1. Osteoporosis

2. osteoporosis The most common bone disease Characterized by:
reduced bone density
micro-architectural deterioration of bone tissue
increased risk of fractures
The risk of osteoporosis increases markedly with age

4. Pathogenesis of osteoporosis
In normal individuals, bone mass increases during skeletal growth to reach its peak at 20 – 40 years of age, and starts to fall thereafter.
Bone remodeling (formation and resorption) is responsible for renewal and repair of skeleton in adult life.
Osteoporosis can occur because of a defect in attaining peak bone mass and/or because of accelerated bone loss (bone resorption exceeding bone formation).

5. Bone remodeling
It starts with attraction of osteoclast precursors from the peripheral blood to the target sites.
Osteoclast precursors express RANK (receptor activator of nuclear factor κB). Osteocytes contain RANK ligand (RANKL) that activates the RANK on osteoclast precursors to differentiate into mature osteoclasts.
Bone formation follows with attraction of osteoblast precursors to the resorption site.

6. Pathogenesis of osteoporosis
Postmenopausal osteoporosis
Age related (senile) osteoporosis
Osteoporosis in men
Secondary osteoporosis
Corticosteroid-induced osteoporosis

7. Postmenopausal osteoporosis
There is an accelerated phase of bone loss after menopause.
Postmenopausal bone loss is caused by oestrogen deficiency, which naturally stimulates bone formation
Postmenopausal osteoporosis is caused by a combination of low peak bone mass and exaggerated postmenopausal bone loss.

8. Postmenopausal osteoporosis
Individual differences in the development of postmenopausal osteoporosis are due to certain additional factors:
Genetic factors: account for 80% of the population variance of the risk of osteoporosis
Environmental factors:
exercise and calcium intake during growth
smoking increases the risk of postmenopausal osteoporosis
alcoholism is a recognized cause of osteoporosis

9. age related osteoporosis
Gradual bone loss occurs with advancing age in both genders.
Bone resorption is not particularly increased, but bone formation is reduced.
The genetic and environmental factors are also responsible for the individual variation in age related osteoporosis

10. Osteoporosis in men Osteoporosis is less common in men than in women.
A secondary cause is identified in 50% of cases, most importantly hypogonadism, corticosteroid treatment and alcoholism.
The mechanism of hypogonadism-induced osteoporosis is similar to postmenopausal osteoporosis
In the remaining 50% of men, genetic susceptibility is probably responsible.

11. Secondary osteoporosis
Osteoporosis occurring as a complication of diseases or drug treatment
Endocrine diseases: hypogonadism, hyperparathyroidism, thyrotoxicosis, Cushing's syndrome
Inflammatory diseases: rheumatoid arthritis, inflammatory bowel disease
Drugs: corticosteroid, thyroid hormones, anticonvulsants and heparin
GIT diseases: malabsorption, chronic liver disease
Miscellaneous: anorexia nervosa, multiple myeloma, immobilization

12. Corticosteroid induced osteoporosis
Corticosteroid therapy is an important cause of osteoporosis.
Corticosteroids also directly inhibit osteoblast activity and stimulate their apoptosis.
The risk is directly related to the dose and duration of treatment.
Osteoporosis is less likely with inhaled corticosteroids and when corticosteroid dose is less than 5 mg prednisolone per day.
The risk is substantial when the dose exceeds 7.5 mg for more than 3 months.

13. Clinical features of osteoporosis
Asymptomatic until fracture occurs
Fractures due to bone fragility are the most common manifestation.
Back pain, height loss, kyphosis and discovery of radiological osteopenia during evaluation for other conditions are also important.
Osteoporotic fractures can affect any bone but the most common sites are the forearm (Colles fracture), spine (vertebral fractures) and femur (hip fracture).

14. Investigations
Diagnosis of osteoporosis requires the measurement of bone mineral density (BMD).
The preferred technique is dual energy X ray absorptiometry (DEXA) of the hip and spine
The machine gives the result of T-score and Z-score.

15. Dual energy X ray absorptiometry

16. Dual energy X ray absorptiometry
T-score measures how many standard deviations (SD) the patient BMD differs from that of a healthy control
Z-score measures how many SD the BMD of the patients differ from that of an aged matched control.
T-score: or below indicates osteoporosis between – 1.0 to – 2.5 is considered osteopenia. Values above are considered normal

18. Indications BMD measurement include:
low trauma fractures
height loss and kyphosis
osteopenia on X ray
corticosteroid therapy
family history of osteoporosis fracture
BMI< 18
menopause <45
diseases causing osteoporosis
high FRAX score

19. Osteoporosis : cause identification
History should be taken to identify causes as early menopause, smoking, alcohol intake and steroid therapy.
Clinical examination should search for endocrine disorders, multiple myeloma or inflammatory diseases.
Routine investigations
Sex hormones and gonadotropines should be assessed in men with osteoporosis and in women with amenorrhoea before 50.

20. Management of osteoporosis
Patients with osteopenia are advised on life style modification including:
smoking and alcohol cessation
increasing dietary calcium
encouragement of exercise
Indications for drug therapy
T-score below -2.5
Corticosteroid induced osteoporosis with T-score below -1.5
Vertebral fractures irrespective to BMD

21. Anti-osteoporosis (anti-resorptive) therapy
Bisphosphanates
Denosumab
Calcium and vitamin D
Parathyroid hormone (teriparatide)
Strontium renalate
Hormone replacement therapy

22. Bisphosphanates The most commonly prescribed drugs for osteoporosis.
Synthetic pyrophosphate analogues that adsorb on bone surface and inhibit osteoclast function.
Increase in BMD of 5 – 8 % after 2 years of therapy.
Alendronate (70 mg/week) and risedronte (35mg/week) are the most commonly prescribed oral bisphosphanates. Zolendronic acid (5mg IV annually) is also effective
These drugs prevents postmenopausal bone loss and reduces the risk of vertebral and non-vertebral fractures. Bisphosphanates are also effective in the prevention and treatment of corticosteroid induced and male osteoporosis.

23. Bisphosphanates
Oral bisphosphanates are poorly absorbed from the GIT and should be taken on empty stomach, with plain water only, avoiding food for min. after being swallowed.
Dyspepsia is a recognized side effect, and they should be prescribed cautiously in patients with GERD and avoided in those with oesophageal stricture or achalasia.
Osteonecrosis of the jaw (rare) and influenza like illness (with zolendronic acid) are other side effects

24. Denosumab
This is a monoclonal antibody that neutralizes the effect of RANKL.
Administered by SC injection every 6 months.
A powerful inhibitor of bone resorption and reduces the risk of all types of osteoporotic fractures.

25. Calcium and vitamin D supplement
Calcium in a dose of 500 mg/day, and vitamin D in a dose of 800 unit/day are adjunctive to other treatments.
Monotherapy with calcium and vitamin D prevents fragility fracture in those with vitamin D deficiency, but not in other patients.

26. Parathyroid hormone (teriparatide)
In contrast to the effect of sustained elevation of PTH in hyperparathyroidism, daily subcutaneous injection of PTH in the form of teriparatide increases BMD by 10% and reduces the risk of vertebral and non-vertebral fractures.
The drug is expensive and is preserved for severe osteoporosis and to those not responding adequately to bisphosphanates
Duration of therapy should not exceed 24 months because of the possible risk of osteosarcoma

27. Strontium renalate The drug is associated with large changes in BMD
This is partly artefactal, due to replacement of calcium in bone by the heavier strontium.
It reduces fracture risk significantly but is associated with increased risk of MI and venous thrombosis

28. Hormone replacement therapy (HRT)
HRT prevents postmenopausal bone loss and reduces the risk of osteoporotic fractures.
The use of HRT as a treatment of osteoporosis has markedly reduced after confirming the excess risk of breast cancer, thromboembolism, stroke and CHD.
Testosterone is indicated for male osteoporosis caused by hypogonadism.

29. Follow up after treatment
Monitoring response to treatment is ideally made by repeating BMD measurement or by measuring markers for bone turnover (like N-telopeptide) in serum or urine
Second assessment of BMD is made after 2 – 3 years of treatment because of the slow effect of antiresorptive therapy