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OSTEOPOROSIS CPD Presentation by Chin Yeun, Shee (f0163)

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Presentation on theme: "OSTEOPOROSIS CPD Presentation by Chin Yeun, Shee (f0163)"— Presentation transcript:

1 OSTEOPOROSIS CPD Presentation by Chin Yeun, Shee (f0163)

2 O steoporosis 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.

3 Osteoporosis Altered bone remodeling cycle An imbalance in favor of bone resorption over bone formation Osteoporotic bone shows an increase in the length of the remodeling cycle and reduced capacity to lay down a new mineralized bone matrix Figure 2: Representation of the bone remodeling cycle in osteoporosis. Abbreviations: BRU, bone remodeling unit; CL, cement line; LC, lining cells; OS, osteoid. From: © 2010, Medscape.www.medscape.com 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. 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.

4 Classification Based on individual bone mineral density (BMD) Dual energy X-ray absorptiometry (DEXA) is the best current test to measure BMD CategoryDescription NormalBMD within 1 SD of young adult reference range (T score > -1) OsteopeniaBMD more than 1 SD but less than 2.5 SD below the young adult mean (T score between -1 and -2.5) OsteoporosisBMD 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:

5 Risk factors Non-modifiableModifiable 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 backgroundLow 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 50Excessive 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.

6 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

7 Management of Osteoporosis

8 Management of Osteoporosis in UMMC

9 Lifestyle interventions Calcium intake Vitamin D intake Increase physical activity Smoking cessation Reduce alcohol consumption From diet or supplements

10 Recommended Daily Calcium Intake CategoryAge / year oldRecommended Intake / mg Neonates & Infants *0 – 6 months 7 – 12 months Children1 – 3 4 – 8 9 – Adolescents14 – Men19 – – Women19 – – 70 (Menopausal) Elderly (men & women)Over Pregnant (Third trimester) & Lactating 14 – – Table 3: Recommended daily calcium intake in different age groups. *Adequate intake

11 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: mg daily Pregnant women (during 3rd trimester and lactation): 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. 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.

12 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)

13 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.

14 Sources of Vitamin D (cont.) Supplementation Active Vitamin D Available forms DosagesPrescribers Calcitriol (or Rocaltrol) 0.25 mcg capsule 0.25 – 0.5 mcg daily (in divided doses – usually bd) Orthopedics, Endocrinologists, Nephrologists, Geriatricians Alfacalcidol0.25 mcg capsule 1 mcg capsule Initial dose: Adults & children > 20kg: 1 mcg daily; Children < 20 kg: 0.05 mcg/kg/day; Neonates: 0.1 mcg/kg/day Maintenance dose: 0.25 – 2 mcg daily Endocrinologists, Nephrologists Table 4: The dosages of Calcitriol and Alfacalcidol.

15 The interrelationships between homeostatic hormones. Schroeder N J, Cunningham J Nephrol. Dial. Transplant. 2000;15: © 2000 European Renal Association-European Dialysis and Transplant Association

16 Other supplement: Metocal Vit D 3 -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

17 Treatment options Bisphosphonates (e.g. alendronate, risedronate) SERM (e.g. raloxifene) Calcitonin Strontium ranelate PTH treatment (e.g. teriparatide)

18 Bisphosphonates (also known as antiresorptive drugs) Generic name Brand name DosagesPrescribersNotes AlendronateFosamax70 mg once a week Endocrinologist, Orthopeadics, O&G, Geriatricians, Rheumatologists 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). RisedronateActonel35 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 IbandronateBonviva150 mg once a month Not prescribed in UMMC Zoledronic acid AclastaSingle IV infusion once a year Lecturers and consultants of Orthopaedics, Endocrinology and Rheumatology 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). Table 5: The available products of bisphosphonates and their dosages. Abbreviation: O & G, obstetrics and gynaecologists.

19 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

20 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 IU daily or every 2nd day. Max supply: 5 days. Prescribers: Endocrinologists or Orthopaedics Common adverse effects: nausea, vomiting, dizziness, and flushing

21 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

22 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

23 Management of Postmenopausal Osteoporosis

24 Management of Glucocorticoid Induced Osteoporosis

25 Management of Male Osteoporosis

26 References Clinical Practice Guidelines on Management of Osteoporosis (downloaded in pdf form; Available from American College of Rheumatology website: oporosis.asp oporosis.asp International Osteoporosis Foundation website: D. Lajeunesse, J. –P. Pelletier, J. Martel – Pelletier (2010). Osteoporosis and Osteoarthritis: Bone is the Common Battleground. Medicographia. Vol. 32. No. 4. Page Arthritis Foundation Malaysia website: Websites: a)http://www.webmd.com/osteoporosis/living-with-osteoporosis-7/causeshttp://www.webmd.com/osteoporosis/living-with-osteoporosis-7/causes b)http://www.webmd.com/osteoporosis/living-with-osteoporosis-7/testshttp://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=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: HealthProfessional/http://ods.od.nih.gov/factsheets/Calcium- HealthProfessional/ MIMS Malaysia website UMMC Online Formulary


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