OSTEOPOROSIS

Prof. Dr. Ülkü Akarırmak

Metabolic Bone Diseases

Osteosclerosis

Osteolysis

Osteoporosis is the most common metabolic bone disease

Vertebral Body

Normal Osteoporotic

Definition of Osteoporosis

A systemic skeletal disease

- characterized by low bone mass - microarchitectural deterioration of bone tissue

- with a consequent increase in bone fragility and susceptibility to fracture

Osteoporosis

1. Low bone mass and

2. Reduced bone quality

Result: Increased risk of fracture

Bone structure

Cortical and trabecular bone

Bone cells

Bone function

Bone Turnover

- Osteoclasts - Bone resorption

- Osteoblasts - Bone formation

- Osteocytes

Formation=Resorption

Osteoclasts

Monocytes

OsteoblastsOsteocytes

Bone Turnover

Bone Metabolism

Bone Metabolism

Local factors: Growth factors

3 Systemic hormones: - Parathormone - Vitamin D - Calcitonin

3 Involved systems: - Bone - Intestines - Renal

Peak Bone Mass

Genetic factors 70%

Nutrition PBM Hormones

Exercises

Risk Factors for Fracture

Age Female sex Family fx Previous fx Glucocorticoids

Risk Factors for Osteoporosis

Modifiable Inadequate exercise Inadequate nutrition

- calcium - vitamin D

- balanced diet Medications

- glucocorticoids - excess thyroid - etc.

Smoking Excessive alcohol intake

Risk Factors for Osteoporosis 2

Nonmodifiable Genetics Gender Race Age

Classification

I. Primary OP

1- Postmenopausal

2- Senile

II. Secondary OP

Sec. OP

Osteoporosis

Fractures: Mortality –

Morbidity Pain

Deformity

Loss of quality of life

Clinical Picture

The traditional picture of an individual with osteoporosis:

An elderly woman with a curved back and stooped posture, a woman who has lost height and who appears small and frail

Major Osteoporotic Fractures

Type Colles Vertebral Hip

Typical age 55 65 75

Female:male ratio 4:1 3:1 2:1

Femur fx Peripheral fx Forearm fx

Spinal Osteoporotic Fractures

Acute – chronic pain

Kyphosis

Nontraumatic - low energy fx

Progressive loss of height; Development of kyphosis

Spinal Fx

Pathogenesis of Osteoporotic Fracture

LOW PEAK POSTMENOPAUSAL AGE-RELATEDBONE MASS BONE LOSS BONE LOSS

Low Bone Mass Other risk factors

Nonskeletal FRACTURE Poor bone quality

factors Increased risk of falls

Hip Fx

Femoral Fractures

Mortality in 20% of patients over 60 years of age

Morbidity in 50%

Clinical Results of Osteoporotic Fractures

Pain Reduction in physical activity Deformity Muscle weakness Social isolation Loss of independence Increased mortality

Evaluation of Osteoporosis

Identify risk factors for OP

Identify contributing factors Medical history: Secondary OP

Physical examination

DXA

X-ray

Laboratory Evaluation

Radiographic Evaluation

0 Normal 1 End plate deformity 2 Fish vertebrae 3 End plate fracture 4 Wedge vertebrae 5 Compression

fracture

X-Ray of Thoracic Spine

Diagnosis of Osteoporosis

Osteodensitometry DXA

DXA = Dual X- ray Absorptiometry

Bone Mineral Density BMD

Indications for Bone Densitometry

Female patients > 65 years Patients with osteoporosis risk factors Vertebral abnormalities and/or osteopenia on x-rays Long – term glucocorticoid therapy Primary hyperparathyroidism or other diseases with

high risk of OP Patients being treated for OP, to monitor changes in

bone mass

Diagnosis Based on BMD (WHO)

BMD T-score

Normal 0 - (-1)SD

Osteopenia (-1) - (-2.5)SD

Osteoporosis <(-2.5)SD

Established OP ‘’ + fracture

Recommendations Based on BMD

BMD Risk of Fx Action

Normal Very low Prevention

Osteopenia Low Prevention

OP High<(-2.5)SD Treatment

Establ OP Very high Treatment

Osteodensitometry is the most important method for diagnosis

Fracture risk may be assessed Low BMD is associated with increased fracture

risk

ROI

Laboratory Tests

- Routine Biochemistry Serum calcium Phosphorus Alkaline phosphatase Creatinine Total protein,albumin,and globulin 25(OH)Vitamin D

- Complete blood count

- Sedimantation rate

- Biochemical markers of bone turnover

Differential Diagnosis

Multiple MyelomaMetastasis OsteoporoticFx

Osteoporosis is a….

Preventable Treatable disease

Recommendations 1. Nutrition 2. Activity 3. Vitamin D

Approaches for Management of Osteoporosis: Pharmac&Nonpharmacologic

Prevent fractures - Medical therapy

- Prevention of falls

Improve physical function

Improve quality of life

Osteoclast

Inhibition of Resorption

Osteoblast

Stimulation of Formation

Therapeutic Agents Used in Osteoporosis

Inhibitors of Bone Resorption

Calcium HT: Estrogens +/- progestogens SERMs Bisphosphonates Alendronate Zoledronate Risedronate Ibandronate Calcitonin

Stimulators of Bone Formation

Parathyroid hormone injections

Dual Action

Strontium ranelate

Vitamin D and active derivatives

Ipriflavon

Anabolic steroids

Calcium – Vitamin D

Calcium - Adults : 1000 mg

Increased: Over 65 years, after menopause,

pregnancy, stilling Vitamin D :

Adults : 400-800 IU

Over 70 years: >800 IU

HRT: Estrogen

Reduces the rate of bone loss Reduces fracture risk in

postmenopausal women

Adverse effects; WHI

Limited time

Calcitonin

Reduces bone loss in postmenopausal women- bone quality

Effective on spinal fractures

Opt.dose: 200 IU/daily nasal spray

High tolerability

Bisphosphonates: Gold Standard Indication: PMO

Male OP

GIO

Decrease fracture incidenceALN: 70mg/w ZOL: 5mgIV/yearly infusion

RIS: 35mg/w-75/mo IBN:150mg/mo - 3mg 3mo inf

Contraindication: Oesaphageal irritation

Strategies for Reducing Falls and Fractures

- Maintain physical activity

- Provide a safe home environment

- Balance training

- Ambulatory support when appropriate

- Avoid sedative medications

- Minimize other contributing medical problems

- Hip pads in the frail elderly

Hip Pads

Prevention of hip fractures in patients with high fracture risk - shock absorbing effect

Decrease Risk of Falls

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