Presentation at the Philippine Orthopedic Association Convention 20 November 2015 EDSA Shangrila Hotel, Manila.

1. HORMONAL CAUSES
OF SECONDARY OSTEOPOROSIS
Iris Thiele Isip Tan MD, MSc
Professor 3, UP College of Medicine
Chief, UP Medical Informatics Unit

2. ?? SECONDARY
osteoporosis
HORMONAL
causes
TREATMENT

3. ?? SECONDARY
osteoporosis
HORMONAL
causes
TREATMENT

4. SECONDARY OSTEOPOROSIS
Low bone mineral density or increased risk of fragility fracture
caused by any factor other than aging or postmenopausal status
Miller PD. Endocrinol Metab Clin N Am 2012;41:613-628

5. OSTEOPOROSIS
Reduction in the strength of bone that
leads to an increased risk of fractures

6. Fractures of the spine or hip that occur
in the absence of major trauma
would be sufficient to diagnose
OSTEOPOROSIS
regardless of BMD
CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-
sa/3.0/)], via Wikimedia Commons

7. Fractures of pelvis, proximal humerus
and wrist diagnosed as
OSTEOPOROSIS
in presence of low BMD
By Ashish j29 (Own work) [CC BY 3.0 (http://
creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

8. ~50% of pre- and perimenopausal
women with osteoporosis have
an associated underlying cause
SECONDARY
OSTEOPOROSIS
UNKNOWN
number of postmenopausal women with
osteoporosis from a secondary cause
Sweet et al Am Fam Physician 2009; 79(3):193-200

9. WORK UP FOR
SECONDARY
OSTEOPOROSIS
Men 65 y or younger
50-65% of cases
Soriano et al Best Pract Res Clin Endoc Metab 2014; 28:885-894

10. SERUM CALCIUM
SERUM PHOSPHATE
1,25 DIHYDROXY VITAMIN D3
PARATHYROID HORMONE
CALCIUM HOMEOSTASIS
Harrison’s Principles of Internal Medicine 19th ed.

11. CONDITIONS, DISEASES &
MEDICATIONS THAT
CONTRIBUTE TO
OSTEOPOROSIS &
FRACTURES
History and PE!
Harrison’s Principles of Internal Medicine 19th ed.

12. DRUGS KNOWN TO CAUSE OSTEOPOROSIS/FRAGILITY FRACTURES
Hofbauer L, Hamann C, Ebeling PR. Eur J Endoc 2010;162:1009-1020.

13. EXCLUSION OF SECONDARY CAUSES OF OSTEOPOROSIS
BLOOD OR SERUM
Complete blood count (CBC)
Chemistry levels (calcium, renal function, phosphorus and magnesium)
Thyroid stimulating hormone (TSH) +/- free T4
25(OH)D
Parathyroid hormone (PTH)
Total testosterone and gonadotropin in younger men
Bone turnover markers
Consider in selected patients: serum protein electrophoresis, serum immunofixation,
serum free light chains, tissue transglutaminase antibodies (IgA & IgG), iron and
ferritin levels, homocysteine, prolactin, tryptase
National Osteoporosis Foundation. Clinician’s Guide to Prevention & Treatment of Osteoporosis 2014

14. EXCLUSION OF SECONDARY CAUSES OF OSTEOPOROSIS
URINE
24-h urinary calcium
Consider in selected patients: protein electrophoresis (UPEP), urinary free cortisol
level, urinary histamine
National Osteoporosis Foundation. Clinician’s Guide to Prevention & Treatment of Osteoporosis 2014

15. ?? SECONDARY
osteoporosis
HORMONAL
causes
TREATMENT

16. Increased BMD but with
alterations in bone geometry &
defects in microarchitecture
Low bone turnover state
Thiazolidinediones
BONE FRAGILITY
& DIABETES
Pathogenesis
Miller PD. Endocrinol Metab Clin N Am 2012;41:613-628
By Gtirouflet (Own work) [CC BY-SA 3.0 (http://
creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

17. Type 1 diabetes:
12-fold increased risk
Longer duration of diabetes
Insulin use
Increased risk of falls
RISK FACTORS FOR
FRACTURES IN DIABETES
Miller PD. Endocrinol Metab Clin N Am 2012;41:613-628
CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-
sa/3.0/)], via Wikimedia Commons

18. 30-50% of patients on chronic
glucocorticoid therapy will
experience a fracture
Most common iatrogenic
cause of osteoporosis
GLUCOCORTICOID EXCESS
& OSTEOPOROSIS
By Gtirouflet (Own work) [CC BY-SA 3.0 (http://
creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Emkey GR & Epstein S. Best Prac Res Clin
Endoc Metab 2014;28:911-935

19. Glucocorticoids decrease
osteoblast precursors
Increased apoptosis
of mature osteoblasts
GLUCOCORTICOID EXCESS
& OSTEOPOROSIS
Emkey GR & Epstein S. Best Prac Res Clin
Endoc Metab 2014;28:911-935
Pathogenesis
By Gtirouflet (Own work) [CC BY-SA 3.0 (http://
creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

20. Rapid decrease in bone
strength with early fracture
risk even at prednisone
as low as 2.5-7.5 mg/day
GLUCOCORTICOID EXCESS
& OSTEOPOROSIS
CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-
sa/3.0/)], via Wikimedia Commons
Soriano et al Best Pract Res Clin Endoc Metab 2014; 28:885-894

21. Predominant spinal bone loss
& vertebral fractures
Increased risk of falls:
muscular atrophy & altered
neuromuscular function
GLUCOCORTICOID EXCESS
& OSTEOPOROSIS
Canalis et al Osteoporosis International 2007; 18:1319-1328
By Dirk69CS (Own work) [CC BY-SA 3.0 (http://
creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

22. Preferentially affects cortical
rather than cancellous bone
Bone loss most prominent at middle
third of forearm and femoral neck
Spine less severely affected
HYPERPARATHYROIDISM
& OSTEOPOROSIS
CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-
sa/3.0/)], via Wikimedia Commons
Hofbauer L, Hamann C, Ebeling PR. Eur J Endoc 2010;162:1009-1020.

23. 686 postmenopausal women
TSH <0.1 mU/L:
four- & five-fold risk of hip and
vertebral fractures respectively
HYPERTHYROIDISM &
OSTEOPOROSIS
CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-
sa/3.0/)], via Wikimedia Commons
Bauer et al. Annals of Internal Medicine 2001;134:561-568

24. Meta-analysis of 21 studies:
Thyroid hormone therapy for TSH
suppression in thyroid cancer
Associated with osteoporosis in
postmenopausal women
HYPERTHYROIDISM &
OSTEOPOROSIS
Heemstra et al. Thyroid 2006;16:583-591

25. ?? SECONDARY
osteoporosis
HORMONAL
causes
TREATMENT

26. Treat underlying disease,
if known
Treat osteoporosis and
prevent further fractures
MANAGEMENT
Secondary Osteoporosis

27. SAME OSTEOPOROSIS TREATMENT
OPTIONS FOR DIABETES
Diabetic nephropathy may limit use of bisphosphonates
Kurra S, Fink DA, Siris ES. Endocrinol Metab Clin N Am 2014;43L233-243

28. DEFICIENT OSTEOBLASTIC FUNCTION IN DIABETES:
USE ANABOLIC DRUGS?
By Gtirouflet (Own work) [CC BY-SA 3.0 (http://
creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Garcia et al. Clinical Practice Guidelines for evaluation and treatment of osteoporosis
associated to endocrine and nutritional conditions. Endocrinol Nutr 2012; 59:174-196

29. MEASUREMENT OF BMD HAS LIMITED PREDICTIVE
VALUE IN DETERMINING FRACTURE RISK
in the context of glucocorticoid therapy
Henneicke et al. Trends Endocrinol Metab 2014;25(4):197-211

30. RECOMMENDED FOR PREVENTION & TREATMENT OF GIO
Intervention Dose
Evidence
Grade
(BMD)
Evidence
Grade
(Fracture)
Calcium Oral: 1000-1500 mg daily A -
Vitamin D Oral: 800-1000 IU daily A -
Alendronate Oral: 70 mg once/week A B
Risedronate Oral: 35 mg once/week A A
Zoledronic acid IV: 5 mg once/year A -
Teriparetide SC: 20 mg once/day A A
Etidronate
Oral: 400 mg daily for 2 weeks
every 3 months
A A
Henneicke et al. Trends Endocrinol Metab 2014;25(4):197-211

31. Indication for parathyroid surgery
in otherwise asymptomatic patient
Osteoporotic fractures
T score of <-2.5
HYPERPARATHYROIDISM
& OSTEOPOROSIS
Hofbauer L, Hamann C, Ebeling PR. Eur J Endoc 2010;162:1009-1020.

32. 8% increase in lumbar spine BMD
& 6% increase in femoral neck 1 year after resection
BMD RECOVERS AFTER PARATHYROIDECTOMY
10 yr data: 12% and 14% increase in BMD for spine and femur respectively
Soriano et al Best Pract Res Clin Endoc Metab 2014; 28:885-894

33. Men age 50-70: 1000 mg/day
Women age >51 y and men age >71 y: 1200 mg/day
CALCIUM INTAKE
Intakes in excess of 1200-1500 mg/day may increase risk of kidney stones, CVD and stroke.
National Osteoporosis Foundation. Clinician’s Guide to Prevention & Treatment of Osteoporosis 2014

34. ESTIMATING DAILY DIETARY CALCIUM INTAKE
National Osteoporosis Foundation. Clinician’s Guide to Prevention & Treatment of Osteoporosis 2014

35. 800 to 1,000 IU per day for adults >50 y
VITAMIN D
IOM Dietary Reference Intakes for vitamin D 600 IU/day
until age 70 y and 800 IU/day for older adults
National Osteoporosis Foundation. Clinician’s Guide to Prevention & Treatment of Osteoporosis 2014

36. ?? SECONDARY
osteoporosis
HORMONAL
causes
TREATMENT

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