OSTEOPOROSIS AND OSTEOMALACIA Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant King...
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OSTEOPOROSIS AND OSTEOPOROSIS AND OSTEOMALACIAOSTEOMALACIA
OSTEOPOROSIS AND OSTEOPOROSIS AND OSTEOMALACIAOSTEOMALACIA
Prof. Mohamad S. Al-HadramyProf. Mohamad S. Al-HadramyProfessor of Medicine/ConsultantProfessor of Medicine/Consultant
King Abdulaziz UniversityKing Abdulaziz UniversityJeddah, Saudi ArabiaJeddah, Saudi Arabia
Prof. Mohamad S. Al-HadramyProf. Mohamad S. Al-HadramyProfessor of Medicine/ConsultantProfessor of Medicine/Consultant
King Abdulaziz UniversityKing Abdulaziz UniversityJeddah, Saudi ArabiaJeddah, Saudi Arabia
F. 19-year-old presented with difficulty F. 19-year-old presented with difficulty in walking for many years, especially in walking for many years, especially going upstairs. She felt parasthesia going upstairs. She felt parasthesia in hands & feet and occasional in hands & feet and occasional spasm. P/E: waddling gait.spasm. P/E: waddling gait.
Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125).(0.7-1.4). Alk Phos: 562 ( - 125).
• What other test results you need?What other test results you need?
F. 19-year-old presented with difficulty F. 19-year-old presented with difficulty in walking for many years, especially in walking for many years, especially going upstairs. She felt parasthesia going upstairs. She felt parasthesia in hands & feet and occasional in hands & feet and occasional spasm. P/E: waddling gait.spasm. P/E: waddling gait.
Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125).(0.7-1.4). Alk Phos: 562 ( - 125).
• What other test results you need?What other test results you need?
Alb: Urea: PTHAlb: Urea: PTHAlb: Urea: PTHAlb: Urea: PTH
1.1. What signs for low Ca What signs for low Ca would you look for?would you look for?
ChovestickChovestick
Trouseau 4 min.Trouseau 4 min.
1.1. What signs for low Ca What signs for low Ca would you look for?would you look for?
ChovestickChovestick
Trouseau 4 min.Trouseau 4 min.
OSTEOMALACIAOSTEOMALACIAOSTEOMALACIAOSTEOMALACIA
• Raised bone turnoverRaised bone turnover• + Failure of mineralization+ Failure of mineralization• Most common cause: Most common cause:
decreased Vitamin Ddecreased Vitamin D• Darker skin more susceptibleDarker skin more susceptible
• Raised bone turnoverRaised bone turnover• + Failure of mineralization+ Failure of mineralization• Most common cause: Most common cause:
decreased Vitamin Ddecreased Vitamin D• Darker skin more susceptibleDarker skin more susceptible
Less common:Less common:
Heriditary resistance to Vitamin DHeriditary resistance to Vitamin D
1 1 αα-hydroxylase def.-hydroxylase def.
Familial X-linked hypophosphatemiaFamilial X-linked hypophosphatemia
Mesynchymal tumours produce Mesynchymal tumours produce phosphatoninphosphatonin
Less common:Less common:
Heriditary resistance to Vitamin DHeriditary resistance to Vitamin D
1 1 αα-hydroxylase def.-hydroxylase def.
Familial X-linked hypophosphatemiaFamilial X-linked hypophosphatemia
Mesynchymal tumours produce Mesynchymal tumours produce phosphatoninphosphatonin
RadiologyRadiologyRadiologyRadiology
Subperiosteal resorption of Subperiosteal resorption of phalangesphalanges
Looser zonesLooser zones
Brown cystsBrown cysts
Subperiosteal resorption of Subperiosteal resorption of phalangesphalanges
Looser zonesLooser zones
Brown cystsBrown cysts
Chemistry:Chemistry:Chemistry:Chemistry:
Decreased corrected CaDecreased corrected Ca
(40-Alb) x 0.02 + Ca(40-Alb) x 0.02 + Ca
Decreased P; Why?Decreased P; Why?
Decreased urinary CaDecreased urinary Ca
Decreased 25 (oH) Vit. DDecreased 25 (oH) Vit. D
Decreased corrected CaDecreased corrected Ca
(40-Alb) x 0.02 + Ca(40-Alb) x 0.02 + Ca
Decreased P; Why?Decreased P; Why?
Decreased urinary CaDecreased urinary Ca
Decreased 25 (oH) Vit. DDecreased 25 (oH) Vit. D
TreatmentTreatmentTreatmentTreatment
1000 – 2000 IU Vitamin D/day + 1000 – 2000 IU Vitamin D/day + 500 – 1000 mg of Ca/day. 500 – 1000 mg of Ca/day. Rarely 50,000 – 100,000 u/d or Rarely 50,000 – 100,000 u/d or 1 1 αα 0.5 – 2.5 0.5 – 2.5 μμg/day ·.· shorter g/day ·.· shorter acting to decrease tox.acting to decrease tox.
Check Ca Q 2-4 weeksCheck Ca Q 2-4 weeks
Phosphate for hypophosph Phosphate for hypophosph RicketsRickets
1000 – 2000 IU Vitamin D/day + 1000 – 2000 IU Vitamin D/day + 500 – 1000 mg of Ca/day. 500 – 1000 mg of Ca/day. Rarely 50,000 – 100,000 u/d or Rarely 50,000 – 100,000 u/d or 1 1 αα 0.5 – 2.5 0.5 – 2.5 μμg/day ·.· shorter g/day ·.· shorter acting to decrease tox.acting to decrease tox.
Check Ca Q 2-4 weeksCheck Ca Q 2-4 weeks
Phosphate for hypophosph Phosphate for hypophosph RicketsRickets
OSTEOPOROSIOSTEOPOROSISSOSTEOPOROSIOSTEOPOROSISS
• Low bone densityLow bone density• Microarchitectural Microarchitectural
deteriorationdeterioration• ↑ ↑ fracturesfractures
• Low bone densityLow bone density• Microarchitectural Microarchitectural
deteriorationdeterioration• ↑ ↑ fracturesfractures
Balance between bone Balance between bone formation and bone formation and bone resorptionresorption
Balance between bone Balance between bone formation and bone formation and bone resorptionresorption
Max bone mass at 25 – 35 Max bone mass at 25 – 35 yearsyears
Increased by exercise and Increased by exercise and good Ca intake. Later bone good Ca intake. Later bone mass ↓, especially with mass ↓, especially with ↓oestrogens (Menopause).↓oestrogens (Menopause).
Max bone mass at 25 – 35 Max bone mass at 25 – 35 yearsyears
Increased by exercise and Increased by exercise and good Ca intake. Later bone good Ca intake. Later bone mass ↓, especially with mass ↓, especially with ↓oestrogens (Menopause).↓oestrogens (Menopause).
Dx: T score. What is it?Dx: T score. What is it?Dx: T score. What is it?Dx: T score. What is it?
Normal T ± 1Normal T ± 1Osteopenia -1> T ≥ -2.5Osteopenia -1> T ≥ -2.5Osteoporosis T < - 2.5Osteoporosis T < - 2.5Severe osteoporosis T <-Severe osteoporosis T <-
2.5 with 1 or more 2.5 with 1 or more fragility, fracturesfragility, fractures
Normal T ± 1Normal T ± 1Osteopenia -1> T ≥ -2.5Osteopenia -1> T ≥ -2.5Osteoporosis T < - 2.5Osteoporosis T < - 2.5Severe osteoporosis T <-Severe osteoporosis T <-
2.5 with 1 or more 2.5 with 1 or more fragility, fracturesfragility, fractures
Chemistry: normalChemistry: normalWhy Why ↑alk, but not persistent↑alk, but not persistentChemistry: normalChemistry: normalWhy Why ↑alk, but not persistent↑alk, but not persistent
Primary OsteoporosisPrimary OsteoporosisPrimary OsteoporosisPrimary Osteoporosis
Senile or post-menopausal – Senile or post-menopausal – 95%95%
IndiopathicIndiopathic
Senile or post-menopausal – Senile or post-menopausal – 95%95%
IndiopathicIndiopathic
Secondary OsteoporosisSecondary OsteoporosisSecondary OsteoporosisSecondary Osteoporosis
Endocrine: Endocrine: Cushing + exog steroidsCushing + exog steroidsHyperthyroidismHyperthyroidismHypogonadismHypogonadismHyperparathyroidismHyperparathyroidismDMDM
ProclatinomaProclatinomaAcromegalyAcromegalyPreg & lactationPreg & lactation
Endocrine: Endocrine: Cushing + exog steroidsCushing + exog steroidsHyperthyroidismHyperthyroidismHypogonadismHypogonadismHyperparathyroidismHyperparathyroidismDMDM
ProclatinomaProclatinomaAcromegalyAcromegalyPreg & lactationPreg & lactation
Connective Tissue:Connective Tissue:Connective Tissue:Connective Tissue:
Osteogenesis inperfectaOsteogenesis inperfecta
MarfanMarfan
HomocystinuriaHomocystinuria
Osteogenesis inperfectaOsteogenesis inperfecta
MarfanMarfan
HomocystinuriaHomocystinuria
Drugs:Drugs:Drugs:Drugs:
HeparinHeparin
SteroidsSteroids
Anti-convulsantsAnti-convulsants
HeparinHeparin
SteroidsSteroids
Anti-convulsantsAnti-convulsants
RenalRenalRenalRenal
C R FC R FC R FC R F
Nutrition and GITNutrition and GITNutrition and GITNutrition and GIT
Malabsorption, CeliacMalabsorption, CeliacGastrectomyGastrectomyT P NT P NHepatobiliary diseaseHepatobiliary diseaseChronic hypophosphatemiaChronic hypophosphatemia
Malabsorption, CeliacMalabsorption, CeliacGastrectomyGastrectomyT P NT P NHepatobiliary diseaseHepatobiliary diseaseChronic hypophosphatemiaChronic hypophosphatemia
Elite female athletes Elite female athletes and anorexia nervosaand anorexia nervosaElite female athletes Elite female athletes and anorexia nervosaand anorexia nervosa
Risk increased by:Risk increased by:Risk increased by:Risk increased by:
F – sexF – sexMenopauseMenopauseDecreased CaDecreased CaSmokingSmokingAlcoholAlcoholInactivityInactivityLeannessLeannessWhite Race (White Race (↓ black)↓ black)
F – sexF – sexMenopauseMenopauseDecreased CaDecreased CaSmokingSmokingAlcoholAlcoholInactivityInactivityLeannessLeannessWhite Race (White Race (↓ black)↓ black)
Signs & Symptoms:Signs & Symptoms:Signs & Symptoms:Signs & Symptoms:
Asymptomatic unless #Asymptomatic unless #Back painBack pain↓ ↓ HeightHeightKyphosisKyphosisEffect especially in:Effect especially in:
DorsalvertsDorsalvertsFemoral neckFemoral neckDistal radiusDistal radius
Asymptomatic unless #Asymptomatic unless #Back painBack pain↓ ↓ HeightHeightKyphosisKyphosisEffect especially in:Effect especially in:
DorsalvertsDorsalvertsFemoral neckFemoral neckDistal radiusDistal radius
DD: Lytic lesionsDD: Lytic lesionsDD: Lytic lesionsDD: Lytic lesions
Ca breast, Lung, Kidney, Ca breast, Lung, Kidney, ThyroidThyroid
Prostate Prostate wall sclerosis wall sclerosis
MM MM generalized thinning generalized thinning
Ca breast, Lung, Kidney, Ca breast, Lung, Kidney, ThyroidThyroid
Prostate Prostate wall sclerosis wall sclerosis
MM MM generalized thinning generalized thinning
Prevention:Prevention:Prevention:Prevention:
ExerciseExercise
Good Ca intakeGood Ca intake
Non-smokingNon-smoking
ExerciseExercise
Good Ca intakeGood Ca intake
Non-smokingNon-smoking
Screening:Screening:Screening:Screening:
Screen post-menopausalScreen post-menopausal
F >64 or with multiple risk F >64 or with multiple risk factors (e.g., factors (e.g., ↓weight, ↓weight, fragility fracturesfragility fractures
Frag #: of limb or spine post fall Frag #: of limb or spine post fall from standing height or lessfrom standing height or less
Screen post-menopausalScreen post-menopausal
F >64 or with multiple risk F >64 or with multiple risk factors (e.g., factors (e.g., ↓weight, ↓weight, fragility fracturesfragility fractures
Frag #: of limb or spine post fall Frag #: of limb or spine post fall from standing height or lessfrom standing height or less
TREATMENT:TREATMENT:TREATMENT:TREATMENT:
Ca 1200 mg/dayCa 1200 mg/dayVitamin D:- 400-2000 IU / dayVitamin D:- 400-2000 IU / dayHRTHRTBiphosphonatesBiphosphonatesCalcintoninCalcintoninS E R M SS E R M SParathyroid hormoneParathyroid hormone
Ca 1200 mg/dayCa 1200 mg/dayVitamin D:- 400-2000 IU / dayVitamin D:- 400-2000 IU / dayHRTHRTBiphosphonatesBiphosphonatesCalcintoninCalcintoninS E R M SS E R M SParathyroid hormoneParathyroid hormone