Bone Health and Osteoporosis

Dr Asso Fariadoon Ali Amin

MRCP(UK),MRCPE,Dip medical teaching.

Osteoporosis

• Osteoporosis is the commonest cause of fragility fracture in older people.

• Fragility fracture is defined as a fracture sustained when falling from standing height or less.

• Assessing risk of fracture depends on assessing risk of fall, risk of osteoporosis and Bone Mineral Density measured by DEXA scan

• Defined by the WHO as a progressive, systemic skeletal disease characterised by low bone mass and micro-architecural deterioration of bone tissue, with increase in bone fragility and susceptibility to fracture.

• 1 in 3 women and 1 in 12 men will suffer from osteoporotic fracture after 50.

• 50% of men will have a possible underlying cause. Main causes are hypogonadotrophic hypogonadism, steroid, alcohol, hyperparathyroidism, malabsorption.

Osteoporosis Clinical Features

• Usually a symptomatic

• Common first presentation is colles’ wrist fracture in women 50-65.

• Loss of height and dorsal kyphosis , loss of > 4cm suggest at least one vertebral fracture

• Other fractures mainly Hip fracture, neck of humerus, pelvis and distal tibia/fibula

Investigation of fragility fracture and possible osteoporosis

• DEXA scan( Dual-energy X-ray absorptiometry.

• Ultrasound of the of calcaneum

• FBC, U&E, AlK phosphatase, Ca, phosphate, ESR, LFT, TFT, protein electrophoresis, and urinary BJP

• Lateral X-ray of thoracic spine, Testosterone and LH in Men, PTH, Vitamin D, 24 hours urine free-cortisol and dexamethason suppression test.

WHO classification of osteoporosis based on BMD

• Normal T-score -1 SD or more

• Osteopenia T- score between -1 and -2.5 SD

• Osteoporosis T-score below -2.5 SD

• Severe (established) osteoporosis :- T-score below -2.5 SD with one or more fragility fracture.

Assessment of Osteoporosis risk

A patient is considered at risk of osteoporosis if one of these risk

factors is present: Non-modifiable Female Gender Caucasian or Asian ethnicity Age more than 65 Previous fragility fracture for example: vertebral fracture,

Colle’s fracture, fractured neck of femur Parental history of hip fracture( maternal history of

hip#,75) Modifiable Low Body Mass Index (BMI) < 22 History of chronic alcohol consumption > 4 units day History of smoking Low calcium and Vitamin D intake Inactivity.

Assessment of Osteoporosis risk

• Hormonal • Early menopause before the age of 45 or prolonged

untreated amenorrhoea• Male hypogonadism Secondary causes• Other medical condition e.g. ankylosing spondylitis,

Crohn’s disease, coeliac disease, Rheumatoid arthritis, primary hyperparathyroidism, thyrotoxicosis, prolonged immobilisation.

Drugs• On long term oral steroids• Anticonvulsant• prolonged heparin• Cytotoxic medication

FRAX WHO Fracture Risk Assessment Tool

• On line means of calculating the 10 year risk of fracture with bone mineral density – Google FRAX UK

• Further tables calculating 10 year risk of fracture according to BMD or BMI.

The role of Vitamin D• Vitamin D regulate calcium and phosphate absorption and

metabolism, and is essential for bone health. Our main source of Vitamin D is through action of sunlight on skin to produce vitamin D3, and smaller contribution is made from diet ( vitamin D2 from vegetables and D3 from meat). These metabolites are converted initially in the liver and then in the kidneys to the fully active metabolite 1,25 dihydroxycholecalciferol. Primary vitamin deficiency is more common in individuals who have little exposure to the sun as well as those with inadequate diet. It is common in older people, and found in 1/3 in those above 65.

Treatment of osteoporosisLife style

1. Regular weight-bearing exercise is effective in prevention and treating post ,menopausal osteoporosis.

2. Stop smoking

3. Reduce alcohol consumption

4. Eating foods rich in vitamin D and calcium.

5. Salt excess increase bone loss

6. Keep use of corticosteroid to minimum possible

Diet rich in calcium and vitamin DFood Milligrams of calcium/100 gm of food

Edman Cheese 795

Chedar 739

Semi-skimed milk (100ml) 120

Whitebait, fried fish 860

Sardin in oil 500

Salmon 91

Tuna 12

Okra vegetables ,stir fried 220

Spinach boiled 160

Watercress 170

White bread 177

Figs dried 250

Orange 47

Medical treatment of Osteoporosis

• All patient from institutes should be offered calcium and vitamin D supplement .

• All patients treated for osteoporosis should have calcium and vitamin D supplements. Daily requirement is calcium (1200 mg) and Vitamin D (800 IU). Medication to be given adcal D3 or calcichew twice daily.

• Bisphosphonate :- first line is fosmax ( alendronate) weekly which is the only bisphosnate licensed for men. And Alendronate, risedronate, and etidronate are licensed for postmenopausal women. Alendronate and risedronate can be given weekly and daily. Patient should be advised to take on empty stomach with 3-4 glasses of water and to stay upright for at least 30 min. RCT has proven their activity in treating and preventing vertebral and non vertebral fractures ( hip) . Aledronate can cause oseophagitis and should be avoided in patients with stricture or achalasia but risedronate may be used with caution. Both are contraindicated with poor renal function GFR of less than 30

Medical treatment of Osteoporosis • Raloxifen:- is a selective estrogen receptors modulator and is lisenced

for treatment and prevention of vertebral fracture . Side effect:- increase risk of hypertension and thrombo-embolism,.

• Strontium ranelate :- has dual action of stimulating new bone formation and reducing bone resorption , for treatment of post-menapousal women , for both vertebral and non vertebral fractures given as 2 gm daily , there is a small increase in risk of venous thromboembolism and should be avioded in GFR of less than 30.

• Teriparatide:- recombinant fragment of PTH given as daily Sc injection for 18 months , indicated for treatment of postmenopausal women indicated for both vertebral and nonvertebral

• Calcitonin

• HRT.

Medical treatment of Osteoporosis • Guidance relates to treatments to prevent fragility fractures in

post menopausal women who have an independent clinical risk factor for fracture & who have osteoporosis (T-score of -2.5 SD or below) on Dexa scan

• The diagnosis of osteoporosis may be assumed in women >75 years of age if they have two or more independent risk factors for fracture without need for a Dexa scan.

• Guidance relates to treatments for women under 75 who have had an osteoporotic fragility fracture & have a T-score of -2.5SD on Dexa scan or who are over 75 & have suffered a fragility fracture & the clinician deems Dexa scanning to be unnecessary

Osteomalacia

• reduced calcification of osteoid matrix due to vitamin D deficiency . The amount of bone is normal, but it is soft and weak compared to normal. Incidence about 4% in elderly.

• Causes:- 1. diet deficiency 2. Reduced sun exposure and 3.

malabsorption. • Clinical features:- 1. Pain in bone ( spine, shoulder, ribs) , 2. Muscle

weakness, 3. Waddling gate 4. fragility fractures

• Investigation :- 1. X-ray may show insufficiency fractures ( loozers body) 2. Bone scan ( Hungry bones) increase uptake 3. Blood test low calcium, phosphate , and high alkaline phosphatase and low vitamin D . 4. Bone biopsy in suspected cases.

• Treatment:- Calcium and vitamin D supplements

Osteoarthritis

• It is the most common joint disorder and the incident increase with age. 75% of people over the of 65 have some X-ray evidence of OA. 2/3 of people over the age of 65 have symptoms of OA.

• Main joints affected are DIPJ,PIPJ, base of thumbs, knees hips, cervical and lumbar spines.

• Clinical features :- Joint pain, swelling, limitation of movement, sleeping disturbance.

• Signs: Tenderness, Swelling, Crepitus, limitaion of movement , gait , walking become painful

• Treatment:- 1. paracetamol 2. NSAID should be reserved for acute attacks 3. COX-2 inhibitors like celecoxib and rofecoxib 3. topical NSAID 4. Topical capsiacin ( Zacin) 4. amitryptalin and other neuropathic pain killers like pergabalin and gabapentin 5. inta-articular steroid.

Osteoarthritis

Paget’s disease • very common bone disease , up to 10% above the age of 65.

• Male> female

• thought to be due to slow viral infection of osteoclasts, which cause abnormal bone re-modelling.

• Most affects pelvis, femur, spine, skull and tibia

• The bone is expanded and disordered and can cause pain, pathological fracture, and predispose to osteosarcoma.

Presentation:-

• Most commonly a symptomatic elevation of ALP

• Incidental finding on X-ray

• Less commonly :- Pathological fracture

Bone pain usually constant , and mainly at night time. Affects hip and femur

Paget’s disease

Paget’s disease Bowing of legs , a symmetrical , . The skull can take on a characteristic bossed shape, due

to overgrowth of frontal bones Deafness bone expansion in the skull compresses the 8 th cranial nerve causing conductive

deafness which can be severe. Other neurological compression symptoms like spinal cord , optic nerve ( blindness),

brain stem causing hydrocephalus and dysphagia. Rarely CCF-High output failure

Investigation:- ALP is constantly elevated , Urine hydroxyproline X-ray:- Lysis, and sclerosis, and expansion. Radio-isotope scan shows hot spots Immobile with very active disease can also have high calcium , however otherwise

usually normal.

Treatment:- Usually no need for treatment analgesia and joint replacement may be needed Bisphosphonate ( risedronate 30mg od for 2/12 or intemittent iv infusion pamidronate .

Useful in bone pain, reduce vascularity before surgery, improve healing after surgery, improve neurological compression and reduce calcium.

Hypercalcaemia • Symptoms and signs :- Abdominal pain, constipation, nausea and vomiting, polyuria,

polydepsia, anorexia, loss of weight, low mood and depression. Tiredness, weakness, hypertension, confusion, pyrexia, renal stone and renal failure. ECG QT interval prolong.

• Causes:- Primary hyperparathyroidism Malignancy due to metastasis or non metastatic-manifestation of malignant disease Meyloma Vitamin intoxication Milk-alkaline syndrome Benign hyper-calciuric hypercalcaemia Meidication like thiazide Sarcoidosis Acromegally thyrotoxicosis Addison disease Hypokalaemia and hypomagnesaemia

Treatment:- 1. Underlying cause 2. if calcium is more 3.5 mmol/l with symptoms test for Ca,PO4,Albumin, U&Creatinine, Mg, K 3. Iv fluid 3-4/L/ 24 hours 4. Diuretic 40 mgiv/oral/24 hours, 5. pamidronate 6. steroid occasionally used for sarcoidosis 40-60mg.