Silent Bone Disease Osteoporosis -Hidden facts,Red flags,Prevention & Treatment dr.sandeep c agrawal agrasen hospital gondia india

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com!
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OSTEOPOROSIS :!
PREVENTION,DIET & TREATMENT
Dr.Sandeep C Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
www.agrasenortho.com
drsandeep123@gmail.com
09960122234
OSTEOPOROSIS:
Red Flags & Preventive Cares

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www.uc-osteoporosis.com

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Selected Risk Factors
“Red flags”  
that can mean
you could be at
high risk for
weak bones.

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❑ I’m older than 65  
❑ I’ve broken a bone after age 50  
❑ My close relative has osteoporosis or
.has broken a bone  
❑ My health is “fair” or “poor”  
❑ I smoke  
❑ I am underweight for my height  
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Selected Risk factors

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❑ I started menopause before age 45  
❑ I've never gotten enough calcium 
❑ I have more than two drinks of
alcohol .several times a week  
❑ I have poor vision, even with glasses  
❑ I am prone to fall  
❑ I'm not active 6
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I have one of these medical conditions:
❑ Hyperthyroidism
❑ Chronic lung disease
❑ Cancer
❑ Inflammatory bowel disease
❑ Chronic liver or kidney disease
❑ Hyperparathyroidism
❑ Vitamin D deficiency
❑ Cushing's disease
❑ Multiple sclerosis
❑ Rheumatoid arthritis
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I take one of these medicines:
❑ Oral glucocorticoids (steroids)
❑ Cancer treatments (radiation, chemotherapy)
❑ Thyroid medicine
❑ Antiepileptic medications
❑ Gonadal hormone suppression
❑ Immunosuppressive agents
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Strategies for prevention of osteoporosis:
1. High risk strategy:
To identify women at risk & offer intervention
2. Global strategy:
Population based, where the aim is to modify the
risk factors in the general community

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ABOUBAKR ELNASHAR

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• Types of prevention of osteoporosis.
1. Primary:
Aims at reaching at adolescent age a peak bone
mass as high as possible.
Should begin in childhood& continue throughout the
life span to maximize bone mass.
E.g. sufficient calcium intake, omit risk factors
2. Secondary:
Aims at reducing bone loss peri & postmenopausal
E.g. estrogens/gestagens, bisphosphonates
&SERMs.
3. Tertiary:
With manifest osteoporosis aims at preventing
fractures.

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Bone mass
•35% of cortical & 50% of cancellous bone mass are
lost over a lifetime
•The peak bone mass attained is a major
determinant of subsequent bone mass& fracture
risk in later life (Bonjour et al,1997).
ABOUBAKR ELNASHAR

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5 steps for maximizing peak bone mass
(National osteoporosis foundation)
Most important for women who haven't reached their
maximum peak bone mass, which usually occurs
around the age of 30.
Step 1: Daily recommended amounts of ca & vitamin
D
Step 2: Regular wt-bearing exercises
Step 3: Avoid smoking& excessive alcohol intake
Step 4: Risk factor assessment of developing
osteoporosis.
To institute strategies to maximize peak bone mass
and minimize loss before it is too late to prevent the
disease.
Step 5: When indicated, BMD test to see if
medication is needed ABOUBAKR ELNASHAR

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5 steps to minimizing bone loss especially after
menopause
(National osteoporosis foundation)
Step 1: Balanced diet
Regular exercise program
Adequate intake of calcium in diet,
Regular sunlight exposure
Step 2: Stop smoking and reduce alcohol consumption
Step 3: Risk factor assessment & screening test
Step 4: If required, medication for osteoporosis
prevention
Step 5: Avoid certain medications
ABOUBAKR ELNASHAR

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Prevention Steps Are Simple
National Osteoporosis
Foundation (NOF) :
!
FIVE simple steps to
improve bone health and
prevent osteoporosis.

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Pyramid for Osteoporosis Prevention and Treatment
Pharmacotherapy
(antiresorptives and anabolics)
Address Secondary Factors
(drugs and diseases)
Lifestyle Changes
(nutrition, physical activity, and fall prevention)
What does this mean for your patients?
Leading the Effort to Help Prevent and
Treat Osteoporosis

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OSTEOPOROSIS CARE:ABCDE
Alcohol…No
!
BMD Check up
!
Calcium supplements:
Cigarette(Smoking)..No
!
Drug therapy,Diet & Doctor consultation
!
Exercise

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Steps 1 + 2
1.Daily recommended
calcium and vitamin D.
 
2. Regular weight-bearing
exercise

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• FDA uses “Percent Daily Value”
(% DV) to describe amount of
calcium needed daily 
• 100% DV for calcium  
= 1,000 mg 
• Look for this label:
– “Nutrition Facts” on foods
– “Supplement Facts” on
vitamin/mineral supplements
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Get enough calcium and
vitamin D :

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Example of “Daily Value”
 
If a food or supplement has
200 mg of calcium per
serving, the “Nutrition
Facts” or “Supplement
Facts” panel shows: 
 
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20% DV for calcium 
(200 mg ÷ 1,000 mg = 20%)

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2. Vitamin D
Essential for intestinal absorption of calcium.
The recommended intake for women is
400 IU/d for ages 51 to 70,
600 IU/d over age 70, and
800 IU/day for all high-risk women
(homebound, institutionalized, on chronic glucocorticoids, or who live in northern latitudes and
therefore have limited exposure to sunlight)
Sources of vitamin D include sunlight, vitamin D–fortified foods, fish oils, and supplements.
Multivitamins typically contain 400 IU of vitamin D.
Adequate calcium and vitamin D supplementation is key to ensure prevention of progressive bone
loss.
Calcium and vitamin D alone are insufficient to prevent fracture in
those with osteoporosis.

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Step 3
Avoid smoking
and excessive
alcohol.

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Cessation of smoking
• accelerates bone loss
• smoking one pack per day throughout adult
life was associated with a 5 to 10 percent
reduction in bone density
• negate the beneficial effect of estrogen
therapy in postmenopausal women by
acceleration of the metabolism of estrogen

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Steps 4 & 5
4.Doctor Consultation
!
5. Bone density test
and medication when
appropriate.

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TESTS AND DIAGNOSIS
▪ Osteopenia refers to mild bone loss that isn't severe enough to be called
osteoporosis, but that increases the risk of osteoporosis.
!
▪ The best screening test is dual energy X-ray absorptiometry (DEXA) – measures
the density of bones in the spine, hip and wrist and it's used to accurately follow
changes in these bones over time.
▪ Ultrasound
▪ Quantitative CT scanning
Dual energy X-ray absorptiometry

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•T score ≥ -1
•T score -1 to -2.5
•T score < -2.5
Normal
Osteopenia
Osteoporosis
WHO Classification of BMD
using DEXA
•T score < -2.5
+ H. of fractureSevere Osteoporosis
T score represents the number of SD a patient is above or below

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DEXA
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ABOUBAKR ELNASHAR
DEXA Scan

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Interpreting DEXA Results
T scores (comparison with the young adult mean):
relates to absolute fracture risk
Z scores (comparison with reference values of the
same age): related to the individual’s relative risk
for their age.

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Low Z-score: Evaluate for secondary
causes of osteoporosis
Hypogonadism
– Estrogen deficiency: menstrual history
– Testosterone deficiency: serum testosterone
Vit. D deficiency/ intestinal malabsorption
– 24-h urine calcium
– serum 25-hydroxy vitamin D
– serum PTH
Primary hyperparathyroidism: serum calcium and PTH
Hyperthyroidism: serum TSH
Idiopathic hypercalciuria: 24-h urine calcium
Myeloma: SPEP

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DEXA– Flaws?
• DEXA overestimate bone mineral density
of taller subjects and underestimate bone
mineral density of smaller subjects.
• In DEXA: bone mineral content is divided
by the area of the site being scanned.
• DEXA calculates BMD using area (aBMD:
areal Bone Mineral Density), it is not an
accurate measurement of true bone
mineral density, which is mass divided by
a volume.

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• A repeat BMD measurements should be done on
the same machine each time, or at least a
machine from the same manufacturer.
• Error between machines, or trying to convert
measurements from one manufacturer's standard
to another can introduce errors large enough to
wipe out the sensitivity of the measurements.
• DEXA results need to be adjusted if the patient is
taking strontium, and calcium supplements.
• Metallic artifacts in cloths or pockets cause
errors.
• Osteomalacia, Osteoarthritis of spine, old
Fractures of spine and hip, aortic calcification
affect BMD readings.

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FRAX- 10 year risk of fragility fracture
• Age, Sex, Height, Weight,
• Previous fracture,
• Family history of fracture,
• Smoking, Alcohol,
• Rheumatoid, Corticosteroid,
• Secondary Osteoporosis
• BMD

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The FRAX® tool has been developed by WHO to evaluate
fracture risk of patients. It is based on individual patient
models that integrate the risks associated with clinical risk
factors as well as bone mineral density (BMD) at the femoral
neck.
The FRAX® models have been developed from studying
population-based cohorts from Europe, North America, Asia
and Australia. In their most sophisticated form, the FRAX®
tool is computer-driven and is available on this site. Several
simplified paper versions, based on the number of risk factors
are also available, and can be downloaded for office use.
The FRAX® algorithms give the 10-year probability of
fracture. The output is a 10-year probability of hip fracture
and the 10-year probability of a major osteoporotic fracture
(clinical spine, forearm, hip or shoulder fracture).

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II. Tests other than DEXA (peripheral bone
densitometry devices
(ACOG guideline, 2004)
1. Quantitative US (QUS) .
2. Single-energy x-ray absorptiometry.
3. Peripheral DEXA
4. Peripheral quantitative computed tomography
less expensive
low radiation exposure
low precision& accuracy.
Measure peripheral bone only.
Cannot replace DEXA scans .
ABOUBAKR ELNASHAR

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BMD Role??
• Osteoporosis is an arbitrary point on a scale,
• Process of micro-architectural deterioration
• Accelerated bone resorption exists throughout
postmenopausal life, whereas osteoporosis does
not.
• Bone densitometry measures bone density, not
bone turnover or bone stability.
• 85% of the rise in risk of fracture in ageing
women is attributable to something other than the
loss of BMD.
• Age is a better predictor of hip fracture than
radial bone density.

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BMD Monitoring Role??
Osteoporosis

Microarchitectural
deterioration
Low bone density
ABOUBAKR ELNASHAR

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DRUG THERAPY
FDA-APPROVED MEDICATIONS
INDICATIONS
Postmenopausal
Osteoporosis
Glucocorticoid-induced
Osteoporosis
Men
Drug Prevention Treatment Prevention Treatment
Estrogen
Calcitonin
(Miacalcin®, Fortical®)
Raloxifene
(Evista®)
Ibandronate
(Boniva®)
Alendronate
(Fosamax®)
Risedronate
(Actonel®)
Zoledronic acid
(Reclast®)
Teriparatide
(Forteo®)

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Pharmacologic Treatment 
Targets
Osteoclast
Inhibition of resorption
Osteoblast
Stimulation of formation

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Bone marrow precursors
Osteoblasts
Osteoclast
Lining cells
Stimulators of
Bone Formation
Fluoride
PTH analogs
Sr Ranelate (?)
Inhibitors of
Bone Resorption
Estrogen, SERMs
Bisphosphonates
Calcitonin
Inhibitors of
RANKL
Cathepsin K
Therapeutic strategies

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Whom to treat ?
Prior Hip/Vertebral Fracture
or
T Score < -2.5
or
T Score -1 to -2.5 &
10 yr risk (FRAX) :
HIP Fracture > 3 % or
major osteoporotic Fracture> 20 %
Postmenopausal women /men > 50 yrs
with

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Australian Family Physician, 2004
ABOUBAKR ELNASHAR

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Exercise
• Any weight-bearing exercise regimen,
including walking
• Women with osteoporosis should exercise
for at least 30 minutes three times per
week
• Improvements in bone density
• reduced risk of hip fracture in older women

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What keeps bones healthy

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II. Regular exercise
•In children& adolescents:
Wt-bearing physical activity e.g.walking or running contributes to
higher peak bone mass.
•In postmenopausal:
weight-bearing exercise produces small increases in bone
density at the hip and improvement in balance& strength.
Exercise in postmenopausal:
resistance training {improve muscle mass, strength and balance}
balance training which should be performed three times/w
•Women with established osteoporosis:
Activities that place an anterior load on the vertebral bodies e.g.
forward flexion exercises: increased incidence of new vertebral
deformities, and patients should be advised to avoid them.

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VI. Fall reduction
•Falls are the direct cause of more than 90% of osteoporotic hip
fractures,and the tendency to fall increases with age.
•Some studies have shown that, for women over age 70, the
most important predictors of hip fractures are fall-related factors
such as poor cognitive function, slow gait and otherwise
impaired mobility, poor vision, drugs that impair alertness or
balance, and history of falls.
In women over 75, age and slow gait are equal to low BMD of
the femoral neck as predictors of hip fracture.Unfortunately,
labeling women as osteopenic or osteoporotic can cause fear of
falling and lack of activity, leading to further acceleration of bone
loss.

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TOP CALCIUM SOURCES
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Be happy when alone. Let happiness be your
quality. And when you move from aloneness
into involvement, into communication,
relationship, carry that quality of happiness
which was in loneliness — carry that.

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References
. IOF web site
.“Osteoporosis and Bone Physiology” web site, 1999 - 2006 http://
courses.washington.edu/bonephys of Dr. Susan Marie Ott, MD.
.Some slides are from teaching slides of British Medical Journal.
• JAMA 2004;291(16):1999
• J Clin Densitom 2004;7(1):1-6
• J Am Acad Orthop Surg 2006;14:347
• National Osteoporosis Foundation (http://www.nof.org)
• NEJM 2003;348:1187
• NEJM 2004;350(12):1189-99
• Osteoporosis Int 1998;8:1

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.!
Information contained and transmitted by this presentation is based
on review of literature from internet and form Institute of Medicine
summary on DRI for Vitamin D & Calcium,BJD AAOS,National
Osteoporosis Foundation websites.!
. Graphics,Images and jpeg files are taken from Google and yahoo
Image to heighten the specific points in this presentation. !
!
• If there is any objection/or copyright violation, please inform
drsandeep123@gmail.com for prompt deletion. !
!
• It is intended for use only by the doctors and orthopaedicians.!
!
. Views expressed in this presentation are personal. • .For any
confusion please contact the sole author for clarification. !
!
• Every body is allowed to copy or download and use the material
best suited to him. !
!
There is no financial involvement.!
!
• For any correction or suggestion please contact
drsandeep123@gmail.com or www.agrasenorth.com.

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Silent Bone Disease Osteoporosis -Hidden facts,Red flags,Prevention & Treatment dr.sandeep c agrawal agrasen hospital gondia india