Transcript OSTEOPOROSIS AND OSTEOMALACIA

Clinical manifestations and
diagnosis of osteoporosis
• INTRODUCTION — Osteoporosis is
the most common bone disease.
• DEFINITION — Osteoporosis is a
skeletal disorder characterized by two
elements:
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low bone mass
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and microarchitectural disruption.
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• There are fewer bony spicules in
osteoporotic bone and they are thinner
• But the bone that is present is normally
mineralized,
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• EPIDEMIOLOGY
• It is estimated that over 1.3 million osteoporotic
fractures in the United States.
• One-half are vertebral fractures,
• One-quarter are hip fractures,
• And one-quarter are Colles' fractures.
• Among subjects age 90 years, 33 percent of
women and 17 percent of men will have a hip
fracture .
• After age 50 years, a woman is three times more
likely than a man to have a vertebral or hip
fracture
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• Risk Factors For Osteoporosis:
• Age.
• Sex.
• Organs Failure.
• Certain drugs include glucocorticoids, heparin,
cyclosporine, medroxyprogesterone acetate, vitamin A and
certain synthetic retinoids, Anxiolytic, anticonvulsant, or
neuroleptic drugs.
• Organ transplantation .
• Cancer treatment.
• Vitamin B12 deficiency
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• Previous fracture between the ages of 20
and 50. years
• History of fracture in a first degree relative.
• Cigarette smoking .
• Inflammatory bowel disease.
• Sedentary life style.
• Consumption of large amounts of caffeine.
• Above average height.
• Low body weight or weight loss.
• Type 2 diabetes mellitus .
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Clinical Manifestations
• Osteoporosis has no clinical manifestations
until there is a fracture.
• many patients with achy hips or feet do not
have osteoporetic fractures but they have
osteomalacia .
• Vertebral fracture
• Vertebral fracture is the most common
• Most of these fractures (about two-thirds)
are asymptomatic;
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• Osteoporotic fracture can lead to the acute
onset of pain.
• Successive fractures lead to increased
thoracic (dorsal) kyphosis with height loss
"dowager's hump“ and complain of "getting
fat" without any change in weight.
• Their abdomen becomes protuberant.
• The distance from the occiput to the wall
(normally 0 cm).
• The size of the gap between the costal
margin and the iliac crest (normally three
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finger breadths).
• Other fractures
• Hip fractures are relatively common in
osteoporosis, affecting 15 percent of women
and five percent of men by 80 years of age.
• RADIOGRAPHIC FEATURES
• Plain radiographs show detectable changes
when bone loss exceeds 30 percent.
• An early manifestation is "codfish"
vertebrae.
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• DIAGNOSIS
• MEASUREMENT OF BONE DENSITY:
• Several different methods are used to
measure bone density :
• Single-photon absorptiometry;wich can
be used only at peripheral sites (radius
and calcaneus).
• Dual-photon absorptiometry (DPA)
that measure bone density at the spine
and hip
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• Dual x-ray
absorptiometry(DEXA):
• The two photons are emitted from an
x-ray tube instead of a radioactive
source.
• DXA is the most popular method for
measuring bone density at the spine
and hip and some times at distal of
radious bone.
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• Ultrasonography
• Potential advantages include lower
expense, portability, and lack of radiation
exposure.
• Measurements are usually made at the
patella or calcaneus (heel).
• Quantitative ultrasound is a good predictor
of fracture risk especially in pregnancy.
• A major limitation to using is that the
criteria for diagnosing osteoporosis and
recommending treatment are not yet well 13
established.
Which Skeletal Sites Should Be
Measured?
Every Patient
• Spine
• L2-L4
• Hip
• Total Proximal Femur
• Osteoporosis
• Femoral Neck
• Trochanter
Some Patients
• Forearm (33%
Radius)
• If hip or spine cannot
be measured
• Hyperparathyroidism
• Very obese
Use lowest T-score of these sites
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Indications For Bone Density
Testing
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All women age 55 and older
All men age 65 and older
Adults with a fragility fracture
Adults with a disease or condition
associated with low bone density
• Adults taking medication associated with
low bone density
• To monitor treatment effect
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DEFINITIONS
• Osteopenia
• Bone mineral density (BMD)
measurement at any site > 1
but  2.5 standard deviations
below the young adult
standard
• T score < -1 but  -2.5
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Definitions
• Osteoporosis
• BMD measurement at any site
> 2.5 standard deviations
below the young adult
standard with or without
previous fracture
• T score of < -2.5
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Diagnostic Classification
Classification
T-score
Normal
-1 or greater
Osteopenia
Between -1 and -2.5
Osteoporosis
-2.5 or less
-2.5 or less and fragility
Severe Osteoporosis
fracture
WHO Study Group. 1994.
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SCREENING FOR SECONDARY CAUSES
Disease Recommended Laboratory Tests
(bolded items are recommended routinely)
Cushing’s disease Electrolytes, 24-hour urinary cortisol
Hyperthyroidism TSH, T4
Hypogonadism Bioavailable testosterone
Multiple myeloma
CBC, serum electrophoresis,
urine electrophoresis
Osteomalacia
Alkaline phosphatase, 25(OH)D
Paget’s disease Alkaline phosphatase
Primary hyperparathyroidism
Calcium, PTH
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Treatment Guidelines
Summary of recommendations for pharmacologic therapy according to T-score from
the National Osteoporosis Foundation (NOF) and the American Association of Clinic
Endocrinologists (AACE)
Patient Profile
T-score
NOF
AACE
No Risk Factors
Less than -2.0
-2.5 or less
Risk Factors†
Less than -1.5
-1.5 or less
† Fragility fracture, family history of fracture, cigarette smoking, low body
weight (<127 lbs.), etc.
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RISK FACTORS FOR
POSTMENOPAUSAL WOMEN
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Early menopause
White or Asian race
Sedentary life style
Smoking
Small frame
Alcohol abuse
Primary hyperparathyroidism
Hyperthyroidism
Glucocorticoid use
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CALCIUM & VITAMIN D
• Calcium and vitamin D maintain or increase
bone density & help prevent hip and
nonvertebral fractures
• Men 65 years and older & postmenopausal
women should ingest a total of 800 IU of
vitamin D and 1200 mg / day of calcium daily.
• Higher doses are required if they have
malabsorption or rapid metabolism of
vitamin D
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Estrogen/progestin therapy
• Estrogen-progestin therapy is no longer a
first-line approach because of Increased risk
of :
• Breast cancer,
• Stroke,
• Venous thromboembolism,
• And perhaps coronary disease.
• HRT Prevents bone loss at hip & spine
when initiated within 10 years of
menopause
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• Possible indications for estrogen-progestin
in postmenopausal women include
persistent menopausal symptoms and…
• women with an indication for antiresorptive
therapy who cannot tolerate the other drugs
or because of side effects.
• There was a significant 33 percent reduction
in clinical vertebral fractures and a 23
percent reduction in other osteoporotic
fractures.
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Bisphosphonates
• Alendronate (10 mg/day or 70 mg once
weekly) or risedronate (5 mg/day or 35 mg
once weekly), are good choices for the
treatment of women with established
osteoporosis.
• These drugs increase bone mass and reduce
the incidence of vertebral and nonvertebral
fractures (even in women who already have
fractures).
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• The beneficial effects of alendronate persist
over several years after treatment is
stopped,
• When given, alendronate or risedronate
should be taken with precautions to avoid
pill-induced esophagitis.
• Alendronate appears to be well tolerated
and effective for at least ten years .
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OTHER
BISPHOSPHONATES
• Residronate (Actonel)
• Approved for osteoporosis prevention &
treatment of osteoporosis: 5 mg / day
• In comparison with placebo:
•  bone density of spine & hip
•  new vertebral fracture rate
• GI side effects
• Zolindronic acid(Aclasta)
• Only infusible drug approved for treatment of
osteoporosis and the most strong members.
• Use for idiopathic osteoporosis only if other
treatments are ineffective or conterindicated.
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SELECTIVE ESTROGEN RECEPTOR
MODULATORS (SERMs)
• Act as estrogen agonists in bone
and heart.
• Act as estrogen antagonists in
breast and uterine tissue
• Potential for preventing
osteoporosis without the increased
risk of breast or uterine cancer
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SERMs: RALOXIFENE
• Rationale
• Approved for osteoporosis prevention &
treatment in postmenopausal women
• In comparison with placebo:
•  vertebral fractures by 60%
•  breast cancer (relative risk 0.24)
•  bone turnover & maintained hip & total body
bone density
•  total cholesterol and LDL levels
• Side effects
• Flu-like symptoms, hot flushes, leg cramps
• Peripheral edema
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Calcitonin
A less popular choice for treatment of
osteoporosis is nasal calcitonin, 200 IU/day.
• It is a weak drug for treatment and because
of tachyphylaxis has a little effect on
density.
• There is one exception,most use calcitonin
as first-line therapy in patients who have
substantial pain from an acute osteoporotic
fracture.
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• Dosing
• Subcutaneous injection
• Nasal spray (fewer reported side effects,
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Monitoring of treatment
Bone density measurement can be repeated
after one year of therapy.
• If BMD is stable or improving, that would
be evidence for treatment response.
• However, if BMD declines at one year,
compliance with drug, calcium and vitamin
D should be verified, and some evaluation
for secondary causes of bone loss should be
performed .
• If the patient is otherwise well and taking
the drug and supplements correctly, the
correct action is controversial.
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• Some physicians believe that the decrease
in BMD truly reflects a treatment failure
and would consider modification of the
primary treatment for the osteoporosis.
• Others believe that the decline in BMD is
not necessarily reflecting inadequate
therapy, but could be ascribed to
measurement error and would repeat BMD
one year later, taking action only if the
decline is reaffirmed.
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