osteoporosis - website staff...

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OSTEOPOROSISOSTEOPOROSIS

ERROL U. HUTAGALUNGERROL U. HUTAGALUNG

Div. Of Orthopaedic & TraumatologyDiv. Of Orthopaedic & TraumatologyFaculty of Medicine, Univ. of IndonesiaFaculty of Medicine, Univ. of Indonesia

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OSTEOPOROSIS

OSTEOPOROSIS (OP) :• Systemic skeletal disease• Low Bone Mass• Changes in microarchitectural of bone tissue Bone Fragility > OP Fx/ Fragility Fx.

• New def 2001: Decreased Bone Strength

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Normal Bone Osteoporosis

Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength primarily reflects the integration of and bone density/ mass& bone quality

What is Osteoporosis?What is Osteoporosis?

Pictures from: http://www.agelessfoundation.org/osteo/The NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. JAMA 285:785-795, 2001

http://www.agelessfoundation.org/osteo/

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OSTEOPOROSIS.

PATHOGENESIS OF OP :• Adult healthy bone- renewal process-

remodelling process resorption (osteoclast) & formation (osteoblast) process.

• Resorption-Formation process coupling process.

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OSTEOPOROSIS

• EACH YEAR 10 % OF SKELETAL BONE IS REPLACED BY NEW BONE.• EVERY 3 – 10 YRS ALL BONES HAS UNDERGONE REMODELLING PROCESS.• IN OP : REMODELLING PROCESS UNCOUPLING PROCESS IMBALANCE OF RESORPTION

& FORMATION PROCESSLOSS OF BONE MASS FRAGILEEASY TO BREAK.• POST MENOPAUSE ESTROGEN DEF.(INHIBITS OSTEOCLAST) RESORPTION >

FORMATION OSTEOPOROSIS +.

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OSTEOPOROSIS

TYPE OF OSTEOPOROSIS :• PRIMARY :

– TYPE I : POSTMENOPAUSAL OP-MEDIATED BY OSTEOCLAST– TYPE II: SENILE OSTEOPOROSIS- MEDIATED BY OSTEOBLAST-OCCUR IN MEN & WOMEN

> 70 YRS –FORMATION OF BONE <.

• 70 – 80 % ARE PRIMARY TYPE• SECONDARY :

– CAUSED BY AN UNDERLYNG DISEASE/DRUG THERAPY- OCCUR AT ANY AGE

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OSTEOPOROSIS

SECONDARY OP :• UNDERLIYNG DISEASE :

– HORMONAL IMBALANCE-CUSHING SYNDR.– CANCER, CRF, GI DISORDERS CAUSING MALABSORPTION, HYPOGONADISM IN MEN– DRUG USE – CORTICOSTEROID- GIOP.– POOR NUTRITION

• 30 – 45 % OF AFFECTED INDIVIDUAL NO CAUSE CAN BE IDENTIFIED

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OSTEOPOROSISOSTEOPOROSISIncidence of OP :Incidence of OP :

-- OP : World study: after 50 yrs :OP : World study: after 50 yrs :- Female 1 out of 3- Female 1 out of 3- Male 1 out of 5- Male 1 out of 5

- World study : 200 mill with OP- World study : 200 mill with OP

- USA,EUROPE,JAPAN : >75 mill- USA,EUROPE,JAPAN : >75 mill -China : 7 % of pop-China : 7 % of pop > 70 mill > 70 mill -Indonesia : > 45 yr : men – 20 %%-Indonesia : > 45 yr : men – 20 %% women- 32 %women- 32 % > 70 yr : men- 38 %> 70 yr : men- 38 % women- 54 %women- 54 %

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Clinical diagnosis• “ Silent Disease”:• No complain until fracture happens.• Most common location :- Prox femur,Distal radius,Vertebra. Vertebra: due to microfractures/VCF chronic-intermitent back pain,loss of height, increase of dorsal kyphosis-Dowager’s hump-

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Radiological Diagnosis

• Rarefaction of metaphysis of long bones,

• Thinning of cortex, vertebral bodiesevidence Of deformity.

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Laboratory diagnosis

• Serum Ca & Phosphor normal • Marker of bone formation : SAP/BSAP,Osteocalcin• Marker of bone destruction : NTX,CTX

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OSTEOPOROSIS

DIAGNOSIS OF OP :• GOLD STANDARD : EXAMINATION OF BMD (BONE MINERAL DENSITY)• WITH DEXA (DUAL ENERGY X-RAY ABSORPTIOMETRY) METHOD.• pDEXA – ultra sound method – os calcis- for screening purposes- must be

confirmed with DEXA.

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OSTEOPOROSIS

• INTERPRETATION OF DEXA EXAMINATION ;

• WHO : Normal : T score : > - 1• Osteopeni : T score : - 1 ~~ - 2.5• Osteoporosis : T score : < - 2.5• Severe OP : T score < - 2.5 with one fragility/insuff. fx.

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OSTEOPOROSIS

• OP –SILENT DISEASE/Asymptomatic• Clinical Problem Fracture +• Fracture Morbidity-Quality Of Life (QOL)• Mortality.• Most common OP Fx:Hip, Vertebra, Wrist• Most seriuos : Hip Fractures

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Fragility or Osteoporotic Fractures

• Fractures occurring at a site associated with low bone mineral density and which increase in incidence after the age of 50 years

Kanis J, Osteoporos Int 2001; 12(5):417-27

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Sites associated with low BMD

HIP SPINE WRIST

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HIP FRACTURESHIP FRACTURES

♦Hip fx is the most serious complication of OP fx in term of Morbidity, Mortality, Economic & Social cost and impact on QOL

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Hip Fractures

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OSTEOPOROSISOSTEOPOROSISOP HIP FRACTURESOP HIP FRACTURES In spite of up to date tx of hip OP fx:In spite of up to date tx of hip OP fx:

- 20% died within one year mostly as- 20% died within one year mostly as a result of preexisting medical conditiona result of preexisting medical condition- 1/3 remain bed/chair ridden- 1/3 remain bed/chair ridden- 1/3 suffer functional limitations and - 1/3 suffer functional limitations and require assistance require assistance - Only 1/3 return to full function- Only 1/3 return to full function

∴Fractures in elderly OP patients do not only affectFractures in elderly OP patients do not only affect quality of life but also life threatening quality of life but also life threatening

WHO 2003, Perren SM 2005WHO 2003, Perren SM 2005

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Hip Surgery

• Another study :

• 25% full recovery 75 % will either :

Use a cane or a walker 50% Confined in a nursing home/ 20 – 40 %

self-care assistance (care-givers)Die within the first 12 months 15-20% (40%)

secondary to other chronic disease and consequences of immobilization, especially among age >50

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VERTEBRAL FRACTURESVERTEBRAL FRACTURES Many are asymptomatic or cause too few Many are asymptomatic or cause too few

symptoms to provoke investigation.symptoms to provoke investigation. Localization: mid thoracic or thoracolumbar Localization: mid thoracic or thoracolumbar

junction junction weakest region weakest region Quality of life < than hip fx Quality of life < than hip fx 4% needs 4% needs

assistance in ADLassistance in ADL Economic burden: mainly due to outpatient care,Economic burden: mainly due to outpatient care,

provision of nursing care and lost of provision of nursing care and lost of working daysworking days

WHO 2003WHO 2003

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Vertebral Fractures

• More commonly occur spontaneously• May be secondary to minimal trauma from

spinal loading during day-to-day activities, such as bending forward, lifting objects, and climbing stairs

• High risk of having another vertebral fracture – ~ 20% within the 1st year

1. Cooper C et al. J Bone Min Res. 1992;7:221–227.2. Frost HM. Orthop Clin North Am. 1981;12:671–681.

3. Parfitt AM, Duncan H. In: Rothman RH, Simeone FA, eds. The Spine. 2nd Edition. Philadelphia: WM Saunders;1982:775–905.

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Vertebral Fracture: underdiagnosed

• Two thirds of new vertebral fractures are not diagnosed1,2

• Often asymptomatic

1. Nevitt MC, et al. Ann Intern Med 1998; 128: 793-800;

2. Cooper C, et al. J Bone Miner Res 1992; 7: 221-7;

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75+ KyphoticAt risk for hip fracture

55+ PostmenopausalAt greater risk for vertebral

fracture than any other type of fracture

Healthy spine

Kyphotic spine

50 MenopausalExperiencing

vasomotor symptoms

The Osteoporosis Continuum

Reproduced with permission from MarketForce

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Vertebral Fractures

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OSTEOPOROSISOSTEOPOROSISWRIST FRACTURES- Colles FxWRIST FRACTURES- Colles Fx

Caused by a fall on the outstretched handCaused by a fall on the outstretched hand

Peak incidence 60 – 70 yrsPeak incidence 60 – 70 yrs

Less morbidity than hip fx, but painfulLess morbidity than hip fx, but painful

Arch Int. Med’91Arch Int. Med’91

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1% needs assistance for ADL1% needs assistance for ADL

50%: fair/poor functional outcome50%: fair/poor functional outcome at 6 mosat 6 mos

Complication: Algodystrophy/Sudeck atrophy:Complication: Algodystrophy/Sudeck atrophy: pain, stiffness, swelling of the pain, stiffness, swelling of the

handhand

Brit J Rheu ‘94Brit J Rheu ‘94

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What are the psychosocial consequences

of fragility fractures?

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Psychological consequences of osteoporosis

General and disease-specific anxiety

Diminished

self-esteem

Depression

Overall worsened

quality of life Osteoporosis

Increased dependency

on others

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OSTEOPOROSISOSTEOPOROSISTREATMENTTREATMENT Colles Fx: Colles Fx:

- undisplaced – cast immob.- undisplaced – cast immob.- displaced – closed reduction- displaced – closed reduction

cast immob.cast immob.- immob: 4-6 weeks- immob: 4-6 weeks- avoid prolonged immob - avoid prolonged immob complication complication ↑↑

Vertebral Fractures:Vertebral Fractures:- Lumbar corsett/bracing- Lumbar corsett/bracing- Vertebro plasty- Vertebro plasty- Kyphoplasty- Kyphoplasty

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TREATMENTTREATMENT Hip Fx:Hip Fx: Goal: immediate return to mobility to avoidGoal: immediate return to mobility to avoid extended bed rest with it’s complicationextended bed rest with it’s complication

Achieved by Hemi/Total arthroplasty,ORIF to Achieved by Hemi/Total arthroplasty,ORIF to alleviate pain and allow early safe weight bearingalleviate pain and allow early safe weight bearing

After management of Fx After management of Fx DO NOT FORGETDO NOT FORGET TO TREAT OP !TO TREAT OP !

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Economic cost of management OP fracturesEconomic cost of management OP fractures

England : £ 942 mill/year – probablyEngland : £ 942 mill/year – probably will will ↑↑ as the number of elderly as the number of elderly ↑↑

USA : $ 13.8 bill in’95 USA : $ 13.8 bill in’95 recently: recently: $ 18 bill/year$ 18 bill/year

and increasingand increasing

Highest cost : Hip fracturesHighest cost : Hip fractures

WHO 2003; Perren SM 2005WHO 2003; Perren SM 2005

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USAUSA : - Hip fractures cost $ 21.000: - Hip fractures cost $ 21.000 - Vertebral fracture - Vertebral fracture $$ 1200 1200

- Colles fractures - Colles fractures $$ 800 800

Hong Kong : - Hip fracture : Hong Kong : - Hip fracture : $$ 11.00011.000 - Colles fracture : - Colles fracture : $$ 600 600

Worldwide projection; Annual cost of HipWorldwide projection; Annual cost of Hip fractures USD 3.6 bill in men andfractures USD 3.6 bill in men and USD 19.3 bill in women.USD 19.3 bill in women.Year 2050 would rise to USD 14 bill in menYear 2050 would rise to USD 14 bill in men and USD 73 bill in women.and USD 73 bill in women.Cost of OP fx : ASTRONOMICAL !.Cost of OP fx : ASTRONOMICAL !.

WHO 2003WHO 2003

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- OP has a healthcare impact second - OP has a healthcare impact second only to C.V. diseaseonly to C.V. disease - Due to very high cost of OP fx - Due to very high cost of OP fx best best policy is avoid/prevent OP fractures policy is avoid/prevent OP fractures identify and treat OP before fx happens !identify and treat OP before fx happens !

I.O.F.I.O.F.

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OSTEOPOROSIS

• First Step : Identify/Evaluation of RISK FACTORS Case Finding Strategy-CFS- can be

done by GP as front liners, then start taking necessary action

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OSTEOPOROSIS

• WITH CFSBMD EXAMINATION CAN BE CONFINED TO A MINORITY OF WOMEN 20 % OF POP.

• MOST COUNTRIES ADOPT CFS IN THE MANAGEMENT OF OP.

• USA: POP. SCREENING WITH BMD FOR WOMEN > 65 YRS

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• RISK FACTORS : -Advanced Age, Low Body Weight/BMI, Early menopause, Maternal history of hip fx, History of fx after age of 40, Gender, Low BMD, Life Style, Specific Medication, Long period of immob., Low sun exposure, Genetics/Family history.

OSTEOPOROSIS

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Non-Modifiable• Age• Female sex• Maternal family history of hip

fracture• Low birth weight• Disease predisposing to

osteoporosis

Risk factors taken from Jordan & Cooper Best Practice and Res Clin Rheumatol, 2002Categorized by Eli Lilly & Co.

Potentially Modifiable• History of falls• Body mass index• Drug therapy (e.g. corticosteroid use,

use of anti-convulsants)• Primary or secondary amenorrhea• Early menopause• Smoking• Excessive alcohol consumption• Dietary calcium and vitamin D

deficiency

Risk Factors for Osteoporosis and Fracture

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Combination of several independentCombination of several independent

clinical risk factors clinical risk factors sufficient sufficient

for treatment w/o BMD examfor treatment w/o BMD exam

Kanis OP Int. 2005Kanis OP Int. 2005

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TreatmentTreatment

Goal :Goal : - Improve bone quality and- Improve bone quality and strengthstrength -Prevent OP fx. -Prevent OP fx.

IOF VISION : A World w/o OP Fractures !IOF VISION : A World w/o OP Fractures !

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• MANAGEMENT OF OSTEOPOROSIS.

• NON PHARMACOLOGIC

• PHARMACOLOGIC

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OSTEOPOROSIS

• NON PHARMACOLOGIC MEASURES : -Adequate exercises, Balanced diet, Intake Ca , Vit D, Life style (smoking, sedentary, alcohol) Fall prevention.

• NON PHARMACOLOGIC MEASURES : -Adequate exercises, Balanced diet, Intake Ca , Vit D, Life style (smoking, sedentary, alcohol) Fall prevention.

• NON PHARMACOLOGIC MEASURES :– Adequate exercises, – Balanced diet, – Intake Ca ,– Vit D, – Life style (smoking, sedentary, alcohol)– Fall prevention

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MANAGEMENT OF OPMANAGEMENT OF OP

Pharmacologic measures :Pharmacologic measures : FDA approved :FDA approved : -Antiresorptives : Biphosphonates,Estrogen-Antiresorptives : Biphosphonates,Estrogen CalcitoninCalcitonin -Stimulates Bone Formation : Parathyroid-Stimulates Bone Formation : Parathyroid HormonHormon -Dual Mode Action : Strontium Ranelate.-Dual Mode Action : Strontium Ranelate.

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NON PHARMACOLOGICNON PHARMACOLOGIC . .

Elderly patient: Exercise include balance training Elderly patient: Exercise include balance training best outcome Tai Chi best outcome Tai Chi reduced fall reduced fall by 50%by 50%

Exercise may increase BMD and strength of Exercise may increase BMD and strength of bone: 30-50% if start before pubertybone: 30-50% if start before puberty

Type of activity: - Tennis, Badminton, Type of activity: - Tennis, Badminton, Aerobics,Dance, etcAerobics,Dance, etc

- Endurance training: - Endurance training: not as efficient not as efficient

MOVE IT OR LOSE IT !!MOVE IT OR LOSE IT !!- JBJS’05- JBJS’05- IOF 2005- IOF 2005

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OSTEOPOROSISOSTEOPOROSISNON PHARMACOLOGICNON PHARMACOLOGIC

Elderly: Avoid Fall in the HomeElderly: Avoid Fall in the Home Eliminate all possible elements of risk whichEliminate all possible elements of risk which could lead to fall in the homecould lead to fall in the home slippery floor, loose carpet, stairs,slippery floor, loose carpet, stairs,

medicationmedication

Especially if history of previous fx (+)Especially if history of previous fx (+)

Safe environment Safe environment falls reduced 30-60% falls reduced 30-60%

Hip protector Hip protector Fx Fx ↓↓ 34% 34% Compliance difficultCompliance difficult

Lancet’99/JBJS’05Lancet’99/JBJS’05

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Lifestyle change may improve skeletalLifestyle change may improve skeletal health: stop smoking, alcohol, health: stop smoking, alcohol,

maintenance of ideal body weightmaintenance of ideal body weight

Body Mass Index (BMI): Europeans: Body Mass Index (BMI): Europeans: Risk of hip fx Risk of hip fx ↑↑ if BMI < 19 kg/m2 if BMI < 19 kg/m2

WHO 2003WHO 2003

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PHARMACOLOGIC.PHARMACOLOGIC.HRT-HRT-H0rmonal Replacement TheraphyH0rmonal Replacement Theraphy

Currently not recommended as the Currently not recommended as the primary prevention of OP in most primary prevention of OP in most

countriescountries

Long term use : questionable Long term use : questionable

Controversy (+)Controversy (+)

WHO 2003; JAMA 2002WHO 2003; JAMA 2002NEJM 2003NEJM 2003

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PHARMACOLOGIC .PHARMACOLOGIC .

Parathyroid Hormone (PTH): RecombinantParathyroid Hormone (PTH): Recombinant PTH (teriparatide) PTH (teriparatide) stimulates bone formation stimulates bone formation

Strontium ranelate: dual mode of action Strontium ranelate: dual mode of action antiresorptive & stimulates bone formationantiresorptive & stimulates bone formation

Alfacalcidol and calcitriol (vit D analogues),Alfacalcidol and calcitriol (vit D analogues), Vit K, growth hormone Vit K, growth hormone can improve BMD can improve BMD

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OSTEOPOROSIS

PREVENTION : ACCORDING TO WOOLF & DIXON :4 PHASES OF PREVENTION : 1. Embryonal phase : NUTRITION during pregnancy

2. Born ~Closure of epiphysis : Diet/Nutrition & Exercise very important.3. Adult : Exercise, optimal Ca, Vit D/Sun exposure

PEAK BONE MASS: Achieved 3rd decadeAfter this bone loss beginMax. gain to minimize bone loss after menopause.4. Menopause : Exercise, Nutrition, Biphosphonate

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OSTEOPOROSIS

• MANAGEMENT OF OP NEED MULTIDISC. APPROACH

• Nutritionist, Sp.OG, Sp.KO, Sp.RM, Sp.OT, Sp.Geriatrics, Paediatrician-SpA.

• Penyuluh Kesehatan, Ahli Bangunan, Dll.

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OSTEOPOROSISOSTEOPOROSISCONCLUSIONCONCLUSION OP fx is universal problemOP fx is universal problem Very high economic cost Very high economic cost

Best policy: - Prevention fx in OP and Best policy: - Prevention fx in OP and treat OP before fx happentreat OP before fx happen

- After tx of the fx: - After tx of the fx: DO NOTDO NOT FORGET TO TREAT OPFORGET TO TREAT OP

Intervention/treatment of OP should Intervention/treatment of OP should NOTNOT be guided solely of on the basis of BMD be guided solely of on the basis of BMD

-MANAGEMENT : Multidisc. Approach.-MANAGEMENT : Multidisc. Approach.

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