Transcript File

CPD Presentation
OSTEOPOROSIS
by Chin Yeun, Shee (f0163)
Osteoporosis
is defined as
‘a systemic skeletal disease characterised by low
bone mass and micro-architectural
deterioration of bone tissue, with a consequent
increase in bone fragility and susceptibility to
fracture.’
Figure 1: Representation of normal and osteoporotic bone tissue.
Osteoporosis
Altered bone remodeling cycle
An imbalance in favor of bone resorption over bone
formation
Figure 2: Representation of the bone remodeling cycle in osteoporosis.
Abbreviations: BRU, bone remodeling unit; CL, cement line; LC, lining cells; OS,
osteoid.
From: www.medscape.com © 2010, Medscape.
Bone remodeling cycle consists of five
phases:
1. Activation: preosteoclasts are
stimulated and differentiate under the
influence of cytokines and growth factors
into mature active osteoclasts;
2. Resorption: osteoclasts digest mineral
matrix (old bone);
3. Reversal: end of resorption;
4. Formation: osteoblasts synthesize new
bone matrix;
5. Quiescence: osteoblasts become
resting bone lining cells on the newly
formed bone surface.
Osteoporotic bone shows an increase in the length of the
remodeling cycle and reduced capacity to lay down a new
mineralized bone matrix
Classification
Based on individual bone mineral density (BMD)
Dual energy X-ray absorptiometry (DEXA) is the
best current test to measure BMD
Category
Description
Normal
BMD within 1 SD of young adult reference range
(T score > -1)
Osteopenia
BMD more than 1 SD but less than 2.5 SD below
the young adult mean (T score between -1 and -2.5)
Osteoporosis
BMD value of 2.5 SD or more below the young adult
mean (T score ≤ -2.5)
Severe /
Established
Osteoporosis
BMD value of 2.5 SD or more below the young adult
mean with the presence of 1 or more fragility
fractures
Table 2: The World Health Organisation (WHO) criteria for classification of osteoporosis.
Abbreviations: BMD, body mineral density; SD, standard deviation.
WHO Fracture Risk Assessment Tool:
http://www.shef.ac.uk/FRAX/tool.jsp?country=35
Risk factors
Non-modifiable
Modifiable
Older age (starting in the mid-30’s but more likely with advancing
age)
Oestrogen deficiency (e.g. menopause)
Non-Hispanic white or Asian ethnic background
Low calcium and vitamin D intake
Small bone structure or low body mass index (<19kg/m²)
Sedentary (inactive) lifestyle or immobility
Family history of osteoporosis or an osteoporosis-related fracture in
a parent or sibling
Cigarette smoking
Prior fracture due to a low-level injury, particularly after age 50
Excessive alcohol consumption
Medications
Long term treatment with glucocorticoids (e.g. prednisolone)
Excess thyroid hormone replacement in patients with hypothyroidism
Heparin
Treatments that deplete sex hormones (e.g. anastrozole (Arimidex) and letrozole (Femara) to treat breast cancer
or leuprorelin (Lupron) to treat prostate cancer and other health problems
Diseases
Endocrine (hormone) diseases
(e.g. hyperthyroidism, hyperparathyroidism, hypogonadism, Cushing’s disease, osteogenesis imperfecta)
Inflammatory arthritis (e.g. rheumatoid arthritis)
Eating disorder (e.g. anorexia nervosa)
Malabsorption / post-gastrectomy
Multiple myeloma and malignancy
Table 1: List of possible risk factors of osteoporosis.
Osteoporosis
May not lead to any
symptoms
Indicated when there is a
broken (fractured) hip, wrist
or spine after a minor fall
Often present with
symptoms of back pain and
potential loss of height and
spinal (vertebrae)
deformity, causing physical
disable and even death
Figure 3: Progressive spinal deformity in osteoporosis
Management of
Osteoporosis
Management of
Osteoporosis in UMMC
Lifestyle interventions
Calcium intake
From diet or supplements
Vitamin D intake
Increase physical activity
Smoking cessation
Reduce alcohol consumption
Recommended Daily Calcium Intake
Category
Age / year old
Recommended
Intake / mg
Neonates & Infants *
0 – 6 months
7 – 12 months
200
260
Children
1–3
4–8
9 – 13
700
1000
1300
Adolescents
14 – 18
1300
Men
19 – 50
51 – 70
1000
1200
Women
19 – 50
51 – 70 (Menopausal)
1000
1500
Elderly (men & women)
Over 71
1200
Pregnant (Third trimester) &
Lactating
14 – 18
19 – 50
1300
1000
Table 3: Recommended daily calcium intake in different age groups.
*Adequate intake
Sources of Calcium
Diet (e.g. milk, yogurt, cereal, soy beverages, and etc)
Supplementation
1. Calcium Carbonate
Recommended dose: 500 mg BD (May be sucked or chewed)
2. Calcium Lactate
Doses: Adults: 300-600 mg daily
Pregnant women (during 3rd trimester and lactation): 9001200 mg daily
Children over 3 years: 300 mg daily
Note
Patient may experience constipation, metallic taste or
vomiting after administer calcium lactate tablets. It is
advised not to take within 2 hours of other oral medications
upon administration of calcium lactate tablets.
Suggested Daily Vitamin D Intake
Adults
< age 50, 400 – 800 International Units (IU);
> age 50, 800 – 1000 IU
Sources of Vitamin D
Exposure under sunlight
Diet
(e.g. cod liver oil, milk, yogurt, salmon, egg, and etc)
Sources of Vitamin D (cont.)
Supplementation
Calcitriol and Alfacalcidol
Both are prescribed only for those who fulfill the
requirements as below:
1. Renal impairment;
2. Patients > 65 years;
3. Intolerant to biphosphonates and SERMs;
4. Persistently low calcium levels;
5. Secondary hyperparathyroidism.
Sources of Vitamin D (cont.)
Supplementation
Active
Vitamin D
Available
forms
Dosages
Prescribers
Calcitriol (or
Rocaltrol)
0.25 mcg
capsule
0.25 – 0.5 mcg daily (in divided
doses – usually bd)
Orthopedics,
Endocrinologists,
Nephrologists,
Geriatricians
Alfacalcidol
0.25 mcg
capsule
Initial dose: Adults & children >
20kg: 1 mcg daily; Children < 20 kg:
0.05 mcg/kg/day; Neonates: 0.1
mcg/kg/day
Endocrinologists,
Nephrologists
1 mcg
capsule
Maintenance dose: 0.25 – 2 mcg
daily
Table 4: The dosages of Calcitriol and Alfacalcidol.
The interrelationships between homeostatic hormones.
Schroeder N J , Cunningham J Nephrol. Dial. Transplant.
2000;15:460-466
© 2000 European Renal Association-European Dialysis and Transplant Association
Other supplement:
Metocal Vit D3
- A combination of calcium and vitamin D
- Dose: 1 – 2 chewable tablets daily
- Take at least 2 hr before or 2 hr after meals due to a
possible decrease of iron absorption
Treatment options
Bisphosphonates (e.g. alendronate, risedronate)
SERM (e.g. raloxifene)
Calcitonin
Strontium ranelate
PTH treatment (e.g. teriparatide)
Bisphosphonates (also known as antiresorptive drugs)
Generic
name
Brand
name
Dosages
Prescribers
Notes
Alendronate
Fosamax
70 mg once a
week
Endocrinologist,
Orthopeadics , O&G,
Geriatricians,
Rheumatologists
Risedronate
Actonel
35 mg once a
week
Prof SP Chan, Dr Vijay, Dr
Sargunan, Dr Lim Soo
San, Dr Tai Cheh Chin,
Prof
Vickneswaran, Prof Philip
Poi, Prof Siti Zawiah Omar,
Prof Tan Peng Chiong
Patients must take on an empty
stomach at least 30 minutes
before breakfast with plain water
only (allow optimal drug
absorption) and remain upright for
at least an hour after taking
medications (bisphosphonates
may irritate the esophagus).
Ibandronate
Bonviva
150 mg once a
month
Not prescribed in UMMC
Zoledronic
acid
Aclasta
Single IV infusion
once a year
Lecturers and consultants
of Orthopaedics,
Endocrinology and
Rheumatology
Table 5: The available products of bisphosphonates and their dosages.
Abbreviation: O & G, obstetrics and gynaecologists.
Patient must drink at least 2
glasses of water before infusion of
drug. Postdose symptoms: fever,
myalgia, flu like symptoms,
arthralgia and headache (Usually
occur within the first 3 days after
administration of Aclasta).
Selective oestrogen receptor modulator (SERM)
Mimics oestrogen’s good effects on bones without some of
the serious side effects such as breast cancer
Decreases the risk of spine fractures, but there is a risk of
blood clots with use of SERMs
Raloxifene (Evista)
Dose: 60 mg daily with or without food
Prescribers: Osteoporosis clinic: Prof SP Chan, Prof Rokiah,
Dr Vijay; Orthopedic clinic: Dr Tai; Menopause clinic: Prof Siti
Zawiyah
Calcitonin (Miacalcin)
A hormone made from the thyroid gland
Regulates calcium homeostasis
Prevents vertebral (spine) fractures and is helpful in
controlling pain after an osteoporotic vertebral fracture
Nasal spray
Recommended dose: 200 IU / day
Injection
Dose: SC/IM 50-100 IU daily or every 2nd day.
Max supply: 5 days.
Prescribers: Endocrinologists or Orthopaedics
Common adverse effects: nausea, vomiting, dizziness, and
flushing
Strontium Ranelate (Protaxos)
Stimulates bone formation and reduces bone
resorption
Reduces fractures, but there is a risk of blood clots
with use of this medication
In powder form; to dissolve 2g sachet in water and
taken daily at bedtime, at least 2 hours after eating
Prescribers: Prof SP Chan, Dr Vijay, Dr Sargunan, Dr
Lim Soo San, Dr Tai Cheh Chin, Prof Vickneswaran,
Prof Philip Poi, Prof Siti Zawiah Omar, Prof Tan Peng
Chiong
Parathyroid hormone (PTH) Treatment
PTH stimulates bone formation and activates bone remodeling,
resulting in significant increases in bone mineral density and a
reduction in fracture risk
Due to the potential risk of carcinogenicity (osteosarcoma) ,
recommended maximum duration of treatment is 18 months
Teriparatide Inj (Forteo) - Parathyroid Hormone Analog
Dose: 20 mcg daily, into the thigh or abdominal wall (initial
administration should occur under circumstances in which the
patient may sit or lie down, in the event of orthostasis)
Prescribers: Prof SP Chan, Dr Vijay, Dr Sargunan, Dr Lim Soo San,
Ddr Tai Cheh Chin, Prof Vickneswaran, Prof Philip Poi, Prof Siti
Zawiah Omar, Prof Tan Peng Chiong
Common adverse events: nausea, constipation, pain in limb,
rashes, headache, sweating and dizziness
Management of
Postmenopausal
Osteoporosis
Management of
Glucocorticoid Induced
Osteoporosis
Management of
Male Osteoporosis
References
Clinical Practice Guidelines on Management of Osteoporosis (downloaded in pdf
form; Available from www.acadmed.org.my/view_file.cfm?fileid=208)
American College of Rheumatology website:
http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/oste
oporosis.asp
International Osteoporosis Foundation website:
http://www.iofbonehealth.org/introduction-bone-biology-all-about-our-bones
D. Lajeunesse, J. –P. Pelletier, J. Martel – Pelletier (2010). Osteoporosis and
Osteoarthritis: Bone is the Common Battleground. Medicographia. Vol. 32. No. 4.
Page 391-398
Arthritis Foundation Malaysia website: http://www.afm.org.my/info/osteoporosis.htm
Websites:
a) http://www.webmd.com/osteoporosis/living-with-osteoporosis-7/causes
b) http://www.webmd.com/osteoporosis/living-with-osteoporosis-7/tests
c) http://www.uptodate.com/contents/search?search=osteoporosis&sp=0&searchType=
PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&searchOff
set=
National Institutes of Health website: http://ods.od.nih.gov/factsheets/CalciumHealthProfessional/
MIMS Malaysia website
UMMC Online Formulary