1. By Siraya Kitiyodom ปัญหาที่เกี่ยวกับสุขภาพ ที่พบบ่อยในสตรีวัยทอง และวิธีการดูแล (Part II)

2. BONE By Siraya Kitiyodom

3. Management Brain symptoms Prevalence Mood Estrogen as an neuromodulator Depression Vasomotor symptom Definition Physiology Management Bone Nonhormonal in menopause Hormone replacement therapy

4. Scope Definition Pathogenesis Evaluate & Diagnosis Treatment

5. Definition Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength primary reflects the integration of bone density and quality NIH Concensus Development Panel an Osteoporosis, 2001

6. Bone Strength NIH Consensus Statement 2001 Bone Strength NIH Consensus Statement 2001 Bone Quality Bone Quality Bone Strength ++ Architecture and geometry Degree of mineralization Properties of collagen/mineral matrix Damage accumulation Turnover/ remodeling rate Architecture and geometry Degree of mineralization Properties of collagen/mineral matrix Damage accumulation Turnover/ remodeling rate Bone Density NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95

7. Scope Definition Pathogenesis Evaluate & Diagnosis Treatment

8. Bone Biology TYPE OF BONE Bone can be divided into 2 major types Cortical - Outer shell of all bones - 75% of total bone mass Trabecular - Spongy, open architectural structure - Most of the volume in bone - 25% of total bone mass

9. Larger surface area Higher turn over rate Show early bone loss First respond to therapy ACOG Practice Bulletin. 2004; NO. 50: 203-216

11. Bone mass peaks at approximately age 30 years in both men and women After reaching peak bone mass, approximately 0.4% of bone is lost per year in both sexes Women lose approximately 2% of cortical bone and 5% of trabecular bone per year for the first 5–8 years after menopause ACOG Practice Bulletin. 2004; NO. 50: 203-216 Bone Biology

13. Osteoblast Bone formation Osteoclast Bone resorption Osteocyte Osteoblast that trap in matrix

15. Calcium deficiency Primary Vit D deficiency Primary 1.25-(OH) 2 D 3 deficiency / resistance Parathyroid hyperplasia Hormone deficiency (estrogen, testosterone, 1.25 (OH) 2 D 3, GH, IGF) Muscle strength  Sense of balance  Mental status  Reflexes  Mobility  Secondary hyperparathyroidism Low bone mass  Bone strength Tendency to fall Fractures OSTEOPOROTIC FRACTURE Type I Type II

16. Type II Endocrine -Cushing -Thyroid/parathyroid -hypogonadism Drug -glucocorticoid -heparin, warfarin -phenytoin, phenobarb -CA drug Systemic disease -renal disease -liver disease -malabsorb -rheumatoid -CA

17. Scope Definition Pathogenesis Evaluate & Diagnosis Treatment

18. Risk factor Non modificationNon modification - Age > 65 - asian - early menopause (< 45 year) - small body built - Hx fragility fracture - Family Hx – osteoporosis/osteoporosis Fx ModificationModification - low intake calcium - sedentary lifestyle - smoking, alcohol, caffeine - BMI < 19kg/m2 - estrogen deficiency

19. Evaluate Risk assessment of osteoporosis fracture (FRAX) LAB Bone strength assessment Biochemical marker of bone turnover

20. FRAX

23. Evaluate Risk assessment of osteoporosis fracture (FRAX) LAB Bone strength assessment Biochemical marker of bone turnover

24. LAB CBC Calcium, phosphate, albumin Liver function test Renal function X-ray – Lateral TL spine or AP hip (suspected fracture)

25. Evaluate Risk assessment of osteoporosis fracture (FRAX) LAB Bone strength assessment Biochemical marker of bone turnover

26. Bone strength assessment Plain X-ray (BMD<30%) Semi-quantitative method (high intra & inter observer) Bone mass measurement -> axial dual energy X-ray absorptiometry (axial DXA)

27. Bone mass measurement IndicationIndication - Age > 65 - Age < 65 - early menopause - estrogen deficiency > 1 yr - on glucocorticoid - BMI < 19 kg/m2 - parent hip Fx history - X-ray find osteopenia/vertebral fracture - fragility fracture - decrease height - screening -> high risk – OSTA score 0.2 X (BW – Age) > -1  low risk -4  moderate risk < -4  high risk

28. Bone mass measurement WHO Study Group. Osteoporos Int,1994;4:368-381.

29. Scope Definition Pathogenesis Evaluate & Diagnosis Treatment

30. NORMALOSTEOPOROSIS FRACTURESMORTALITY & MORBIDITY “ Prevention ” “ Treatment ” “ Surgery & Rehabilitation ” “ Surgery & Rehabilitation ” Stategy

31. Prevention Strategy to maximize peak bone mass Strategy to prevent bone loss - weight bearing exercise - life style modification - nutrition – Calcium Daily intake of calcium. Women < 50 years : 1,000 mg Women > 50 years : > 1,200 mg In dietary  ~ 500-600 mg. calcium/day Calcium supplement Divided dose, with meal, and single dose< 1,000 mg – Vitamin D (800 iu) - prevent fall

32. Treatment IndicationIndication - Primary indication - Menopause – Fragility fracture (vertebrae or hip) – BMD T score < -2.5

33. Treatment IndicationIndication - Secondary indication - BMD – 2.5 < T score < -1 with - major fragility Fx e.g. ankle, wrist, pelvis - use glucocorticoid - secondary osteoporosis e.g. thyrotoxicosis - FRAX (no BMD) 10 yr probability of hip Fx > 3% other Fx > 20% - clinical risk factor - parent Hx hip Fx - Premature menopause - smoking / alcohol

34. DRUG Hormonal Bisphosphonate Calcitonin Parathyroid hormone Strontium ranelate Vitamin K2 New drug

35. www.umich.edu/news/Release/2005/Feb05/bonehtml Inhibit bone resorption HRT Bisphosphonate SERM Calcitonin Stimulate bone formation PTH Strontium ranelate Vitamin k 2 Effects of Medication on Bone Remodeling Inhibit bone resorption & Stimulate bone formation

36. DRUG Hormonal Bisphosphonate Calcitonin Parathyroid hormone Strontium ranelate Vitamin K2 New drug

37. HRT Estrogen therapy (ET) - prevention of bone loss and fractures in postmenopausal women with or without established osteoporosis - FDA approved only for the prevention of postmenopausal osteoporosis - reduce vertebral and non vertebral fracture - effect are exerted through estrogen receptors (present on monocyte lineage and osteoblasts) - anti bone resorption

38. THE END