logging in or signing up osteoporosis ( د/ أشرف الأباصيري) ashrafalabasiry 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: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 4289 Category: Education License: All Rights Reserved Like it (16) Dislike it (0) Added: September 21, 2008 This Presentation is Public Favorites: 4 Presentation Description No description available. Comments Posting comment... By: nhassan (8 month(s) ago) It is very nice presentation. Could I get a copy. my e-mail: namhassan@yahoo.com Saving..... Post Reply Close Saving..... Edit Comment Close By: nhassan (8 month(s) ago) It is very nice presentation. Could I get a copy. My e-mail: namhassan@yahoo.com Saving..... 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See all Premium member Presentation Transcript Slide 1: Dr.Ashraf Sobhy Al-Abasiry.MBBCh.MSc Internist,Primary Care Department Saad Specialist hospital OSTEOPOROSIS UPDATE Email: ashrafalabasiry@yahoo.com Osteoporosis : Osteoporosis Osteoporosis is the most prevalent bone disease, characterized by: ♣ low bone mass. ♣ Microarchitectural deterioration of bone tissue. ♣ Enhanced bone fragility and a consequent increase in fracture risk. National Osteoporosis Foundation, 2008 Slide 3: Osteoporosis is a silent disease until it is complicated by fractures - fractures that can occur following minimal trauma. Prevention, detection, and treatment of osteoporosis should be a mandate of primary care providers. National Osteoporosis Foundation, 2008 Osteoporosis Epidemiology : Epidemiology ►Osteoporosis is a major public health problem worldwide. ► In the United States alone, 10 million individuals have osteoporosis causing 1.5 million fractures annually. ► In the United Kingdom, 200,000 fractures per year are attributed to osteoporosis . Epidemiology : Epidemiology ► Presence of osteoporosis carries 4-fold increase in fracture rate (over 50 years old). ► Up to 25% of hip fracture patients may require long-term nursing home care. ► Mortality is also increased following vertebral fractures, which cause significant complications including back pain, height loss and kyphosis. Osteopenia/ osteoporosis and fractures in the Middle East. : Osteopenia/ osteoporosis and fractures in the Middle East. ► Local and regional information about osteoporosis and fracture rates is sparse. ► In a study of 483 postmenopausal Saudi women 52-62 years of age, Al Desouki found the rate of osteopenia and osteoporosis to be 34% and 24% respectively. El-Douski M. Bone mineral density of the spine and femur in the normal Saudi population. Saudi Med J 1995; 16:30-35 . Slide 7: In a study by Al Ghannam et al of 321 healthy Saudi women, the prevalence of osteoporosis was 3.2, 5.9, and 28 % for age groups 31- 40 years, 41- 50 years, and > 50 years respectively. BMD in healthy Saudi females is significantly lower than in their USA counterparts. This may be due in part to increased number of pregnancies and longer duration of lactation together with prevalent vitamin D deficiency. Ghannam NN, Hammami, MM, Bakheet SM, and Khan BA. Bone mineral density of the spine and femur in healthy Saudi females: Relation to vitamin D status, pregnancy, and lactation. Calci Tissue Int. 1999; 65:23-28. Osteopenia/ osteoporosis and fractures in the Middle East. BASIC PATHOPHYSIOLOGY : BASIC PATHOPHYSIOLOGY ► Bones are living tissue, they provide structural support, protect vital organs and store calcium. ► Bone mass in older adults equals the peak bone mass achieved by age 25-30 years minus the amount of bone subsequently lost. ► Peak bone mass is determined largely by genetic factors, with contributions from nutrition, endocrine status, physical activity, and health during growth . Bone Architecture : Bone Architecture Cortical bone Forms a compact outer shell Primary component of peripheral skeleton Cancellous bone Interconnected latticework of trabeculae. Loss increases 3-fold just after menopause. Found in vertebrae. Illustration copyright © 2004 Scott Bodell, Bodell Communications Inc. Bone Strength : Bone Strength Factors that influence bone strength Bone mass (measured by BMD). Remodeling frequency (bone turnover). Bone size. Bone area. Microarchitecture. Degree of bone mineralization. Slide 12: Normal bone Osteoporosis Clinical manifestations and Complications : Clinical manifestations and Complications ► Osteoporosis is a silent disease, as bone loss occurs without symptoms. There are no warning signs until a fragility fracture occurs. ► Osteoporosis- related fractures may occur in any bone but are most likely to occur at sites of low bone mass. ► The most typical sites of osteoporosis related fractures are the vertebrae, distal radius, proximal femur, and ribs. Clinical Consequences : Clinical Consequences Kyphosis Loss of height Bulging abdomen Acute and chronic pain Breathing difficulties, reflux and other GI symptoms Depression Slide 16: APPROACH TO THE DIAGNOSIS AND MANAGEMENT OF OSTEOPOROSIS National Osteoporosis Foundation, 2008 Risk Assessment : Risk Assessment ►All postmenopausal women and older men should be evaluated clinically for osteoporosis risk in order to determine the need for BMD testing. ►A detailed history and BMD assessment is utilized in establishing the patient’s fracture risk using the WHO 10-year estimated fracture probability model. ►In general, the more risk factors that are present, the greater the risk of fracture. National Osteoporosis Foundation, 2008 Risk Factors Included in the WHO Fracture Risk Assessment Model : Risk Factors Included in the WHO Fracture Risk Assessment Model National Osteoporosis Foundation, 2008 Secondary Causes of Osteoporosis : Secondary Causes of Osteoporosis ► Estrogen Deficiency. ► Inflammatory Bowel Disease. ► Type 1 Diabetes Mellitus. ► Celiac disease. ► Cystic fibrosis. ► Hyperthyroidism. ► Hyperparathyroidism. ► Hypogonadism. ► Liver Disease. ► Corticosteroid use. ► Heparin use. ► Cyclosporine use. ► Depo-Provera use. ► Vitamin A (systemic retinoid) use. Clinical Evaluation : Clinical Evaluation ► In patients in whom a specific secondary, treatable cause of osteoporosis is being considered relevant blood and urine studies should be obtained prior to initiating therapy such as: serum and urine calcium. alkaline phosphatase. serum thyrotropin. protein electrophoresis. cortisol . antibodies associated with gluten-sensitive enteropathy. ► Elderly patients with recent fractures should be evaluated for secondary etiologies and, when considering osteomalacia or vitamin D insufficiency, a serum 25(OH)D level should be obtained. ► Biochemical testing (such as serum calcium, creatinine, etc.) should be considered in patients with documented osteoporosis prior to initiation of treatment. Diagnosis : Diagnosis ►The diagnosis of osteoporosis is established by measurement of BMD ►A presumptive or clinical diagnosis can often be made in at-risk individuals who sustain a low-trauma fracture. ►Dual energy X-ray absorptiometry, or DXA, is the most common method to measure a patient's BMD DXA Measurement Sites: Hip : DXA Measurement Sites: Hip Femoral neck. Trochanteric. Intertrochanteric. Ward’s triangle. Total hip. Lateral Vertebral Assessment: : Lateral Vertebral Assessment: BMD Measurement: T and Z Scores : BMD Measurement: T and Z Scores WHO Definition of Low Bone Density and Osteoporosis Based on BMD : Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser. 1994;843:1-129. Normal Osteopenia Osteoporosis Severe Osteoporosis BMD value within 1 S.D. of young-adult mean (T-score at or above -1) BMD value between -1 S.D. and -2.5 S.D. below young-adult mean (T-score between -1 and -2.5) BMD value at least -2.5 S.D. below young adult mean (T-score at or below -2.5) BMD value at least -2.5 S.D. below young adult mean and presence of fracture WHO Definition of Low Bone Density and Osteoporosis Based on BMD Indications for BMD Measurement : Indications for BMD Measurement BMD measurement should only be done if it will influence the management decision: 1- All women aged 65 and &men age70 and older, regardless of clinical risk factors. 2-Younger postmenopausal women and men age 50-70 about whom you have concern based on their clinical risk factor profile. 3-Women in the menopausal transition if there is a specific risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture, or high risk medication. 4 -Adults who have a fracture after age 50. National Osteoporosis Foundation, 2008 Indications for BMD Measurement : Indications for BMD Measurement 5- Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids, ≥5 mg/day for ≥3 months) associated with low bone mass or bone loss . 6- Anyone being treated for osteoporosis, to monitor treatment effect As the BMD is generally lower in Saudi women compared to their western counterparts, they may develop osteoporosis and fractures at an earlier age. Thus, it is reasonable to start screening postmenopausal Saudi women at an earlier age than that recommended for western women. Treatment Goals: Postmenopausal Osteoporosis : Treatment Goals: Postmenopausal Osteoporosis ►Prevent fractures. ► Stabilize or increase bone mass. ► Relieve symptoms of fractures and skeletal deformity. ► Maximize physical function. Hodgson SF, Watts NB, Bilezikian JP, et al. Endocr Pract. 2003;9:544-564. Pyramid Approach to Osteoporosis : Pyramid Approach to Osteoporosis Bone health and osteoporosis: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services; 2004. UNIVERSAL RECOMMENDATIONS FOR ALL PATIENTS : UNIVERSAL RECOMMENDATIONS FOR ALL PATIENTS Initiatives should be directed at the following measures: ► Building strong bones in childhood and adolescence is the best defense. ► A balanced diet rich in calcium and Vitamin D. ► Weight bearing exercise. ► Avoidance of tobacco smoking and excessive alcohol intake. ► Bone density testing and medication when appropriate. National Osteoporosis Foundation, 2008 Calcium and Vitamin D: : Calcium and Vitamin D: ►Should not be used as the sole treatment of osteoporosis, but rather as adjuncts to therapy. ►Advise all individuals to obtain an adequate intake of dietary calcium (at least 1200 mg per day. ►The NOF recommends an intake of 800 to 1000 international units (IU) of vitamin D3 per day for adults over age 50. ► Chief dietary sources of vitamin D include vitamin D-fortified milk, cereals ,egg yolks, salt-water fish, and liver. ►Controlled clinical trials have demonstrated that the combination of supplemental calcium and vitamin D can reduce the risk of fracture. National Osteoporosis Foundation, 2008 Exercise and Physical Activity : Exercise and Physical Activity Weight-bearing exercises are most effective: Walking Jogging Stair climbing Dancing Tennis Images: National Cancer Institute Falls : Falls Fracture risk is still significantly linked to risk of fall. AACE Recommendations for Fall Prevention : AACE Recommendations for Fall Prevention √ Minimize risk of falls with gait and balance training. √ Adjust dosage of drugs with sedative effects. √ Use nonskid mats √ Install handrails in bathrooms, halls, and along stairways √ Light hallways, stairwells, and entrances. √ Hip protectors √ Remove loose wires. Hodgson SF, Watts NB, Bilezikian JP, et al. Endocr Pract. 2003;9:544-564. AACE Recommendations for Fall Prevention : Assistant Devices Hip pads Mobility aids Cane Walkers Wheelchairs Bathroom aids Raised toilet seats Grab bars Hodgson SF, Watts NB, Bilezikian JP, et al. Endocr Pract. 2003;9:544-564. AACE Recommendations for Fall Prevention Who Should Be Treated? : Who Should Be Treated? Postmenopausal women and men age 50 and older presenting with the following should be treated: 1- A hip or vertebral fracture. 2-T-score < -2.5 at the femoral neck, total hip or spine after appropriate evaluation to exclude secondary causes. 3-Other prior fractures and low bone mass (T -score between -1.0 and -2.5 at the femoral neck, total hip, or spine). National Osteoporosis Foundation, 2008 Who Should Be Treated? : Who Should Be Treated? 4- Low bone mass (T -score between -1.0 and -2.5 at the femoral neck, total hip, or spine) and secondary causes associated with high risk of fracture (such as glucocorticoid use or total immobilization) 5-Low bone mass (T -score between -1.0 and -2.5 at the femoral neck, total hip, or spine) and 10-yr probability of hip fracture ≥3% or a 10-yr probability of any major osteoporosis related fracture ≥ 20% based on the U.S.-adapted WHO algorithm. National Osteoporosis Foundation, 2008 Pharmacologic measures : Pharmacologic measures . ► Treat secondary causes of osteoporosis, and associated disorders. ► Treat pain, discomfort and other associated morbidity. ► Increase bone mass. In general, there is no cure for osteoporosis, however FDA has approved some of the medications for postmenopausal women to either prevent and / or treat osteoporosis. Slide 41: ► Drugs for osteoporosis primarily reduce bone turnover by inhibiting osteoclast activity. Although they may lead to an early increase in bone mass. ► The drugs mainly prevent further loss of bone. Agents that primarily increase bone formation. (e.g. PTH) have only recently become available. ►Dual mechanism of action ( stronchium ranelate). Pharmacologic measures OSTEOPOROSIS TREATMENT OPTIONS : OSTEOPOROSIS TREATMENT OPTIONS Bone Formation: Osteoblasts Bone Resorption: Osteoclasts Antiresorptive: HRT Raloxifene Bisphosphonates Calcitonin Anabolic: Teriparatide Dual Acting: Strontium Ranelate Slide 43: ► Estrogen/hormone therapy is approved by the FDA for the prevention of osteoporosis, relief of vasomotor symptoms and vulvovaginal atrophy associated with menopause. ► WHI confirmed that hormone therapy decrease hip and vertebral fractures by one-third. ► Adverse effects (increased risk of stroke, cognitive impairment, deep vein thrombosis) offset benefits. ► Estrogen/hormone therapy is no longer considered the first line of therapy for osteoporosis 1- Hormonal Repalcment Therapy. National Osteoporosis Foundation, 2008 2-Estrogen Agonist/Antagonist {SERM} : 2-Estrogen Agonist/Antagonist {SERM} Raloxifene : { Evista } is approved by the FDA for both prevention and treatment of osteoporosis in postmenopausal women.. ►Raloxifene reduces the risk of spine fracture by 30% in patients with and by 55% in patients without a prior spine fracture, over 3 years. ► Reduction of hip and other nonvertebral fractures not demonstrated. ► Other benefits include decreased cholesterol and LDL, reduced breast cancer risk. ► Adverse effects included hot flashes and venous thromboembolism. National Osteoporosis Foundation, 2008 3. Bisphosphonate : 3. Bisphosphonate Alendronate, Brand name: Fosamax ►Alendronate sodium is approved by the FDA for the prevention (5 mg daily and 35 mg weekly) and treatment (10 mg daily and 70 mg weekly) of osteoporosis in postmenopausal women. . ► It reduces the incidence of spine, hip and wrist fractures by about 50% over 3 years in patients with a prior spine fracture. ► It reduces the incidence of spine fractures by 48% over 3 years in patients without a prior spine fracture.. National Osteoporosis Foundation, 2008 Slide 46: Ibandronate, Brand name: Boniva® ►Ibandronate sodium as 2.5 mg per day orally,150 mg per month orally, and 3 mg every 3 months by intravenous injection are approved by the FDA for the treatment of postmenopausal osteoporosis. ►Ibandronate reduces the incidence of spine fractures by about 50% over 3 years. National Osteoporosis Foundation, 2008 Slide 47: Risedronate, Brand name: Actonel® or Actonel® with Calcium ► Risedronate sodium (5 mg daily dose; 35 mg weekly dose. ► is approved by the FDA for the prevention and treatment of postmenopausal osteoporosis. ► reduces the incidence of spine fractures by 41-49% and non-spine fractures by 36% over 3 years in patients with a prior spine fracture. National Osteoporosis Foundation, 2008 Slide 48: Zoledronate, Brand name: Reclast® ► Zoledronate (5 mg by intravenous infusion over at least 15 minutes once yearly) is approved by the FDA for the treatment of osteoporosis in postmenopausal women. ► Zoledronate reduces the incidence of spine fractures by 70%, hip fractures by 41%, and non-vertebral fractures by 25% over 3 years. National Osteoporosis Foundation, 2008 4-Calcitonin, Brand name: Miacalcic : 4-Calcitonin, Brand name: Miacalcic ► Salmon calcitonin is a synthetic hormone that inhibits bone resorption and is is FDA-approved for the treatment of osteoporosis in women 5 years after menopause has occurred. ► Continuous use associated with decreased bone resorption. ► Has analgesic properties and can decrease the pain associated with acute vertebral fractures. ► PROOF trial showed that only the 200-u dose produced a significant (36%) reduction of vertebral fractures, with no reduction in hip fractures and no significant change in either bone density or bone turnover. PROOF Study Group. Am J Med. 2000;109(4):267-276. 5-Parathyroid hormone [PTH(1-34), teriparatide] Brand name: Forteo : 5-Parathyroid hormone [PTH(1-34), teriparatide] Brand name: Forteo ♦ PTH is approved by the FDA for the treatment of osteoporosis in postmenopausal women at high risk for fracture. ♦ PTH in a dose of 20 µg daily was shown to decrease the risk of spine fractures by 65% and non-spine fractures by 53% in patients with osteoporosis, after an average of 18 months of therapy. ♦ Since PTH is used for a maximum of 2 years, it is common practice to follow PTH treatment with an anti-resorptive agent, usually a bisphosphonate, to maintain or further increase BMD. National Osteoporosis Foundation, 2008 6-Stronchium ranelate( protelos) : 6-Stronchium ranelate( protelos) ♦ Stronchium ranelate is recently registered agent for treatment of postmenopausal osteoporosis. ♦ There is some evidence that stronchium both inhibits bone resorption &stimulate bone formation ♦ Stronchium ranelate significantly reduces number of patients experiencing hip fracture by 36% over 3 years,new vertebral fractures by 59% and new nonvertebral fractures by 41% over 1 years & have the same significance over 3& 5 years of treatment. ♦ Stronchium ranelate is easy to use 2-g sachet diluted in water ,taken at bedtime. Postmenopausal Women: Monitoring Therapy : Postmenopausal Women: Monitoring Therapy Serial BMD BMD changes slowly. Assessment is required every 2 years to measure change. Measurements from peripheral sites are not useful. Should be performed on the same machine if possible. Bone turnover markers Evolving method of clinical assessment. Large changes in biochemical markers associated with fracture reduction. National Osteoporosis Foundation, 2008 Slide 53: Thanks.. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
osteoporosis ( د/ أشرف الأباصيري) ashrafalabasiry 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: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 4289 Category: Education License: All Rights Reserved Like it (16) Dislike it (0) Added: September 21, 2008 This Presentation is Public Favorites: 4 Presentation Description No description available. Comments Posting comment... By: nhassan (8 month(s) ago) It is very nice presentation. Could I get a copy. my e-mail: namhassan@yahoo.com Saving..... Post Reply Close Saving..... Edit Comment Close By: nhassan (8 month(s) ago) It is very nice presentation. Could I get a copy. My e-mail: namhassan@yahoo.com Saving..... Post Reply Close Saving..... Edit Comment Close By: manalhelalrheuma (8 month(s) ago) excellent presentation please i want a copy manalhelal2@yahoo.com Saving..... Post Reply Close Saving..... Edit Comment Close By: gargar (10 month(s) ago) Thanks a lot for this excellent presentation can you please send me a copy of this presentation to my e mail cangimy@yahoo.com Saving..... Post Reply Close Saving..... Edit Comment Close By: coldzero3 (13 month(s) ago) Thank you very much , It's a very useful information and will help me in my research Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Slide 1: Dr.Ashraf Sobhy Al-Abasiry.MBBCh.MSc Internist,Primary Care Department Saad Specialist hospital OSTEOPOROSIS UPDATE Email: ashrafalabasiry@yahoo.com Osteoporosis : Osteoporosis Osteoporosis is the most prevalent bone disease, characterized by: ♣ low bone mass. ♣ Microarchitectural deterioration of bone tissue. ♣ Enhanced bone fragility and a consequent increase in fracture risk. National Osteoporosis Foundation, 2008 Slide 3: Osteoporosis is a silent disease until it is complicated by fractures - fractures that can occur following minimal trauma. Prevention, detection, and treatment of osteoporosis should be a mandate of primary care providers. National Osteoporosis Foundation, 2008 Osteoporosis Epidemiology : Epidemiology ►Osteoporosis is a major public health problem worldwide. ► In the United States alone, 10 million individuals have osteoporosis causing 1.5 million fractures annually. ► In the United Kingdom, 200,000 fractures per year are attributed to osteoporosis . Epidemiology : Epidemiology ► Presence of osteoporosis carries 4-fold increase in fracture rate (over 50 years old). ► Up to 25% of hip fracture patients may require long-term nursing home care. ► Mortality is also increased following vertebral fractures, which cause significant complications including back pain, height loss and kyphosis. Osteopenia/ osteoporosis and fractures in the Middle East. : Osteopenia/ osteoporosis and fractures in the Middle East. ► Local and regional information about osteoporosis and fracture rates is sparse. ► In a study of 483 postmenopausal Saudi women 52-62 years of age, Al Desouki found the rate of osteopenia and osteoporosis to be 34% and 24% respectively. El-Douski M. Bone mineral density of the spine and femur in the normal Saudi population. Saudi Med J 1995; 16:30-35 . Slide 7: In a study by Al Ghannam et al of 321 healthy Saudi women, the prevalence of osteoporosis was 3.2, 5.9, and 28 % for age groups 31- 40 years, 41- 50 years, and > 50 years respectively. BMD in healthy Saudi females is significantly lower than in their USA counterparts. This may be due in part to increased number of pregnancies and longer duration of lactation together with prevalent vitamin D deficiency. Ghannam NN, Hammami, MM, Bakheet SM, and Khan BA. Bone mineral density of the spine and femur in healthy Saudi females: Relation to vitamin D status, pregnancy, and lactation. Calci Tissue Int. 1999; 65:23-28. Osteopenia/ osteoporosis and fractures in the Middle East. BASIC PATHOPHYSIOLOGY : BASIC PATHOPHYSIOLOGY ► Bones are living tissue, they provide structural support, protect vital organs and store calcium. ► Bone mass in older adults equals the peak bone mass achieved by age 25-30 years minus the amount of bone subsequently lost. ► Peak bone mass is determined largely by genetic factors, with contributions from nutrition, endocrine status, physical activity, and health during growth . Bone Architecture : Bone Architecture Cortical bone Forms a compact outer shell Primary component of peripheral skeleton Cancellous bone Interconnected latticework of trabeculae. Loss increases 3-fold just after menopause. Found in vertebrae. Illustration copyright © 2004 Scott Bodell, Bodell Communications Inc. Bone Strength : Bone Strength Factors that influence bone strength Bone mass (measured by BMD). Remodeling frequency (bone turnover). Bone size. Bone area. Microarchitecture. Degree of bone mineralization. Slide 12: Normal bone Osteoporosis Clinical manifestations and Complications : Clinical manifestations and Complications ► Osteoporosis is a silent disease, as bone loss occurs without symptoms. There are no warning signs until a fragility fracture occurs. ► Osteoporosis- related fractures may occur in any bone but are most likely to occur at sites of low bone mass. ► The most typical sites of osteoporosis related fractures are the vertebrae, distal radius, proximal femur, and ribs. Clinical Consequences : Clinical Consequences Kyphosis Loss of height Bulging abdomen Acute and chronic pain Breathing difficulties, reflux and other GI symptoms Depression Slide 16: APPROACH TO THE DIAGNOSIS AND MANAGEMENT OF OSTEOPOROSIS National Osteoporosis Foundation, 2008 Risk Assessment : Risk Assessment ►All postmenopausal women and older men should be evaluated clinically for osteoporosis risk in order to determine the need for BMD testing. ►A detailed history and BMD assessment is utilized in establishing the patient’s fracture risk using the WHO 10-year estimated fracture probability model. ►In general, the more risk factors that are present, the greater the risk of fracture. National Osteoporosis Foundation, 2008 Risk Factors Included in the WHO Fracture Risk Assessment Model : Risk Factors Included in the WHO Fracture Risk Assessment Model National Osteoporosis Foundation, 2008 Secondary Causes of Osteoporosis : Secondary Causes of Osteoporosis ► Estrogen Deficiency. ► Inflammatory Bowel Disease. ► Type 1 Diabetes Mellitus. ► Celiac disease. ► Cystic fibrosis. ► Hyperthyroidism. ► Hyperparathyroidism. ► Hypogonadism. ► Liver Disease. ► Corticosteroid use. ► Heparin use. ► Cyclosporine use. ► Depo-Provera use. ► Vitamin A (systemic retinoid) use. Clinical Evaluation : Clinical Evaluation ► In patients in whom a specific secondary, treatable cause of osteoporosis is being considered relevant blood and urine studies should be obtained prior to initiating therapy such as: serum and urine calcium. alkaline phosphatase. serum thyrotropin. protein electrophoresis. cortisol . antibodies associated with gluten-sensitive enteropathy. ► Elderly patients with recent fractures should be evaluated for secondary etiologies and, when considering osteomalacia or vitamin D insufficiency, a serum 25(OH)D level should be obtained. ► Biochemical testing (such as serum calcium, creatinine, etc.) should be considered in patients with documented osteoporosis prior to initiation of treatment. Diagnosis : Diagnosis ►The diagnosis of osteoporosis is established by measurement of BMD ►A presumptive or clinical diagnosis can often be made in at-risk individuals who sustain a low-trauma fracture. ►Dual energy X-ray absorptiometry, or DXA, is the most common method to measure a patient's BMD DXA Measurement Sites: Hip : DXA Measurement Sites: Hip Femoral neck. Trochanteric. Intertrochanteric. Ward’s triangle. Total hip. Lateral Vertebral Assessment: : Lateral Vertebral Assessment: BMD Measurement: T and Z Scores : BMD Measurement: T and Z Scores WHO Definition of Low Bone Density and Osteoporosis Based on BMD : Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser. 1994;843:1-129. Normal Osteopenia Osteoporosis Severe Osteoporosis BMD value within 1 S.D. of young-adult mean (T-score at or above -1) BMD value between -1 S.D. and -2.5 S.D. below young-adult mean (T-score between -1 and -2.5) BMD value at least -2.5 S.D. below young adult mean (T-score at or below -2.5) BMD value at least -2.5 S.D. below young adult mean and presence of fracture WHO Definition of Low Bone Density and Osteoporosis Based on BMD Indications for BMD Measurement : Indications for BMD Measurement BMD measurement should only be done if it will influence the management decision: 1- All women aged 65 and &men age70 and older, regardless of clinical risk factors. 2-Younger postmenopausal women and men age 50-70 about whom you have concern based on their clinical risk factor profile. 3-Women in the menopausal transition if there is a specific risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture, or high risk medication. 4 -Adults who have a fracture after age 50. National Osteoporosis Foundation, 2008 Indications for BMD Measurement : Indications for BMD Measurement 5- Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids, ≥5 mg/day for ≥3 months) associated with low bone mass or bone loss . 6- Anyone being treated for osteoporosis, to monitor treatment effect As the BMD is generally lower in Saudi women compared to their western counterparts, they may develop osteoporosis and fractures at an earlier age. Thus, it is reasonable to start screening postmenopausal Saudi women at an earlier age than that recommended for western women. Treatment Goals: Postmenopausal Osteoporosis : Treatment Goals: Postmenopausal Osteoporosis ►Prevent fractures. ► Stabilize or increase bone mass. ► Relieve symptoms of fractures and skeletal deformity. ► Maximize physical function. Hodgson SF, Watts NB, Bilezikian JP, et al. Endocr Pract. 2003;9:544-564. Pyramid Approach to Osteoporosis : Pyramid Approach to Osteoporosis Bone health and osteoporosis: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services; 2004. UNIVERSAL RECOMMENDATIONS FOR ALL PATIENTS : UNIVERSAL RECOMMENDATIONS FOR ALL PATIENTS Initiatives should be directed at the following measures: ► Building strong bones in childhood and adolescence is the best defense. ► A balanced diet rich in calcium and Vitamin D. ► Weight bearing exercise. ► Avoidance of tobacco smoking and excessive alcohol intake. ► Bone density testing and medication when appropriate. National Osteoporosis Foundation, 2008 Calcium and Vitamin D: : Calcium and Vitamin D: ►Should not be used as the sole treatment of osteoporosis, but rather as adjuncts to therapy. ►Advise all individuals to obtain an adequate intake of dietary calcium (at least 1200 mg per day. ►The NOF recommends an intake of 800 to 1000 international units (IU) of vitamin D3 per day for adults over age 50. ► Chief dietary sources of vitamin D include vitamin D-fortified milk, cereals ,egg yolks, salt-water fish, and liver. ►Controlled clinical trials have demonstrated that the combination of supplemental calcium and vitamin D can reduce the risk of fracture. National Osteoporosis Foundation, 2008 Exercise and Physical Activity : Exercise and Physical Activity Weight-bearing exercises are most effective: Walking Jogging Stair climbing Dancing Tennis Images: National Cancer Institute Falls : Falls Fracture risk is still significantly linked to risk of fall. AACE Recommendations for Fall Prevention : AACE Recommendations for Fall Prevention √ Minimize risk of falls with gait and balance training. √ Adjust dosage of drugs with sedative effects. √ Use nonskid mats √ Install handrails in bathrooms, halls, and along stairways √ Light hallways, stairwells, and entrances. √ Hip protectors √ Remove loose wires. Hodgson SF, Watts NB, Bilezikian JP, et al. Endocr Pract. 2003;9:544-564. AACE Recommendations for Fall Prevention : Assistant Devices Hip pads Mobility aids Cane Walkers Wheelchairs Bathroom aids Raised toilet seats Grab bars Hodgson SF, Watts NB, Bilezikian JP, et al. Endocr Pract. 2003;9:544-564. AACE Recommendations for Fall Prevention Who Should Be Treated? : Who Should Be Treated? Postmenopausal women and men age 50 and older presenting with the following should be treated: 1- A hip or vertebral fracture. 2-T-score < -2.5 at the femoral neck, total hip or spine after appropriate evaluation to exclude secondary causes. 3-Other prior fractures and low bone mass (T -score between -1.0 and -2.5 at the femoral neck, total hip, or spine). National Osteoporosis Foundation, 2008 Who Should Be Treated? : Who Should Be Treated? 4- Low bone mass (T -score between -1.0 and -2.5 at the femoral neck, total hip, or spine) and secondary causes associated with high risk of fracture (such as glucocorticoid use or total immobilization) 5-Low bone mass (T -score between -1.0 and -2.5 at the femoral neck, total hip, or spine) and 10-yr probability of hip fracture ≥3% or a 10-yr probability of any major osteoporosis related fracture ≥ 20% based on the U.S.-adapted WHO algorithm. National Osteoporosis Foundation, 2008 Pharmacologic measures : Pharmacologic measures . ► Treat secondary causes of osteoporosis, and associated disorders. ► Treat pain, discomfort and other associated morbidity. ► Increase bone mass. In general, there is no cure for osteoporosis, however FDA has approved some of the medications for postmenopausal women to either prevent and / or treat osteoporosis. Slide 41: ► Drugs for osteoporosis primarily reduce bone turnover by inhibiting osteoclast activity. Although they may lead to an early increase in bone mass. ► The drugs mainly prevent further loss of bone. Agents that primarily increase bone formation. (e.g. PTH) have only recently become available. ►Dual mechanism of action ( stronchium ranelate). Pharmacologic measures OSTEOPOROSIS TREATMENT OPTIONS : OSTEOPOROSIS TREATMENT OPTIONS Bone Formation: Osteoblasts Bone Resorption: Osteoclasts Antiresorptive: HRT Raloxifene Bisphosphonates Calcitonin Anabolic: Teriparatide Dual Acting: Strontium Ranelate Slide 43: ► Estrogen/hormone therapy is approved by the FDA for the prevention of osteoporosis, relief of vasomotor symptoms and vulvovaginal atrophy associated with menopause. ► WHI confirmed that hormone therapy decrease hip and vertebral fractures by one-third. ► Adverse effects (increased risk of stroke, cognitive impairment, deep vein thrombosis) offset benefits. ► Estrogen/hormone therapy is no longer considered the first line of therapy for osteoporosis 1- Hormonal Repalcment Therapy. National Osteoporosis Foundation, 2008 2-Estrogen Agonist/Antagonist {SERM} : 2-Estrogen Agonist/Antagonist {SERM} Raloxifene : { Evista } is approved by the FDA for both prevention and treatment of osteoporosis in postmenopausal women.. ►Raloxifene reduces the risk of spine fracture by 30% in patients with and by 55% in patients without a prior spine fracture, over 3 years. ► Reduction of hip and other nonvertebral fractures not demonstrated. ► Other benefits include decreased cholesterol and LDL, reduced breast cancer risk. ► Adverse effects included hot flashes and venous thromboembolism. National Osteoporosis Foundation, 2008 3. Bisphosphonate : 3. Bisphosphonate Alendronate, Brand name: Fosamax ►Alendronate sodium is approved by the FDA for the prevention (5 mg daily and 35 mg weekly) and treatment (10 mg daily and 70 mg weekly) of osteoporosis in postmenopausal women. . ► It reduces the incidence of spine, hip and wrist fractures by about 50% over 3 years in patients with a prior spine fracture. ► It reduces the incidence of spine fractures by 48% over 3 years in patients without a prior spine fracture.. National Osteoporosis Foundation, 2008 Slide 46: Ibandronate, Brand name: Boniva® ►Ibandronate sodium as 2.5 mg per day orally,150 mg per month orally, and 3 mg every 3 months by intravenous injection are approved by the FDA for the treatment of postmenopausal osteoporosis. ►Ibandronate reduces the incidence of spine fractures by about 50% over 3 years. National Osteoporosis Foundation, 2008 Slide 47: Risedronate, Brand name: Actonel® or Actonel® with Calcium ► Risedronate sodium (5 mg daily dose; 35 mg weekly dose. ► is approved by the FDA for the prevention and treatment of postmenopausal osteoporosis. ► reduces the incidence of spine fractures by 41-49% and non-spine fractures by 36% over 3 years in patients with a prior spine fracture. National Osteoporosis Foundation, 2008 Slide 48: Zoledronate, Brand name: Reclast® ► Zoledronate (5 mg by intravenous infusion over at least 15 minutes once yearly) is approved by the FDA for the treatment of osteoporosis in postmenopausal women. ► Zoledronate reduces the incidence of spine fractures by 70%, hip fractures by 41%, and non-vertebral fractures by 25% over 3 years. National Osteoporosis Foundation, 2008 4-Calcitonin, Brand name: Miacalcic : 4-Calcitonin, Brand name: Miacalcic ► Salmon calcitonin is a synthetic hormone that inhibits bone resorption and is is FDA-approved for the treatment of osteoporosis in women 5 years after menopause has occurred. ► Continuous use associated with decreased bone resorption. ► Has analgesic properties and can decrease the pain associated with acute vertebral fractures. ► PROOF trial showed that only the 200-u dose produced a significant (36%) reduction of vertebral fractures, with no reduction in hip fractures and no significant change in either bone density or bone turnover. PROOF Study Group. Am J Med. 2000;109(4):267-276. 5-Parathyroid hormone [PTH(1-34), teriparatide] Brand name: Forteo : 5-Parathyroid hormone [PTH(1-34), teriparatide] Brand name: Forteo ♦ PTH is approved by the FDA for the treatment of osteoporosis in postmenopausal women at high risk for fracture. ♦ PTH in a dose of 20 µg daily was shown to decrease the risk of spine fractures by 65% and non-spine fractures by 53% in patients with osteoporosis, after an average of 18 months of therapy. ♦ Since PTH is used for a maximum of 2 years, it is common practice to follow PTH treatment with an anti-resorptive agent, usually a bisphosphonate, to maintain or further increase BMD. National Osteoporosis Foundation, 2008 6-Stronchium ranelate( protelos) : 6-Stronchium ranelate( protelos) ♦ Stronchium ranelate is recently registered agent for treatment of postmenopausal osteoporosis. ♦ There is some evidence that stronchium both inhibits bone resorption &stimulate bone formation ♦ Stronchium ranelate significantly reduces number of patients experiencing hip fracture by 36% over 3 years,new vertebral fractures by 59% and new nonvertebral fractures by 41% over 1 years & have the same significance over 3& 5 years of treatment. ♦ Stronchium ranelate is easy to use 2-g sachet diluted in water ,taken at bedtime. Postmenopausal Women: Monitoring Therapy : Postmenopausal Women: Monitoring Therapy Serial BMD BMD changes slowly. Assessment is required every 2 years to measure change. Measurements from peripheral sites are not useful. Should be performed on the same machine if possible. Bone turnover markers Evolving method of clinical assessment. Large changes in biochemical markers associated with fracture reduction. National Osteoporosis Foundation, 2008 Slide 53: Thanks..