Osteoporosis

Dr. Uday PawarJunior Spine Consultant

DNB Orthopaedic

Hinduja Hospital, Mahim, Mumbai

http://www.hindujahospital.com/dr-uday-pawar/

With age comes wisdom………..

and Osteoporosis

What is osteoporosis ?

Normal Osteoprosis

Jargon buster………

• Softening of bones …….

• A reduction in the quantity and quality of bones

What is osteoporosis

• A condition rather than a disease

• Silent until complications arise

• Spine, hip & wrist fractures

WHO criteria for diagnosis of Osteoporosis

Kanis et al. J Bone Miner Res 1994; 9:1137-41

T-scoreNormal - 1.0 and above

Osteopaenia - 1.0 to - 2.5

Osteoporosis - 2.5 and below

Severe (established) osteoporosis

- 2.5 and below, plus one or more osteoporotic

fracture(s)

Food for thought…..

1. Osteoporosis ≠ Calcium deficiency

• So, calcium is NOT the treatment of osteoporosis

• Bone mineral v/s bone mass

2. Osteoporosis is a generalized disease

• affects all the bones

3. Treating osteoporosis

• Prevention is the only treatment of osteoporosis

• Hence early diagnosis is the most important step in treating osteoporosis !

Size of the Problem in India

• 26 million (2003) 36 million by 2013

• 1 out of 8 males and 1 out of 3 females suffers from osteoporosis

• The high incidence among men and the lower age of peak incidence compared to Western countries

• Peak incidence of osteoporosis – Western countries-70-80 years of age– India –50-60 years

International Osteoporosis Foundation

The Magnitude Of The ProblemIn women > 50 years, the lifetime risk of:• Vertebral fracture is 1/3• Hip fracture is 1/5

NICE guidance 160 October 2008

Osteoporotic Fractures in Women: Comparison with Other Diseases

1 500 000*

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500

1000

1500

2000

Osteoporotic Fractures

*annual incidence all ages † annual estimate women 29+

‡annual estimate women 30+ §1996 new cases, all ages

513 000†

228 000‡184 300§

750 000 vertebral

250 000 other sites

250 000forearm

250 000hip

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Osteoporosis affects entire skeleton

• Osteoporosis is responsible for >1.5 million vertebral and non-vertebral fractures per year

• Spine, hip, and wrist fractures are most common

Morbidity associated with Fractures

Osteoporosis: Classification

• Primary OsteoporosisType 1- Post menopausal osteoporosisType 2- Senile/Age related osteoporosis

• Secondary OsteoporosisSecondary to various causes

17

Consequences

Reduced quality of life

How is osteoporosis diagnosed

Diagnosis is made on the basis of-

• Detailed medical history• Examination• Blood and other tests

Early diagnosis of Osteoporosis

• Clinical parameters– ‘at risk’ subject– Bone pains– Generalized tiredness– Progressive kyphosis

• Investigations– Radiographs– DEXA– QCT, MRI, Bone scan– Blood markers

Clinical Risk Fractures (CRF)

Predictors of low bone mass-• Female• Advanced age• Low bone mineral density• Gonadal hormone deficiency ( estrogen or testosterone )• White race• Low body weight & BMI• Family history of osteoporosis• Low calcium intake• Smoking / excessive alcohol intake• Low level of physical activity• Chronic glucocorticoid use• Prior fragility fracture

National Osteoporosis Foundation (NOF)

Clinical Presentation

• Severe backache after minor injury• Pain worse on sneezing, coughing , standing

erect, changing positions.• Limited to wheelchair• Stooped Posture• Weakness in legs

X-rays

• Osteopenia• Loss of height of vertebral

body• Wedging

Osteoporosis – RadiographicOsteoporosis – RadiographicDifferential DiagnosisDifferential Diagnosis

• Osteomalacia• Hyperparathyroidism• Hypercortisolism• Hyperthyroidism• Renal insufficiency• Chronic immobilization

• Osteogenesis imperfecta• Hepatic insufficiency• Diabetes mellitus• Multiple myeloma• Metastatic disease• Drug induced

Osteoporosis other causesOsteoporosis other causes

Assessment of bone mineral density by DXACurrent gold standard for diagnosis of osteoporosis

BMD (g/cm2) = Bone mineral content (g) / area (cm2)

Diagnosis based on comparing patient’s BMD to that of young, healthy individuals of same sex

• Blood count , CRP • Calcium, Phosphate, Alkaline

Phosphatase (AP)• Kidney function studies• Basal Thyroid and parathyroid.• Protein-immunoelectrophoresis.• Vit D (25 and 1.25)

Laboratory tests*

NOTES:

- * These are in addition to routine labs tests.

- These are screening labs, more may be indicated based on these results

Preventing Osteoporosis

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Modifiable Risk Factors

Vit D

CalciumExercise

Quit Alcohol Quit Smoking

Non-modifiable 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

Treatments of osteoporosis• Calcium and vitamin D

• HRT

• SERMs (raloxifene)• Calcitonin• Bisphosphonates

– ibandronateibandronate

– etidronate etidronate

– alendronatealendronate

– risedronate risedronate • PTH (1–34) • Fluoride

• Strontium ranelate• Combination

Hormonal agentsHormonal agents

Anti-resorptive Anti-resorptive agentsagents

Anabolic agents Anabolic agents

Dual mechanism of Dual mechanism of actionaction

SERMs = selective oestrogen receptor modulatorsSERMs = selective oestrogen receptor modulatorsPTH = parathyroid hormonePTH = parathyroid hormone

How much and which Calcium??

• 1000-1500mg “elemental calcium”

Type of calcium Elemental Calcium

Calcium carbonate 40%Calcium gluconate 9%Calcium lactate 13%Calcium citrate 20-30%Calcium acetate 30%Micro cryst HA complex 100%

◦ May be difficult to attain those levels.◦ To try a combination of diet and medicines◦ Can’t give more than 500mg elemental calcium as tabs at a single dose

Bisphoshonates

• Etidronate, Alendronate, Risendronate, Ibandronate, Zolendronate

– Anti resorptive agents

– Reduce osteoclasis

Bisphoshonates

• Induce apoptosis (self destruction) in the osteoclasts

• Thus it reduces bone resorption

Bisphoshonates

• On this ‘preserved’ lattice – mineralization takes place

• Thus ‘better mineralized’ bone is formed and DEXA improves

Teriparatide (PTH)

• In small / pulse doses, is a powerful stimulant for bone formation

• The only drug that can induce osteogenesis

Teriparatide

• Teriparatide stimulates formation of new bone matrix / framework

Teriparatide

• On this denser, better structured matrix, mineralization takes place giving rise to an overall stronger bone

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Effect of Anabolic vs Anti-resorptives on Bone Strength

Anabolic‘Laying down new bone’

Anti-resorptive‘reducing bone resorption’

Treatment with PTH(woman 69 years)

Dempster DW et al, J Bone Miner Res, 2001;16:1846-1853

Before CtTh: 0.32 mmCD: 2.9 mm3

After CtTh: 0.42 mmCD: 4.6 mm3

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Take home points…

• No longer a problem of the WEST

• Awareness essential amongst general public

• Prevention is the best treatment

• Moms and grandmoms vulnerable group

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