1. Postmenopausal
osteoporosis
M.M.EMAM MD
Rheumatologist
SBMU

2. WHO criteria for osteoporosis
Normal a value of Tscore >-1
Osteopenia a value of -1>Tscore>-2.5
Osteoporosis a value of T-score<-2.5
Severe Osteoporosis Osteoporosis + fragility fracture
References: WHO 1994

3. T-Score
Z-Score

9. TBS especially informative in :
Hyperparathyroidism
DM type 2
Osteoarthritis
Clinical and subclinical hypercortisolism
Lumbar spine
TBS may be particularly helpful in type 2 diabetes where
BMD measurements and FRAX without TBS input do
not adequately capture diabetes-associated fracture risk

10. Osteoporosis Treatment :

11. Who should be treated?
If threshold WHO criteria T<-2.5 =60% lost of osteoporotic fractures

12. Who should be treated?
In Postmenopausal women and men age 50 and older
T- score<-2.5
Fragility fracture(hip and spine) after age 50
Osteopenia when:
10-year overall major fracture risk > 20% or the 10-year hip fracture > 3%
In % according to judgment of physician
NOF's New Clinician's Guide to Prevention and Treatment of Osteoporosis., 2013

13. 20%
3 %

15. The case represents a woman the original FRAX probabilities for major osteoporotic
and hip fracture, respectively, were 16 and 5.9%. The probabilities after entering the TBS
value of 1.08 are shown.

16. Basic therapy for osteoporosis :
Calcium & Vit.D supplementation
Counteract individual risk factors
Recommendation for physical activity
Prevention of falls
Smoke & alcohol ceasation
References: 1. Spector TD. Rheum Dis Clin North Am 16: , Alarcón GS. Rheum Dis Clin North Am 21: , Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp

17. Basic therapy for osteoporosis :
Calcium & Vit.D supplementation
Recommendation for physical activity
Prevention of falls
Smoke & alcohol ceasation
Counteract individual risk factors
References: 1. Spector TD. Rheum Dis Clin North Am 16: , Alarcón GS. Rheum Dis Clin North Am 21: , Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp

18. Risk Factors for Osteoporosis and Fracture
Non-Modifiable
Age
Female sex
Maternal family history of hip fracture
Low birth weight
Disease predisposing to osteoporosis
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 taken from Jordan & Cooper Best Practice and Res Clin Rheumatol, 2002
Categorized by Eli Lilly & Co.

19. Basic therapy for osteoporosis :
Calcium & Vit.D supplementation
Counteract individual risk factors
Prevention of falls
Smoke & alcohol ceasation
Recommendation for physical activity
References: 1. Spector TD. Rheum Dis Clin North Am 16: , Alarcón GS. Rheum Dis Clin North Am 21: , Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp

20. Exercises : At least 30 minute 3 times per week
Any weight bearing exercises especially jogging accepted
Can increase BMD & muscle strength & propensity to fall

21. Basic therapy for osteoporosis :
Calcium & Vit.D supplementation
Counteract individual risk factors
Recommendation for physical activity
Smoke & alcohol ceasation
Prevention of falls
References: 1. Spector TD. Rheum Dis Clin North Am 16: , Alarcón GS. Rheum Dis Clin North Am 21: , Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp

22. Prevention of falls & complications :
Correction of decreased visual acuity
Reduction of drug consumption that altered wakefulness & balance
Improve cardiac & neurologic function
Improve muscle strength
Improving home environment
Wearing hip protectors
References: 1. Spector TD. Rheum Dis Clin North Am 16: , Alarcón GS. Rheum Dis Clin North Am 21: , Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp

24. Mechanism Of Treatment
Resorption
Formation
Teriparatide
Anabolic hormones
Rocaltrol
Statins
Fluoride !???
Bisphosphonates
Miacalcic
EPT
SERM
Prolia
Strontium ranelate

25. Mechanism of treatment
Resorption
Formation
Teriparatide
Anabolic hormones
Rocaltrol
statins
Fluoride !???
Bisphosphonates
Miacalcic
EPT
SERM
Prolia
Strontium ranelate

26. Bisphosphonates :
First line treatment in postmenopausal ,steroid induced & men
 Alendronate or FOZAMAX (10 mg/day or 70 mg once weekly) or risedronate or Actonel (5 mg/day, 35 mg once weekly, or 150 mg once monthly), and ibandronate or Bonviva (150 mg once monthly or 3 mg intravenously every three months) are effective for both the prevention and treatment of osteoporosis and  Zoledronic acid (ZA) or aclasta , 5 mg administered intravenously (IV) once yearly, is also effective for the treatment of osteoporosis
Has good effect on spinal & hip BMD & fracture risk
Low intestinal absorption(So use in fasting state)
Recently Actonel SR available that can be use after breakfast

27. Mechanism Of Treatment
Resorption
Formation
Teriparatide
Anabolic hormones
Rocaltrol
Statins
Fluoride !???
Bisphosphonates
Miacalcic
EPT
SERM
Prolia
Strontium ranelate

29. Calcitonin
A less popular choice for treatment of osteoporosis is nasal calcitonin 200 international units daily.
modest effect on BMD and weak antifracture efficacy
Don't use in first years of menopause and fast looser state and hip involvement
Had some analgesic effect
Long term use associated with an increase risk of some cancers

30. Mechanism Of Treatment
Resorption
Formation
Teriparatide
Anabolic hormones
Rocaltrol
Statins
Fluoride !???
Bisphosphonates
Miacalcic
EPT
SERM
Prolia
Strontium ranelate

31. Denosumab

32. Denosumab
Denosumab is a humanized monoclonal antibody against RANKL that reduces osteoclastogenesis.
In several trials, Denosumab reduces the incidence of vertebral fractures by about 68 percent, hip fractures by about 40 percent and
non-vertebral fractures by about 20 percent over three years
60 mg subcutaneously every 6 months

33. Denosumab Drug safety
Hypocalcemia. Hypocalcemia must be corrected before starting
increased the risk of serious skin infections (cellulitis) and skin rash.
ONJ both when used to treat osteoporosis and to treat patients with cancer, although it is much more common in the latter setting
Atypical femur fractures

34. long-term extension(8 years ) trial with Denosumab
Zoledronate extending to 9 years that were also presented at the ASBMR meeting did not show similar progressive improvements in bone density or declines in fracture rates
Denosumab seems to exert superior effects in the long term compared with the bisphosphonates
Also reported at the ASBMR meeting in a late-breaking poster were the 8-year results from FREEDOM, which included 1382 subjects in the long-term denosumab group, who have so far received a cumulative 8 years of treatment, and 1296 patients in the group that crossed over from placebo.
long-term data on zoledronate extending to 9 years that were also presented at the ASBMR meeting did not show similar progressive improvements in bone density or declines in fracture rates, casting some doubt as to the role of a healthy cohor
American Society for Bone and Mineral Research 2013 Annual Meeting. ; Abstract LB-MO26, presented October 7, 2013

35. Combined teriparatide and denosumab increased BMD more than either agent alone and more than has been reported with approved therapies. Combination treatment might, therefore, be useful to treat patients at high risk of fracture
Lancet Jul 6;382

36. Forteo (PTH)
(Cinopar)

37. Forteo (PTH)
Increase bone formation at existing remodeling sites

38. Teriparatide Increase bone formation at existing remodeling sites
Greater cost compared to other treatments
Limited in severe osteoporosis or in patient who had progression despite of treatments
No good effect on hip osteoporosis
Duration of treatment in most studies 18 months but can use for 2 year

39. Teriparatide Use 20 mcg/d by sc injection Contraindicated in :
Hypercalcemia
Hyperparathyroidism
Unexplained elevated ALP
Exposure to external beam radiation or prior
skeletal radiation

40. Strontium Ranelate : Trace element with Dual action
Predominantly taken up by adsorption onto bone mineral
Agonist of calcium -sensing receptor(independent PTH ,1 25 D)
Dose 1-2gr/d
After 3y has 11.5% increase in lumbar BMD & 41% in Fx rate
References: 1. Spector TD. Rheum Dis Clin North Am 16: , Alarcón GS. Rheum Dis Clin North Am 21: , Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp

41. A review of available safety data for strontium ranelate (Protelos) has raised concern about its cardiovascular safety beyond the already recognised risk of venous thromboembolism. An analysis of randomised controlled trial data has identified an increased risk of serious cardiac disorders, including myocardial infarction (relative risk compared with placebo was 1.6 [95% CI 1.07–2.38]).
Meeting highlights from the Committee for Medicinal Products for Human Use (CHMP) April 2013

42. OP
prolia BP
severe spinal OP BP
forteo BP

43. Thank You