The document discusses osteoporosis, including its characteristics, risk factors, diagnosis, and management. It defines osteoporosis as a disease characterized by low bone mass and increased fracture risk. While it has no symptoms, it can be prevented and treated. For a 62-year-old lady with risk factors including diabetes and hypertension, an initial evaluation may include a history, exam, labs, and bone mineral density test to assess fracture risk and diagnose osteoporosis. Management includes lifestyle changes like calcium/vitamin D supplementation and exercise, as well as pharmacologic therapies like bisphosphonates. Monitoring involves follow-up bone density tests and reassessing fracture risk to determine duration of treatment.

1. OSTEOPOROSIS
Done by..
Dr.Manar Al Sanaa AlZeedi

2. Osteoporosis
• Is characterized by low bone mass, microarchitectural
disruption, and skeletal fragility, resulting in
decreased bone strength and an increased risk of
fracture.
• Osteoporosis is preventable and treatable, but
because there are no warning signs prior to a
fracture, many people are not being diagnosed in time
to receive effective therapy during the early phase of
the disease.

3. • 62 years old lady
• Known to have:
• Diabetic on metformin
• HTN on Lisinopril
• Dyslipidemia on atorvastatin
• Came with generalized bodyache.
• Her daughter asking you, could she has osteoporosis?

4. The initial evaluation includes:
A history to assess for clinical risk factors for fracture and to
evaluate for other conditions that contribute to bone loss (chronic
disease, medication, smoking, excessive alcohol, physical
inactivity, and poor nutrition).
A physical examination( Height and weight) .
Basic laboratory tests.
•Biochemistry profile (especially calcium, phosphorous, albumin,
total protein, creatinine, liver enzymes including alkaline
phosphatase, electrolytes).
•25-hydroxyvitamin D (25[OH]D).
•Complete blood count (CBC).

5. • Clinical manifestation :
• has no clinical manifestations until there is a fracture.
• Most of these fractures (about two-thirds) are
asymptomatic; they are diagnosed as an incidental finding
on chest or abdominal radiograph.
• Hip fractures are relatively common in osteoporosis,
affecting up to 15% of women.

7. DIAGNOSIS
• Made in the presence of:
• ●Fragility fracture, particularly at the spine, hip, wrist,
humerus, rib, and pelvis.
• Or
• ●T-score ≤-2.5 standard deviations (SD) at any site based
upon bone mineral density (BMD) measurement by dual-
energy x-ray absorptiometry (DXA).

8. • Fragility fractures:
• Occurring from a fall from a standing height or less,
without major trauma such as a motor vehicle accident.
• Spine fracture occurs spontaneously with minimal or no
trauma.
• (Certain skeletal locations, including the skull, cervical
spine, hands, feet, and ankles, are not associated with
fragility fractures.
• Stress fractures are also not considered fragility fractures,
as they are due to repetitive injury).

9. • Is it recommended for her to do BMD?

10. Candidates for BMD testing

14. ●Fracture Risk Assessment Tool
(FRAX)
• A computer-based calculator which estimates the 10-year
probability of hip fracture and major osteoporotic fracture
(hip, clinical spine, proximal humerus, or forearm)
between ages 40 and 90 years, using easily obtainable
clinical risk factors for fracture, with or without femoral
neck bone mineral density (BMD).

19. • Site of measurement :
• spine and hip because fractures at these sites have the
greatest impact on patients' health.
• In addition, if pharmacologic therapy is planned,
measurement of spine BMD is useful as it shows less
variability and can detect responses to therapy earlier
than hip BMD.
• Diagnosis according to the lowest T-score measured.

20. • T score should not be used in premenopausal women, men
under the age of 50, and in children
• The Z-score is a comparison of the patient's BMD to an age-
matched population.
• A Z-score of -2.0 or lower is considered below the expected
range for age.
• Low Z-scores : A more extensive evaluation should be
undertaken coexisting problems that can contribute to
osteoporosis .
• Laboratory evaluation may help to diagnose secondary causes
of osteoporosis such as renal or liver disease, hyperthyroidism,
hyperparathyroidism, Cushing's syndrome or subclinical
hypercortisolism, early menopause, celiac disease or other
forms of malabsorption, idiopathic hypercalciuria, or rarely,
connective tissue disorders.

22. Hip fractures per 1000 patient-years
WHO category Age 50–64 Age > 64 Overall
Normal 5.3 9.4 6.6
Osteopenia 11.4 19.6 15.7
Osteoporosis 22.4 46.6 40.6

27. Management

28. LIFESTYLE MEASURES
• Lifestyle measures should be adopted universally to
reduce bone loss in postmenopausal women.
• Include adequate calcium and vitamin D, exercise,
smoking cessation, counseling on fall prevention, and
avoidance of heavy alcohol use.
• Avoid, if possible, drugs that increase bone loss, such as
glucocorticoids.

29. • Calcium/vitamin D :
• An optimal diet for treatment (or prevention) of
osteoporosis includes an adequate intake of calories (to
avoid malnutrition), calcium 1200MG, and vitamin D 800
iu.
• Exercise :
• Women with osteoporosis (or who are seeking to prevent
it) should exercise (prudently) for at least 30 minutes
three times per week.

31. • Initial therapy:
• oral bisphosphonates as first-line therapy because of their
efficacy, favorable cost, and the availability of long-term
safety data.
• alendronate or risedronate as best choice due to efficacy
in reducing vertebral and hip fracture.
• For patients with severe osteoporosis (T-score of -3.5 or
below even in the absence of fractures, or T-score of -2.5
or below plus a fragility fracture), initial treatment with
teriparatide is an alternative.

32. • Side effects:
• -gastrointestinal problems such as difficulty swallowing and
inflammation of the esophagus and stomach.
• can affect renal function.
• osteonecrosis of the jaw (ONJ) with long-term use.
• low-trauma atypical femur fractures with the long-term use of
bisphosphonates.
• Contraindication: esophageal disorders, an inability to follow
the dosing requirements (eg, stay upright for at least 30 to 60
minutes), or chronic kidney disease (CKD) (estimated
glomerular filtration [eGFR] rate <30 mL/min), after certain
types of bariatric surgery in which surgical anastomoses are
present in the GI tract (eg, Roux-en-Y gastric bypass).

33. Monitoring
• A follow-up DXA of hip and spine after one to two years,
and if BMD is stable or improved, less frequent monitoring
thereafter.

34. •Duration of therapy:
• Should be individualized based upon patient characteristics and
preferences.
• Treatment review should be performed after 5 years of treatment
with alendronate, risedronate or ibandronate and after 3 years of
treatment with zoledronic acid .

35. • Reassessment of fracture risk by FRAX with femoral
neck BMD .
• If at low risk for fracture in the near future>>> discontinuing the
drug as there appears to be residual BMD and fracture benefit.
• If at highest risk for fracture (history of osteoporotic fracture
before or during therapy, T-score below -3.5 in the absence of
fractures) >>> continuing therapy for up to 10 years .
• For similar women treated with zoledronic acid >>>continue
therapy up to six years.
• • There is no evidence base to guide decisions about treatment
beyond 10 years and management of such patients should be
considered on an individual basis.

36. • Length of holiday :
• There are no data to support one strategy over another for
determining when to restart bisphosphonates after a drug
holiday.
• Fracture risk should be reassessed:
• • after a new fracture regardless of when this occurs.
• • if no new fracture occurs, after 18 months to 3 years .
• In clinical practice, the decision to resume the drug is often
based on a combination of factors, including duration of the
holiday, decrease in BMD, clinical risk factors for fracture, and
increase in markers of bone turnover.
•

37. • Restart bisphosphonates when there is persistent bone
loss (approximately 5 percent) on at least two (DXA)
measurements taken at least two years apart, using the
same make and model DXA scanner.
• An alternative, bisphosphonates can be restarted after a
three- to five-year holiday in women who showed
improvement during their initial course of
bisphosphonates and did not have a previous fracture.

39. • The aim of the clinician in managing
osteoporosis:
 to reduce the risk of fractures.
 to identify patients at increased risk of fracture.
 to assess that risk accurately.
 to improve the patient’s perception of that risk.
 to give advice & aid understanding of the disease, the
aims of therapy and the choice of therapy treatment -
lifestyle advice - therapeutic agents

40. Thank you…