This document discusses updates in the diagnosis and treatment of osteoporosis. It defines osteoporosis as a disease characterized by low bone mass and deterioration of bone structure. Osteoporosis increases the risk of fractures, with vertebral fractures being the most common. It can lead to pain, disability, and increased mortality. An estimated 8 million women and 2.5 million men in the US have osteoporosis, and these numbers are expected to increase by 40% by 2020. Osteoporosis poses a significant economic burden and reduces quality of life. Advances have been made in assessing fracture risk levels based on 10-year probability in addition to bone mineral density scores. Treatment involves lifestyle changes and medications

1. UPDATES IN DIAGNOSIS &UPDATES IN DIAGNOSIS &
TREATMENT OF OSTEOPOROSISTREATMENT OF OSTEOPOROSIS
Dr Shahjada SelimDr Shahjada Selim
Assistant ProfessorAssistant Professor
Department of Endocrinology & MetabolismDepartment of Endocrinology & Metabolism
Bangabandhu Sheikh Mujib Medical UniversityBangabandhu Sheikh Mujib Medical University
Dhaka, BangladeeshDhaka, Bangladeesh

2. OsteoporosisOsteoporosis
Osteoporosis is defined as a low bone massOsteoporosis is defined as a low bone mass
with bone mass with bone arcitechturoulwith bone mass with bone arcitechturoul
deformity.deformity.
NIH Consensus Development Conference, March 2000NIH Consensus Development Conference, March 2000
Normal Bone Osteoporotic Bone

3. Vertebral Fracture Cascade

4. THE HUMAN COSTTHE HUMAN COST
Downward SpiralDownward Spiral

5. Definition of a Fragility FractureDefinition of a Fragility Fracture
A fragility fracture is one that resultsA fragility fracture is one that results
from mechanical forces that wouldfrom mechanical forces that would
not ordinarily cause fracture in anot ordinarily cause fracture in a
healthy young adult.healthy young adult.
This is quantified as forcesThis is quantified as forces
equivalent to a fall from a standingequivalent to a fall from a standing
height or less.height or less.

6. OsteoporosisOsteoporosis
8 million Osteoporotic Women and 2.5 million Osteoporotic Men in USA8 million Osteoporotic Women and 2.5 million Osteoporotic Men in USA
Expected to increase by about 40% by 2020Expected to increase by about 40% by 2020 11
EstimatedEstimated DirectDirect costs in 2001 = $ 11.6 - 17.1 billion annuallycosts in 2001 = $ 11.6 - 17.1 billion annually 11
Based on relative older Canadian populationBased on relative older Canadian population 22
&&
Australian estimates of 7:1 ratio for Indirect to direct costsAustralian estimates of 7:1 ratio for Indirect to direct costs 33
⇒⇒ $6 - $40 million every single day in Canada$6 - $40 million every single day in Canada
Mortality increased 2-3 fold in women and womenMortality increased 2-3 fold in women and women
after all types of Osteoporotic fracturesafter all types of Osteoporotic fractures 44
1
Surgeon-Generals Report
2
Canadian and US census data
3
Access Economics, 4
Center 1999

7. Prevalence of VCF’sPrevalence of VCF’s
Lifetime prevalence in Caucasians:Lifetime prevalence in Caucasians:
15% in women15% in women
5-9% in men5-9% in men
Higher than risk of breast cancerHigher than risk of breast cancer

8. Osteoporotic fractures, Cardiovascular events &Osteoporotic fractures, Cardiovascular events &
Breast cancerBreast cancer
in osteoporotic postmenopausal womenin osteoporotic postmenopausal women
Any fracture
Spine #
Clinical Spine #
Hip fracture
CVS event
Breast
Cancer
No prior spine fracture (938)
Prior spine fracture (1627)
0
20
40
60
80
100
120
from Silverman et al, 2004
J Am Geriatr Soc 52:1543-8
Events
per 1000
women-yr
MORE study
placebo arm
over 3 years

9. SITESITE INCREASE ININCREASE IN
MORTALITY RISKMORTALITY RISK
VertebraeVertebrae 8.68.6
HipHip 6.76.7
Any Clinical FractureAny Clinical Fracture 2.22.2
Fracture and Mortality Risk

10. Each year, one in three Ontarians over the age
of 65 will take a serious tumble that may land
them in hospital with a broken hip. One in three
of those who do break their hip will die within
a year. Two thirds will experience dementia-like
symptoms. Most will never see home again.

11. Osteoporosis-associatedOsteoporosis-associated
MortalityMortality
Age-standardised mortality riskAge-standardised mortality risk
increased 2-3 foldincreased 2-3 fold
after all types of osteoporotic fractureafter all types of osteoporotic fracture
WomenWomen MenMen
Proximal femurProximal femur 2.22.2 3.23.2
VertebralVertebral 1.71.7 2.42.4
Other majorOther major 1.91.9 2.22.2
Center et al, Lancet 1999

12. ““THE CARE GAP”THE CARE GAP”
IN OSTEOPOROSISIN OSTEOPOROSIS
Despite the introduction of methods toDespite the introduction of methods to
identify those with osteoporosis andidentify those with osteoporosis and
despite effective treatment, a largedespite effective treatment, a large
‘care gap’ continues to exist for these‘care gap’ continues to exist for these
patients.patients.

13. THE TIP OF THE ICEBERG
ASSESSMENT
MANAGEMENT

14. Recommendations for BoneRecommendations for Bone
Mineral Density Reporting inMineral Density Reporting in
CanadaCanada..
Siminoski K, Leslie WD, Brown JP, Frame H, Hodsman A,
Josse RG, Khan A, Lentle BC, Levesque J, Lyons DJ, Tarulli G
Can Assoc Radiol J 2005; 56: 178-188

15. 2002 Definitions: BMD Results2002 Definitions: BMD Results
1. Kanis JA, et al. J Bone Miner Res 1994;9:1137-1141.
2. WHO, Geneva 1994.
StatusStatus 1, 21, 2 T-scoreT-score
NormalNormal +2.5 to+2.5 to −−1.0, inclusive1.0, inclusive
OsteopeniaOsteopenia BetweenBetween −−1.0 and1.0 and −−2.52.5
OsteoporosisOsteoporosis ≤−≤−2.52.5
Severe osteoporosisSevere osteoporosis ≤−≤−2.5 + fragility fracture2.5 + fragility fracture

16. ABOUTABOUT
T-SCORES?T-SCORES?
Advantages
Unitless
Basis for the majority of
osteoporosis guidelines
Simplicity
Disadvantages
Depends on site measured
Depends on technology
Depends on reference
database—population mean
and standard deviation
Only includes BMD
information and not additional
risk factors
Adapted from Faulkner K. Osteoporos Int 2005;16(4):347-52.

17. Fracture RiskFracture Risk
vs. BMDvs. BMD
At Different AgesAt Different Ages
Fracture RiskFracture Risk
vs. BMDvs. BMD
At Different AgesAt Different Ages
BMD PREDICTS FRACTURESBMD PREDICTS FRACTURES
Hui et al. J Clin Invest 1988; 81:1804-9

18. AGEAGE T-ScoreT-Score
= -1.0= -1.0
T-ScoreT-Score
= -2.5= -2.5
5050 6 %6 % 11 %11 %
6060 8 %8 % 16 %16 %
7070 12 %12 % 23 %23 %
8080 13 %13 % 26 %26 %
Risk of Fractures Over 10 Years in WomenRisk of Fractures Over 10 Years in Women

19. Proposed ChangeProposed Change
Previous OSC guidelines advised interventionPrevious OSC guidelines advised intervention
based on WHO category as a marker of relativebased on WHO category as a marker of relative
fracture risk.fracture risk.
Now propose that anNow propose that an individual’s 10-yearindividual’s 10-year
absolute fracture riskabsolute fracture risk, rather than BMD alone,, rather than BMD alone,
be used for fracture risk categorizationbe used for fracture risk categorization

20. 5-STEPS IN5-STEPS IN
TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEPS 1 and 2STEPS 1 and 2
Begin with the table appropriate forBegin with the table appropriate for
the patient’s sexthe patient’s sex
Identify the row that is closest toIdentify the row that is closest to
the patient's agethe patient's age

21. CATEGORIZATION BASED ON 10-YEARCATEGORIZATION BASED ON 10-YEAR
FRACTURE RISKFRACTURE RISK
Absolute fracture risk in 10 years:Absolute fracture risk in 10 years:
low:low: <10%<10%
moderate:moderate: 10-20%10-20%
high:high: >20%>20%

22. USING LOWEST T-SCORE TO FIND 10-YEARUSING LOWEST T-SCORE TO FIND 10-YEAR
FRACTURE RISK - WOMENFRACTURE RISK - WOMEN
WOMEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LOWESTT-Score
Moderate RiskModerate Risk
High RiskHigh Risk
Low Risk

23. 5-STEPS IN5-STEPS IN
TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEP 3STEP 3
Determine the preliminary fracture riskDetermine the preliminary fracture risk
category by using the lowest T-scorecategory by using the lowest T-score
from the recommended skeletal sitesfrom the recommended skeletal sites

24. 5-STEPS IN5-STEPS IN
TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEP 4STEP 4
Evaluate clinical factors that may moveEvaluate clinical factors that may move
the patient into an even higher fracturethe patient into an even higher fracture
risk categoryrisk category

25. USING LOWEST T-SCORE TO FIND 10-YEARUSING LOWEST T-SCORE TO FIND 10-YEAR
FRACTURE RISK - MENFRACTURE RISK - MEN
MEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LOWESTT-Score
Low RiskLow Risk
High RiskHigh Risk
Moderate RiskModerate Risk

26. Additional Clinical FactorsAdditional Clinical Factors
Certain clinical factors increase fractureCertain clinical factors increase fracture
risk independent of BMD.risk independent of BMD.
The most important are:The most important are:
– Fragility fractures after age 40 (especiallyFragility fractures after age 40 (especially
vertebral compression fractures)vertebral compression fractures)
– Systemic glucocorticoid therapy >3 monthsSystemic glucocorticoid therapy >3 months
duration.duration.

27. Additional Risk FactorsAdditional Risk Factors
Each factor effectively increases riskEach factor effectively increases risk
categorization to the next level:categorization to the next level:
– from low risk to moderate risk, orfrom low risk to moderate risk, or
– from moderate risk to high riskfrom moderate risk to high risk
When both factors are present theWhen both factors are present the
patient should be considered at highpatient should be considered at high
risk regardless of the BMD result.risk regardless of the BMD result.

28. 5-STEPS IN5-STEPS IN
TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEP 5STEP 5
Determine the individual’s finalDetermine the individual’s final
absolute fracture risk category.absolute fracture risk category.

29. Woman – age 52Woman – age 52
- t is -2.6- t is -2.6
Fracture Risk Category?Fracture Risk Category?
CASE EXAMPLECASE EXAMPLE

30. High RiskHigh Risk
Moderate RiskModerate Risk
Low RiskLow Risk
WOMEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LOWESTT-Score CASE EXAMPLECASE EXAMPLE
Low Risk
Moderate Risk
High Risk

31. AGE LOW MODERATE HIGH
<10% 10 to 20% >20%
50 >-2.3 -2.2 to -3.9 <-3.9
55 >-1.9 1.9 to -3.4 <-3.4
60 >-1.4 -1.4 to -3.0 <-3.0
65 >-1.0 -1.0 to -2.6 <-2.6
70 >-0.8 -0.8 to -2.2 <-2.2
75 >-0.7 -0.7 to -2.1 <-2.1
80 >-0.6 -0.6 to -2.0 <-2.0
85 >-0.7 -0.7 to -2.2 <-2.2
10-YEAR RISK
WOMEN
CASE EXAMPLECASE EXAMPLE
-2.2- -3.9

32. Fracture Risk CategoryFracture Risk Category
Moderate RiskModerate Risk
CASE EXAMPLECASE EXAMPLE

33. Fracture Risk CategoryFracture Risk Category
High RiskHigh Risk
Moderate RiskModerate Risk
If Fragility Fracture HistoryIf Fragility Fracture History
CASE EXAMPLECASE EXAMPLE

34. 70 year-old man70 year-old man
CASE EXAMPLECASE EXAMPLE
Lowest T-score –2.7 in total hipLowest T-score –2.7 in total hip
BMD done because of strong familyBMD done because of strong family
history of osteoporosishistory of osteoporosis (mother fractured hip, sister(mother fractured hip, sister
has OP)has OP)

35. USING LOWEST T-SCORE TO FIND 10-YEARUSING LOWEST T-SCORE TO FIND 10-YEAR
FRACTURE RISK - MENFRACTURE RISK - MEN
MEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LOWESTT-Score
Low RiskLow Risk
High RiskHigh Risk
Moderate RiskModerate Risk
X

36. Fracture Risk CategoryFracture Risk Category
Moderate RiskModerate Risk
CASE EXAMPLECASE EXAMPLE

37. OTHER ISSUES FOR THIS 70OTHER ISSUES FOR THIS 70
YEAR OLD MALEYEAR OLD MALE
Chest x-ray – mild loss of vertebral heightChest x-ray – mild loss of vertebral height
at T4, T5at T4, T5
What if he had had polymyalgiaWhat if he had had polymyalgia
rheumatica at age 69 and was onrheumatica at age 69 and was on
prednisone 10 mg./day?prednisone 10 mg./day?

38. Fracture Risk CategoryFracture Risk Category
Moderate RiskModerate Risk
If Fragility Fracture History,If Fragility Fracture History,
Corticosteroid useCorticosteroid use
High RiskHigh Risk
CASE EXAMPLECASE EXAMPLE

39. EndorsementsEndorsements
Canadian Association of Nuclear MedicineCanadian Association of Nuclear Medicine
Canadian Association of RadiologistsCanadian Association of Radiologists
Canadian Rheumatology AssociationCanadian Rheumatology Association
International Society of Clinical DensitometryInternational Society of Clinical Densitometry
Society of Obstetricians and Gynecologists of CanadaSociety of Obstetricians and Gynecologists of Canada
Canadian Society of Endocrinology and MetabolismCanadian Society of Endocrinology and Metabolism
Canadian Orthopedic AssociationCanadian Orthopedic Association
College of Family Physicians of CanadaCollege of Family Physicians of Canada

40. Osteoporosis Prevention andOsteoporosis Prevention and
TreatmentTreatment
Age
Hormonal Replacement
Bisphosphonates
Strontium
SERM
20 40 60 80
Vitamin D
PTH
Life Style
Treatment
choice

41. ** with prev vert fracture(s)with prev vert fracture(s) **** without prev vert fractureswithout prev vert fractures ****** with or without prev verfractureswith or without prev verfractures
Antifracture efficacy of antiosteoporotic agents
0.6 1.00.2
Incident nonvertebral fractures
Relative risk
RLX 60, 120
(MORE)***
CT 200 (PROOF)*
Teriparatide 20µg*
ALN 5/10 (FIT1)*
ALN 5/10 (FIT2)**
RIS 5 (VERT-NA)*
RIS 5 (VERT-MN)*
RIS 2.5/5 (Hip Study)***RIS 2.5/5 (Hip Study)***
Incident vertebral fractures
Relative risk
0.60.6 1.01.00.20.2
RLX 60 (MORE)*
RLX 60 (MORE)**
CT 200 (PROOF)*
Teriparatide 20µg*
ALN 5/10 (FIT1)*
ALN 5/10 (FIT2)**
RIS 5 (VERT-NA)*
RIS 5 (VERT-MN)*
Strontium ranelate
(SOTI)*
Strontium ranelate
(SOTI +TROPOS)**
Strontium ranelate
(TROPOS)***
Strontium ranelate
(SOTI)*
Updated from Delmas, Lancet 2002
RR ± 95% CI

42. Medications Available forMedications Available for
Post-Menopausal OsteoporosisPost-Menopausal Osteoporosis
ActonelActonel®®
(risedronate sodium tablets) (1/day;1/wk; 1/mo)(risedronate sodium tablets) (1/day;1/wk; 1/mo)
Didrocal® (etidronate sodium tablets)Didrocal® (etidronate sodium tablets)
FosamaxFosamax®®
(alendronate sodium tablets) 1day/1/wk; Fosovance)(alendronate sodium tablets) 1day/1/wk; Fosovance)
AclastaAclasta ®®
(zolendronate IV)(zolendronate IV)
Estrogen (some use)Estrogen (some use)
EvistaEvista®®
(raloxifene HCl)(raloxifene HCl)
MiacalcinMiacalcin®®
(calcitonin salmon) Nasal Spray(calcitonin salmon) Nasal Spray
Forteo (Teriparatide) (sc)Forteo (Teriparatide) (sc)
Consult with your physician to determine what medication mayConsult with your physician to determine what medication may
be best for yoube best for you

43. Bisphosphonates — CyclicalBisphosphonates — Cyclical
EtidronateEtidronate
pp=NS=NS
00
1010
2020
3030
4040
5050
1818
Etidronate (n = 20)Etidronate (n = 20)
4343
Placebo (n = 20)Placebo (n = 20)
LumbarspinefracturerateLumbarspinefracturerate
(fractures/100patient-years(fractures/100patient-years))
Storm T.Storm T. N Engl J MedN Engl J Med 1990;1990;322322:1265.:1265.
• 3-year RCT, 66 subjects3-year RCT, 66 subjects
• High risk subgroup: reduction in fracture rate with etidronate,High risk subgroup: reduction in fracture rate with etidronate, pp = 0.023= 0.023
• No statistically significant effect at nonvertebral sitesNo statistically significant effect at nonvertebral sites

44. Cumulative Hip FractureCumulative Hip Fracture
IncidenceIncidence
Baseline Month 6 Month 12
%ofcohortwithahipfracture
0.00
0.10
0.20
0.30
0.40
0.50
0.58
alendronate
risedronate
Silverman SL. Osteoporos Int 2007 Jan;18(1):25-34. Epub 2006 Nov 15.
↓ 43%*
Adjusted Relative Rate
Reduction at Month 12
p = 0.01
95% CI: 13% - 63%
↓ 46%*
Adjusted Relative Rate
Reduction at Month 6
p = 0.02
95% CI: 9% - 68%
80 fractures
n= 21,615
29 fractures
n = 12,215

45. Osteoporosis in MenOsteoporosis in Men
Has Its Time Come?Has Its Time Come?

46. HEADLINESHEADLINES
7.8.077.8.07

47. HIP FRACTURESHIP FRACTURES
MORBIDITY AND MORTALITYMORBIDITY AND MORTALITY
“One-third of all hip fractures occur in men and are
associated with as much illness and increased risk
of death as those that occur in women .”
“The average 50-year-old Caucasian man has a 13
per cent chance of having a fracture related to
osteoporosis sometime in his remaining lifetime. A
60-year-old Caucasian man has a 29 per cent
chance.”
Dr. John Schousboe, Minneapolis 2007

48. Male Osteoporosis: Morbidity andMale Osteoporosis: Morbidity and
MortalityMortality
As compared to women, while lifetimeAs compared to women, while lifetime
fracture risk may be less,fracture risk may be less,
– Men have higher rates of morbidity andMen have higher rates of morbidity and
mortality due to fracturesmortality due to fractures
– Men are twice as likely to die in hospital afterMen are twice as likely to die in hospital after
a hip fracturea hip fracture
– Men have a higher mortality rate than womenMen have a higher mortality rate than women
one year after a hip fractureone year after a hip fracture
Cooper C, et al. Osteoporos Int 1992;2:285-9; Singer BR, et al. J Bone Joint Surg
Br 1998;80:243-8; Center JR, et al. The Lancet 1999;353:878-82; Forsen L, et al.
Osteoporos Int 1999;10:73-8; Johnell O., et al. Calcif Tissue Int 2001;69:182-4;
Amin S. Curr Osteoporos Rep 2003;1:71-7; Campion JM, et al. Am Fam Phys

49. GLUCOCORTICOIDS and BONEGLUCOCORTICOIDS and BONE
Have a reflex! SGC > 3 mo > 7.5 mg./dayHave a reflex! SGC > 3 mo > 7.5 mg./day
-Ca, vitamin D, bisphosphonate-Ca, vitamin D, bisphosphonate
Bone density evaluation?Bone density evaluation?

51. Back injuries.Back injuries. If you think that golf is for wimps, considerIf you think that golf is for wimps, consider
this: Athis: A golf swinggolf swing puts a higher compressive load on theputs a higher compressive load on the
low back (low back (8 times body weight8 times body weight) than) than runningrunning ((33 timestimes) or) or
eveneven rowingrowing ((77 timestimes). That’s why a single swing can). That’s why a single swing can
produce a herniated disc or even aproduce a herniated disc or even a compressioncompression fracturefracture
of one of the vertebral bodies. Although these injuriesof one of the vertebral bodies. Although these injuries
are extremely painful and can be quite serious, they areare extremely painful and can be quite serious, they are
rare. Muscle strains, however, are quite commonrare. Muscle strains, however, are quite common
because of the twisting that is required for a good swing.because of the twisting that is required for a good swing.
The “modern” swing, with its inverted-C follow-through,The “modern” swing, with its inverted-C follow-through,
may make for longer drives than the “classic” swing but itmay make for longer drives than the “classic” swing but it
also produces more torque — and more injuries (also produces more torque — and more injuries (seesee
Golf injuriesGolf injuries aboveabove).).
Harvard Men’s Health Watch Aug 2004

52. SUMMARYSUMMARY
REDUCING THE ‘CARE GAP’REDUCING THE ‘CARE GAP’
Assess bone health in woman >50 and inAssess bone health in woman >50 and in
men > 60.men > 60.
Evaluate risk factors; evaluate BMDEvaluate risk factors; evaluate BMD
Consider preventative approach toConsider preventative approach to
reduction of fracture risk (the way youreduction of fracture risk (the way you
think of hypertension and MI and stroke)think of hypertension and MI and stroke)
Treat and monitorTreat and monitor