osteoporosis and role of vitamin d and calcium in its management

1. Osteoporosis
Dr.S.Sethupathy
1

2. Defining Osteoporosis
⚫“Progressive systemic skeletal disease
characterized by low bone mass and
microarchitectural deterioration of bone
tissue, leading toenhanced bone fragility
and aconsequent increase in fracture risk”
⚫True Definition: bonewith lowerdensity
and higher fracturerisk
⚫WHO: utilizes Bone Mineral Density as
definition (T score <-2.5); surrogate marker

3. Who Gets Osteoporosis?
⚫Age
⚫Estrogen deficiency
⚫Testosteronedeficiency
⚫Family history/genetics
⚫Femalesex
⚫Low calcium/vitamin D intake
⚫Poorexercise
⚫Smoking
⚫Alcohol

4. Who gets osteoporosis?
⚫Low body weight/anorexia
⚫Hyperthyroidism
⚫Hyperparathyroidism
⚫Prednisone use
⚫Liverand renal disease (think aboutvitd
synthesis)
⚫Low sunexposure
⚫Medications (antiepileptics, heparin)
⚫Malignancies (metastaticdisease; multiple
myeloma can presentasosteopenia!)
⚫Hemiplegia s/p CVA/ immobility

5.  Back pain, which can be severe if fractured or collapsed
vertebra
 Loss of height over time, with an accompanying stooped
posture
 Fractureof thevertebrae, wrists, hipsorother bones

6. Hypogonadal states
•Turnersyndrome,
•Klinefelter syndrome,
•Kallmann Syndrome,
•anorexia nervosa,
•hypothalamic
amenorrhea,
•hyperprolactinemia.
Nutritional and
gastrointestinal disorders
•malnutrition,
•parenteral nutrition,
•malabsorptionsyndromes,
•gastrectomy,
•severe liverdisease
(especially biliarycirrhosis),
•perniciousanemia.
Hematologic
disorders/malignancy
•multiple myeloma,
•lymphomaand
leukemia,
•mastocytosis,
•hemophilia,
•thalassemia.
Etiology
Endocrinedisorders
•Cushing's syndrome,
•hyperparathyroidism
• thyrotoxicosis,
•insulin-dependent
diabetes mellitus,
•acromegaly,
•adrenal insufficiency

7. Drugs associated with increased risk of
osteoporosis
⚫- Glucocorticoids
⚫- Cycosporine
⚫- Cytotoxicdrugs
⚫- Anticonvulsants
⚫- Excessive alcohol
⚫- Excessive thyroxine
⚫- Heparin
⚫- Lithium
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8. T-Score
WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.
World Health Organization (WHO)
Osteoporosis Guidelines
1.4
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
20 30 40 50 60 70 80
Age
BMD
Mean
–2 SD
Considerpreventive interventio
Considertherapeutic interventio
Mean LumbarSpineBMD:
Decades 3 to 9 of a Woman’s Life
Bone Mineral Density Values

9. Osteoporosis
⚫PATHOGENESIS
⚫1. Peak bone mass : about 20 yearsold
- genetic, hormone, nutrition, lifestyle
⚫2. Rateof bone loss : afterage 30-45, bone resorption
(osteoclast)> formation (osteoblast) and become
exaggerated after menopause
(50 yearsold)
⚫3. Boneremodeling : keep balanceat 20-30 yearsold,
afterthat become negative balance
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10. Mechanism

11. Osteoporosis
⚫ Type 1
Postmenopausal
Type 2
Senile
Type 3
secondary
⚫Age 55 -70 years
⚫Sex(F/M)
⚫Fxsite
6:1
vertebrae
70-90 years
2 :1
vertebrae
distal forearm hip
all
1:1
vertebrae
hip
distal forearm
⚫The threshold for Fx is reduced forosteoporotic
bone
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12. Risk factor for osteoporosis fracture
⚫ Potentially modifiable
1. Cigarettesmoking
2. Low bodyweight ( < 58 kg.)
3. Estrogen deficiency : early
menopause (<45 years)
4. Low calcium intake, high saltand proteindiet
5. Alcoholism
6. Inadequatephysical activity
7. Poor health
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13. Lab Investigations
CBC
ESR
Serum calcium (8.6 – 10.4 mg/dl)
Serum phosphorus (3.00 – 4.5 mg/dl) Children 4-6 mg/dl
Serum alkaline phosphatase (44 – 147 Iu/lit.) Children 1.5 -
2.5 times more
Liver function tests
Renal function tests
T3,T4, TSH
Para thyroid hormones
Vitamin D 25 (25 – 80 ng/ml)
Protein electrophoresis (M band)
Anti endomysial antibody (Coeliacdisease)

14. Osteoporosis Treatment: Calcium and
Vitamin D
⚫Fewerthan half adults take recommended
amounts
⚫Higher risk: malabsorption, renal disease, liver
disease
⚫Calcium and vit D supplementation shown to
decrease risk of hip fracture in olderadults
⚫1000 mg/day standard; 1500 mg/day in
postmenopausal women/osteoporosis
⚫Vitamin D (25 and 1,25): 400 IU day at least;
⚫Frail older patients with limited sun exposure may need
up to 800 IU/day

15. Osteoporosis Treatment: Calcitonin
⚫Likely notas effectiveas
bisphosphonates
⚫200 IU nasally/day (alternating
nares)
⚫Decrease pain with acutevertebral
compression fracture

16. Osteoporosis Treatment: Bisphosphonates
⚫Decrease bone resorption
⚫Multiple studies demonstratedecrease in hipand
vertebral fractures
⚫Alendronate, risodronate
⚫IV: pamidronate, zolendronate (usually used for
hypercalcemiaof malignancy, malignancy related
fractures, and multiple myeloma related
osteopenia)
⚫Ibandronate (boniva): once/month
⚫Thoseat highest risk of fracture (pre-existing
vertebral fractures) had greatest benefitwith
treatment

17. RECOMMENDED DAILY INTAKE OF VITAMIN D

19. A study of disease management in
a rural healthcare population
demonstrated that a preventive
program was able to reduce hip
fractures and save money.
98% of a woman’s skeletal mass is acquired byage 20
Optimal strategies for building strong bonesoccurs during childhood and
adolescence
1. A balanced dietrich in calciumand
vitamin D
2. Weight-bearingand resistance-
training exercises
3. A healthy lifestylewith nosmoking
orexcessivealcohol intake
4. Talking toone’s healthcare
professional about bone health
5. Bone density testing and
medicationwhen appropriate
Five Steps Toward Prevention

20. THANK U…
Thankyou