2. DEFINITION –
• Chronic, progressive disease characterized by low bone mass,
microarchitecture deterioration of bone tissue, bone fragility, and a
consequent increase in fracture risk. (National Osteoporosis Foundation)
• Osteoporotic fractures are associated with increased risk of disability,
nursing home placement, total health care costs, and mortality.
3.
4. DIAGNOSIS
• Radiographically based on bone mineral density (BMD) determinations from
dual energy x-ray absorptiometry (DEXA) assessment.
• Others – Calcaneal Ultrasonography & Peripheral DEXA
6. • WHO criteria can not be applied to men younger than 50years, pre-
menopausal women and children
• Z-score 2.0 or less (International Society for Clinical Densitometry)
7. SCREENING
• (US Preventive Services Task Force – USFSTF) recommendations –
• Women 65 years and older
• Women younger than 65 years whose 10 year fracture risk is greater than or equal to that of
a 65 year old white woman with additional risk factors
• Men with a minimal trauma fracture who are older than 50 years or those with secondary
causes associated with bone loss
• National Osteoporosis Foundation recommends screening all men 70 years and
older
• based on the assumption that this group has a similar osteoporotic fracture risk and
treatment effectiveness as 65-year-old white women
• DEXA of hip and lumbar spine – preferred assessment method
• FRAX WHO – Fracture Risk Assessment Tool was used to determine increased
fracture risk
• Normal screening results – Rescreening – 4 years?
8.
9. EVALUATION OF SECONDARY CAUSES
• Primary Osteoporosis is due to aging and loss of gonadal function
• Secondary Osteoporosis –
• 30% post-menopausal women
• 50% men, pre-menopausal women, peri-menopausal women with Vit-D def
• Lab investigations –
• 25-Hydroxyvitamin D
• Calcium
• Creatinine
• Thyroid stimulating hormone
10.
11. TREATMENT
• National Osteoporosis Foundation recommendations –
• Postmenopausal women and men with a personal history of hip or vertebral fracture,
a T-score of –2.5 or less, or a combination of low bone mass (T-score between –1 and
–2.5) and a 10-year probability of hip fracture of at least 3% or any major fracture of
at least 20% as calculated by the FRAX WHO Fracture Risk Assessment Tool.
• WHO recommendations –
• Individuals with or at risk of Osteoporosis should be considered for treatment
• RCTs – Reduction of fracture with T-score <2.5 and those who have already
experienced a hip or vertebral fracture
12. NICE Guidelines
• Consider treatment for women >65 years & men > 75 years and presence of
risk factors:
oPrevious fragility fracture
oUse of glucocorticoids
oHistory of falls
oFamily history of hip fracture
oSmoking
oAlcohol intake > 14 units/week for women & > 21 units/week for men
oBMI < 19
oYounger patients with risk factor - FRAX score
13. NON-PHARMACOLOGIC RX
• USPSTF recommended –
• Fall prevention (More closely related with increased fracture risk than BMD)
• Weight and balance training exercises
• Vit D supplementation
• Quit smoking; restrict alcohol, caffeine (Major risk factors)
• Balanced diet consisting of Vit D, Calcium, Proteins, Vegetables and fruits
14.
15. PHARMACOLOGIC RX
• Bisphosphonates
• Antiresorptive agents – Inhibit Osteoclastic activity
• First line of treatment
• For Post-menopausal women –
• Ibandronate (Bonviva) 3mg every 3 months
• Zoledronic acid (Reclast) 5mg every year
• Atypical femoral fractures / Osteonecrosis of jaw – Rare complications associated with
prolonged use
• Discontinue after 5 years in patients without hx of Vertebral/hip fractures / low risk patients
• Selective Estrogen Receptor Modulator (SERM) – Raloxifene (Evista)
• Decreased risk of breast CA
• Increased risk of Venous thromboembolism, Vasomotor symptoms
• Recombinant Human Parathyroid Hormone – Teriparatide (Forteo)
• Bone anabolic activity
• 20mcg for upto 2 years
•
16. • Calcitonin
• Antiresorptive agent
• Increased risk of CA
• Human monoclonal antibody – Denosumab (Prolia)
• Inhibits formation and activity of Osteoclasts
• Caution – Renal insufficiency
• Hormone therapy
• Estrogen, with or without Progesterone
• Increased risk of Venous thromboembolism, Coronary artery disease, Breast CA
• Combination therapy
• ?
