RRC

OSTEOPOROSIS

Rheumatology Research Center

INTERNAL MEDICINE CONGRESS 1382INTERNAL MEDICINE CONGRESS 1382

RRCRRC

RRCDEFINITION

• Systemic Skeletal Disease • Low Bone Mass • Micro Architectural Deterioration

– Increase in Bone Fragility– Susceptibility to Fracture Am J Med 1993;94:644-650

• Bone Densitometry– t score: –2.5SD

WHO 1990

RRC

EPIDEMIOLOGY

RRC

EPIDEMIOLOGY

• USA (NHANESS III 1997)

– Women 13 - 18%

– Men 1 - 4%

• IRAN 4,575,000 - 7,150,000

RRCFRACTURE RISK

50 YEARS AND OVER

WOMEN MEN

• Femur 17.5% 6.0%

• Spine 15.6 5.0

• Wrist16,0 2.5

• Any Fracture 39.7 13.1

RRC

BONE PHYSIOLOGY

RRC

BONE PHYSIOLOGY

• Bone Resorption– Osteoclast

• Bone Formation– Osteoblast

• Bone Remodeling Unit– Positive < age 30

– Negative > age 30

00.10.20.30.40.50.60.70.80.9

1

10 15 20 25 30 35 40 45 50 55 60 65 70 75

RRC

OSTEOBLAST• Origin: Mesenchymal Cell

• Activation: PTH, Vitamin D

• Function

– Matrix Formation

– Bone Mineralization

– Matrix Degradation RANK L

RRC OSTEOCLAST• Origin

– Blood Mononuclear Cells

• Differentiation– CSF-1

– RANK L• Lymphocyte

• Osteoblast

• Action– Acidification

– Protein Degradation

H2O + CO2

HCO3

H+

Cl

RRC

BONE REMODELING UNIT

. . . ... . . .. . . .

. . . . . .

Resorption Formation Completion

RRC

STIMULATION

IL-1TNF-IL-6IL-11

PTHVit D

RANK

BONE RESORPTIONM-CSF

IL-1TNF-IL-6IL-11

PTHVit D

RANKSTIMULATION

RRC

STIMULATION

PROGESTERONE

ANDROGEN

ILGF PTHVit D

ESTROGEN

ESTROGEN

STIMULATION

CALCITONIN

INHIBITION

COUPLING FACTOR

IL-1TNF-IL-6IL-11

INHIBITION

PTHVit D

RANK

BONE FORMATION

RRC

CLINICAL MANIFESTATIONS

RRC

CLINICAL MANIFESTATIONS

• Symptoms Non

• Complications Fractures

– Macroscopic• Vertebra

• Femoral Neck

• Wrist

• Others

– Microscopic• Vertebrae: Mechanical Pain, Spine Deformity

RRC

DIAGNOSIS

RRC

OLD DAYS

RRC20th CENTURY

• X-RAY

• BONE BIOPSY

RRC

RRC

NOWADAYS

BONE DENSITOMETRY

RRC Dual Energy X-ray Absorptiometry

(Gold Standard)

• NON INVASIVE– Irradiation: 1/100 Chest X-ray

– 1 h. Sun Exposure

• SENSITIVITY 1.0%

• ACCURACY 2.8%

• REPEATABLE

• LONGITUDINAL STUDY

RRC

BONE MINERAL DENSITY

• SPINE

• FEMUR

• FOREARM

• OTHERS– Whole Body– Heel– hand

RRC

RESULT

• BMD 0.857

• Comparison To Young Adult– % 76%

– t Score -2.4

• Comparison To Same Age– % 101%

– z Score+0.1

RRC SPINE

RRC SPINE

RRC FEMUR

RRC FEMUR

RRC FOREARM

RRC FOREARM

RRC

DIFFERENT STANDARDS

• COUNTRIES and ETHNICITIES

• MACHINES – Hologic

– Lunar

– MediLink

– Norland

RRC AMERICAN STANDARD

400

500

600

700

800

900

1000

1100

1200

20 30 40 50 60 70

Standardized BMD

PBM1124 mg

1006 mg

829 mg

Osteopenia

Osteoporosis

Female - Spine

RRC IRANIAN STANDARD

400

500

600

700

800

900

1000

1100

1200

20 30 40 50 60 70

Standardized BMD

PBM1097 mg Female - Spine

RRC COMPARISON

400

500

600

700

800

900

1000

1100

1200

20 30 40 50 60 70

Standardized BMD

PBM diff2.5%

1006 mg

829 mg

Osteopenia

Osteoporosis

Female - Spine

RRC

DEFINITIONS

• NORMAL BONE– 1.0 to -1.0 SD over/bellow PBM

• OSTEOPENIA– -1.0 to -2.4 SD bellow PBM

• OSTEOPOROSIS– -2.5 SD bellow PBM

RRC BMD REPORT

• FRACTURE RISK Spine Neck

– t = -1 SD 2.2 2.6

– t = -2 SD 5.0 7.0

– t = -3 SD 11.0 18.0

• Comparison Iranian Standard

• Advice– Evaluation

– Prevention/Treatment

RRC PURPOSE and APPLICATION

• DIAGNOSIS

– Osteoporosis

– Osteopenia

– Normal Bone

• CALCULATION

– Time to Osteopenia

– Time to Osteoporosis

RRC BONE LOSS

0.53

0.85

1.02 1.05

0.9

0.5

0

0.2

0.4

0.6

0.8

1

1.2

35-40 40-45 45-50 50-55 55-60 60-65

%

Age

22% Loss 35-65 Y

Spine – Iranian Women

RRC INDICATION(People at Risk)

• Menopause

• Inflammatory Diseases

• Endocrine Disorders

• Predisposing Drugs

• Familial History

• Fracture

RRC

BONE TRABECULA

RRC

BONE TRABECULA

RRC

RRC

BONE TRABECULA

RRC

PREVENTION

RRC

PREDISPOSING FACTORS• Genetic

– Stature– Vitamin D Receptor: DD, Dd, dd

• Alimentation– Calcium, Protein

• Physical Activity• Habits

– Coffee, Alcohol, Smoking

• Disease– Endocrine, Inflammatory Diseases, Renal Disorders

• Drugs– Steroids, Cytotoxic, Anti-epileptic, Heparin, Thyroxine

RRC PREVENTION(Normal Person, Normal BMD)

• Young– Alimentation– Sport

• Mid Age (up to menopause)– Habits

• Menopause– HRT (Allendronate?), Calcium, Exercises

• Senile– Exercises

RRC

PREVENTION(Disease or Medication, Normal BMD)

• Same as for Normal Person

• Adequate Management of the Disease– Minimum Required Dose of Predisposing Drug

• Medication

• Calcium

• Exercise

RRC

RRC DRUGS• Bone Forming

– Synthetic PTH

– Fluoride 20-40 mg/daily + Ca + Vit D

– Progesterone

– Anabolic agents Nandrolone Decanoate

• Resorption Preventing– Estrogen & Analogs ERT, HRT, Ralloxiphen

– Calcitonin Injectable, Nasal Spray

– Bisphosphonate Etidronate, Allendronate

RRCALLENDRONATE

• Osteofos• Prevention

– 5 mg daily

• Treatment– 10 mg daily

• Precautions– 30 Minutes Before Breakfast– Upright Position

• Side Effects

RRC INTERNAL MEDICINE CONGRESS 1382

Rheumatology Research Center