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7/27/2019 o Steopo Ross

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B Y :

D R M E H R U N N I S A A S S I S T A N T P R O F E S S O R

D E P A R T M E N T O F M E D I C I N E

OSTEOPOROSIS


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OSTEOPOROSIS

It is a disease characterized by low bone mass and

microarchitectural deterioration of bone tissue,

leading to enhanced bone fragility and an increase in

fracture risk.


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DEFINITION

WHO defines osteoporosis as a

Bone density more than 2.5 standard deviation

(SDs) below the young adult mean value(T-score < -2.5).

values between 1 and 2.5 SDs below the young adultmean are termed OSTEOPENIA.


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INCIDENCE

Fractures related to osteoporosis effect around

- 30% women

- 12% men at some point.

Immediate mortality after fracture is 12%.

Cont increase in mortality when compared to agematched controls.


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Pathophysiology

There is disruption of balance between bone formationand bone loss.

Inc bone loss.

Peak bone mass is attained around 30 yrs of age.

Gradual decline in men and in women accelerated boneloss occurs 10 yrs following menopause.

Bone mass depends on the peak mass attained and onthe rate of loss later in life.


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Role of Genetic Factors

Genetic factors has the influence on peak bone mass.

Polygenic.

Polymorphism in the genes for the collagen type IA1,vitamin D receptors and estrogen rec


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Risk Factors/ Causes

Risk factors:

- Female gender- Increasing age

- Early Menopause- Caucasians and Asians- Slender habitus- Lack of Exercise/immobility

- Smoking- Family History- Excess alcohol- Nutrition(low calcium diet,high protein intake for a

long time)


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Drug Therapy:

- Corticosteroids

- Heparin- Ciclosporin

- Cytotoxics

- Gonadotrophin releasing Hormone agonists

- Thyroxine over replacement- Sedatives

- Anticonvulsants


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Diseases Associated With Osteoporosis

Endocrine: Others:

- Cushings syndrome - Chronic Renal failure

- Hyperparathyroidism - Chronic liver disease

- Hypogonadism - Mastocytosis- Acromegaly - Anorexia Nervosa

- Type 1 diabetes - IBD

- Celiac Disease Joints:

- Rheumatoid Arthritis


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Clinical Features

Fractureusually the first symptom.- low trauma fracture

Common sites of fracture:

- Forearm (Colles fracture)- Spine (vertebral Fracture)- Hip joint

Backache

Loss of height


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Investigations

If Fracture suspected:

Plain Radiographs

If plain films normal

Then

Bone scintigrahy(Especially for pelvic and vertebral

hairline fractures)


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Bone Density

DXA (Dual energy X- Ray absorptiometry):

- Measures the areal bone density(mineral per surface area)usually of lumbar spine andproximal femur.

- It is precise and accurate.

- Uses low dose radiation.

- Gold standard for diagnosis of osteoporosis.

- Provides the T- Score reflecting fracture risk which mayinfluence the treatment decisions.


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Indications for DXA Scan

Low Trauma fracture

Clinical Features of Osteoporosis

Osteopenia on plain X-Ray.

Previous fragility fracture Corticosteroid Therapy(>7.5mg daily for>3 months)

Family history of Osteoporotic fracture

Body mass index


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Others

Quantitaive CT scanning:

- True volumetric assessment.

- More expensive.

- Higher radiation

- No clinical advantage.

Associated disease and risk factors :- Exclude other diseases

- Identify contributory factors


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Prevention and Treatment

Address the predisposing lifestyle factors

Identify high risk patients with DXA scan.

Diet:

- Ca1000 mg daily.- Vit D 400-800 mg daily

Exercise:30 min wt bearing exercise 3 times/week.

Smoking cessation

Reduce falls

Physiotherapy


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Those on long term steroids(6 months or more)

- Assess for co existing risks- Start preventive treatment with Bisphosphanates

Secondary prevention:(Reducing fracture risk in those with Osteoporosis)

- Bisphonates (Alendronate,Risedronate)

- Raloxifene (selective estrogen receptor modulator)

- Combined calcium and Vitamin D.


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Drug Therapies

Bisphosphonates

Hormone replacement therapy

Raloxifene(SERM)

Androgens

Combination of Calcium and Vitamin D


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Strategies less commonly used

Combination Therapies

- HRT or SERM and a Bisphosphonate

Calcitriol (1,25-(OH)2D3)

Calcitonin

Flouride

Parathroid hormone therapy


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Management

IF previous Fracture:

Bisphosphonates

If NO previos fracture:

Premenopausal women or Men:

Identify and treat cause or contributory factors

Bisphosphanates(with caution in women of child bearingage)


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Amenorrheic women or postmenopausal:

If menopausal symptomsHRT If HRT not tolerated/used for >10 yrs/no menopausal

symptomsSERM or Bisphonates

If no menopausal symptoms Bisphonates (SERM orcalcitriol if poorly tolerated)

Older Men or women(70 +) Vitamin D and calcium. Consider Hip Protectors


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THANK YOUANY QUESTIONS

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