OSTEOPOROSIS AND TREATMENT OPTIONS

1. Osteoporosis
Dr.Rahul kapoor
MBBS, 2nd yr. ortho

2. Defination
• Osteoporosis is a systemic disorder of the skeleton
characterized by low total skeletal bone mass and
microarchitectural deterioration of bone tissue with
a consiquent increase in bone fragility and
susceptibility to fracture .

3. Acknowledgement
• Most common metabolic bone disease
• 3x more common in women than men
• Fewer than 1/3rd cases are diagnosed
• Only 1/7th receive treatment
• Hip # have 20% mortality in first yr.
• 50% of women(>65yr) have spinal compression # and
2/3rd unrecognised

4. • Multifactorial origin
• Classified as :- primary :- type I & type II
secondary
• other :- involutional , post-climacteric and
idiopathip transient osteoporosis of the hip

5. • Type I :- result of estrogen loss
increased osteoclastic bone resorption
• Type II :- slow progressive decline in osteoblastic
activity with ageing
• Unfortunately the elderly female often suffers the
effect of both

6. Risk factors
• h/o # in adults ( >40 yrs.)
• Low body weight ( < 127 lbs)
• Smoking
• Alcohol (> 60 ml)
• Corticosteroid therapy ( >3 months)
• Impaired vision
• Early Estrogen deficiency (<45yr)
• Prolonged premenopausal amenorrhoea(>1yr)
• Low physical activity
• Low calcium intake
• dementia

7. Secondary osteoporosis
• Affect any age group
• Men and women equally affected
• Results from chronic medical conditions & prolong
use of medication

8. causes
• Drugs :-
 Steroids
 Heparin
 Anticonvulsant
 Cytotoxins
 Lithium
 Aluminium
 cytotoxins

9. • Malignancy :-
 Multiple myeloma
 Leukemia
 Lymphoma
• Disuse prolonged immobilization

10. • Endocrine diseases:-
 Diabetes
 Thyroid disease
 Cushing syndrome
 Hyperparathyroidism
 Exercise induced amenorrhea
 Eating disorders

11. • Gastrointestinal disorders:-
 Gastrectomy
 Malabsorption syndrome
 Liver diseases
 Inflammatory conditions
 sprue

12. Clinical features
• Asymptomatic silent bone changes
• Spontaneous vertebral fractures
• Acute or chronic back ache
• Loss of height
• Protuberant abdomen
• dowager’s hump
• Oral alveolar bone loss

13. WHO
• The world health organization has estblished an
operational definition depending on BMD, commonly
expressed as T- score.
• A T – score of atleast - 2.5 SD and below the young
adult mean
• A T score represents a pateints bone density
expressed as the number of SD above or below the
mean BMD value of normal young adult

14. BMD
• Proxy to measure bone strength
• Predicts the risk of fracture
• Expressed as SD in T AND Z score
• 50%-100% increase in fracture risk for each SD
decline in bone density
• DEXA is the standard for measuring BMD

15. • 3 Sites
1) Radius distal end
2) Hip
3) Spine

18. Others
• CT - trabecular bone ,expensive
• ULTRASOUND – inexpensive
• X-RAY - 30% - 40% of bone loss
• MRI -

19. Laboratory Assessment
1) CBC count
2) Serum chemistry :-
3) urinary calcium excretion

20. Additional
1. Serum thyrotropin
2. ESR
3. Serum PTH
4. Serum 25-hydroxyvitamin D concentration
5. Urinary free cortisol
6. Serum electrolyte
7. Serum or unine protein electrophoresis
8. Bone marrow biopsy or aspiration
9. Biochemical markers of bone turnover

21. Biochemical markers
• Assessing fracture risk in elderly
• Therapeutic response to antiresorptive agents
• Identifying patients with high bone turnover

22. Prevention goals
1) Optimize skeletal development in the young
2) Maximize peak bone mass at skeletal maturity
3) Prevent bone loss (age , secondary causes)
4) Preserve the structural integrity of skeleton
5) Prevent fractures

23. Preventive measures
• Adequate calcium diet
• Good general nutrition
• Adequate vitamin D intake
• Regular weight bearing exercise
• Avoiding tobacco and caffeine

24. Additional measures
• Pharmacological agents to pevent bone loss
• Bisphosphonate for all on prednisolone > 3 mths
• Periodic monitoring of thyroid function
• Identification and treatment of conditions that
predispose to low peak bone mass
• Identification of patients predisposed to fall

25. Goals of treatment
1) Preventing fractures
2) Increase in bone mass
3) Relieving symptoms of fracture
4) Maximizing physical function

26. Candidates for treatment
• Women with T-score -1.5 with at least one risk factor
• Women with ineffective nonpharmacological
measures
• Postmenopausal osteoporosis
• Men with hypogonadism

27. Management
• Pharmacological measures
• Hormone treatment
• SERMs
• Surgical

28. Pharmacology options
• Calcium supplements
• Bisphosphonates
• Raloxifine
• Salmon calcitonin
• Teriparatide

29. Calcium supplements
• Recommended intake is 1500mg/day
• Safe upper limit is 2500mg/day
• Judicialy used in kidney stones pt.
• S/E :- flatulence and constipation
• Eg. Calcium carbonate ,
• calcium citrate ,
• calcium phosphate

30. Vitamin D
• 200 IU for young adults < 50 yrs.
• 400 IU for 50 – 70 yrs.
• 600 IU for > 70 yrs.
• Higher doses in malabsorption syndrome
• Safe upper limit :- 2000 IU

31. Bisphosphonates
• Synthetic analogs of pyrophosphate
• Natural inhibitor of bone resorption
• Use :- prevention (35mg/week)
• treatment (70mg/week)
• steroid induced osteoporosis
• Weekly administration reduce side effects
• Duration :- alendronate (< 7yrs.)
• risendronate (< 3yrs.) 35mg/week
• zoledronate (5mg/yr ) iv
• idanbronate ( 150mg/month)

32. Calcitonin
• Hormone secreted by thyroid gland
• Diminishes bone resorption
• Useful when hormones and bisphosphonates are
contraindicated
• Recombinant salmon calcitonin more potent
• Route :- injection or nasal spray
• Dose :- 200 IU/day by spray
• 50 – 100 IU/day im or sc

33. Teriparatide
• Recombinant human PTH
• Directly stimulates osteoblasts to form new bone
• Dose :- 20 mcg/day sc for max. 2 yrs
• S/E :- osteosarcoma
• Contraindicated :- hypercalcemia , pagets ds.,
open epiphysis ,

34. Hormone treatment
• Estradiol level of 40-60 pg/ml
• Best if started 5 – 10 yrs. after menopause
• Comnbination with progestins
• S/E :- Myocardial infarction , stroke , breast cancer
venous thromboimbolism , dementia
• Reduction in colon cancer

35. SERMs
• Raloxifene , a potent teratogen
• No effect on endometrium
• Benefits :- reduce incidence of breast cancer,
lowers LDL , cholesterol
• S/E :- deep vein thrombosis ,
pulmonary embolism

36. Combined therapy
• Calcium + vitamin D
• Teriparatide + bisphosphonate
• Testosterone replacements in hypogonadism

37. SURGERY
• ORIF with pins and plates
• Hemi- arthroplasty
• Arthroplasties
• Vertebroplasty / kyphoplasty

38. Follow up
• DEXA is done at least 1 yr. apart
• Post- menopausal screening @ yr.
• Pt. on prevention programme every yr.
• Pts. with normal BMD every 2yrs.

39. •
• Thank you
• Have a nice day
• bye –bye