logging in or signing up Osteoporosis aSGuest10229 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 6562 Category: Science & Tech.. License: All Rights Reserved Like it (6) Dislike it (0) Added: January 12, 2009 This Presentation is Public Favorites: 3 Presentation Description No description available. Comments Posting comment... By: manalhelalrheuma (20 month(s) ago) ihope if i can download this nice presentation Saving..... Post Reply Close Saving..... Edit Comment Close By: johnkirubakaran (28 month(s) ago) Its a useful presentation Saving..... Post Reply Close Saving..... Edit Comment Close By: abbirr (41 month(s) ago) Useful presentation. I wish if I could download this presentation Thankyou Saving..... Post Reply Close Saving..... Edit Comment Close By: karawan_007 (43 month(s) ago) i'd like to thank the presenter of this useful presentation thanks alot Saving..... Post Reply Close Saving..... Edit Comment Close By: jamaldeenz (47 month(s) ago) very interesting and useful presentation. I wish if I could download this presentation Thankyou Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member 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 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Osteoporosis aSGuest10229 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 6562 Category: Science & Tech.. License: All Rights Reserved Like it (6) Dislike it (0) Added: January 12, 2009 This Presentation is Public Favorites: 3 Presentation Description No description available. Comments Posting comment... By: manalhelalrheuma (20 month(s) ago) ihope if i can download this nice presentation Saving..... Post Reply Close Saving..... Edit Comment Close By: johnkirubakaran (28 month(s) ago) Its a useful presentation Saving..... Post Reply Close Saving..... Edit Comment Close By: abbirr (41 month(s) ago) Useful presentation. I wish if I could download this presentation Thankyou Saving..... Post Reply Close Saving..... Edit Comment Close By: karawan_007 (43 month(s) ago) i'd like to thank the presenter of this useful presentation thanks alot Saving..... Post Reply Close Saving..... Edit Comment Close By: jamaldeenz (47 month(s) ago) very interesting and useful presentation. I wish if I could download this presentation Thankyou Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member 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