King Abdul Aziz UniversityKing Abdul Aziz University

Faculty Of PharmacyFaculty Of Pharmacy

Department Of Clinical PharmacyDepartment Of Clinical Pharmacy

Prepared by:Prepared by: Ahmed Fahad BasilimAhmed Fahad Basilim

Supervised by:Supervised by: Dr. Abdurrahman Al AhdalDr. Abdurrahman Al Ahdal

OSTEOPOROSISOSTEOPOROSIS

MAIN POINTMAIN POINT

I- Definition and types.I- Definition and types.

II- Pathogenesis.II- Pathogenesis.

III- Diagnosis of osteoporosis.III- Diagnosis of osteoporosis.

IV- Prevention & Treatment.IV- Prevention & Treatment.

I- Definition:I- Definition:

A systemic skeletal disease A systemic skeletal disease characterized by low bone mass and characterized by low bone mass and micro architectural deterioration of micro architectural deterioration of bone tissue lead to bone fragility and bone tissue lead to bone fragility and susceptibility to fracture.susceptibility to fracture.

Common Fracture SitesCommon Fracture Sites

VertebralVertebralFractureFracture

ForearmForearmFractureFracture

HipHipFractureFracture

Cont.Cont.

►There are two types:There are two types:

A- Primary osteoporosis.A- Primary osteoporosis.

B- Secondary osteoporosis.B- Secondary osteoporosis.

A- Primary osteoporosis:A- Primary osteoporosis:

-Primary osteoporosis classified as :-Primary osteoporosis classified as :

1. Type I (menopausal):1. Type I (menopausal):- Occurs mainly in persons aged 51 to 75. - Occurs mainly in persons aged 51 to 75.

- Six times more common in women. - Six times more common in women.

- Associated with vertebral and Colles' (distal - Associated with vertebral and Colles' (distal radius) fractures.radius) fractures.

Cont.Cont.

2. Type II (senescent):2. Type II (senescent):- Occurs in persons > 60. - Occurs in persons > 60.

- Two times more common in women. - Two times more common in women.

- Associated with vertebral and hip fractures.- Associated with vertebral and hip fractures.

►Overlap between types I and II is Overlap between types I and II is substantial, so this classification is of substantial, so this classification is of limited clinical use. limited clinical use.

B- Secondary osteoporosis:B- Secondary osteoporosis:

Endocrine Nutritional Drug-Induced Immobilization Other

HyperthyroidismHypogonadism

Cushing Syndrome

GlucocorticoidsImmunosuppressly

Anticonvulsants

Rheumatoid A.DiabetesTumors

(Myeloma, etc.)

II- Pathogenesis:II- Pathogenesis:

• • Diminished bone mass can result from:Diminished bone mass can result from: A- Failure to reach an optimal peak bone mass in early A- Failure to reach an optimal peak bone mass in early

adulthood.adulthood.

B- Increased bone resorption.B- Increased bone resorption.

C- Decreased bone formation after peak bone mass has C- Decreased bone formation after peak bone mass has been achieved.been achieved.

• • All three of these factors probably play a role in most All three of these factors probably play a role in most elderly persons. Low bone mass, rapid bone loss, and elderly persons. Low bone mass, rapid bone loss, and increased fracture risk correlate with high rates of increased fracture risk correlate with high rates of bone turnover (i.e., resorption and formation).bone turnover (i.e., resorption and formation).

Cont.Cont.

• • In osteoporosis, the rate of formation In osteoporosis, the rate of formation is inadequate to offset the rate of is inadequate to offset the rate of resorption and maintain the structural resorption and maintain the structural integrity of the skeleton.integrity of the skeleton.

III- Diagnosis of Osteoporosis:III- Diagnosis of Osteoporosis:

A- Physical examination.A- Physical examination.

B- Measurement of bone mineral content:B- Measurement of bone mineral content:

1. Dual X-ray absorptiometry (DXA).1. Dual X-ray absorptiometry (DXA).

2. Ultrasonic measurement of bone.2. Ultrasonic measurement of bone.

3. CT scan.3. CT scan.

4. Plain radiography4. Plain radiography ..

A- Physical examination:A- Physical examination:Osteoporosis:Osteoporosis:►Height lossHeight loss► Body weightBody weight► KyphosisKyphosis►Humped backHumped back► Tooth lossTooth loss

No single maneuverNo single maneuver is sufficient to rule in is sufficient to rule in or rule out osteoporosis without further or rule out osteoporosis without further testingtesting..

1. Dual X-ray absorptiometry1. Dual X-ray absorptiometry

-The test is non-invasive and involves no special preparation.

-Accuracy at hip > 90%.

-Low radiation exposure and the procedure is rapid.-Error in

OsteomalaciaOsteoarthritis

Previous fracture

2. Ultrasonic measurement2. Ultrasonic measurement-Can assess the density and structure of the skeleton.

-No radiation exposure,Inexpensive and portable.

-Preferred use in assessment of fracture risk.

3. CT scan3. CT scan-True volumetric study.

-Most useful in cancellous bone assessment.

-Drawback:High costHigh radiation exposureDifficult quality control

4. Plain radiography4. Plain radiography

-Low sensitivity.-Low sensitivity.-High availability.-High availability.

IV- Prevention and treatment:IV- Prevention and treatment:

►Optimal calcium intake reduces bone loss.Optimal calcium intake reduces bone loss.

►Routine to recommend supplemental Routine to recommend supplemental vitamin D.vitamin D.

►Exercise in young individuals increase the Exercise in young individuals increase the likelihood that they will attain the maximal likelihood that they will attain the maximal genetically determined peak bone mass.genetically determined peak bone mass.

Cont.Cont.

►Person with low bone mass and Person with low bone mass and multiple risk factors, particularly those multiple risk factors, particularly those who have already had an osteoporotic who have already had an osteoporotic fracture should be consider for fracture should be consider for antiresorptive therapy.antiresorptive therapy.

Antiresoptive drugs:Antiresoptive drugs:

► Include:Include:

1- Estrogens.1- Estrogens.

2- Bisphosphonate.2- Bisphosphonate.

3- Selective estrogen receptor 3- Selective estrogen receptor modulators (SERMs).modulators (SERMs).

4- Calcitonin.4- Calcitonin.

1- Estrogens:” Activella”1- Estrogens:” Activella”

► Can prevent menopausal bone loss in most Can prevent menopausal bone loss in most women.women.

► The treatment of choice for postmenopausal The treatment of choice for postmenopausal women, particularly those who had an early women, particularly those who had an early menopause, and for women who have had a menopause, and for women who have had a hysterectomy.hysterectomy.

►Decreases the risk of osteoporotic fractures Decreases the risk of osteoporotic fractures by 30 to 50%.by 30 to 50%.

2- Bisphosphonates:2- Bisphosphonates:

► Bisphosphonates drugs like alendronate “Fosamax “ and Bisphosphonates drugs like alendronate “Fosamax “ and pamidronate.pamidronate.

► Use for women cannot tolerate estrogen or have Use for women cannot tolerate estrogen or have contraindications (e.g., preexisting breast cancer, risk contraindications (e.g., preexisting breast cancer, risk factors of breast cancer).factors of breast cancer).

► These drugs increased bone mass and decrease the risk These drugs increased bone mass and decrease the risk of fractures, particularly in patient taking glucocrticoids.of fractures, particularly in patient taking glucocrticoids.

Cont.Cont.

3- Selective estrogen receptor 3- Selective estrogen receptor modulators:modulators:

-These drugs are antiestrogenic and -These drugs are antiestrogenic and have antiresorptive effects on bone.have antiresorptive effects on bone.

4- Calcitonin:4- Calcitonin:

-Used for many years in prevention and -Used for many years in prevention and treatment of osteoporosis.treatment of osteoporosis.

Other therapies:Other therapies:1- Anabolic therapy.1- Anabolic therapy.2- Parathyroid hormone and fluoride:2- Parathyroid hormone and fluoride:- Stimulate bone formation and inhibit Stimulate bone formation and inhibit

bone resorption.bone resorption.- Their efficacy and safety remain to be Their efficacy and safety remain to be

established.established.3- Thiazides:3- Thiazides:- Decrease urinary calcium excretion Decrease urinary calcium excretion

and slow bone loss.and slow bone loss.

Conclusion:Conclusion:►Osteoporosis is chronic silent Osteoporosis is chronic silent

disease disease no symptoms at the early no symptoms at the early stage of bone loss.stage of bone loss.

►Osteoporosis requires early Osteoporosis requires early intervention before the dramatic intervention before the dramatic 11stst fracture followed by a cascade fracture followed by a cascade of others fractures.of others fractures.

Cont.Cont.►Patient should be educated to Patient should be educated to

reduce the likelihood of any risk reduce the likelihood of any risk factors associated with bone loss factors associated with bone loss and falling.and falling.

►Osteoporosis does not directly cause Osteoporosis does not directly cause death. However, an excess mortality death. However, an excess mortality of 10 to 20% occurs in patient with of 10 to 20% occurs in patient with established osteoporosis, established osteoporosis, particularly those with hip fractures.particularly those with hip fractures.

sources:sources:

1- www.1- www.osteoporosisosteoporosis..

2- www.osteo.org.2- www.osteo.org.

3- www.webmd.com 3- www.webmd.com //osteoporosisosteoporosis/default./default.

4-www.nof.org.4-www.nof.org.

5- 5- www.endocrineweb.com/www.endocrineweb.com/osteoporosiosteoporosis.s.