Osteoporosis

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Presentation Transcript

OSTEOPOROSIS : 

OSTEOPOROSIS Diagnosis and prevention Dr.Kwanpeemai Panorchan

Definition : 

Definition A systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue lead to bone fragility and susceptibility to fracture

Prevalence of osteoporosis : 

Prevalence of osteoporosis NHANES III. J Bone Miner Res.1997 Melton L. J. J Bone Miner Res.1992

Incidence of osteoporotic Fx : 

Incidence of osteoporotic Fx Riggs BL. Bone 1995;17(s5)

Incidence of osteoporotic Fx : 

Incidence of osteoporotic Fx Vertebral Fracture Forearm Fracture Hip Fracture

Incidence of osteoporotic Fx : 

Incidence of osteoporotic Fx The European Prospective Osteoporosis Study Group ( EPOS ) J Bone Miner Res 2002;17

Impact of osteoporotic Fx : 

Impact of osteoporotic Fx Center JR et al. Lancet 1999; 353

Impact of osteoporotic Fx : 

Impact of osteoporotic Fx 50% Discharged from hospital to nursing home 40% Regained mobility 25% Regained to full former status Increased mortality Increased cost of health care

Pathogenesis : 

Pathogenesis

Pathogenesis : 

Pathogenesis

Pathogenesis : 

Pathogenesis Microdamage Peak bone mass Precipitating factors Loss of Estrogen

Diagnosis of osteoporosis : 

Diagnosis of osteoporosis

Diagnosis of Osteoporosis : 

Diagnosis of Osteoporosis Physical examination Measurement of bone mineral content Dual X-ray absorptiometry (DXA) Ultrasonic measurement of bone CT scan Radiography

Physical examination : 

Physical examination Osteoporosis Height loss Body weight Kyphosis Humped back Tooth loss Skinfold thickness Grip strength Vertebral fracture Arm span-height difference Wall-occiput distance Rib-pelvis distance

Slide 15: 

Physical examination Amanda D. Green. JAMA 2001 vol.292(23)

Physical examination : 

Physical examination Amanda D. Green. JAMA 2001 vol.292(23)

Physical examination : 

No single maneuver is sufficient to rule in or rule out osteoporosis or vertebral fracture without further testing Amanda D. Green. JAMA 2001 vol.292(23) Physical examination

Diagnosis of Osteoporosis : 

Diagnosis of Osteoporosis Physical examination Measurement of bone mineral content Dual X-ray absorptiometry (DXA) Ultrasonic measurement of bone CT scan Radiography

Dual X-ray absorptiometry : 

Dual X-ray absorptiometry 2-dimensional study BMD = Amount of mineral Area Accuracy at hip > 90% Low radiation exposure Error in Osteomalacia Osteoarthritis Previous fracture

Dual X-ray absorptiometry : 

Dual X-ray absorptiometry WHO criteria - Hip BMD Normal Low bone mass (Osteopenia) Osteoporosis Severe osteoporosis

Dual X-ray absorptiometry : 

Dual X-ray absorptiometry

Ultrasonic measurement : 

Ultrasonic measurement Broad-band ultrasound attenuation or ultrasound velocity No radiation exposure Cannot be used for diagnosis Preferred use in assessment of fracture risk

CT scan : 

CT scan True volumetric study Most useful in cancellous bone assessment Avoid effect of degenerative disease Drawback High cost High radiation exposure Difficult quality control

Plain radiography : 

Plain radiography Low sensitivity High availability Subclinical vertebral fracture is a strong risk factor for subsequent fractures at new vertebral site and other sites

Assessment of fracture risk : 

Assessment of fracture risk

Assessment of fracture risk : 

Assessment of fracture risk DXA and quantitative ultrasound Clinical risk factors Markers of bone turnover Bone formation Bone resorption

Assessment of fracture risk : 

Assessment of fracture risk DXA Risk of fracture = 1.5-3.0 for each SD decrease in BMD Low sensitivity ( comparable to BP in predicting stroke ) Screening is not recommended Quantitative ultrasound Risk of fracture = 1.5-2.0 for each SD decrease in BMD

Assessment of fracture risk : 

Assessment of fracture risk Markers of bone turnover Bone resorption markers Hydroxyproline Pyridinium crosslinks & associated peptides Bone formation markers Alkaline phosphatase Bone isoenzyme AP Osteocalcin Procollagen propeptides of type I collagen

Assessment of fracture risk : 

Assessment of fracture risk Markers of bone turnover Associated with osteoporotic fracture independent of bone density 2-Fold increase in fracture risk ? Combined approach with BMD to increased sensitivity

Assessment of fracture risk : 

Assessment of fracture risk Clinical risk factors for fracture Low bone mass History or falls Impaired cognition ( plus medication adverse effect ) Low physical function Presence of environmental hazards Long hip axis length Chronic glucocorticoid use Existing fracture Chronic use of seizure medications Renal, hepatic, thyroid, parathyroid, malabsorptive disorder, vitamin D deficiency, MM and local neoplasia to be ruled out National Osteoporosis Foundation 1998

Assessment of fracture risk : 

Assessment of fracture risk Predictors of low bone mass Female Advanced age 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 acitivity Chronic glucocorticoid use History of fracture National Osteoporosis Foundation 1998

Assessment of fracture risk : 

Assessment of fracture risk The U.S. Preventive Services Task Force Recommendation for BMD screening Women 65 years and older without risk factors Women at age 60 years with increased risk

Assessment of fracture risk : 

Assessment of fracture risk Guideline for management of osteoporosis. Osteoporos Int 1997;7

Assessment of fracture risk : 

Assessment of fracture risk Gulideline for management of osteoporosis. Osteoporos Int 1997;7

Prevention & Treatment : 

Prevention & Treatment

Available treatment : 

Available treatment Calcium and vitamin D Hormone replacement therapy Selective estrogen receptor modulators ( SERMs ) Bisphosphonates Calcitonin Parathyroid hormone Other treatments Non-pharmacologic intervention

Pathogenesis : 

Pathogenesis Peak bone mass Loss of Estrogen HRT Ca & Vit D Bisphosphonates Ca Calcitonin HRT & SERMs rhPTH

Calcium : 

Calcium Benefit Slower rate of bone loss Reduction of fractures in some studies Adjunct to other osteoporosis Rx Risk Mild GI upset Constipation ?? Kidney stone

Calcium : 

Calcium 1994 consensus on optimum calcium intake

Calcium preparations : 

Calcium preparations

Vitamin D : 

Vitamin D Essential for intestinal absorption of calcium Daily recommendation 400 - 800 IU/day Esp. Low sunlight exposure, elderly, low vitamin D intake ? Decreased risk of fracture in healthy elderly with normal intake & BMD

Hormone replacement therapy : 

Hormone replacement therapy 33% risk reduction in vertebral fracture 27% risk reduction in nonvertebral fracture Drawback Effective only in age < 60 yr Nonsustainable effect

SERMs - Tamoxifen : 

SERMs - Tamoxifen

SERMs - Raloxifene : 

SERMs - Raloxifene

Bisphosphonates : 

Bisphosphonates

Bisphosphonates : 

Bisphosphonates Benefit Potent inhibitor of bone resorption Reduce osteoclast recruitment&activity Safe Most effective Rx** Risk Low oral bioavailability (1-3%) Food, calcium, iron, coffee, tea, orange juice decreased absorption GI discomfort Rarely - esophagitis High cost

Calcitonin : 

Calcitonin Peptide from Thyroid C cell Direct inhibition of osteoclast activity Less effective in cortical bone Salmon calcitonin nasal spray Dose 200 IU/day

Parathyroid hormone : 

Parathyroid hormone Intermittent injection stimulate new bone formation CONTRAST to continuous infusion Teriparatide ( rhPTH[1-34] ) was approved by US-FDA for Rx of osteoporosis Transient dose-related hypercalcemia Long term effects are not known

Efficacy-Vertebral fracture : 

Efficacy-Vertebral fracture

Efficacy-Hip fracture : 

Efficacy-Hip fracture

Efficacy : 

Efficacy

Other treatment : 

Other treatment Fluoride Vitamin K2 Strontium ranelate Meunier PJ. The effect of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. NEJM 2004;350:459-68 Statins

Available treatment : 

Available treatment Calcium and vitamin D Hormone replacement therapy Selective estrogen receptor modulators ( SERMs ) Bisphosphonates Calcitonin Parathyroid hormone Other treatments Non-pharmacologic intervention

Treatment decision : 

Treatment decision Primary prevention Adequate calcium & vit D intake HRT is no longer recommended Few RCTs ( FIT,MORE ) show benefit of Alendronate and Raloxifene Secondary prevention/Treatment Bisphosphonate ( Risedronate, Alendronate ) together with calcium +/- vit D supplement*** rh-PTH ( Teriparatide ) Salmon calcitonin Raloxifene

Exercise&Osteoporosis : 

Exercise&Osteoporosis Exercise effect Adolescent - Increased peak bone mass Elderly - Small increase in BMD Fitness may prevent falling ? Evidence-based data Reduction of hip&leg fractures in observational studies

Other measures : 

Other measures Treat predisposing factors Fall prevention Correct visual impairment Avoid drugs - BZs, hypnotics, antidepressant, drugs cause hypotension Extrinsic factors External hip protector Decrease the risk of hip fracture by 50% in 2 small studies

Comment : 

Comment