1. Osteoporosis

2. Objectives:
At the end of this session, the trainees should be able to:
Discuss the epidemiology and WHO definition of osteoporosis
Discuss the types and risk factors of osteoporosis .
Describe the signs and symptoms of osteoporosis.
Describe evidence based management (EBM) plan of osteoporosis 2

3. Epidemiology
Approximately 8 million women and 2 million men in the United States have osteoporosis
34 million persons have osteopenia
About one in two white women will experience an osteoporotic fracture in her lifetime.
Overall, hip fractures cause an excess mortality of 10 to 20 percent at 12 months
Up to 25 percent of patients with hip fractures require long-term nursing home care.

4. Bone Mass

5. Statistics

6. Prevalence of Osteopenia and Osteoporosis in Postmenopausal Women by Ethnicity

7. Prevalence of Osteoporosis Among Females > 50 years (Last five years)
KSA
Thai
Jordan

8. Definition
The World Health Organization (WHO) defines osteoporosis as a spinal or hip bone mineral density (BMD) of 2.5 standard deviations or more below the mean for healthy, young women (T-score of −2.5 or below)

9. Osteoporosis A disease characterized by: Leading to: low bone mass
microarchitectural deterioration of the bone tissue
Leading to:
enhanced bone fragility
increase in fracture risk

10. Osteopenia
defined as a spinal or hip BMD between 1 and 2.5 standard deviations below the mean.

11. WHO guidelines for determining osteoporosis
Normal: Not less than 1 SD below the avg. for young adults
Osteopenia: -1 to -2.5 SD below the mean
Osteoporosis: More than 2.5 SD below the young adult average
70% of women over 80 with no estrogen replacement therapy qualify
Severe osteoporosis
More than 2.5 SD below with fractures

12. Operational definition
WHO criteria
-2.5 SD
- 1SD
Osteopenia
Osteoporosis
Normal

13. Operational definition (WHO)
Normal
T score > -1 SD
Osteopenia
-1  T score >-2.5 SD
Osteoporosis
T score  -2.5 SD
Established Osteoporosis
T score  -2.5 SD + low energy fracture

15. Types
Primary osteoporosis is the result of bone loss related to the decline in gonadal function associated with aging.
Secondary osteoporosis may result from chronic diseases, exposures, or nutritional deficiencies that adversely impact bone metabolism.

16. Risk Factors

17. Selected Factors Associated with Fracture or Low Bone Mineral Density in Postmenopausal Women
Increasing age
Low body weight (< 127 lb [58 kg])
Personal history of fracture
Family history of osteoporotic fracture
Not using hormone therapy
White or Asian race
Excessive alcohol (> 2 drinks per day), caffeine, and tobacco use
History of falls

18. Low level of physical activity Low calcium or vitamin D intake
Selected Factors Associated with Fracture or Low Bone Mineral Density in Postmenopausal Women
Low level of physical activity
Low calcium or vitamin D intake
Use of certain medications or presence of certain medical conditions

19. Risk Factors Genetic Gender Race Small body frame
Prior fragility fracture
Maternal history of hip fracture
Low BMI

20. Risk Factors Lifestyle Nutrition Gynecological Drugs Diseases
Physical inactivity
Smoking
Nutrition
Gynecological
Drugs
Diseases

21. Age

22. Causes of Secondary Osteoporosis
Chronic medical and systemic diseases:
Amyloidosis
Ankylosing spondylitis
Chronic obstructive pulmonary disease
Human immunodeficiency virus or acquired immunodeficiency syndrome
Inflammatory bowel diseases
Liver disease (severe)
Multiple myeloma
Renal insufficiency or renal failure
Rheumatoid arthritis
Systemic lupus erythematosus

23. Causes of Secondary Osteoporosis
Medication :
Anticonvulsants (e.g., phenobarbital, phenytoin)
Drugs causing hypogonadism (e.g., parenteral progesterone, methotrexate, gonadotropin-releasing hormone agonists)
Glucocorticoids
Heparin (long-term)
Immuno suppressants (e.g., cyclosporine , tacrolimus)
Lithium
Thyroid hormone excess

24. Causes of Secondary Osteoporosis
Endocrine and metabolic disorders :
Athletic amenorrhea
Cushing syndrome
Diabetes mellitus, type 1
Hemochromatosis
Hyperparathyroidism (primary)
Hyperthyroidism
Hypogonadism (primary and secondary)
Hypophosphatasia

25. Causes of Secondary Osteoporosis
Nutrition
Alcohol (> 2 drinks per day)
Anorexia nervosa
Celiac disease
Gastric bypass or gastrectomy
Vitamin D deficiency

26. Mechanisms 1. Accelerated bone loss
2. Sub optimal bone growth during childhood and adolescence ( low Peak Bone Mass)
3. Bone loss secondary to disease conditions, eating disorders, or certain medications.

27. Symptoms of osteoporosis
Silent disease until fracture occur.
Bone loss and failure to attain peak bone mass not associated with any signs or symptoms.
In late stage loss of height and change in posture.
History and physical examination neither
sensitive enough nor sufficient for
Diagnosis of primary osteoporosis

28. Diagnosis
Osteoporosis may present with low-impact fractures (occurring from a fall at or below standing height)
Or fragility fractures (occurring spontaneously).
In pre- and perimenopausal women, a basic laboratory evaluation should be considered if there is no clear etiology evident by history and physical examination

29. Fracture risk

30. Biochemical bone markers
Assess bone formation and resorption.
Useful for follow up the treatment effect.

31. Diagnosis Dual Energy X-Ray Absorptiometry
Gold standard
Dual Energy X-Ray Absorptiometry
Quantitative Computed Tomography
Quantitative Ultrasound
Single X ray absorptiometry
Simple Radiography

32. جهاز قياس كثافة العظام DXA
When to Measure BMD inPostmenopausal Women
All women 65 years and older
Postmenopausal women <65 years of age:
If result might influence decisions about intervention
One or more risk factors
History of fracture

33. When Measurement of BMD Is Not Appropriate
Healthy premenopausal women
Healthy children and adolescents
Women initiating ET/HT for menopausal symptom relief (other osteoporosis therapies should not be initiated without BMD measurement)

34. Hip
Spine

35. Evaluation for Suspected Secondary Osteoporosis in Selected Patients
Possible etiology
Test
Chemistry panel
High levels in Paget disease, immobilization
Alkaline phosphates
Low levels in vitamin D deficiency malabsorption -High levels in hyperparathyroidism
Calcium
Liver or kidney disease
Liver or kidneyfunction
Hyperthyroidism
Thyroid-stimulating hormone
Hypogonadism
Total testosterone (men)
Vitamin D deficiency
25-hydroxyvitamin D (men)
Bone marrow malignancy
Malabsorption
Complete blood count

36. Evaluation for Suspected Secondary Osteoporosis in Selected Patients
Possible etiology
Test
Additional tests (based on level of severity of osteoporosis or clinical suspicion of underlying disease)
Hypogonadism
Estradiol (pre- or perimenopausal women)
Hyperparathyroidism
Intact parathyroid hormone
Multiple myeloma
Serum protein electrophoresis
Vitamin D deficiency
25-hydroxyvitamin D (women)

37. Pharmacologic Treatment

38. Medications Approved by the U. S
Medications Approved by the U.S. Food and Drug Administration for Osteoporosis
Fracture type
Route
Typical dosage
Medication
Indication
Hip, vertebral, non vertebral
Oral
0.625 mg daily
Estrogen†, with or without progesterone
Prevention
70 mg weekly
Alendronate (Fosamax)
Prevention and treatment
Vertebral
150 mg monthly
Ibandronate (Boniva)
35 mg weekly
Risedronate (Actonel)
60 mg daily
Raloxifene (Evista)

39. Medications Approved by the U. S
Medications Approved by the U.S. Food and Drug Administration for Osteoporosis
Fracture type
Route
Typical dosage
Medication
Indication
Increases bone mineral density, but fracture end point not evaluated
Intravenous
. 3 mg every three months for four doses
Ibandronate
Treatment
Hip, vertebral, nonvertebral
5 mg annually for three doses
Zoledronic acid (Reclast)
Vertebral
Nasal
200 IU daily
Calcitonin (Miacalcin)
Vertebral, nonvertebral
Subcutaneous
20 mcg daily up to two years
Teriparatide (Forteo)

40. BISPHOSPHONATES
Oral bisphosphonates inhibit osteoclastic activity and are potent antiresorptive agents.
Both daily and intermittent uses of ibandronate (Boniva) have demonstrated antifracture effectiveness at the spine only.
Weekly and monthly dosing make taking bisphosphonates easier

41. RALOXIFENE
Raloxifene (Evista), a selective estrogen receptor modulator, is approved for the treatment of postmenopausal osteoporosis.
Raloxifene has estrogen agonist activity on the bones and lipids, and an estrogen antagonist effect on the breast and uterus.
Raloxifene is effective for reducing the incidence of vertebral fractures, but effectiveness at the hip has not been shown.
Raloxifene is commonly associated with increased vasomotor symptoms.
Although Raloxifene increases the risk of venous thromboembolism, it is indicated to decrease the risk of invasive breast cancer in postmenopausal women with osteoporosis.

42. RALOXIFENE
it may be best used in postmenopausal women with osteoporosis who are unable to tolerate bisphosphonates, have no vasomotor symptoms or history of venous thromboembolism, and have a high breast cancer risk score.

43. CALCITONIN
Calcitonin nasal spray (Miacalcin) is an antiresorptive agent approved for the treatment of postmenopausal osteoporosis at a dosage of 200 IU in alternating nostrils each day. It is shown to decrease the occurrence of vertebral compression fractures, but not non vertebral or hip fractures.2
Although Calcitonin has modest analgesic properties in the setting of acute and chronic vertebral compression fracture, it is not considered first-line treatment for osteoporosis because more effective medications are available.

44. TERIPARATIDE
Teriparatide (Forteo) is a recombinant human parathyroid hormone with potent bone anabolic activity. In a dosage of 20 mcg per day given subcutaneously for up to two years, teriparatide decreases vertebral and nonvertebral fractures.
Adverse effects may include orthostatic hypotension, transient hypercalcemia, nausea, arthralgia, and leg cramps. Increased risk of osteosarcoma is seen in rats exposed to high doses.
Teriparatide is contraindicated in patients with risk of osteosarcoma, such as those with Paget disease, previous skeletal radiation, or unexplained elevation of alkaline phosphatase level.

45. TERIPARATIDE
Teriparatide is approved for the treatment of postmenopausal women with severe bone loss, men with osteoporosis who have a high risk of fractures, and persons who have not improved on bisphosphonate therapy.
One study suggests that it is advisable to follow Teriparatide therapy with bisphosphonate therapy to maintain BMD gained.

46. HORMONE THERAPY
The Women's Health Initiative confirmed that estrogen, with or without progesterone, slightly reduced the risk of hip and vertebral fractures, but found that this benefit did not outweigh the increased risk of stroke, venous thromboembolism, coronary heart disease, and breast cancer, even for women at high risk of fractures.
Lower doses of conjugated equine estrogens and estradiol have been shown to improve BMD, but the reduced risk of fracture has not been demonstrated and the safety is unknown.
The FDA recommends hormone therapy for osteoporosis only in women with moderate or severe vasomotor symptoms, using the lowest effective dose for the shortest time.

47. Spine BMD

48. Total Hip BMD

49. Forearm BMD

50. Non pharmacologic Treatment

51. FALL PREVENTION
Vision deficits, balance and gait abnormalities, cognitive impairment, and dizziness are the cornerstone of fall prevention.
Improving lighting; removing loose rugs; and adding grab bars near bathtubs, toilets, and stairways can enhance safety.
Formal home safety evaluations and physical therapy treatments are beneficial.
Eliminating medications that can affect alertness and balance is critical.
The use of hip protectors is no longer considered effective.

52. CALCIUM
One subgroup from a recent meta-analysis showed decreased fracture rates in older women with 80 percent or greater adherence to calcium supplementation.
A daily intake of at least 1,200 mg of calcium is recommended for all women with osteoporosis.
Calcium carbonate is the least expensive, requires acid for absorption, and should be taken with meals.
Calcium citrate is more expensive and does not need to be taken with meals.
Medications should be given several hours before or after calcium supplements (levothyroxine, fluoroquinolones, tetracycline, phenytoin, angiotensin-converting enzyme inhibitors, iron, and bisphosphonates)
References:
Diagnosis and Treatment of Osteoporosis -American family physician –feb

53. VITAMIN D
Daily intake of at least 700 to 800 IU of vitamin D is shown to prevent hip fractures in older persons
For patients with documented vitamin D deficiency, oral ergocalciferol (vitamin D2) in a dosage of 50,000 IU weekly for eight weeks is usually an effective treatment. This should be followed by a maintenance dosage of 50,000 IU every two to four weeks or oral cholecalciferol (vitamin D3) in a dosage of 1,000 IU once daily.

54. Treatment Follow-Up
It is reasonable to assess response to therapy at least once, after no less than 24 months.
More frequent testing might be appropriate in the setting of accelerated bone loss, such as the chronic administration of glucocorticoids.
A decrease in BMD suggests noncompliance, inadequate calcium and vitamin D supplementation, an unidentified secondary cause of osteoporosis, or treatment failure.

55. Thank U