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 Osteoblasts Osteocytes Bone Turnover

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 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-RELATED BONE 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 Myeloma Metastasis Osteoporotic Fx

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 : 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 incidence ALN: 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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