Osteoporosis€¦ · You order a central DEXA scan to the patient and scan returns with T score of...
Transcript of Osteoporosis€¦ · You order a central DEXA scan to the patient and scan returns with T score of...
OSTEOPOROSIS
DR.DUAA HIASAT
Objectives :
To define osteoporosis.
To know the causes & risk factors of
osteoporosis.
To know when to screen for osteoporosis.
To talk about preventive measures of
osteoporosis.
To recognise general principles of
management.
What is osteoporosis??
A skeletal disorder characterised by decreased
bone strength ( density and/or quality) leading
to increased risk for fragility fracture.
Bones of hip,spine and wrist most commonly
affected.
Why is it important ??
Osteoporosis is a major public health problem,
which results in substational
morbidity,mortality and high costs.
Osteoporosis is an extremely serious disease
and is not part of the natural aging process.
Pathogenesis :
Maximum bone density is attained in young
adulthood. Women then typically lose 50% bone
mass over their remaining lifetime.
Bone loss begins in the premenopausal years &
accelerates in the early postmenopausal years.
Lack of estrogen causes a release of
osteoclastic inhibition leads to imbalance b/w
bone resorption and formation.
Causes of osteoporosis:
1 – Idiopathic age related osteoporosis (most
common).
2- Secondary osteoporosis.
Cont…
Osteoporosis secondary to disease states:
1. Metabolic conditions:
Ex: Calcium deficiency ,Vit.D deficiency,
Malnutrition,Idiopathic hypercalciurea,Scurvy.
2. Endocrine conditions :
Ex:Thyrotoxicosis,Cushings,Hypogonadism
Prolactinoma,HyperPTH,Hypoamenorrheic
female runners (Athletes triad).
3. Gastrointestinal disease:
Ex:IBD,Malabsorption (e.g Celiac sprue).
4. Bone marrow infiltration :
Ex: Lymphoma,Leukemia,Multiple myeloma.
5. Drugs :
Ex: Anticonvulsants,Thyroid hormones ,PPIs,SSRIs, Corticosteroids ( 7.5 mg/d/3 mo),GnRH agonists,
Chronic heparin/warfarin therapy,furosemide,Lithium.
6. Lifestyle:
Ex: Nutrition ,Alcohol,Smoking ,Immobilazion,
Inactivity.
7. Others : Rhematoid arthritis,COPD.
Organs involved
Trabecular bone more commonly affected than
compact bone.
Spine ( vertebral column),pelvis,hip ( femoral
neck),distal radius.
Who is at risk??
Majors risk factors for osteoporosis :
Age ≥ 65 years.
Gender ( more in females).
White or Asian race.
Menopausal status.
Personal history of fracture as an adult (esp. older than 45 years ; not including fingers,toes, and skull).
History of fragility fracture in a first-degree relative (esp.maternal hip fracture).
Current smoking.
Low body weight ( BMI <21 kg/m2).
Use of oral steroids > 3 months.
Additional risk factors:
Estrogen deficiency at an early age (<45
years).
Low physical activity.
Excessive alcohol (more than 2 drinks/day
Poor health.
Clinical manifestations of osteoporosis:
It’s usually asymptomatic until fracture occurs.
Loss of height is common.
Spontaneous fracture.
Collapse of vertebrae.
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.
Cont…
Central DEXA is the gold standard for assessment
of BMD.
-Two beams of different energy are directed at
The patient and the difference in absorption rate
by the patient body is recorded to quantify the
amount of BMD.
T and Z score
T–score is bone density expressed as number
of standard deviations above or below mean
BMD value for a normal young adult measured
by DEXA.
WHO criteria for diagnosis of bone status are :
T-score -1 is normal.
T-score between -1 and -2.5 is osteoponia.
T-score ≤ -2.5 is osteoporosis.
T-score ≤ -2.5 + fractue is sever osteoporosis.
CONT..
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 osteoporosis.
In premenopausal women,men <50 years old,
and children,use Z-score instead of T-score.
When to do bone densometry??
National Osteoporosis Foundation (NOF)
recommends that all women 65 years should
be screened regardless of the presence or
absence of risk factors.
Younger postmenopausal women with one or
more risk factors (other than being
white,postmenopausal,and female) should also
be screened for osteoporosis.
U.S Preventive Services Task Force (USPSTF)
also recommends universal BMD screening for
all women ≥ 65 years and
for women ≥ 60 years if there are risk factors
for osteoporotic fractures.
In contrast to NOF, the USPSTF makes no
recommendation for or against routine
screening in postmenopausal women younger
than age 60 years or aged 60 to 64 years
without increased risk for osteoporotic
fracture.
Prevention:
It’s the least costly approach to osteoporosis
and should begin in youth .
Treatment : All patients being considered for pharmacologic
therapy should be counseled on the
importance of calcium,vitamin D,weight-bearing
exercise and fall preventive strategies to further
reduce their risk of fracture.
Before initiating pharmacologic treatment
patients should also be evaluated for
secondary causes of osteoporosis.
Who should be treated?
NOF recommends treatment for :
1. Patients with T-score below -2.
2. Patients with T-score below -1.5 if one or more
risk factors are present.
3. Patients who already have had osteoporotic
fracture (s).
Cont..
FDA – Approved therapeutic options
A) Prevention (stops bone loss) :
Estrogen.
Bisphosphonates ( Alendronate,Risedronate,
Ibandronate).
SERM (Raloxifne).
B) Treatment ( reduces spine fractures):
Calcitonin.
Parathyroid hormone.
Bishosphanates :
The most commonly used therapies for
osteoporosis.They are potent inhibitors of bone
resorption.
Alendronate was the first FDA-Approved drug ,
it’s taken orally 5 mg daily or 35 mg weekly for
prevention ,10 mg daily or 70 mg weekly for
treatment.
It reduces the incidence of vertbral and non-
vertebral fractures by about half.
Cont..
Because a minority of patients may suffer from
erosive esophagitis ,the patient should be advised to take it on empty stomach with water upon awakening ,remain upright ,and avoid food for 30 minutes afterwards.
Other Side effects:
GERD ( common).
Myalgia,arthralgia.
Jaw neck necrosis (rare but serious ).
Atrial fibrillation.
Estrogen:
Estrogen therapy alone or with a progestin is
indicated for the prevention of osteoporosis only.
However, because of the potential risks of
estrogen, the FDA recommends that if a woman
doesn’t have menopausal symptoms,
nonestrogen treaments should be carefully
considered before using estrogen therapy solely
for the prevention of postmenopausal
osteoporosis.
SERM:
It selectively binds to estrogen receptors and
inhibits bone resorption.
Raloxifene is FDA-Approved for both the
prevention and the treatment of osteoporosis.
Although Raloxifene decreases the risk of
vertebral fractures,there is no evidence that it
decreases the risk of nonvertebral fractures
including the hip.
How long should treatment continue?
It remains unclear whether anti-fracture
efficacy is sustained beyond 3-5 yrs.
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
bisphosphonates.
When we should re-evaluate ??
It is generally recommended tht central DEXA
be repeated no less than 2 years from initiation
or change in drug therapy to detect significant
changes in BMD.
It is also important to note that drug therapy
may decrease fracture risk without an apparent
increase in BMD.
IN CONCLUSION
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.
CASE 1
A 61-year old white postmenopausal woman
comes to your office for routine health
examination.She has a history of
osteoarthritis , she smokes 1 pack of cigarettes
Per day.She fractured her left wrist at age of 50
after falling down some stairs.Her diet is low at
calcium-rich food.She is on no medication except
calcium.Her physical examination is normal.
Q.1
You believe that she is at risk for osteoporosis the test of choice is ?
A.Ultrasound
B.Peripheral DEXA.
C.Central DEXA.
D.Plain X-ray.
E.Quantitative CT scan.
Q.2 You order a central DEXA scan to the patient and scan returns
with T score of -1.3 for the lumbar spine and -1.9 for the total
hip.What do you recommend to the patient at this time?
A.No action needed.
B.Repeat DEXA in 6 months.
C.Recommend adequate Ca intake, weight bearing exercise .
D.Recommend adequate Ca intake, weight bearing exercise and
bisphosphonates.
E.Recommend adequate Ca intake , weight bearing exercise and
calcitonin.
Q.3
Which of the following is not an established major
risk factor for osteoporosis?
A.Low body weight
B.Current smoking.
C.History of fragility fracture in 1st degree relative.
D.Low calcium intake.
E.Chronic use of steroids.
Q.4
Which of the following is in not an associated
risk factor for osteoporosis?
A.COPD
B.HyperPTH.
C.Cigarette smoking.
D.Obesity.
E.Excessive alcohol intake.
Q.5
What is the most common presenting fracture
in osteoporosis?
A.Wrist fracture (Colles fracture).
B.Vertebral compression fracure.
C.Femoral neck fracture.
D.Tibial fracture.
E.Femoral head fracture.
Q.6
Which of the following sites for osteoporotic
fracure is most commonly associated with
morbidity and mortality?
A.Ward’s triangle (hip).
B.Femoral neck ( hip).
C.Thoracic vertebrae (spine).
D.Lumbar vertebrae ( spine).
E.Distal radius (wrist).
Q.8
Which of the following is not recommended for
treatment of established osteoporosis?
A.Estrogen.
B.Calcium and Vitamin D.
C.Bisphosphonates.
D.SERMs.
E.Calcitonin.
Q.9
Which of the following studies may be indicated
in an asymptomatic patient recently diagnosed
with osteoporosis?
A.24-hr urine calcium.
B.Serum 25-hydroxy vitamin D.
c.PTH.
D.TSH.
E.All of the above.
CASE 2
A 32 years old woman is seeing because her mother as been diagnosed with osteoporosis.She asks you what type of exercise will help her prevent the development of the disease.According to the recommendations,which of the following excercises is most appropriate to help her maintain bone mass??
A.Tennis.
B.Swimming.
C.Cycling.
D.Skating.
E.Skiing.
CASE 3
You are treating an elderly postmenopausal woman with osteoporosis . She recently suffered an acute osteoporotic vertebral fracture and is suffering from secondary pain.Which of the following treaments alo has an analgesic effects with respect to bone pain?
A.Estrogen.
B.Combination of calcium & Vitamin D.
C.Calcitonin.
D.Alendronate.
E.Raloxifene.
CASE 4
You have just diagnosed osteoporosis in a postmenopausal woman.She is considering treatment alternatives and wonders about the bisphosphonates.Which of the following is the best description of how this class of medication works?
A.They increase calcium absorption in the GI tract.
B.They block the activity of the cytokines that stimulates bone reabsorption.
C.They bind to bone surfaces to inhibit osteoclast activity.
D.They stimulate osteoblasts and increase bone formation.
E.They mimic estrogen’s effect on bone.
Answers:
Case 1
Q1 c Q4 d Q7 a
Q2 d Q5 b Q8 a
Q3 d Q6 b Q9 e
CASE 2 answer is a
CASE 3 answer is c
CASE 4 answer is c
Thank you