1. OSTEOPOROSIS AND LUPUS HAROLD MICHAEL GOMEZ, MD

2. PF, 3 May 2004SLE Prednisone Plaquenil Calcium supplements October 2004back pain

4. BMD Young-Adult Age-Matched Region g/cm 2 % T-Score % Z-Score L1-L4 0.726 65 -3.2 64 -3.4 L1-L4 Comparison to Reference UNIV. OF SANTO TOMAS HOSPITAL JOINT AND BONE CENTER OSTEOPOROSIS (BONE DENSITOMETRY) UNIT AGE (years) 0.63 0.87 1.11 1.35 20406080100 2.0 0.0 -4.0 -2.0 Normal Osteopenia Osteoporosis BMD g/cm 2 T Score FP, 31/F, SLE in 1991

5. Ano ang nangyari? Ano ang kanyang sakit? Ito ba ay pangkaraniwan sa pasyenteng may lupus? Paano ito maiiwasan?

6. Osteoporosis Marami ang maaaring maapektuhan ng hindi nalalaman, hindi nararamdaman hanggang sumakit ô nabalian. Sakit sa buto na nakapagpaparupok at mahina. Nagiging dahilan ng madaling pagkabali. JOINT & BONE CENTER UST HOSPITAL

9. What is the Scope of the Problem Ito ay isang pambansang kalusugang interes. Mataas ang posibilidad na magkalamat ô mabalian. Mababang kaalaman ng publiko. Maaaring maiwasan. JOINT & BONE CENTER UST HOSPITAL

10. Peak Bone Mass (PBM) Naaabot ang pinakabigat ô kapal ng buto natin sa edad 20-30 at 30-40. Naaapektuhan ng genetics at paraan ng ating pamumuhay. Ang malaking bahagi ng pagkapal ô paglaki ng buto ay nangyayari sa panahon ng adolescence. JOINT & BONE CENTER UST HOSPITAL

11. Bone Loss: Menopause Related and Age-Related PEAK BONE DENSITY MALE FEMALE FRACTURE RISK FRACTURE THRESHOLD AGE (YEARS) BONE DENSITY

12. Primary Prevention: Primary Prevention: Building strong bone Pangunahing paraan ng pag-iwas: Patibayin ang buto Healthy well balanced diet, containing adequate calcium (milk), vitamin D and protein. Wastong pagkain ng may sapat na calcium, Bitamina D, at protina. Regular weight bearing exercise. Regular na pag-e ehersisiyo. JOINT & BONE CENTER UST HOSPITAL

13. Corticosteroid therapy Excessive thyroid medication GnRH analogs Aluminum-containing antacids Anticonvulsants (dilantin and phenobarbital) Immunosuppressive agents Heparin Cholestyramine JOINT & BONE CENTER UST HOSPITAL Drugs that may Contribute to Bone Loss

14. HOW DOES INCREASED BONE REMODELLING / EXCESSIVE BONE TURNOVER ALTER THE CHARACTERISTICS OF BONE QUALITY? Increased Bone Remodeling / Turnover Reduced Bone Strength / Increased Fracture Risk Increased Porosity Decreased Bone Mass Disrupted Trabecular Connectivity Decreased Mineralization

15. JOINT & BONE CENTER UST HOSPITAL ProD3  PreD3  Vitamin D UVB Maintain Serum Calcium & Phosphorus Increase Calcium & Phosphorus Absorption Mobilize Calcium Stores metabolic functions bone health neuromuscular functions SKIN Diet Vitamin D 3 Vitamin D 2 Liver Kidney PTH (+)    (+) low PO 2, 1,25(OH) 2 D HH 25(OH)D Intestine Bone

16. Glucocorticoids Decreased Gut absorption of Ca++ Increased urinary excretion of Ca++ Suppression of gonadal function Suppression of adrenal androgen secretion ↓ Osteoblast activity ↑ # remodeling sites ↓ Bone formation ↑ Bone resorption ↓ Bone matrix ↓ Muscle mass PTH Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, Fourth Ed

17. ABNORMAL CYCLE IN GIOP 1 2 34 1 2 3 4 NORMAL CYCLE OF BONE REMODELLING

18. 64206420 Relative risk <2.5 mg/day 2.5–7.5 mg/day > 7.5 mg/day HipSpine Daily Oral Glucocorticosteroid Dose ORAL GLUCOCORTICOSTEROID DOSE CORRELATES TO FRACTURE RISK

19. Odds ratio Daily prednisolone dosage Van Staa, JBMR, 2000 CORTICOSTEROID DOSE AND FRACTURES

20. Bone-conserving Regimen for Patients Starting/Started Long-term GC Therapy Calcium intake 800 to 1,200 mg/day premenopause 1,500 mg/day postmenopause 1,500 mg/day for men Vitamin D (after hypercalciuria is controlled) Children 400 IU/day, Adults 800 IU/day Vitamin D metabolites: alfacalcidol, calcitriol Bisphosphonates Alendronate 10 mg/day /70 mg/week Risedronate 5 mg/day JOINT & BONE CENTER UST HOSPITAL

21. BISPHOSPHONATES IN GIOP Bisphosphonates most effective when started early, before the rapid and early bone loss. Beneficial effects less impressive in patients with established disease. Bisphosphonates prevent osteoblast and osteocyte apoptosis induced by glucocorticoids. JOINT & BONE CENTER UST HOSPITAL S Manolagas, JBMR 14:1061-1066,1999

22. CALCIUM AND VITAMIN D IN GIOP Elemental calcium at 1200-1500 mg/D is necessary but not sufficient for GIOP in most patients Vitamin D should be supplemented Vitamin D 3 800 I.U/D Calcitriol 0.25-0.50 mcg/D requires cautious use of exogenous calcium and careful monitoring of urine and serum calcium Homik J: Cochrane Library, 1999 JOINT & BONE CENTER UST HOSPITAL

23. Iwasan ang paninigarilyo at sobrang pag-inom ng alak

24. Recommended Daily Calcium Intake NIH(USA)*FNRI (Phil)** Infants >6 mos Infants 6 mos – >12 mons Children 1-3 yrs Children 4-5 yrs Children 6 yr Children 7-9 yrs Children 10 yr Adolescents/young adults 11-18 yrs Adolescents/young adults 19 - 24 yrs Premenopausal women 25-49 yrs Premenopausal women 50 yrs Postmenopausal <65 yrs on ERT Postmenopausal not on ERT All women >65 yrs Pregnant/nursing women Men 19-24 yrs Men 25-49 yrs Men 50-65 yrs Men >65 yrs 400 mg 600 mg 800 mg 800-1200 mg 1200-1500 mg 1000 mg 1500 mg 1200-1500 mg 1000 mg 1500 mg 200 mg 300 mg 500 mg 600 mg 700 mg 1200 mg 800 mg 1100 mg 1000 mg 800 mg 1100 mg *1991 **2002

25. JOINT & BONE CENTER UST HOSPITAL

26. Vitamin D Mahalagang bitamina na kailangan ng buto. Importante sa “mineralization” ng buto at sa pag “absorb” ng calcium sa bituka. JOINT & BONE CENTER UST HOSPITAL

27. Vitamin D Major source is the action of sunlight on the skin. Pangunahing pinagkukunan ng bitamin D, nakukuha sa sinag ng araw. Sun bathing for 15 minutes daily between7AM to 9AM is already considered adequate. Sapat na ang magbilad sa araw ng 15 minuto araw- araw mula ika-7 hanggang ika-9 ng umaga. Other sources are margarine, fish oils, egg yolks. Iba pang pinagkukunan ay margarina, langis ng isda, pula ng itlog. JOINT & BONE CENTER UST HOSPITAL

28. Sa paglalaro, ang mga bata ay nakakakuha ng sapat na ehersisiyo.

29. JOINT & BONE CENTER UST HOSPITAL

30. Practical ways to optimise bone health Always eat a varied, nutritionally balanced diet providing adequate energy Maintain healthy body weight Encourage enjoyment of regular sport throughout the year Consume three to five servings of calcium-rich foods daily Provide dairy products as health snacks (milk, yoghurt, cheese) Discourage substitution of carbonated drinks for milk Golding,A ; Bone Health 9: February 2001 JOINT & BONE CENTER UST HOSPITAL

31. Practical ways to optimise bone health Provide alternative calcium sources for children who habitually avoid milk Spend 15 to 30 minutes daily outdoors to ensure vitamin D adequacy Ensure at least 30 to 60 minutes of vigorous weight- bearing activity daily Do not slim or exercise to excess (anorexia nervosa/ athletic amenorrhea thin bone) Do not smoke cigarettes, drink alcohol or consume too many salty foods Golding,A ; Bone Health 9: February 2001 JOINT & BONE CENTER UST HOSPITAL

32. JOINT & BONE CENTER UST HOSPITAL