1. OSTEOPOROSIS

2. GOALS:
RECOGNIZE THE IMPORTANCE OF OSTEOPOROSIS.
APPLY GENERAL DIAGNOSTIC AND TREATMENT GUIDELINES FOR OP.
OBJECTIVES:
BY THE END OF THIS PRESENTATION, THE STUDENT SHOULD BE ABLE TO:
-DEFINE OP
-KNOW THE CAUSES AND RISK FACTORS OF OP.
-WHEN TO SCREEN FOR OP.
-RECOGNIZE GENERAL PRINCIPLES OF MANAGEMENT.
-TALK ABOUT PREVENTIVE MEASURES OF OP.

3. Description:
Decreased bone strength (density and/or quality) leading to increased risk for fragility fracture.
Bones of hip, spine and wrist most commonly affected.

4. IMPORTANCE
- Osteoporosis is a major public health problem, which results in substantial morbidity, mortality and high costs.
-Osteoporosis is an extremely serious disease and is not part of the natural aging process.

5. - Osteoporosis is underdiagnosed, undertreated and a neglected disease.
--The loss occur primarily in trabecular bone and is therefore most noticeable in the vertebrae and distal radius

6. Pathogenesis:
increased bone resorption and/or decreased bone formation (defective mineralization of osteoid)
maximum bone density reached at age years (95% reached by mid-teens)
10% decrease in bone mass doubles risk of fracture. 

7. Normal BMD is within 1 SD of young adult mean (T-score at -1 and above)
Osteopenia is BMD within -1 SD and SD below young adult mean (T-score between -1 and -2.5)
osteoporosis is BMD ≤ -2.5 SD below young adult mean (T-score at or below -2.5)

8. Z-scores represent the number of SDs from normal mean value for age- and sex-matched control subjects.
clinical diagnosis of osteoporosis is fragility fracture regardless of T-score.

9. Types of Osteoporosis:
(A) Type I osteoporosis is postmenopausal and
usually presents with type A fractures.
(e.g fractured of trabecular bone which is found in vertebrae and the wrist).

10. (B) Type II osteoporosis is senile osteoporosis that involves loss of cortical and trabecular bone and presents with type B fractures (hip).
Type II occurs primarily in men and women over the age of 75.

11. Causes of Osteoporosis (A) Idiopathic age-related osteoporosis (most common): (1) Juvenile The mean age of onset 7 yr. no sex difference. long bone fractures, pain in the back and difficulty walking, often it resolves itself after puberty (2) Young adults unknown cause, the bones become fragile and break, just as they do in people with Type I and Type II osteoporosis.

12. (3) Postmenopausal (type I)
only women, loss of estrogen that occurs after menopause, affect the trabecular (porous, spongy) bone mainly in the vertebrae and wrist
(4) Senile (type II)
both men and women, age related changes , affect cortical and trabecular …suffer from hip, wrist and spine fractures .

13. Secondary Osteopoosis
(B) Osteoporosis secondary to disease states:
1. Metabolic conditions
e.g calc. deficiency, vit. D deficiency, malnutrition, Idiopathic hypercalciuria, renal tubular acidosis, scurvy.
2. Endocrine conditions
e.g Thyrotoxicosis, Cushing, hypogonadism, Prolactinoma, Hyperparathyroidism, Hypoamenorrheic female runners.
3. Renal disease.

14. 4. Gastrointestinal disease.
Eg. IBD, interfere with absorption of calcium
5. Hereditary connective tissue diseases e.g marfan syndrome, homocystinuria.
6.Bone marrow infiltration
e.g Multiple myeloma, lymphoma, leukemia.

15. 7. Drugs
e.g Phenytoin, Phenobarbital, Thyroid hormones, Corticosteroid(7.5mg pred for >3 months), chronic heparin/warfarin therapy , lasix , lithium, .
8. Life style
e.g Nutnition, alcohol, smoking, inactivity, immobilization, excessive caffeine, excess phosphate intake (soft drinks, red meat).
9. Miscellaneous
e.g Rh. arthritis , DM, Hypetension.

16. Organs involved:
Trabecular bone more commonly affected than compact bone
Spine (vertebral column), pelvis, hip (femoral neck), distal radius, metacarpals

17. Who is most affected: women (especially postmenopausal), elderly
older white women have higher risk of incident nonspinal fractures than older black women

18. osteoporosis can develop in men
main risk factors for osteoporosis
smoking
alcohol excess
body mass index < 21 kg/m2
family history of osteoporosis

19. factors associated with osteoporotic fractures
Age
body mass index (BMI)
smoking status
recorded alcohol use
rheumatoid arthritis
cardiovascular disease

20. type 2 diabetes
asthma
use of tricyclic antidepressants
use of corticosteroids
history of falls
liver disease

21. Complications:
osteoporosis associated with significantly increased risk for clinical fractures at 1 year.
low bone mineral density (BMD) associated with risk of high-trauma fractures as well as low-trauma fractures

22. Clinical manifestations of Osteoporosis:
Osteoporosis is usually asymptomatic until fracture occurs.
May present as backache of varying degrees of severity
Spontaneous fracture
Collapse of vertebrae
Loss of height is common -

23. There is greater loss of trabecular bone than compact bone which cause crush fractures of vertebrae, fractures of the neck of femur and fractures of the distal end of the radius.
- The rate of bone formation is often normal whereas the rate of bone resorption is increased. Bone is normally mineralized

24. Physical Exam:
Signs are few, may decreasing height or a dorsal kyphosis .
p.t should be assessed for localized pain, muscle spasm, Neurologic deficit, loss of strength and range of motion in the affected area.
Fractures most commonly occur in the vertebral bodies, wrist, humerus, hip. rib and pelvis (in that order).

25.  Diagnosis
1-Based on bone densometry (DEXA scan) with the use of T or z score.
2- Clinical diagnosis if fragility fracture, regardless of T/Z-score.

26. T and Z scores
T-score is bone density expressed as number of standard deviations (SD) above or below mean bone mineral density (BMD) value for a normal young adult, measured by dual-energy x-ray absorptiometry(DEXA).

27. T score ≥ -1 is normal.
T-score between -1 and -2.5 is osteopenia
T-score ≤ -2.5 is osteoporosis

28. In premenopausal women, men < 50 years old, and children, use z-score instead of T-score .
z-score is bone density expressed as number of SDs from normal mean value for age, sex, and ethnicity/race
z-score > -2 is normal
z-score ≤ -2 is OP

29. Laboratory Findings:
Do Serum calcium, phosphate and PTH (they are normal).
The alkaline phosphatase is usually normal but may be slightly elevated esp. following a fracture.
TSH and Vit. D for deficiency may be required.
other tests is guided by clinical suspicion.

30. When to do bone densometry:
1. Estrogen-deficient women at clinical risk.
2. An individual with vertebral abnormalities on plain film.
3. More than 3 months of steroid Rx or pt.

31. 4. Primary hyperparathyroidism. 5. Monitoring of drug therapy. 6
4. Primary hyperparathyroidism. 5. Monitoring of drug therapy. 6. Women who have multiple risk factors. 8. Pt. with strong F.H of osteoporosis. 9. All women age>65

32. 1-clacium. rich diet esp. in childhood.
Prevention:
Exercise
Calcium and vitamin D
Bisphosphonates
Vitamin K
Estrogen
Raloxifene (Evista
1-clacium. rich diet esp. in childhood.
daily calcium intake of at least 1000mg , adolescents may need 1200mg and postmenopausal women may need 1500mg daily.
Women of any age unable to meet minimal calc. needs through diet should be advised to use supplemental calcium.
Elderly should be advised to take >800 units of Vit. D daily.
Milk, cheese and yogurt are rich in calcium.
2- No Smoking

33. Screening: women men any adult with age ≥ 65 years
Before that if women with clinical risk factors
men
age ≥ 70 years
age years with clinical risk factors
any adult with
fracture after age 50 years
condition (such as rheumatoid arthritis) associated with low bone mass or bone loss
use of medication (such as glucocorticoids) associated with low bone mass or bone loss

34. Treatment of Osteoporosis 1
Treatment of Osteoporosis 1. If history of fragility fractures treatment should be started . 2. Bisphosphonates: alendronate and risedronate, the selective estrogen-receptor modulator raloxifene, the anabolic agent PTH and strontium ranelate are known to reduce vertebral fractures.

35. 4. HRT is not recommended in women for fracture risk reduction alone.
5. The efficacy of calcitonin, fluoride, anabolic steroids and active vitamin D metabolites is questionable.
individual’s absolute risk of fracture is the single most important consideration .

36. Who should be treated. (a) T score of <-2. 5(OP)
Who should be treated ? (a) T score of <-2.5(OP). (B) Previous fragility fracture: the risk of further fractures increases threefold to fivefold. (C)Osteopenia with: history of fracture or family history of osteoprosis. (D) Risk factors for bone loss e.g hyperparathyroidism, corticosteroid therapy, immobilization, chronic illness.

37. Which drug should be used?
a) alendronate, risedronate , raloxifene or PTH are used to reduce risk of vertebral facture
b) biphosphonates only for non vertebral fractures.
For the treatment of postmenopausal symptoms use HRT .
to reduce breast cancer risk use raloxifene.

38. How long should treatment continue?
It remains unclear whether anti-fracture efficacy is sustained beyond 3-5 years.
Stopping treatment is followed by increased remodeling, bone loss and further structural damage.
Bone loss is likely to recur sooner after cessation of HRT or raloxifene than biphosphonates.

39. In conclussion If BMD is > -1 SD do not treat
If BMD is –1 to –2.5 SD treat if fracture is present
If BMD is < -2.5 SD treat whether or not a fracture is present