Osteoporosis

5/26/2018 Osteoporosis

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OSTEOPOROSISBy. Dr. Bambang SN, Sp.PD


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METABOLIC BONE DISEASE

a. The condition produces diffusely

decreased bone density

(osteopenia) and diminished bonestrength

b. Histologic appearance:

-osteoporosis (common), bone matrixand mineral are decreased

-Osteomalacia(unusual), bone matrix

intact, mineral is decreased


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OSTEOPOROSIS

An excess of resorptive over formative bone cellactivities, result in loss of bone mass and

eventually bone fragility and fractures.

Resorption occurs principally in trabecular bone

and from endosteal surfaces.


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OSTEOPOROSIS

The most common metabolic bonedisease

Estimated to cause 1.5 million fractures

anually in US, mainly of the spine

Rate of bone formation is often normal,

rate of bone resorption is increased


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FACTORS INFLUENCING BONE FORMATION AND

RESORPTION

PROCESS FACTORS THATINCREASE

FACTORS THATDECREASE

LABORATORYINDICES OF THE

PROCESS

Bone formation Physical activity,

stress on bones

Growth

Bone repair following

fracture or surgical

cure of

hyperparathyroidism

with bone lesionsPharmacologic and

therapeutic agents

Immobilization,

disuse, bed rest

Aging

Growth hormone

deficiency

Glucocorticoid

excess (Cushings

syndrome)Hypophosphatasia

Bone-derived

serum alkaline

phosphatase

Urinary non

dialyzable

hydroxyproline


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PROCESS FACTORS THAT

INCREASE

FACTORS THAT

DECREASE

LABORATORY

INDICES OF

THE PROCESS

Bone resorption Ageing

Gonadal hormonedefciency

(postmenopausal,

hypogonadism in male

or female)

Hyperpharathyroidism

(primary or secondary)

Vit. D excess

Calcium or phosphate

deficiency (dietary,

malabsorption or renal

loss)

Osteolytic neoplasm

Glucocorticoid excess(Chusings syndrome)

Prostaglandin E2,

osteoclastactivating

factor, and other

osteolytic agents

secreted by

nonosseous neoplasm

Adequate dietary

calcium andphosphate

Hypoparathyroidism

Magnesium

deficiency

Pharmacological

and therapeutic

agents

Serum calcium

Urinary calciumTotal urinary

hydroxyproline


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TYPES AND CAUSES OF

OSTEOPOROSIS

1. Primary Osteoporosis

Naturally occured, cause by decreasing level of sex

hormone and by aging

a. Post menopause osteoporosis

- started onmenopause until aged of 65 years

- decreasing of estrogen hormone

- loss of bone density 3 % / year


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TYPES AND CAUSES OF

OSTEOPOROSIS

b. Senile Osteoporosis

- occured on male and female after aged of 65 years

- often cause by less intake of calcium and vitamin D

2. Secondary Osteoporosis

Cause by:

- chronic condition,

- medication effect or

- under nutrition.All cause less bone density


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CONDITION AND RISK FACTORS TO

OSTEOPOROSIS

1. Menstruation

- Early menopause (Hysterectomy)

- Irregularly menstruation

2. Ras

- white and Asia are easier than black

- Peak bone density on black more than white

3. Family history


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OSTEOPOROSIS

4. Posture, underweight more risky than normoweight andoverweight

5. Smoker

cigarrete influences of bone strength

6. Alcoholic

alcohol decreases bone formation andddecreases calcium resorption

7. Corticosteroid

increases bone resorption and decreases bone

formation


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OSTEOPOROSIS

8. Breast cancer

cancer medication suppress estrogen effect

9. Less calsium and vitamin D intake

10. Life style

- less contain of calcium in nutrition

- less exercise and physical activity


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ETIOLOGIC CLASSIFICATION OF

OSTEOPOROSIS1. Hormone deficiency

Estrogen

Androgen

2. Hormone Excess Cushings syndrome / glucocorticoid

administration

Thyrotoxicosis Hyperparathyroidism

3. Immobilization

4. Tobacco Use


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5. Alcoholism

6. Malignancy especially multiplemyeloma

7. Genetic disorders

8. Miscellaneous


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SYMPTOMS & SIGNS OF

OSTEOPOROSIS

Usually asymptomatic, until fractures accured

May present as : - backache of varying degrees

- spontaneous fractures- colaps of a vertebra

Loss of height is common


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IMAGING OF OSTEOPOROSIS

Demineralization areas : spine, pelvis, femoral

neck and head Demineralization is less marked in the skull and

extremities

Compression of vertebrae is common

Bone densitometry, screening for osteopenia

CT densitometry of vertebrae, highly accurate

and reproducible

Dual energy xray absorptiometry (DEXA), candetermine the density of any bone (quite

accurate)


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TREATMENT OF OSTEOPOROSIS

1. Education and prevention

2. Exercise and rehabilitation

3. Medicamentous therapies

a. Sex hormone

b. Biphosphonates

c. Selective Estrogen Receptor Modulators

(SERMs)

d. Calcitonin

e. Calcium and vit. D

4. Surgical


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EDUCATION AND PREVENTION

The diet should be adequate in protein,total calories, calcium, vit. D

Pharmacologic glucocorticoid doses

should be reduced or discontinued ifpossible

High impact physical activity increasesbone density in men and women


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MEDICAMENTOUS THERAPIES1. Sex hormone

Estrogen for female Testoteron for male

2. Biphosphonates

Inhibit osteoclast bone resorption

Must be taken in the morning 30 minutes beforeconsumption of anything else, to ensure intestinal

absorption

Must remain upright after taking alendronate, to

reduce the risk of esophagitis Alendronate dose :10 mg/d orally, effective for

increasing bone density and reducing fracture risk

Ses : esophagitis, gastritis, anorexia, weight loss


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Residronate dose : 5 mg / d orally, has a

lower incidence of GI side effects

All patients should receive some

supplementation with oral calcium and vit. D

Pamidronate, a parenteral biphosphonate :

60 mg, by i.v infusion in normal saline every 3months

Zoledronate is third generation bihosphonate,

is a potent osteoclast inhibitor

Can be given 24 mg i.v. ly every 612

months


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SELECTIVE ESTROGEN RECEPTOR

MODULATORS (SERMs)

Raloxifene 60 mg / d / orally, can be used for post

menopausal women, prevention of osteoporosis

Raloxifene :

reduces LDL cholesterol, not rises in HDL cholesterol

like seen with estrogen

No direct effect on coronary plaque

Not reduces hot flushes (often intensifies)

Not relieves vaginal dryness

Does not cause endometrial hyperplasia, uterinebleeding, cancer, breast sourness

Increases risk for thromboembolism


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CALCITONIN

Nasal spray of calcitonin salmon (miacalcim)

2200 units/mL in 2 mL metereddose bottles Usual dose is one puff (0.09mL, 200 IU) once

daily by alternating nostril

Nasal administration causes significanly lessnausea and flushing than parenteral route

Rhinitis, epitaxis, accure commonly

Less common adverse reactions include flu like

symptoms, allergy, arthralgias, back pain orheadache


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CALCIUM AND VITAMIN D

Adequate oral intake of calcium and vit. D are

required throughout life in order to maintain peakbone mass and reduced the risk of subsequent

osteoporosis and osteomalacia

Supplements are recommended for patients at

high risk for osteoporosis and for those with

established osteoporosis

Vit. D reduces the risk of breast cancer, calcium,

supplements may reduce the risk of coloncancer

Calcium citrate 0.40.7 g/d, calcium carbonate

11.5 g/d, vit. D 4001000 IU daily


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Osteoporosis

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