1.Prevention and Management

2. 1. INTRODUCTION 2. EPIDEMIOLOGY 3. CLASSIFICATION 4. PATHOPHYSIOLOGY 5. S/S 6. INVESTIGATIONS 7. BMD 8. BTM 9. DIAGNOSIS 10. DD 10.MANAGEMENT 11.RECENT ADVANCES 12. ORTHOPAEDICIAN) 13.COMPLICATIONS 14.CASE PRESENTATION 15.CONCLUSION 3. Osteoporosis: Nightmare Of Post- menopause/ Old Age Normal vs Osteoporotic Bone 4. 1. It is a disease of aging- 2. Silent disease- 3. fragility fracture/low trauma fracture 4. spontaneous fracture 5. Hip fractures-Morbidity 6. QOL 5. What is Osteoporosis? Osteoporosis is a systemic skeletal disease characterized 1. low bone density and 2. a micro- architecture deterioration of bone tissue 3. that enhances bone fragility and 6. 2.Epidemiology 7. Osteoporosis affects entire skeleton Osteoporosis is responsible for >36.8 million vertebral and non-vertebral fractures per year in USA Spine, hip, and wrist fractures are most common 8. Common Sites of fracture Hip Vertebral column Wrist 9. women In women it isThree times more common than men 1.low peak bone mass (PBM) 2.hormonal changes at menopause 3.live longer than men vertebral #s and wrist #s more common in women 10. A Retrospective Study Suggests that Vertebral Fractures are Under-Diagnosed 934 hospitalised women with a lateral chest x-ray 0 20 40 60 80 100 120 140 Patients(n) 132 65 23 25 Fracture identified by study radiologists Fracture noted in radiology report Fracture noted in medical record Received osteoporosis treatment Gehlbach et al.,Osteoporos Int 2000, 11:577 11. Hip fractures Hip fractures accounts for most of the morbidity, mortality and cost of the disease 12. 2.Classification 13. Osteoporosis: Classification Primary Osteoporosis Type 1- Post menopausal osteoporosis Type 2- Senile/Age related osteoporosis Secondary Osteoporosis Secondary to various causes 13 14. Post-Menopausal Osteoporosis Caused by a lack of estrogens, which helps to regulate, the incorporation of calcium into bone in women Lack of estrogen increased bone resorption 14 15. Age Related/Senile Osteoporosis Usually affects people over 70 y. Results from age-related calcium deficiency There is decreased bone formation Patients usually present with fractures of the hip and the vertebrae 15 16. Secondary Osteoporosis Congenitl Condition Homocystinuria; hemolytic anemia; hypophosphatasia; osteogenesis imperfecta Diet Calcium deficiency; malabsorption syndromes; scurvy; starvation Drugs Alcohol; anticonvulsants; cancer chemotherapy; excess thyroid hormone; glucocorticoids; heparin; methotrexate 16 17. Endocrine Disorders Cushing's syndrome; growth hormone deficiency; hypercortisolism; hyperparathyroidism; hyperthyroidism; hypogonadism Other Systemic Disorders Diabetes mellitus; leukemia; multiple myeloma; renal tubular acidosis Rheumatologic disorders Ankylosing spondylitis, rheumatoid arthritis G.I. diseases Gastrectomy, primary biliary cirrhosis, celiac disease 18. A.CHILDHOOD-chronic diseases During growth 30 -50y >50 y. Bed rest due to chronic illness Undernutrition or malnutrition Chronic Paediatric disorders Glucocorticoid/growth hormone Anorexianervosa Exercise-associated amenorrhoea Severe chronic paediatric diseases requiring immunosuppressive agents 19. B.During late adulthood- endocrine diseases Hypogonadism is a major cause 1.Women-menopause-estrgen deficiency-bone marrow of cytokines such as tumour necrosis factors and interleukins that stimulate osteoclastic bone resorption 2.Men declining levels of gonadal hormones-low rates of bone formation Primary hyperparathyroidsm,,hyperthyroidsm and hypercortisolism 20. C.Elderly-diet(calcium) Low calcium intake associated with a reduced endogenous production of vit.D accelerate bone loss By increasing the secretion of PTH. 21. 3.Risk factors 22. Non-modifiable/Fixed Risk Factors Older age Female gender Ethnic background Small bone structure Family history of osteoporosis or osteoporosis-related fracture in a parent or siblings Previous fracture Menopause/hysterectomy Some medicines like steroids, anti-epileptics Rheumatoid arthritis Reduced levels of gonadal hormones in men 23. Modifiable Risk Factors Alcohol Smoking Poor nutrition Vitamin D deficiency/Lack of sunlight exposure Insufficient exercise Low calcium intake in food 24. 4.Pathophysiology 1.Peak bone mass 2.remodling 25. Determinants Of Peak Bone Mass Peak Bone Mass Physical activity Gonadal status Nutritional statusGenetic factors 26. 1.Peak bone mass & Osteoporosis Peak bone mass is the maximum mass of bone achieved by an individual at skeletal maturity, typically between ages 25 and 35 After peak bone mass is attained, both men and women lose bone mass over the remainder of their lifetimes Because of the subsequent bone loss, peak bone mass is an important factor in the development of osteoporosis 26 27. Peak Bone Mass in Women 10 20 30 40 50 60 Women achieve lesser peak bone mass than men 27 28. Stages of Peak Bone Mass in Women 28 29. 2.Bone formation takes place throughout life-remodeling Bone is a living tissue and is constantly resorbed and formed by the process known as remodeling 30. Remodelling 31. Imbalance 1.In Osteoporosis imbalance occurs between bone resorption and bone formation This imbalance might occur as a result of one or a combination of the following factors: Increased bone resorption Decreased bone formation A negative balance occurs and results in a net loss of bone 31 32. 5.Signs & Symptoms 33. Signs & Symptoms In early stages usually no symptoms therefore also known as silent disease There may be back pain due to spinal compression First sign may be fractures due to slight trauma or even due to bending or lifting or rising-spontaneous or low trauma fracture If several vertebrae break, an abnormal curvature of spine (a dowager's hump) may develop, causing muscle- strain and soreness A loss of height by 4 to 8 inches may occur 33 34. Osteoporosis related bone loss Vertebrae, which have a large proportion of trabecular bone, are commonly the first sites to show bone loss in Osteoporosis leading to spine collapse (upto-4-8 inches) 34 35. Backbone Deformity in Osteoporosis Three generations of women are shown. The elderly women have hunched back which is a sign of vertebral fractures caused by osteoporosis 36. 6.Differential Diagnoses 37. Differential Diagnoses Other Problems to Be Considered 1. Bony metastases 2. Multiple myeloma 3. Primary hyperparathyroidism 4. Secondary hyperparathyroidism 5. Osteomalacia 6. Renal osteodystrophy 7. Paget disease of bone 38. Osteomalacia/osteoporosis osteomalacia osteoporosis .h/o persistant skeletal pain of long duration and muscle weakness h/o gastric surgery Skeletal tenderness A shuffling penguin gait Biochemistry low ca,ph and increased s.Alka.ph. Reduced 24h urinary ca 1.transient episodes of pain usually associated with #s 39. osteomalacia osteoporosi X-ray-diminished bone density- marked in the peripheral bone than in the axial Skeletal deformity without # Loosers zone Histology presence of excess osteoid tissue in undercalcified Treatment is rapidly and consitently successful 40. 7.Diagnosis 41. BMD Dual energy x-ray absorptiometry (DEXA) is the best current test to measure bone density The ability of the BMD to predict hip # is better than the measurement of BP to predict stroke 42. BMD 2.5 standard deviation or more below the average for the young healthy female population- osteoporosis T score for BMD measured at the hip using DEXA is best one For each standard deviation decrease in BMD, fracture risk increases by approximately 50%. 43. How is osteoporos is diagnosed Diagnosis is made on the basis of 1. Detailed medical history 2. Physical examination 3. Investigations-1.BMD by DEXA or by single energy x-ray absorptiometry 2.BTM 44. BMD Tests Other than DEXA Quantitative CT vertebral scanning Single photon and dual photon absorptiometry Peripheral DEXA 45. Bone Mineral Density (BMD) It is a simple test that measures bone thickness/ density at different parts of the body, like spine, hip etc It employs two x-ray beams of different energy levels Dual energy x-ray absorptiometry (DEXA) is the best current test to measure bone density 46. Dual-energy x-ray absorptiometry (DEXA) 47. Indications for Bone Density test 1.All postmenopausal women 65 yr regardless of additional risk factors 3.Documenting reduced bone density in a patient with a vertebral abnormality or osteopenia on a radiograph 4.Estrogen-deficient women at risk for low bone density, considering use of estrogen or an alternative therapy, if bone density would facilitate the decision 48. 5.Women who have been on estrogen replacement therapy for prolonged periods or to monitor the efficacy of a therapeutic intervention or interventions for osteoporosis 6.Diagnosing low bone mass in glucocorticoid- treated individuals(Prednisolone at 7.5mg daily for 6m.) 7. patients with asymptomatic primary or secondary hyperparathyroidism 49. 8.Previous low trauma fragility # 9.Premature menopause 1.y.) 11.Primary or secondary hypogonadism 12.Chronic disorders asso. With osteoporosis 13.A meternal h/o hip # 14.Alow BMI 50. BMD Report 51. WHO Classification: T score 1Normal BMD or bone mineral content (BMC) not more than 1 SD below the young adult mean (T-score above -1) 2.Osteopenia BMD or BMC between 1 SD and 2.5 SD below the young adult mean (T-score between -1 to-2.5) 3.Osteoporosis BMD or BMC 2.5 SD or more below the young adult mean (T- score at or below -2.5) 4.Severe osteoporosis (or established osteoporosis) BMD or BMC 2.5 SD or more below the young adult mean in the presence of one or more fragility fractures 51 52. Bone Turnover Markers(BTM) Biochemical markers of bone turnover are substances in blood and urine that reflect rates of bone resorption or bone formation they measure the relative activity of osteoclasts and osteoblasts 53. Bone resorption markers Currently available markers of bone resorption include Pyridinoline (PYR) Deoxy pyridinoline (DPD) N-telopeptides of type 1 collagen (NTX) C-telopeptides of type 1 collagen (CTX) 1.Pyridinolines are measured in urine 2. telopeptides can be measured in both serum and urine 54. Markers of bone formation The most common markers of bone formation are: Osteocalcin (OC) Bone specific alkaline phosphatase (bone ALP) Procollagen type 1 N-terminal propeptide (P1NP) Procollagen type 1 C-terminal propeptide (P1CP) 55. Prevention & Treatment 56. 9.Pharmacological management 57. 1.Pharmacological Management Osteoporosis Calcium Vitamin D Estrogens/HRT Selective Estrogen Receptor Modulator (SERM)Raloxifene Bisphosphonates Strontium ranelate Calcitonin PTH Teriparatide 58. Normal calcium requirement Age Calcium/day (mg) Birth-6 months 210 6 months-1 year 270 1-3 500 4-8 800 9-18 1300 19-50 1000 51-70 1200 58 59. Calcium Calcium citrate may be advantageous for older seniors Divided 2 to 3 times daily 60. Vitamin D Doses: 1).400IU per day until 60 2)600-800 IU per day after 60 3.)50,000 IU-D2Every 2-4 weeks 4.)To treat deficiency-50,000 D2IU every week for 2 to 4 m. 61. 25 hydroxy Vit.D status 1. .30ng-sufficient 2. 20-29ng/ml-insufficiency 3. 3month. 2.BMD-T-score below -2.5SD-oral-IV bisphosphonates ,calcium,Vit.D 80. prevention 1. prevention of falls 2.prevention and treatment of bone fragility 3.use of external hip protectors. 81. 1. prevention of falls 1.Impaired balance 2.gait and mobility 3.Poor vision 4.reduced muscle strength 5.impaired cognition 82. Other causes for falls- Medication&co-morbid disease Psychoactive medication- benzodiazepines. antidepressant Certain co-morbid disease- stroke, Alzheimers dementia and parkinsons diseases 83. Insufficient Vit.D increases the Falls Essential to maintain muscle function and strength Reduced handgrip strength heaviness in the legs Reduced walking distance -Less outdoor activity 84. Home environment modifications 1 removing loose rugs or extension cords 2.repairing rickety stairs 3.Bathroom ergonomics-adding grab bars 4.increasing lighting 85. Regular physical activity plays a therapeutic role in severe osteoporosis 86. Hip protectors Specialized undergarments Poor compliance Latest data-ineffective and should not be recommended alone 87. 13.RECENT ADVANCES 88. Latest in Osteoporosis Treatment 1.Carotenoids, Lycopene Reduce Fracture Risk (Antioxidants) reactive oxygen intermediates may be involved in the bone- resorptive process and that fruit and vegetable-specific antioxidants, such as carotenoids, are capable of decreasing this oxidative stress. Therefore carotenoids may help in preventing osteoporosis. In particular, an inverse relation of carotenoids and lycopene with biochemical markers of bone turnover has recently been demonstrated. 89. 2.Omega-3 Fatty Acids Reduce hs-CRP1 This study provides evidence that in healthy individuals, plasma n-3 fatty acid concentration is inversely related to hs-CRP High sensitivity C-reactive protein (hs-CRP) is a marker of low grade sustained inflammation. Increased hs-CRP by just 1SD increases fracture risk by an amazing 23 percent2. Consider supplementing the diet with omega-3 fatty acids (fish oil). Theyre a great way to help reduce inflammation, hs-CRP, cardiovascular disease, and fractures related to osteoporosis. 1. Micallef M A et al., European Journal of Clinical Nutrition, 2009; April 8 [Epub ahead of print]. 2. Pasco et al. JAMA. 2006;296(11):1353-1355 90. 3.Vitamin K Improves Bone Strength and Reduces Fractures Review of RCTs showed that vitamin K(1) and vitamin K(2) supplementation reduced serum undercarboxylated osteocalcin levels regardless of dose but that it had inconsistent effects on serum total osteocalcin levels and no effect on bone resorption. Iwamoto J et al., Nutrition Research, 2009; 29(4): 221-228. 91. 4.Atypical femoral fractures due to bisphosphonates Atypical femoral fractures with bisphosphonate treatment Experience in two large United Kingdom teaching hospitals 92. 14. Case study 93. Case 1. Sitaratnam 85y. Severe osteoporoti, Known diabetic ,HTN and hemiplegic pt . presented with 1.y.post operative non union troch.# with PFN 94. Cemented bipolar 95. Excised the femoral head from fracture site reconstucted the femoral neck taking bone graft from femoral head and cement Replaced with bipolar porstesis And put her on bisphosponates,calcium and vit.D Pt.was followed up for 2years-pt.is walking without any 96. Operative procedure more difficult than conventional arthroplasty Reduced length of hospital stay Indications for primary prosthetic replacement are remain ill defined Prospective randomized trails are needed to determine the role for acute prosthetic replacement for treatment of IT #s 97. Case no 2.Secondary osteoporosis 98. Pallavi,31/f,on Antiepileptic drugs since 6m. age Ref. from Apolo hospital Secunderabad 9053725362,9700178806 D0A-27-4-12,4-5-12 She presented with fracture shaft femur due to slip &fall in bath room on 9-4-12 First -.treated with pop cast for 3 weeks by an orthopaedic surgeon subsequantly they went to APOLO hospital from there she was referred to GANDHI hospital 99. 3rd x-ray on 18 -5- 12 100. Investigations Low s.calcium and phosphorus 25 hydroxy vit.D- Insufficient -20Ng/ml PTH,,Alk.phosphatase-normal DEXA-severe osteoporosis 101. Calcium-7.5 (8.5-11mg%) insufficiency 102. 25 hydroxy Vit.D-20Ng/ml insufficiency(6-20ng/ml) 103. BMD tasted by DEXA 104. DEXA-OSTEOPOROSIS-severe osteoporosis LT.FEMUR3.8 RT.FEMUR3.2 SPINE4.1 105. Now pt. is on 1.)Calcium-1g/d 2.)Vit.D 6o ooo/w 3)high protien diet 4.)Teriparatide-25microgram/day 106. BONISTA/FORTEO 1)BONISTA-ORTHOLANDS RANBAXY 2)FORTEO-Eli LILLY 107. Iatrogenic fracture Epilepsy has been diagnosed at the age of 6m.in NIMS Since then she is on antiepileptic drugs for 30y. Though she was suffured from multiple fractures, attended big hospitals,and treated by qualified doctors. No one has suspected this problem and adviced her 108. Had it diagnosed at early stage and treated with simple calcium and vit.D it would have been prevented both fracture, as well as this costly treatment (teriparatide) This amounts to a iatrogenic fracture 109. 15.CONCLUSION 110. Education -Ignorance about osteoporosis is still common among Health professionals Patients and Public, - So that the education of all of these groups is necessary. 111. So ,Our aim should be 1. increase knowledge of bone physiology and osteoporosis 2.raise the awareness of major risk factors and 3.provide information on possibilities of primary and secondary prevention and management of the disease