Webinar on Osteoporosis by Hinduja Hospital
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Transcript of Webinar on Osteoporosis by Hinduja Hospital
Osteoporosis
Dr. Uday PawarJunior Spine Consultant
DNB Orthopaedic
Hinduja Hospital, Mahim, Mumbai
http://www.hindujahospital.com/dr-uday-pawar/
With age comes wisdom………..
and Osteoporosis
What is osteoporosis ?
Normal Osteoprosis
Jargon buster………
• Softening of bones …….
• A reduction in the quantity and quality of bones
What is osteoporosis
• A condition rather than a disease
• Silent until complications arise
• Spine, hip & wrist fractures
WHO criteria for diagnosis of Osteoporosis
Kanis et al. J Bone Miner Res 1994; 9:1137-41
T-scoreNormal - 1.0 and above
Osteopaenia - 1.0 to - 2.5
Osteoporosis - 2.5 and below
Severe (established) osteoporosis
- 2.5 and below, plus one or more osteoporotic
fracture(s)
Food for thought…..
1. Osteoporosis ≠ Calcium deficiency
• So, calcium is NOT the treatment of osteoporosis
• Bone mineral v/s bone mass
2. Osteoporosis is a generalized disease
• affects all the bones
3. Treating osteoporosis
• Prevention is the only treatment of osteoporosis
• Hence early diagnosis is the most important step in treating osteoporosis !
Size of the Problem in India
• 26 million (2003) 36 million by 2013
• 1 out of 8 males and 1 out of 3 females suffers from osteoporosis
• The high incidence among men and the lower age of peak incidence compared to Western countries
• Peak incidence of osteoporosis – Western countries-70-80 years of age– India –50-60 years
International Osteoporosis Foundation
The Magnitude Of The ProblemIn women > 50 years, the lifetime risk of:• Vertebral fracture is 1/3• Hip fracture is 1/5
NICE guidance 160 October 2008
Osteoporotic Fractures in Women: Comparison with Other Diseases
1 500 000*
0
500
1000
1500
2000
Osteoporotic Fractures
*annual incidence all ages † annual estimate women 29+
‡annual estimate women 30+ §1996 new cases, all ages
513 000†
228 000‡184 300§
750 000 vertebral
250 000 other sites
250 000forearm
250 000hip
HeartAttack
Stroke BreastCancer
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Riggs BL, Melton LJ. Bone 1995Heart and Stroke Facts, 1996, American Heart AssociationCancer Facts & Figures, 1996, American Cancer Society
Osteoporosis affects entire skeleton
• Osteoporosis is responsible for >1.5 million vertebral and non-vertebral fractures per year
• Spine, hip, and wrist fractures are most common
Morbidity associated with Fractures
Osteoporosis: Classification
• Primary OsteoporosisType 1- Post menopausal osteoporosisType 2- Senile/Age related osteoporosis
• Secondary OsteoporosisSecondary to various causes
17
Consequences
Reduced quality of life
How is osteoporosis diagnosed
Diagnosis is made on the basis of-
• Detailed medical history• Examination• Blood and other tests
Early diagnosis of Osteoporosis
• Clinical parameters– ‘at risk’ subject– Bone pains– Generalized tiredness– Progressive kyphosis
• Investigations– Radiographs– DEXA– QCT, MRI, Bone scan– Blood markers
Clinical Risk Fractures (CRF)
Predictors of low bone mass-• Female• Advanced age• Low bone mineral density• Gonadal hormone deficiency ( estrogen or testosterone )• White race• Low body weight & BMI• Family history of osteoporosis• Low calcium intake• Smoking / excessive alcohol intake• Low level of physical activity• Chronic glucocorticoid use• Prior fragility fracture
National Osteoporosis Foundation (NOF)
Clinical Presentation
• Severe backache after minor injury• Pain worse on sneezing, coughing , standing
erect, changing positions.• Limited to wheelchair• Stooped Posture• Weakness in legs
X-rays
• Osteopenia• Loss of height of vertebral
body• Wedging
Osteoporosis – RadiographicOsteoporosis – RadiographicDifferential DiagnosisDifferential Diagnosis
• Osteomalacia• Hyperparathyroidism• Hypercortisolism• Hyperthyroidism• Renal insufficiency• Chronic immobilization
• Osteogenesis imperfecta• Hepatic insufficiency• Diabetes mellitus• Multiple myeloma• Metastatic disease• Drug induced
Osteoporosis other causesOsteoporosis other causes
Assessment of bone mineral density by DXACurrent gold standard for diagnosis of osteoporosis
BMD (g/cm2) = Bone mineral content (g) / area (cm2)
Diagnosis based on comparing patient’s BMD to that of young, healthy individuals of same sex
• Blood count , CRP • Calcium, Phosphate, Alkaline
Phosphatase (AP)• Kidney function studies• Basal Thyroid and parathyroid.• Protein-immunoelectrophoresis.• Vit D (25 and 1.25)
Laboratory tests*
NOTES:
- * These are in addition to routine labs tests.
- These are screening labs, more may be indicated based on these results
Preventing Osteoporosis
alciumalciumCCCC
DDDDVitaminVitamin
xercisexerciseEEEE
FFFFPreventPrevent allsalls
ain weightain weightGGGG
StopStop mokingmokingSSSS
Modifiable Risk Factors
Vit D
CalciumExercise
Quit Alcohol Quit Smoking
Non-modifiable Risk Factors
• Older age• Female gender• Ethnic background • Small bone structure • Family history of osteoporosis or osteoporosis-related fracture in a parent
or siblings• Previous fracture• Menopause/hysterectomy• Some medicines like steroids, anti-epileptics• Rheumatoid arthritis• Reduced levels of Gonadal hormones in men
Treatments of osteoporosis• Calcium and vitamin D
• HRT
• SERMs (raloxifene)• Calcitonin• Bisphosphonates
– ibandronateibandronate
– etidronate etidronate
– alendronatealendronate
– risedronate risedronate • PTH (1–34) • Fluoride
• Strontium ranelate• Combination
Hormonal agentsHormonal agents
Anti-resorptive Anti-resorptive agentsagents
Anabolic agents Anabolic agents
Dual mechanism of Dual mechanism of actionaction
SERMs = selective oestrogen receptor modulatorsSERMs = selective oestrogen receptor modulatorsPTH = parathyroid hormonePTH = parathyroid hormone
How much and which Calcium??
• 1000-1500mg “elemental calcium”
Type of calcium Elemental Calcium
Calcium carbonate 40%Calcium gluconate 9%Calcium lactate 13%Calcium citrate 20-30%Calcium acetate 30%Micro cryst HA complex 100%
◦ May be difficult to attain those levels.◦ To try a combination of diet and medicines◦ Can’t give more than 500mg elemental calcium as tabs at a single dose
Bisphoshonates
• Etidronate, Alendronate, Risendronate, Ibandronate, Zolendronate
– Anti resorptive agents
– Reduce osteoclasis
Bisphoshonates
• Induce apoptosis (self destruction) in the osteoclasts
• Thus it reduces bone resorption
Bisphoshonates
• On this ‘preserved’ lattice – mineralization takes place
• Thus ‘better mineralized’ bone is formed and DEXA improves
Teriparatide (PTH)
• In small / pulse doses, is a powerful stimulant for bone formation
• The only drug that can induce osteogenesis
Teriparatide
• Teriparatide stimulates formation of new bone matrix / framework
Teriparatide
• On this denser, better structured matrix, mineralization takes place giving rise to an overall stronger bone
Bon
e S
tren
gth
(Mas
s +
Qua
lity
)
Time
Effect of Anabolic vs Anti-resorptives on Bone Strength
Anabolic‘Laying down new bone’
Anti-resorptive‘reducing bone resorption’
Treatment with PTH(woman 69 years)
Dempster DW et al, J Bone Miner Res, 2001;16:1846-1853
Before CtTh: 0.32 mmCD: 2.9 mm3
After CtTh: 0.42 mmCD: 4.6 mm3
1 5 10
1520
25 30
Ser Val Ser Glu Ile Gln Leu Met His Asn
Leu
Gly
LysHisLeuAsnSerMetGluArgValGlu
Trp
Leu
Arg Lys Lys Leu Gln Asp Val His Asn Phe
Take home points…
• No longer a problem of the WEST
• Awareness essential amongst general public
• Prevention is the best treatment
• Moms and grandmoms vulnerable group
OPD Schedule: Tue- 1500 to 1600 hours, Thu- 0900 to 1100 hours, Sat- 1100 to 1300 hours
Appointment Helpline: 022-39818181/67668181/24451515
For any Queries, please write us on: [email protected]
Thank You