OSTEOPOROSIS• An extremely common disease• Characterised by low bone mass & loss of bone tissue that

may lead to weak & fragile bone• If left untreated , it can progress without causing any pain

until a bone breaks (fracture)• Most likely fractures – the hip bone, a bone in the spine or

wrist• Hip fracture requires hospitalisation & major surgery – leads

to serious walking disability & sometimes death• Fractures of spine or vertebrae can sometimes result in loss of

height, severe back pain & deformity• Develops very slowly over a long period• Preventable & treatable

DIAGNOSIS• DEXA Scan – Dual Energy X-ray Absorptiometry - measure bone density compared to

normal range - fast, simple & accurate T-score : -1.0 or greater – normal -1.0 and -2.5 – low bone mass

(osteopenia) - 2.5 and below – osteoporosis

• Ultrasound & CT Scan- also provide a reliable indication of bone mass

OSTEOPOROSISOSTEOPOROSISHow is it diagnosed?How is it diagnosed?

Gold Standard – bone densiometry(central DEXA) scan

OSTEOPOROSISOSTEOPOROSISHow is it diagnosed?How is it diagnosed?

Evaluating bone mineral density (BMD) and comparing to norms

OSTEOPOROSISOSTEOPOROSISHow is it diagnosed?How is it diagnosed?

T score = -2.5 is osteoporosisT score -1.0 to -2.5 is osteopenia

OSTEOPOROSISOSTEOPOROSISWho should be screened?Who should be screened?

Women age 65 and olderMen age 70 and olderPost-menopausal women age <65 with a

single additional risk factorWomen going through menopause with

significant risk factorsMen age 50-70 with risk factorsPrevious low-impact fractureLong-term use of high-risk medication

SYMPTOMS OF OSTEOPOROSIS

• Joint pain• Loss of height over time• Fracture• Difficulty standing / sitting up straight –

stooping position of elderly people is a visible sign of possible osteoporosis

RISK FACTORS OF OSTEOPOROSIS• Sex – women 2x more likely to develop

osteoporosis• Age - peak bone mass in 20’s after that ↓• Race – white or southeast Asians greater risk• Family history – gene is involved• Frame size – very thin or small at greater risk

because less peak bone mass• Lifetime exposure to estrogen – more estrogen

exposure less risk e.g. women who have late menopause

RISK FACTORS OF OSTEOPOROSIS- contd

• Eating Disorder – anorexia or bulimia• Medications – steroids, hyperthyroidism, loop diuretics• Low calcium consumption• Sedentary life style – even childhood activity level

affects bone mass• Chronic alcoholism – main cause of osteoporosis in men• Depression – faster loss of bone mass• Smoking – higher incidence• Caffeine - ↑ amount of calcium excreted. Caffeine also

found in fizzy drinks

Treatments for osteoporosis• Calcium & Vitamin D• Hormone Replacement Therapy• Selective Estrogen Receptor Modulators (SERMs)• Bisphosphonates• Calcitonin• Parathyroid Hormone• Others

Calcium Supplements• Slower rate of bone loss• Reduction of fractures in some pt• Adjunct to other osteoporosis treatment• Ca requirement is greatest in childhood, pregnancy & breastfeeding• Post menopausal women & older men also need to consume more

calcium• Calcium requirement : Adults < 50 years – 1000mg/day

> 50 years – 1200mg/day Women > 65 years – 1500mg/day

• Calcium preparationms --- Calcium citrate, Ca gluconate, Ca carbonate• Risk : mild GI upset, constipation, ?? Kidney stones

OSTEOPOROSISOSTEOPOROSISPreventionPrevention

Am I getting enough calcium??8 oz. glass of milk = 300mg?6 oz. cup yogurt = 300mg?1 oz or 1 cu in. cheese = 200mg?8 oz. fortified orange juice = 300mg

Vitamin D

• Sunlight is the best source of vit D• It is essential for intestinal absorption of calcium• Daily recommendation 400 -800 iu/day- esp in low

sunlight exposure, elderly, low vit D intake• ↓ risk of fracture in healthy elderly• Vit D derivatives e.g. calciferol, calcitriol (Rocaltrol),

alfacalcidol (One-Alpha) – effective alternative but expensive

Hormone Replacement Therapy (HRT)• For women going through menopause• Prevent bone density loss• Bone density loss greatest at beginning of menopause• Estrogen when initiated in the immediate post-menopausal

period can prevent osteoporosis• S/E : ↑ risk of stroke, heart disease, thromboembolism &

breast cancer• Can be estrogen alone or estrogen-progestogen in pt with

itact uterus• Progestogen added to reduce endometrial cancer • E.g. Prempak – an estrogen-progestogen therapy – no longer

the therapy of choice for osteoporosis in post-menopausal women

Bisphosphonates• Risedronate (Actonel), alendronate (Fosamax), ibandronate

(Bonviva) have been approved for osteoporosis• ↑ bone density loss by ↓ bone resorption and ↑ production

of new bone cells• ↓ risk of vertebral & non-vertebral fractures• These drugs are poorly absorbed• Elimination fr the body is SOLELY through renal clearance – so

contraindicated in pt with severe renal impairment

Bisphosphonates- contd• Dose : Alendronate – 70mg once a week or 10mg/day

Risedronate – 35mg once weekly Ibandronate – 150mg once a month• Tablets should be swallowed whole, do not chew or crush• Food significantly interferes with absorption , therefore

should be taken on empty stomach with 6-8 oz of water at least ½ hr before breakfast

• Cause esophagitis – pt should not lie down for an hour after taking med – prevent reflux

• S/E : abd pain, nausea, inflamed esophagus & esophagus ulcers

Calcitonin• Hormone made by the thyroid gland• Inhibit the cells that break down bones - osteoclasts• Improves bone architecture, relieves pain & increase function• Available in both injectable & nasal spray• Approved for treatment of osteoporosis in late menopausal

women• E.g. Miacalcic Nasal Spray – dose : 200 UNITS (1 Spray) into

one nostril daily• Downside : tolerance occurs with continuous use

Selective Estrogen Receptor Modulators (SERM)

• SERMs mimics the good effects of estrogen on bones• Raloxifene ( Evista) has been approved for prevention of osteoporosis• It reduces the occurrence of vertebral fracture in post-menopausal

women• No significant effect on CV, stroke & breast cancer• ↑ occurrence of hot flushes, risk of thromboembolism (comparable to

that of estrogen)• Dose : 60 mg daily• Special precaution : co-administration with systemic estrogen is not

recommended Not to be taken with cholestyramine

• Tamoxifen – is not FDA approved for osteoporosis management – but it has beneficial effects on bones

Parathyroid Hormone• Teriparatide (Forteo) –a form of parathyroid hormone that

help stimulate bone formation• Approved for use in post-menopausal women & men at high

risk for osteoporotic fractures• Shown to have greater increase in spine density greater

decrease in risk of non-vertebral fracture then with alendronate

• Also useful in glucocorticoid-induced osteoporosis• Dose : 20mcg once daily by SC inj in thigh or abdomen• Use with caution in pt with renal impairment• Contraindicated in pt with high PTH or who had radiation• AR : nausea, pain in the limb, headache, dizziness

Strontium Ranelate (Protaxos)• Stimulate bone formation & reduce bone resorption• ↓ risk of vertebral & hip fracture• Dose : 2g/day – a powder dissolve in water and taken once

daily• Take on empty stomach between meals, preferably at

bedtime at least 2 hr after food/milk or Ca supplement• Used when bisphosphonate not tolerated or is

contraindicated• Not recommended in severe renal impairment• S/E : headache, nausea, diarrhoea, dermatitis, memory loss,

seizures• Can sometimes cause severe allergic reactions