“Progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk” True Definition: bone with lower density and higher fracture risk WHO: utilizes Bone Mineral Density as definition (T score <-2.5) Osteoporosis is silent because there are no symptoms initially. The most common are fractures of the spine, hip, and wrist. Osteoporosis is not an inevitable part of aging, but is a disease that can be prevented and treated, provided it is detected early. The main goal of treating osteoporosis is to prevent such fractures in the first place. Bare bone term used for “necked bone with necked eye” “There is clearly a problem of underdiagnosis and undertreatment of osteoporosis and we want to raise awareness about the risk factors for osteoporosis so that those who need treatment get treatment”. Learning Objectives Utilize recent recommendations for osteoporosis prevention and treatment and how to apply them in practice. Explain controversies surrounding pharmacologic osteoporosis therapy including side effects and the risk/benefit ratio of therapy. Determine when and how to utilize the current pharmacologic therapies including anabolic versus anti-resorptive approaches and how to transition or discontinue treatment Osteoporosis only causes symptoms when it is far advanced. Symptoms include loss of height, deformed spine (“dowager’s hump”), unexplained back pain, and fractures. It is best to detect problems at an early stage, when treatment is most effective. The best test for detecting osteoporosis is bone densitometry, done with a technique called “Dual-energy X-ray Absorptiometry” or DXA.

1. OSTEOPOROSIS:
A Barebone guide to diagnosis and
management
Dr. C L Nawal
Senior Professor & Unit Head,
Department of General Medicine,
SMS Medical College and attached Hospital, Jaipur

2. Incidentally Discovered Vertebral Fracture
 No previous fractures
 No current or past history use of
steroids
 Alcohol intake is one glass of wine
daily
 50 pack year history of smoking
 Menopause age 52
 No weight gain or weight loss
 No diarrhea or malabsorption
symptoms
 Physically active and rarely falls
 Normal renal function with no kidney
stones
A 70 year old female smoker being evaluated for a
cough presents for discussion of recently order chest
X-ray.
CXR shows no infiltrates or masses in the lung tissue
itself but there is an incidental vertebral compression
fracture at T12 noted.
Upon further discussion:
 She remembers a 2 month history of significant
back pain that spontaneously resolved after a fall
from standing height while working in the yard 3
years ago shortly after she retired
 She is 2 inches shorter than her peak adult height

3. Medical History
Past Medical History:
1. Hypertension
2. Hyperlipidemia
Medications:
1. Amlodipine 5 mg,
2. Simvastatin 20 mg,
3. Multiple vitamin for “seniors”
Family History:
 Not Significant
Physical examination
Pulse=75 per minut,
BP=135/80 mmHg,
Wt: 65 kg,
Ht: 66 inches,
BMI=24.2
No Cushing Features
No kyphosis or pain on spinal
palpation
No goiter, tremor, thyroid, eye findings

4. Laboratory and Imaging
DXA
Lumbar Spine T score -1.6
Femoral Neck T score -1.5
Total Hip T score -1.3
FRAX 10 year Probability Major Osteoporotic
fracture (MOF) 16%, Hip Fracture (HF) 3.7%
Secondary Evaluation is normal
 Includes CBC, TSH, 24hr urine
calcium/creatinine, Vit D3, PTH, Serum and
urine protein electrophoresis (SPEP/UPEP)
What do you Advise?
 Counsel for smoking cessation
 Treat with appropriate calcium and
vitamin D
 Counsel about Fall prevention
Initiate treatment with
pharmacotherapy ??
OR
Reassure the patient that no
intervention is needed ??

5. Fracture is a Powerful
Risk Factor for Future Fracture
Relative Risk
Thinness 1.3 If BMI <21
Smoking 1.5 If current
Family history 1.6 Sister
of hip fracture 1.3 Mother
Spine Non-Spine
Fractures
Non-spine 2.2 1.5
Spine
1 fracture 3.2 1.6
2 fractures 8.0 2.0
Outcomes of Hip Fractures
 300,000 hip fractures
annually
 24% excess mortality in 12
months
 50% do not recover baseline
function
 25% require long-term
nursing home care

6. {
Osteoporosis

7.  “Progressive systemic skeletal disease characterized by low bone
mass and microarchitectural deterioration of bone tissue, leading to
enhanced bone fragility and aconsequent increase in fracturerisk”
 True Definition: bonewith lowerdensity and higherfracturerisk
 WHO: utilizes Bone Mineral Density as definition (Tscore <-2.5)
 Osteoporosis is silent because there are no symptoms initially.
 The most common are fractures of the spine, hip, and wrist.
 Osteoporosis is not an inevitable part of aging, but is a disease that can
be prevented and treated, provided it is detected early.
 The main goal of treating osteoporosis is to prevent such fractures in the
first place.
What is Osteoporosis?
Reduction in the mass of bone per
unit volume

8. Wrist Fractures:
200,000+
Hip Fractures:
300,000+
Vertebral Fractures:
700,000+
Other Fractures:
300,000+
1.5 Million Fractures Annually

9.  Bare bone term used for “necked bone with necked eye”
 “There is clearly a problem of underdiagnosis and undertreatment of osteoporosis and we want to raise
awareness about the risk factors for osteoporosis so that those who need treatment get treatment”.
Learning Objectives
 Utilize recent recommendations for osteoporosis prevention and treatment and how to apply them in
practice.
 Explain controversies surrounding pharmacologic osteoporosis therapy including side effects and the
risk/benefit ratio of therapy.
 Determine when and how to utilize the current pharmacologic therapies including anabolic versus anti-
resorptive approaches and how to transition or discontinue treatment

10. 2–4 weeks 3–4 months
Resting
stage
Reversal
phase
Formation Remodeling
completed
Activation Resorption
Lining cells
Osteoclast
precursors
Osteoclasts Osteoblasts
Bone remodeling unit
Lining cells
Normal Bone Remodeling
 Osteoporosis results from a loss of bone mass (measured as bone density) and from a change in bone structure.
 Recognizing your risk factors is important so you can take steps to prevent this condition or treat it before it
becomes worse.

11.  Female
 Postmenopausal
 Family history of osteoporosis
 Lack of exercise
 Small body frame
 Low calcium intake
 Vitamin D deficiency
 Smoking
 Age (starting in the mid-30s but more likely with advancing
age)
 Rheumatoid arthritis, hyperthyroidism, hyperparathyroidism,
hypogonadism
 Medications – corticosteroids (Prednisone), excess thyroid
hormone, some diuretics (Lasix), and anticonvulsants (Dilantin,
Phenobarb, Tegretol)
Common risk factors for osteoporosis

12. Lifestyle changes Genetic disorders Endocrine causes Hematologic causes
Smoking Cystic fibrosis Central obesity Hemophilia
Alcohol use Glycogen storage dis. Cushing syndrome Leukemia
Vit..D deficiency Marfan syndrome DM 1&2 Lymphoma
Immobilization Gaucher’s disease Thyrotoxicosis Sickle cell disease
Sedentary lifestyle Hemochromatosis Hyperparathyroidism Thalassemia
Frequent falls Osteogenesis imperfecta Premature Menopause Monoclonal gammopathy
Low calcium intake Porphyria Hyperprolactinemia Multiple myeloma
Primary biliary cirrhosis Ehler Danlos syndrome Turner’s Syndrome Mastocytosis
Inflammatory bowel disease Homocysteinuria Klinefelter’s syndrome
Gastrointestinal causes Rheumatological causes Neurological causes Others
Celiac disease Ankylosing spondylosis Multiple sclerosis HIV
Gastric bye-pass Systemic lupus Epilepsy COPD
Malabsorption RA Muscular dystrophy Amyloidosis
Pancreatic disease Autoimmune disorders Parkinson’s disease Sarcoidosis
Stroke Depression
Proximal myopathy Congestive heart failure
Common risk factors for osteoporosis

13.  Osteoporosis only causes symptoms when it is far
advanced.
 Symptoms include loss of height, deformed spine
(“dowager’s hump”), unexplained back pain, and
fractures.
 It is best to detect problems at an early stage, when
treatment is most effective.
 The best test for detecting osteoporosis is bone
densitometry, done with a technique called “Dual-
energy X-ray Absorptiometry” or DXA.
Osteoporosis: Patient Searching

14. Underdiagnosed
Unrecognized
Underreported
Inadequately researched
Men & Osteoporosis
14

15. Diagnosis
• Medical history
• Physical exam
• X-rays
• Bone densitometry
15
 Back pain
 Focal kyphosis
 Loss of height
 Localized tenderness
Clinical presentation

16.  In India, osteoporosis is a major public health problem.
 However, in the absence of any robust regional guidelines, the screening,
treatment, and follow-up of patients with osteoporosis are lagging behind in the
country.
 Implementation of the position statement in clinical practice is expected to
improve the overall care of patients with osteoporosis in India.

17. DIAGNOSIS OF OSTEOPOROSIS
• Dual energy X-rayabsorptiometry (DXA).
• Urine and blood tests (bone markers).
Markers of bone resorption include:
• Telopeptide
• N-telopeptide (NTX) – ELISAmethod.
• C-telopeptide (CTX) – ELISAmethod.
Markers of bone formation
• Bone ALP
• Osteocalcin
 Xrays
 Bone Scan
 MRI
 Delineating benign and
malignant
 Acute vs chronic
Radiography

18. Plain Radiographs
• Marker at max pain site
• Cobb angle
• Fracture pattern
• Limitations: poor judge of
acuity
 Excellent predictive value for
response to vertebral
augmentation
 DRAWBACKS: poor detail,
 Best in conjunction with CT in
pts with MRI not feasible
Bone Scan Advanced imaging MRI
T1
STIR

19.  This is important because the amount of calcium in bone determines how strong it is.
 The most advanced is called “Dual-energy X-ray Absorptiometry” or DXA.
Bone Densitometry
What is Bone Density Testing?

20.  1 standard deviation drop (10%) in BMD is
associated with a doubling of the fracture risk
Cummings, Lancet 341: 72-5, 1993
Huang, J Bone Min Res 13: 107-13, 1998
Bone Mineral Density
DEXA

21. DEXA
 Simple test that measures bone mineral
density.
 Often the measurements are at spine and hip.
 The test is quick and painless.
 It is similar to an X-ray, but uses much less
radiation.
 Even so, pregnant women should not have this
test, to avoid any risk of harming the fetus.

22.  DXA test results are scored compared with the BMD of young, healthy people.
 This results in a measure called a T-score.
 The risk of fracture most often is lower in people with osteopenia than those with osteoporosis.
 But, if bone loss continues, the risk of fracture increases.
DEXA
DXA T-score Bone mineral density (BMD)
Not lower than –1.0
Normal
Between –1.0 and –2.5
Osteopenia (mild BMD loss)
–2.5 or lower
Osteoporosis

23.  WHO definition
 DXA
 1- 2.5 SD below mean – osteopenia
 > 2.5 SD below mean – osteoporosis
Who needs bone densitometry?
 Anyone who wants an accurate measurement of bone density.
 However, because of cost concerns, the test
is most often done for those with high risk of developing osteoporosis, or to
monitor the effectiveness of treatment for osteoporosis.

24. High Risk Group
 Estrogen deficient women undecided about taking hormones.
 Those with spinal abnormalities or X-ray evidence of bone loss.
 Anyone taking long-term corticosteroid treatment (such as Prednisone).
 Primary hyperparathyroidism with no symptoms.
 Monitoring of therapy for osteoporosis.
The categories for which bone densitometry is most
often done are:

25.  SCORE (Simple Calculated Osteoporosis Risk
Estimation) (value > 6 having good sensitivity)
 OSTA(osteoporosis self-assessment tool for
Asians)
 MORES (male osteoporosis risk
estimation score)
Screening tools (Indians)

26. Novel imaging techniques for osteoporosis diagnosis and fracture risk
Adami G, Fassio A, Gatti D, Viapiana O, Benini C, Danila MI, Saag KG, Rossini M. Osteoporosis in 10 years time: a glimpse into the future of osteoporosis. Ther Adv Musculoskelet Dis. 2022 Mar 20;14:1759720X221083541. doi:

27. Calcium
 Take enough calcium in diet.
 The recommended daily dose is 1,000 milligrams per day
for most adults and 1,200 mg per day for women over
age 50 or men over age 70.
Vitamin D
 Get adequate amounts of vitamin D.
 The recommended daily dose is 400–800 International
Units (called IU) for adults younger than age 50, and
800–1,000 IU for those age 50 and older.
Physical activity
 Get exercise most days, especially weight-bearing
exercise, such as walking
How is osteoporosis treated?

28. Medication
1. Bisphosphonates
2. Estrogen Replacement
Therapy
3. Medications made from
natural hormones
4. SERMs (Selective Estrogen
Receptor Modulators)

29. Vitamin D metabolites
Parathyroid hormone
New bisphosphonates
New SERMs
Medication-Under Investigation

30. { {
Antiresorptives Anabolics
FDA-Approved Osteoporosis Medications
*reduces non vertebral fracture
Estrogen/HRT*
Bisphosphonates
Alendronate (Fosamax)*
Risedronate (Actonel)*
Ibandronate (Boniva)
Zoledronic Acid (Reclast)*
SERMS:
Raloxifene (Evista)
Bazedoxifene (Duavee)
Calcitonin (Miacalcin)
Denosumab(Prolia)*
Parathyroid Hormone
(Teriparatide, Forteo)
PTHrPAnalogue
(Abalopartide, Tymlos)*
Romosozumab (Evenity)

31. Cumulative Incidence of Fractures and Change in Height.
Participants were randomly assigned
to receive four infusions of either
zoledronate at a dose of 5 mg
(zoledronate group) or normal saline
(placebo group) at 18-month intervals.
The risk of nonvertebral or
vertebral fragility fractures was
significantly lower in women with
osteopenia who received
zoledronate than in women who
received placebo

32. Recommended pharmacological treatment for osteoporosis

33. How is osteoporosis treated?
Bisphosphonate Medications for Osteoporosis (OP)
Generic drug name Approved uses for OP Dosing and form
Alendronate
Prevention and treatment of postmenopausal OP in
women
Treatment of OP due to use of glucocorticoid medicines
Once-daily or once-weekly pills
Risedronate
Prevention and treatment of postmenopausal OP in
women
Prevention and treatment of OP due to use of
glucocorticoid medicines
Once-daily, once-weekly or once-
monthly pills
Ibandronate
Prevention and treatment of postmenopausal OP in
women
Once-monthly pills, or every three
months by intravenous infusion (often
called IV) given through a vein
Zoledronic acid Same as for risedronate
Once a year by IV

34. CLASS AND DRUG BRAND NAME FORM FREQUENCY GENDER
Antiresorptive Agents
Bisphosphonates
Alendronate
Fosamax®, Fosamax Plus D™ Oral (tablet, solution)
Daily/Weekly Women & Men
Binosto® Oral (effervescent tablet) Weekly Women & Men
Ibandronate
Boniva® Oral (tablet) Monthly Women
Boniva® Intravenous (IV) injection Every 3 months Women
Risedronate
Actonel® Oral (tablet) Daily/Weekly/Monthly Women & Men
Atelvia™ Oral (tablet) Weekly Women
Zoledronic Acid Reclast® Intravenous (IV) infusion One Time per Year/Once every two years
Women & Men
RANK ligand (RANKL) inhibitor
Denosumab Prolia® Injection Every 6 Months
Women & Men
Estrogen* (Hormone Therapy)
Estrogen
Multiple Brands Oral (tablet) Daily Women
Multiple Brands Transdermal (skin patch) Twice Weekly/Weekly Women
Estrogen Agonists/Antagonists also called selective estrogen receptor modulators (SERMs)
Raloxifene Evista® Oral (tablet) Daily Women
Tissue Specific Estrogen Complex (TSEC)
Estrogen/Bazodoxifene Duavee® Oral (tablet) Daily Women
Anabolic Agents
Sclerostin Inhibitor
Romosozumab-aqqg Evenity® Injection 2 injections once monthly for 12 months Women
Parathyroid Hormone (PTH) Analog
Teriparatide
Forteo® Injection Daily Women & Men
Bonsity® Injection Daily Women & Men
Parathyroid Hormone-Related Protein (PTHrp) Analog
Abaloparatide Tymlos® Injection Daily Women & Men
*Estrogen is also available in other preparations including a vaginal ring, cream, by injection and as an oral tablet taken sublingually (under the tongue). The vaginal preparations do
not provide significant bone protection
FDA-approved
drugs
for
osteoporosis

35. In postmenopausal women with
low bone mass, romosozumab
was associated with increased
bone mineral density and
bone formation and with
decreased bone resorption
Percentage Change from Baseline in Bone Mineral Density.

36. Denosumab given subcutaneously twice yearly for 36
months was associated with a reduction in the risk of
vertebral, nonvertebral, and hip fractures in women
with osteoporosis
Incidence of New Vertebral,
Nonvertebral, and Hip Fractures.

37. Selective estrogen receptor modulators
These medications, often referred to as SERMs, mimic estrogen’s good effects on
bones without some of the serious side effects such as breast cancer.
Teriparatide
Teriparatide is a form of parathyroid hormone that helps stimulate bone formation.
It is approved for use in postmenopausal women and men at high risk of
osteoporotic fracture.
It also is approved for treatment of glucocorticoid-induced osteoporosis.
It is given as a daily injection under the skin and can be used for up to two years.

38. Percent Change in Mean Bone Mineral Density at
the Lumbar Spine and Total Hip from Baseline to
18 Months or the Last Measurement
 Once-daily recombinant human parathyroid
hormone (teriparatide) stimulates bone
formation, increases bone mass, and reduces
the risk of vertebral and nonvertebral fractures
 Among patients with osteoporosis who were at
high risk for fracture, bone mineral density
increased more in patients receiving
teriparatide than in those receiving alendronate

39. Treatment compliance is poor with daily Alendronate, weekly Risedronate and
monthly Ibandronate regimen along with calcium and vitamin D3 in Indian
paramedical workers suffering OP.

40. Bone remodeling and therapeutic targets for osteoporosis. RANK: Receptor activator
of nuclear factor-kb; RANKL: RANK ligand; OPG: osteoprotegerin

41.  Different anti-osteoporotic delivery systems includes injectable hydrogels
and naoparticles as well as anti-osteoporotic bone tissue
enginnering materials.
 Fabrication techniques such as 3D printing, electrostatic spinning and
artificial intelligence are appraised in the context of how the use of these
adjunctive techniques may improve treatment efficacy.

42. Calcitonin
 Hormone made from the thyroid gland, is given most often as a nasal spray or as an injection
(shot) under the skin.
 Approved for the management of postmenopausal osteoporosis and helps prevent vertebral (spine)
fractures.
 It also is helpful in controlling pain after an osteoporotic vertebral fracture.
Estrogen or hormone replacement therapy
 Estrogen treatment alone or combined with another hormone, progestin, has been shown to
decrease the risk of osteoporosis and osteoporotic fractures in women.
 Consult with your doctor about whether hormone replacement therapy is right for you.
How is osteoporosis treated?

43. In postmenopausal women with
osteoporosis who were at high risk
for fracture, romosozumab
treatment for 12 months followed
by alendronate resulted in a
significantly lower risk of fracture
than alendronate alone
Incidence of New Vertebral, Clinical, and Nonvertebral Fracture

44. Mean percent change (SEM) in
BMD from baseline to 24 months in
the
A. lumbar spine (A),
B. one-third distal radius (B),
C. femoral neck (C), and
D. total hip (D)
in the teriparatide (TPTD),
denosumab (DMAB), and
combination (Combo) groups.
P < .05 compared with other groups.
Two years of concomitant teriparatide and denosumab therapy increases
BMD more than therapy with either medication alone and more than has
been reported with any current therapy.

45.  Vibration therapy also shows promising
results in regaining muscle mass and
function after degeneration.
 It reinforces the blood supply to the bones
and reduces osteoclast formation.
 It reactivates the inactive muscle fibers and
the neuronal and proprioceptive sensory
systems around them.
 Vibration therapy can be regarded as an
alternative to stimulating physically
restricted patients with mechanical
stimulation to rebuild musculoskeletal
strength.

46. Young women and pregnancy
 Young women who have risk factors for osteoporosis and fractures need to
carefully consider their medication options if they are planning a
pregnancy.
 None of the drugs for managing osteoporosis has enough safety data
available to recommend using them in women who are pregnant or
breastfeeding.
 Bisphosphonates, even after you stop taking them, can stay in your body a
long time.
 Thus, women who want to become pregnant later should weigh the
expected benefits of bisphosphonates against the possible risks.
 If a woman who has taken a bisphosphonate becomes pregnant, she should
have her blood calcium levels checked, because they could become low.

47. ForprevalentVF (Vertebral
Fracture)
1. Teriparatide : 24 months of therapy
followed by Anti-Resorptives
2. Inj Zoledronic acid for 3-5 years
3. Oral BPN
ForprevalentHF (Hip
Fracture)
1. IV Zoledronic
2. Denosumab
Therapy without Fracture
(high risk)
1. Oral/IVBPN
(Alendronate/Risedronate/Zoled
ronic)
2. Denosumab
3. Teriparatide ( T < -3.5)
Therapy without Fracture
(low/moderate risk)
1. BPN
2. Denosumab
In Chronic kidney Disease or Heart
Disease
1. BPN C/I in stage IV/V
2. Denosumab : risk of Hypocalcemia
3. Adynamic bone disease

49. Identification and appropriate management of skeletal fragility can reduce fractures,
and preserve mobility, autonomy and quality of life in this population
CMAJ 2023 October 10;195:E1333-48. doi: 10.1503/cmaj.221647

50. Prevention of Osteoporosis
Calcium and Vitamin D Intake
Adults: 1000-1200 Units per day
Lifestyle changes may be the best way of preventing osteoporosis.
 Get enough calcium in diet or through supplements (roughly 1,000–1,200
mg/day, but will depend on your age).
 Get enough vitamin D (400–1,000 IU/day).
 Stop smoking.
 Avoid excess alcohol intake: no more than two or three drinks a day.
 Engage in weight-bearing exercise. Aim for at least 2½ hours a week (30
minutes a day five times a week or 50 minutes a day three times a week),
or as much as you can. Exercises that can improve balance, such as yoga,
may help prevent falls.

51. 10-20 YEAR OLD 25-30 YEAR OLD 35-50 YEAR OLD 35-50 YEAR OLD
Calcium rich diet and
a regular, moderate
exercise program
Calcium-rich diet and
regular exercise, consider
bone density screening
calcium-rich diet and a healthy
lifestyle that includes exercise
of at least 20 minutes at least 3
times per week
1 0 2 5 4 0 5 5 7 0 8 5
A g e i n Ye a r s
Stages of
Bone Growth
and
Bone loss
Calcium rich diet to
deposit in the bone
bank

53. Thank you