocytes are derived from these cells.
• Osteoblasts - Involved in the creation and mineralization of bone tissue.
• Osteocytes - Respond to mechanical strain and send signals of bone
formation or bone resorption to the bone surface and regulate both local and
systemic mineral homeostasis.
• Osteoclasts – Very large multinucleate cells that are responsible for the
breakdown of bones by the process of bone resorption. As it is derived
from monocyte stem-cell lineage, they are equipped with phagocytic-like
mechanisms.
Hematopoietic stem cells – These are present Within the bone marrow. These
cells give rise to other cells, including white blood cells, red blood cells,
and platelets. 14

15. 15

16. 16
(CYP2R1 gene)
DIET
(25-hydroxyvitamin D) / Calcifediol
1,25-dihydroxy vitamin D
(↓Melanin↑)
Sources of Vitamin D3
(Natural
Cholecalciferol)
• Oily fish and fish oil
• Liver
• Egg yolk
• Butter
• Dietary supplements
Sources of Vitamin D2
(Ergosterol → UVB →
Ergocalciferol)
• Mushrooms (grown
in UV light)
• Fortified foods
• Dietary supplements
UVA
UVB
UVC
(Cholecalciferol)
(Ergocalciferol)
(storage type of vitamin D , Measured in serum to vitamin D status)
• 1,25(OH)2D circulating in blood as a hormone
• 1,25-(OH)2D feedback negatively on itself
Inactive
water soluble
compound that is
excreted in bile
Vitamin D Metabolism

17. 17
Phosphate homeostasis
Fibroblast growth factor 23
(Calcidiol)
(Calcitriol)

18. Pathophysiology of Osteoporosis
• Under physiologic conditions, bone formation and resorption are in a
fair balance.
• The hallmark of osteoporosis is a
 Reduced total bone mass. Normal homeostatic bone turnover
is altered. Following change may result in osteoporosis
→ Increased bone resorption (↑Osteoclast action)
→ Decreased bone formation (↓Osteoblasts action)
18

19. 19
Osteoclastic Bone Resorption
(Bone Removal Performed by
Osteoclasts)
Osteoblastic Bone Apposition
(Bone Formation Performed by
Osteoblasts)
Disbalance
Balance

20. 20
 Progression. The bones become porous, brittle, fragile; they fracture
easily under stresses that would not break normal bone.
 Postural changes. The postural changes result in relaxation of the
abdominal muscles and a protruding abdomen.
 Age-related losses. Calcitonin and estrogen decrease with aging,
while parathyroid hormone increases, increasing bone turnover and
resorption.
 Consequence. The consequence of these changes is net loss of bone
mass over time.

21. Etiology
Primary or Secondary
Classification of Osteoporosis
• Primary osteoporosis (Idiopathic osteoporosis / does not have direct cause)
 Postmenopausal osteoporosis (type I)
 Age-associated or senile osteoporosis (type II)
• Secondary osteoporosis
 Medical conditions
 Medications
21

22.  Primary osteoporosis
• Postmenopausal osteoporosis (type I)
• Caused by lack of estrogen
• Causes PTH to over stimulate osteoclasts
• Excessive loss of trabecular bone (spongy bone where all blood cells
made)
• Age-associated osteoporosis (type II)
• Bone loss due to increased bone turnover
• Malabsorption
• Mineral and vitamin deficiency
22

23.  SECONDARY OSTEOPOROSIS
23
 Acromegaly (pitutary growth hormone )
 Addison’s disease (adrenal gland hormone)
 Amyloidosis (abnormal protein)
 Anorexia
 COPD
 Hemochromatosis ( Iron)
 Hyperparathyroidism
 Lymphoma and leukemia
 Malabsorption states
 Multiple myeloma (plasma cell cancer)
 Multiple sclerosis
 Rheumatoid arthritis
 Sarcoidosis (inflammatory cells)
 Severe liver disease
 Thalessemia
 Thyrotoxicosis
A. Medical conditions / Disease states

24. B. Medications / Drugs
24
 Aluminum
 Anticonvulsants
 Excessive thyroxine
 Glucocorticoids (steroids)*
 GnRH agonists
 Heparin
 Lithium
*Called as steroid induced or glucocorticoid-induced osteoporosis.

25. Risk factors
Age. as people grow older and their bones lose tissue.
Gender. Women are smaller and start out with less bone. They also lose
bone tissue more rapidly as they age. While women commonly lose 30-50%
of their bone mass over their lifetimes, men lose only 20-33%.
Race. Caucasian and Asian women are most at risk for the disease, but
African American and Hispanic women can get it too.
Figure type. Women with small bones and those who are thin are more
liable to have osteoporosis.
Heavy metals: A strong association between cadmium and lead with bone
disease has been established. Low-level exposure to cadmium is associated
with an increased loss of bone mineral density readily in both genders,
leading to pain and increased risk of fractures, especially in the elderly and in
females. Higher cadmium exposure results in osteomalacia (softening of the
bone).
25

26. Soft drinks: Some studies indicate soft drinks (contain phosphoric acid)
may increase risk of osteoporosis, at least in women. Others suggest
soft drinks may displace calcium-containing drinks from the diet rather than
directly causing osteoporosis.
Early menopause. Women who stop menstruating early because of
heredity / surgery / lots of physical exercise may lose large amounts of
bone tissue early in life.
Lifestyle. People who smoke or drink too much, or do not get enough
exercise have an increased chance of osteoporosis.
Diet. Those who do not get enough calcium / protein or have Vitamin D
deficiency may be more likely to have osteoporosis.
Genetics. Research in Europe reported in 2003 that variations of a gene
on chromosome 20 might make some postmenopausal women more likely
to have osteoporosis. 26

27. Clinical Manifestations
 Asymptomatic (Osteoporosis itself has no symptoms)
 Symptoms appear due to fractured or collapsed vertebra
 Acute and Chronic pain in the elderly
 Fragility Fractures (A bone fracture that occurs much more easily than
expected)
(The first clinical manifestation of osteoporosis may be fractures, which
occur most commonly as compression fractures)
 A stooped posture / Kyphosis (The gradual collapse of a vertebra is
asymptomatic, and is called progressive kyphosis or “dowager’s
hump” associated with loss of height.
 Loss of height over time
 Reduction in mobility
27
Even a sneeze or a sudden movement may be enough to break a bone in someone with severe osteoporosis.

28. Osteoporosis
Micro Fractures
Normal bone Osteoporotic
bone
Micro-fracture
28

29. Posture change
(stooped posture)
Dowager's hump
29

30. The vertebrae
collapse down on
themselves, and the
person actually loses
height. These changes
bring about a loss of as
much as 6 to 9 inches in
height
widow‘s hump
Hunchback
appearance
30

31. Osteoporotic fractures occur in situations where healthy
people would not normally break a bone.
Typical fragility fractures occurs in
• Vertebral Column
• Rib
• Wrist
• Hip
Fragility fractures
31

32. Vertebra Fractures
32

33. Wrist Fractures (Colle’s fracture)
Fracture of the distal forearm in which the broken end of the radius is bent backwards.
33

34. Hip Fractures
Intertrochanteric fracture
34

35. Investigations
• Radiography (X-ray of bones)
(May be undetectable on routine x-rays until there has been 25% to 40% demineralization)
• Bone Mineral Density (BMD)
The most popular method of measuring BMD is Dual-energy x-ray absorptiometry (DEXA).
• Serum Calcium, phosphate, Vitamin D
• LFT, KFT, Protein, Albumin
• Bone markers
• Markers for the bone formations (Osteocalcin Bone specific Alk. Phosphatase, Procollagen
extension peptides)
• Markers for bone resorption (Tartrate-resistant acid phosphatase, Urinary calcium, Urinary
hydroxyproline, Urinary hdroxyproline/creatinine ratio, Urinary pyridinoline/deoxypyridinoline,
Urinary N-telopeptide
• Other Blood tests according to pathology (CBC, Electrolytes, Urine etc)
35

36. Ultrasound Densitometry
Dual-energy X-ray absorptiometry
36

37. W.H.O. Criteria for Diagnosis of Osteoporosis
Bone Mineral Density (BMD)
Category
T-score range
Expressed in grams per cm2 (g/cm2)
Normal ≥ −1.0
Osteopenia −1.0 to −2.5
Osteoporosis ≤ −2.5
Severe osteoporosis ≤ −2.5 with fragility fracture
 T score – number of SDs a patient’s BMD deviates from a reference
population of normal young adults
 Z score – number of SDs a patient’s BMD deviates from a reference
population of subjects of the same age and sex
 Z scores indicate whether the BMD result is expected for the patient’s
age. If it is much less than expected, suspect a secondary cause of
osteoporosis (use –2 as a cutoff)
37

38. 38
Comparison of Bone pathology
Condition Calcium Phosphate
Alkaline
phosphatase
Parathyroid
hormone
Comments
Osteopenia Unaffected Unaffected Normal Unaffected
Decreased Bone
Mass
Osteopetrosis
(extremely
rare inherited disorder)
Unaffected Unaffected Elevated Unaffected
Thick Dense Bones
Also Known As
Marble Bone
Osteomalacia
and Rickets
(Vitamin D deficiency)
Decreased Decreased Elevated Elevated Soft Bones
Osteitis fibrosa
cystica
(overproduction of PTH)
Elevated Decreased Elevated Elevated Brown Tumors
Paget's disease of
bone
(Viral/ Genetic)
Unaffected Unaffected
Variable (Depending
On Stage Of Disease)
Unaffected
Abnormal Bone
Architecture
In osteoporosis, the bones are porous and brittle, whereas in osteomalacia, the bones are soft. This difference in bone
consistency is related to the mineral-to-organic material ratio. In osteoporosis, the mineral-to-collagen ratio is within the reference range,
whereas in osteomalacia, the proportion of mineral composition is reduced relative to organic material content. (normal human skeleton is
composed of a mineral component, calcium hydroxyapatite (60%), and organic material, mainly collagen (40%).)

39. Management
39
1. Preventive aspect of osteoporosis
2. Therapeutic aspect of osteoporosis
20th Oct
World Osteoporosis Day
API Medicine -
• Bone substance is made out of protein and mineral
• So. the foundation of any preventive or therapeutic regimen is an adequate dietary intake of :
 High quality protein
 Calcium
 Phosphorus
• The various antiresorptive and anabolic agents available to date are not capable of stopping
bone loss or producing bone gain if the patient is in negative nitrogen and mineral balance
because of inadequate intake of these nutrients

40. PREVENTION OF OSTEOPOROSIS
• Exposure to sunlight – 30 mins per day, 5 days/week
• Diet - Adequate in protein, total calories, calcium and vitamin D.
 Protein intake 1 gm / kg body weight/day
 Phosphorus (700 mg / day)
• Cessation of smoking - Tobacco smoking has been proposed to inhibit the activity of
osteoblasts. Smoking also results in increased breakdown of exogenous estrogen, lower body weight
and earlier menopause, all of which contribute to lower bone mineral density.
• Decreased caffeine intake - ≤ 2.5 cups of coffee or ≤ 5 cups of tea per day
• Stop or reduce Alcohol intake - Although small amounts of alcohol are probably beneficial (bone
density increases with increasing alcohol intake), chronic heavy drinking (alcohol intake greater than
three units/day) probably increases fracture risk despite any beneficial effects on bone density.
• Fall prevention
 Adequate Spinal Support – avoid braces or corsets, rigid and excessive immobilization
 Use of hip Protectors
40

41. 41
WOMEN AND MEN 1 mcg = 40 units
Under age 50 400-800 international units (IU) daily**
Age 50 and older 800-1,000 IU daily**
**The safe upper limit of vitamin D is 4,000 IU per day for most adults
VITAMIN D
• ERGOCALCIFEROL-D2
• CHOLECALCIFEROL-D3
Vitamin D and Analogs
• Antihypocalcemic— Alfacalcidol; Calcifediol; Calcitriol; Dihydrotachysterol ;
Ergocalciferol;
• Nutritional supplement (vitamin)— Calcifediol; Calcitriol; Ergocalciferol;
• Antihypoparathyroid— Calcitriol; Dihydrotachysterol; Ergocalciferol;
• Antihyperparathyroid—Doxercalciferol; Paricalcitol ;

42. 42
• WOMEN
Age 50 & younger 1,000 mg* daily
Age 51 & older 1,200 mg* daily
• MEN
Age 70 & younger 1,000 mg* daily
Age 71 & older 1,200 mg* daily
*The safe upper limit of Calcium is 2000 mg for adults ages > 19 years
CALCIUM
• Calcium riched foods - Milk, yogurt, Butter (cheese), Kale, broccoli , Green leafy vegetables, almonds, Fish (with soft
bones, Oily fish, Fish oils)
• Avail - Calcium carbonate, Calcium sulphate, Calcium citrate maleate, Ionic calcium , MCHC (microcrystalline
hydroxyapatite – a unic form of calcium from whole animal bone)
• All calcium salts must be taken interrupted at 3 weeks for a interval of 10 days & continued for 3 weeks.
• Calcium carbonate and calcium citrate are the two most commonly used forms of calcium.
• Calcium citrate products can be taken on an empty stomach or with food, while calcium carbonate products should be
taken with meals.
• Calcium carbonate provides 40 percent elemental calcium; the other 60 percent is the carbonate ingredient. Therefore,
600 milligrams (mg) of calcium carbonate provides 240 mg elemental calcium.
• Calcium citrate is 20 percent elemental calcium; 600 mg of calcium citrate provides 120 mg elemental calcium.
• Osteoporosis by corticosteroid : Divided daily doses of 0.5-1 gram of elemental calcium daily.

43. 43
Weight-bearing physical activity
and exercises
 Improves balance and posture can strengthen bones and
reduce the chance of a fracture.
 The more active and fit you are as you age, the less likely you
are to fall and break a bone.
 High Impact Physical Activity :
 Jogging – Significantly increases bone density in men
and women
 Stair climbing – increases bone density in women
 Regular Exercises – helps to increase strength and
reduce the risk of falling
 Weight Training – helpful to increase muscle strength as
well as bone density
 Balance Exercises - reduce falls.
Corner
stretch
Hip abductor strengthening
Prone leg lifts
Toe raises/heel raises
Wall slide

44. 44
MODERN MANAGEMENT
OF OSTEOPOROSIS
• Antiresorptive Medications - A category of medications that slows the breakdown of
bone. These medications protect bone mineral density and reduce the risk of fractures.
 Bisphosphonates - Etidronate, Alendronate, Risendronate, Ibandronate,
Pamidronatem Zolidronate
 RANK ligand (RANKL) inhibitor - Denosumab
 Calcitonin - Salmon calcitonin
 Hormone Replacement Therapy - Estrogen
 SERMs (selective estrogen receptor modulators / Estrogen agonist-antagonist) -
Raloxifene
 Tissue Specific Estrogen Complex (TSEC) - Estrogen/Bazodoxifene
• Anabolic Medications - A category of medications that helps build bone.
 Parathyroid Hormone (PTH) Analog – Teriparatide
 Sclerostin Inhibitor - Romosozumab-aqqg
 Parathyroid Hormone-Related Protein (PTHrp) Analog - Abaloparatide
(Drug Therapy)

45. 45

46. 46
Bisphosphonates should be used as first-line pharmacologic treatment. In patients who cannot
tolerate or whose symptoms do not improve with bisphosphonate therapy, teriparatide (Forteo)
and denosumab (Prolia) are effective alternative medications to prevent osteoporotic fractures.
Bisphosphonates
They are compounds that specifically bind to the hydroxyapatite
crystals on bone surfaces and inhibit osteoclast functions.
• Etidronate - First bisphosphonate (Avail - 200mg, 400mg)
 Dose - 11–20mg/kg/day; max 3 months, Retreat after 3 etidronate-free months
Give once daily (preferred) or in divided doses at least 2hrs before or after food.
Take with a full glass of water in upright position; do not lie down afterwards.
 Use- Treatment of symptomatic Paget's disease of bone. Prevention and treatment of
heterotopic ossification after total hip replacement or due to spinal cord injury.
 Adv. Effect - Diarrhea, nausea, musculoskeletal pain, esophagitis, esophageal
ulcers/erosions, gastritis (may be severe); osteomalacia, bone fractures, jaw
osteonecrosis.

47. 47
• Alendronate (Alendronic acid) - Avail - 70 mg; 35 mg; 40 mg; 5 mg; 10 mg; 70 mg/75 mL
 Dose – Treatment - 10 mg orally once a day or 70 mg orally once a week
Prevention - 5 mg orally once a day or 35 mg orally once a week
(Alendronate/cholecalciferol - 70 mg plus 2,800 IU or 5,600 IU per week, oral)
 USE - Osteoporosis caused by menopause, steroid use, or gonadal failure, Paget's
disease of bone, high risk of bone fracture due to osteoporosis.
 Adv. Effect - Decreased serum calcium and decreased serum phosphate. Abdominal
or stomach pain, arthralgia, myalgia etc.
• Risendronate
 Dose – Orally 5mg/day 0r 35 mg / week or 75 mg two consecutive days/month or 150mg/month (Risedronate
with calcium - 35 mg per week (day 1) plus 1,250 mg calcium per day - days 2 to 7 each week)
Risedronate with calcitriol + calcium carbonate + Zinc
• Ibandronate (Ibandronic acid) – Avail - 2.5 mg; 150 mg; 3 mg/3 mL
 Dose – Orally 150mg/month or 2.5mg/day
IV – 3mg every 3months (over 15 to 30 seconds)
Ibandronic acid (150mg) with calcium carbonate (1250mg) + calcitrion (0.25mg)+ Vit MK (50mcg)+ Zinc
(7.5mg)

48. 48
• Pamidronate - Avail - 30 mg/10 mL or 90 mg/10 mL
 Dose – 60 to 90 mg given as a SINGLE-DOSE IV infusion over 2 to 24 hours
Paget’s Disease – IV 30 mg daily, for 3 consecutive days (total dose of 90 mg)
Osteolytic Bone Lesions of Multiple Myeloma – IV 90 mg / monthly
Osteolytic Bone Metastases of Breast Cancer – IV 90 mg / every 3 to 4 weeks.
 USE - Hypercalcemia of Malignancy, Osteolytic Bone Metastases of Breast Cancer
and Osteolytic Lesions of Multiple Myeloma, Paget’s Disease
 Adv. Effect - Flu-like symptoms; mild fever sometimes accompanied by malaise,
chills, fatigue and flushing etc
• Zolidronate - Avail - 4 mg; 4 mg/5 mL; 5 mg/100 mL; 4 mg/100 mL
 Dose – 5 mg IV infusion over no less than 15 minutes, once a year
Hypercalcemia of Malignancy - Single dose of 4 mg IV infusion
Osteolytic Bone Metastases of Solid Tumors - 4 mg IV every 3 to 4 weeks
 Adv. Effect – Agitation, black/tarry stools, blurred vision, chest pain, coma, confusion,
convulsions etc

49. 49
RANK ligand (RANKL) inhibitor
RANK (Receptor activator of nuclear factor κ B) is activated by the RANK-Ligand
(RANKL), which exists as cell surface molecules on osteoblasts. Activation of RANK by
RANKL promotes the maturation of pre-osteoclasts into osteoclasts. Denosumab inhibits
this maturation of osteoclasts by binding to and inhibiting RANKL.
• Denosumab
 Dose –60 mg SC every 6 months, Supplement with calcium 1000 mg/day
and vitamin D 400 IU/day
(Hypercalcemia of Malignancy 120 mg SC every 4 weeks, Give 2 additional 120
mg doses during the first month of therapy on Days 8 and 15)
 USE – Osteoporosis, Women with breast cancer, Hypercalcemia of Malignancy
 Adv. Effect - Back pain, Serious infection of abdomen, UTI, Pancreatitis etc

50. 50
CALCITONIN
Calcitonin produced in humans by the parafollicular cells/C-cells of the thyroid
gland. It inhibits bone resorption by osteoclasts and promotes bone formation by osteoblasts.
This leads to a net increase in bone mass and a reduction in plasma calcium levels. It also
promotes the renal excretion of ions such as calcium, phosphate, sodium, magnesium, and
potassium by decreasing tubular reabsorption.
• Calcitonin Salmon (Calcitonin was extracted from the ultimobranchial glands
(thyroid-like glands) of fish, particularly salmon fish )
 Avail - Nasal spray, Injection (SC/IM)
 USE & DOSE - Hypercalcemia (4-8 IU/kg every 12 hours)
Post-menopausal osteoporosis in women >5 years post-menopause (100 IU / day)
Symptomatic Paget's disease (100 IU / day)
Spray - once a day, alternating nostrils every day
 Adv. Effect – Runny nose, nosebleed, sinus pain, Hives etc
Add calcium (1000 mg / day) and vitamin D (400 IU/day) with this.

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HORMONE REPLACEMENT THERAPY (HRT)
• Estrogen therapy (ET) alone or Estrogen + Progesterone
 HRT restores the Ca 2+ balance , Bone loss is prevented
 HRT is particularly useful for women who have undergone early menopause (before
45 years of age)
 Administered orally or transdermally
 Doses: Oral estrogens (Lowest effective dose) + Progesterone 2.5mg /d (if uterus
present)
 Esterified estrogens - 0.3 mg/d
 Conjugated equine estrogens - 0.625 mg/d
 Ethinyl estradiol – 5 mcg/d
 Transdermal estrogen - 50 mcg estradiol per day.
 Adv. Effect – Bloating, Breast swelling or tenderness, Headaches, Mood
changes, Nausea, Vaginal bleeding

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SERMs (selective estrogen receptor modulators)
SERMs are "selective" — this means that a SERM that blocks estrogen's action
in breast cells can activate estrogen's action in other cells, such as bone, liver, and uterine
cells.
• Raloxifene
Raloxifene mediates anti-estrogenic effects on breast and uterine tissues,
and estrogenic effects on bone, lipid metabolism and blood coagulation.
 Dose - 60mg/day Oral (tablet)
 Use - Osteoporosis in postmenopausal women, Osteoporosis caused by
glucocorticoid and breast cancer.
 Adv. Effect – Hot flashes, flu syndrome, cramps/muscle spasm, infection,
insomnia etc
Anti-estrogenic effects on breast - The cell doesn't receive estrogen's signals to grow and multiply.

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Tissue selective estrogen complex (TSEC)
A tissue-selective estrogen complex (TSEC) is a combination of
an estrogen, such as estradiol or conjugated estrogens, and a selective estrogen
receptor modulator (SERM), such as tamoxifen, raloxifene, or bazedoxifene
• Bazedoxifene (BZA) with conjugated Estrogens (CE)
 BZA 20 mg/CE 0.45 mg and BZA 20 mg/CE 0.625 mg have shown efficacy in
reducing the frequency and severity of hot flushes, relieving Vulvovaginal
atrophy, and maintaining bone mass while protecting the endometrium and
breast.

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Parathyroid Hormone (PTH) Analog
• Parathyroid hormone analogs are the synthetic form of parathyroid hormone
• High levels of parathyroid hormone triggers transfer of calcium from the bones to the
blood. It increases absorption of calcium by the intestine and increases reabsorption of
calcium by the renal tubules. A low level of parathyroid hormone reduces calcium levels
in the blood.
• Teriparatide
 Dose – 20 mcg subcutaneously once a day into the thigh or abdominal wall
 USE – Osteoporosis, Osteoporosis caused by glucocorticoid, Primary
Osteoporosis
 Adv. Effect – nausea, joint aches, pain etc

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Sclerostin Inhibitor
Sclerostin is an osteocyte-derived glycoprotein that inhibits Wnt/β-catenin signaling and
activation of osteoblast function, thereby inhibiting bone formation. Inhibitors of
sclerostin can stimulate bone formation by allowing Wnt to bind to LDL receptor-related
proteins 5 and 6
• Romosozumab
 Use - Osteoporosis in post menopausal women at high risk of fractures.
 Dose - 210 mg SC once a month (administered as 2 separate injections of 105 mg
each - one after the other)
 Duration of therapy: 12 months
 Adv. Effect – Fast heartbeat, fever, hives, itching, skin rash, hoarseness, irritation etc

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Parathyroid Hormone-Related Protein (PTHrp) Analog
• PTHrP acts as an endocrine, autocrine, paracrine, and intracrine hormone.
• It regulates endochondral bone development by maintaining the endochondral growth
plate at a constant width.
• It also regulates epithelial–mesenchymal interactions during the formation of the
mammary glands.
• Abaloparatide
 Primarily regulates calcium homeostasis and bone resorption
 Use - Postmenopausal women with osteoporosis at high risk for fracture
 Dose - 80 mcg subcutaneously once a day
 Adv. Effect – Constipation, depression, loss of appetite, loss of weight, muscle
weakness

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SURGERY
Vertebroplasty and Kyphoplasty (stabilizing compression fractures in the spine)
• Vertebroplasty - Bone cement is injected into back bones (vertebrae) that have
cracked or broken. The cement hardens, stabilizing the fractures and supporting the
spine.
• Kyphoplasty - It involves inserting a balloon device into a fractured vertebra and
inflating it to restore the height of the vertebra. The space is then filled with bone
cement.

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