2. OSTEOPOROSIS AND OSTEOMALACIA Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant King Abdulaziz University Jeddah, Saudi Arabia Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant King Abdulaziz University Jeddah, Saudi Arabia

3. F. 19-year-old presented with difficulty in walking for many years, especially going upstairs. She felt parasthesia in hands & feet and occasional spasm. P/E: waddling gait. Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125). What other test results you need?What other test results you need? F. 19-year-old presented with difficulty in walking for many years, especially going upstairs. She felt parasthesia in hands & feet and occasional spasm. P/E: waddling gait. Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125). What other test results you need?What other test results you need?

4. Alb: Urea: PTH

5. 1.What signs for low Ca would you look for? Chovestick Trouseau 4 min. 1.What signs for low Ca would you look for? Chovestick Trouseau 4 min.

6. OSTEOMALACIAOSTEOMALACIA Raised bone turnoverRaised bone turnover + Failure of mineralization+ Failure of mineralization Most common cause: decreased Vitamin DMost common cause: decreased Vitamin D Darker skin more susceptibleDarker skin more susceptible Raised bone turnoverRaised bone turnover + Failure of mineralization+ Failure of mineralization Most common cause: decreased Vitamin DMost common cause: decreased Vitamin D Darker skin more susceptibleDarker skin more susceptible

7. Less common: Heriditary resistance to Vitamin D 1 α-hydroxylase def. Familial X-linked hypophosphatemia Mesynchymal tumours produce phosphatonin Less common: Heriditary resistance to Vitamin D 1 α-hydroxylase def. Familial X-linked hypophosphatemia Mesynchymal tumours produce phosphatonin

8. RadiologyRadiology Subperiosteal resorption of phalanges Looser zones Brown cysts Subperiosteal resorption of phalanges Looser zones Brown cysts

9. Chemistry:Chemistry: Decreased corrected Ca (40-Alb) x 0.02 + Ca Decreased P; Why? Decreased urinary Ca Decreased 25 (oH) Vit. D Decreased corrected Ca (40-Alb) x 0.02 + Ca Decreased P; Why? Decreased urinary Ca Decreased 25 (oH) Vit. D

10. TreatmentTreatment 1000 – 2000 IU Vitamin D/day + 500 – 1000 mg of Ca/day. Rarely 50,000 – 100,000 u/d or 1 α 0.5 – 2.5 μg/day ·.· shorter acting to decrease tox. Check Ca Q 2-4 weeks Phosphate for hypophosph Rickets 1000 – 2000 IU Vitamin D/day + 500 – 1000 mg of Ca/day. Rarely 50,000 – 100,000 u/d or 1 α 0.5 – 2.5 μg/day ·.· shorter acting to decrease tox. Check Ca Q 2-4 weeks Phosphate for hypophosph Rickets

11. OSTEOPOROSISOSTEOPOROSIS Low bone densityLow bone density Microarchitectural deteriorationMicroarchitectural deterioration ↑ fractures↑ fractures Low bone densityLow bone density Microarchitectural deteriorationMicroarchitectural deterioration ↑ fractures↑ fractures

12. Balance between bone formation and bone resorption

13. Max bone mass at 25 – 35 years Increased by exercise and good Ca intake. Later bone mass ↓, especially with ↓oestrogens (Menopause). Max bone mass at 25 – 35 years Increased by exercise and good Ca intake. Later bone mass ↓, especially with ↓oestrogens (Menopause).

14. Dx: T score. What is it? Normal T ± 1 Osteopenia -1> T ≥ -2.5 Osteoporosis T < - 2.5 Severe osteoporosis T <-2.5 with 1 or more fragility, fractures Normal T ± 1 Osteopenia -1> T ≥ -2.5 Osteoporosis T < - 2.5 Severe osteoporosis T <-2.5 with 1 or more fragility, fractures

15. Chemistry: normal Why ↑alk, but not persistent

16. Primary Osteoporosis Senile or post-menopausal – 95% Indiopathic Indiopathic

17. Secondary Osteoporosis Endocrine: Cushing + exog steroids HyperthyroidismHypogonadismHyperparathyroidismDMProclatinomaAcromegaly Preg & lactation Endocrine: Cushing + exog steroids HyperthyroidismHypogonadismHyperparathyroidismDMProclatinomaAcromegaly Preg & lactation

18. Connective Tissue: Osteogenesis inperfecta MarfanHomocystinuria MarfanHomocystinuria

19. Drugs:Drugs: HeparinSteroidsAnti-convulsantsHeparinSteroidsAnti-convulsants

20. RenalRenal C R F

21. Nutrition and GIT Malabsorption, Celiac Gastrectomy T P N Hepatobiliary disease Chronic hypophosphatemia Malabsorption, Celiac Gastrectomy T P N Hepatobiliary disease Chronic hypophosphatemia

22. Elite female athletes and anorexia nervosa

23. Risk increased by: F – sex Menopause Decreased Ca SmokingAlcoholInactivityLeanness White Race ( ↓ black) F – sex Menopause Decreased Ca SmokingAlcoholInactivityLeanness White Race ( ↓ black)

24. Signs & Symptoms: Asymptomatic unless # Back pain ↓ Height Kyphosis Effect especially in: Dorsalverts Femoral neck Distal radius Asymptomatic unless # Back pain ↓ Height Kyphosis Effect especially in: Dorsalverts Femoral neck Distal radius

25. DD: Lytic lesions Ca breast, Lung, Kidney, Thyroid Prostate  wall sclerosis MM  generalized thinning Ca breast, Lung, Kidney, Thyroid Prostate  wall sclerosis MM  generalized thinning

26. Prevention:Prevention: Exercise Good Ca intake Non-smokingExercise Non-smoking

27. Screening:Screening: Screen post-menopausal F >64 or with multiple risk factors (e.g., ↓weight, fragility fractures Frag #: of limb or spine post fall from standing height or less Screen post-menopausal F >64 or with multiple risk factors (e.g., ↓weight, fragility fractures Frag #: of limb or spine post fall from standing height or less

28. TREATMENT:TREATMENT: Ca 1200 mg/day Vitamin D:- 400-2000 IU / day HRTBiphosphonatesCalcintonin S E R M S Parathyroid hormone Ca 1200 mg/day Vitamin D:- 400-2000 IU / day HRTBiphosphonatesCalcintonin S E R M S Parathyroid hormone