2. Definition
National Osteoporosis Foundation:
“A disease characterized by, low bone mass,and
micro-architectural deterioration of bone
tissue, leading to bone fragility and an
increased susceptibility to fractures.”
5. Composition of bone
Bone has both Organic and Inorganic
components.
Organic part - consists mainly of protein
collagen & specialized cells called
osteoclasts, osteoblasts, and osteocytes
Inorganic part - consists mainly of calcium
phosphate.
9. • We are born with about 300 soft bones.
During childhood and adolescence, cartilage
grows and is slowly replaced by hard bone.
Some of these bones then later fuse together,
resulting in an adult skeleton with 206 bones.
10. Different bone cells
Osteoblasts and Osteocytes: these are bone forming cells
Osteoclasts: these are bone resorbing cells
Osteoid: this is the non-mineral, organic part of the bone matrix made of
collagen and non-collagenous proteins
Inorganic mineral salts deposited within the matrix
11. The combined processes of breaking down bone and
building new bone are called Bone Remodeling.
It is the body’s way of maintaining bone homeostasis.
5 Stages:
Initiation,
Resorption,
Reversal,
Bone formation and
Completion of remodeling.
12. Bone Homeostasis:
Situation when body requires,
and achieves an equal amount
of bone resorption and bone
formation.
Amount of bone eroded by
osteoclasts is equal to
amount of bone produced by
osteoblasts, thereby producing
a stable net mass of bone in the
body.
Homeostasis
15. Remodelling is the replacement of old tissue by, new bone tissue and
continues,throughout life.So most of the adult skeleton is replaced about every 10
years. This process involves,the coupling of bone formation and bone resorption
and consists of five phases as shown below.
Osteoblast became
active
Osteoblast
Synthesize new
matrix
21. Worldwide, over age of 50
1 in 3 women / 1 in 8 men have
osteoporosis.
80 % of those suffering from
osteoporosis are women.
Affects 75 million persons in the
US, Europe and Japan.
Osteoporosis is responsible for
1.3 millions fractures each year.
Prevalence…
22. Prevalence…
Approximately 1 in 2 women and 1 in 4 men over
age 50 will have an osteoporosis related fracture
in their remaining lifetime.
24. Risk factors
Being Female
With the onset of
menopause (mid-forties
or fifties), diminishing
estrogen levels lead to
excessive bone
resorption that is not
fully compensated by
an increase in bone
formation
25. • Being female
• Older age
• Family history of osteoporosis.
• History of broken bones
• Low sex hormones
– Low estrogen levels in women,
including menopause
– Missing periods (amenorrhea)
– Low levels of testosterone in
male.
Risk factors…
26. • Diet
– Low calcium intake
– Low vitamin D intake
– Excessive intake of protein,
sodium and caffeine
• Inactive lifestyle
• Smoking , Alcohol abuse
Risk factors…
27. • Certain medications
– steroid, anticonvulsants
etc
• Certain diseases
– anorexia nervosa,
rheumatoid arthritis,
gastrointestinal
diseases and others
Risk factors…
31. • Vertebral (spinal) fractures may
initially be felt or seen in the form of
• Persistent, unexplained back pain
• Loss of height
• Spinal deformities such as
kyphosis or stooped posture.
Presentations…
34. Diagnosis
• Bone mineral density (BMD) tests can
measure bone density in various sites
of the body.
• BMD also predicts fracture risk.
• For patients on pharmacotherapy, it is
performed 2 years after initiating
therapy and every 2 years thereafter.
35. X-Ray
• Post menopausal
osteoporosis :Trabecular
resorption and cortical
resorption
• Senile osteoporosis: Endosteal
resorption
• Hyperparathyroidism: Sub
periosteal resorption
• Note: Osteoporosis produces
increased radiolucency of
vertebral bone. Approximately
30 to 80 %of bone tissue must
be lost before a recognizable
abnormality can be detected on
spinal radiographs.
37. Subperiosteal resrption
• Hyperparathyroidism:
• Subperiosteal bone resorption
• Subperiosteal resorption at the joint
corners (arrows) is continuous with
intra-articular erosions, resulting in a
squared appearance of the phalanx.
38. • X-ray : thinning of
bone trabaculae +
generalized
rarefaction
• In spinal column:
osteoporotic
compression
fracture may be
seen in vertebrae
39. Dual-energy X-ray Absorptiometry (DXA) Scan
• “Gold-standard” for BMD measurement.
• Measures “central” or “axial” skeletal sites: spine and
hip.
• May measure other sites: total body and forearm.
40. Principle
The DXA machine sends a thin, invisible beam of low-dose x-rays
with two distinct energy peaks through the bones being
examined. One peak is absorbed mainly by soft tissue and the
other by bone. The soft tissue amount can be subtracted from
the total and what remains is a patient's bone mineral density.
45. • The soft tissue amount is
subtracted from the total and
what remains, is a patient's
bone mineral density.
46. DXA scans can also be used to measure total body
composition and fat content.
From two
different
beam ,one
is peaked
by soft
tissue.
And other
beam is peaked
by bones.
47. DXA Fat shadow of a child with rare congenital
generalized lipodystrophy
48. • T-scores---- compare your bone density with
that of a young adult.
• While z-scores---- compare your bone density
with that of your peer group.
49. Z score
• This score is more useful for diagnosing secondary osteoporosis, especially
for children and younger adults.
• If you have a high z-score, you may be referred to an endocrinologist to
look at secondary causes of osteoporosis, which may include:
• gastrointestinal diseases
• autoimmune conditions
• kidney conditions
• medications
50. Z-score range Description
-1.5 and above typical bone density for peer group
Lower than -1.5 atypical BMD, needs investigation
57. • FRACTURE RISK ASSESSMENT TOOL (FRAX®)
• The FRAX®
tool was developed by Centre for Metabolic
Bone Diseases (1991-2010) at the University of Sheffield.
• Launched in 2008 following approximately 10 years of
meta-analyses of a variety of risk factors for
osteoporotic fracture.
• Although not the only fracture prediction tool but,
FRAX®
is the only risk calculator which indicates rates of
fracture and mortality per individual country and
identify a risk associated to available treatments.
59. Complications
FRACTURE ,
The most serious complication of
Osteoporosis that leads to
Increased morbidity
Increased mortality
Decreased quality of life
60. Complications…
• Women with hip fracture are at a fourfold
greater risk of a second one.
• 1 in 4 (25%) people die within a year of the
fracture
•1 in 4 become disabled
• 2 of the 4 can walk again but, with lower mobility
than before.
• Many become isolated and depressed.
62. Lumbosacral support
:or a more rigid type
of brace provides,
localized support,
decreases pain,and
attempt to realign
the vertebrae
Orthotics
CASH brace
63. • Prevent further bone loss
• Increase or at least stabilize bone density.
• Relieve pain and prevent fracture.
• Increase level of physical functioning
• Increase quality of life
Goals of management
65. Page 65
Decrease
Fracture
Risk
Lifestyle
Modifications
Minimizing factors that
contribute to falls
Modification of risk
factors (diet, exercise)
NAMS Position Statement. Menopause. 2006;13:340-367.
Heaney, RP. Bone. 2003;33:457-465.
Siris ES, et al. Mayo Clin Proc. 2006;81:1013-1022.
Therapeutic
Interventions
Slowing/stopping
bone loss
Maintaining or
increasing bone
density and strength
Maintaining or
improving bone
microarchitecture
Improving medication
adherence
66. • Men age 50–70 should consume 1000 mg/day
of calcium.
• Women age 51 and older and men age 71 and
older consume 1200 mg/day of calcium.
• Intakes in excess of 1200 to 1500 mg/day may
increase the risk of developing kidney stones,
cardiovascular disease, and stroke.
PHARMACOLOGICAL PREVENTION
OF OSTEOPOROSIS
67. VIT D
• 800 to 1000 international units
(IU) of vitamin D per day for
adults age 50 and older.
• Treatment of vitamin D
deficiency-
Adults should be treated with
50,000 IU once a week or the
equivalent daily dose (7000 IU
vitamin D2 or vitamin D3)
for8–12 weeks to achieve a 25(OH)D
blood level of
approximately 30 ng/ml.
This regimen should be followed by
maintenance therapy of 1500–
2000 IU/day.
68. • Alendronate-
• prevention -5 mg daily and
35 mg weekly tablets.
• treatment -10 mg daily tablet,
70 mg weekly tablet.
• Alendronate is also used in
treatment of osteoporosis in
men and women taking
glucocorticoids.
69. • Ibandronate-
• Treatment-150 mg
monthly tablet and 3 mg
every 3 months by
intravenous injection.
• Risedronate-
• prevention and
treatment -5 mg daily
tablet; 35 mg weekly
tablet ,150 mg monthly
tablet.
70. • Zoledronic acid
• prevention and treatment -5 mg
by intravenous infusion over at
least 15 min once yearly for
treatment and once every 2 years
for prevention.
• Drug administration-
• Oral tablets should be taken early
morning on empty stomach, 6o
mins before breakfast ,and
patient should sit upright for 1 hr.
71. Bisphosphonates work by inhibiting osteoclast activity, the cells responsible for bone
resorption, thereby reducing bone breakdown and increasing bone density. This is
achieved through two main mechanisms: inhibiting the mevalonate pathway or
inducing osteoclast apoptosis.
72. Hormone replacement Therapy
• For many years, HRT was the only therapeutic available
for the management of osteoporosis.
• HRT patients were found to be at a significantly
increased risk of
• Breast cancer
• Coronary heart disease
• Stroke and embolism
• HRT is no more considered as the first-line therapy for
the management of osteoporosis/osteoporotic fracture
75. Prevention of complications
•Exercise/activity programs to improve strength and
endurance
•Gait training
•Awareness creation to prevent slipping
•Regular medical check-up
•Treat medical conditions, e.g., as postural
hypotension, anemia, dementia
•Alarm systems, assistive devices
78. • A new class of osteoporosis
treatments, sclerostin inhibitors, like
romosozumab (Evenity), are now
available. These medications work by
increasing bone formation and slowing
down bone breakdown.
• Romosozumab is administered as a
monthly injection and is limited to one
year of treatment. To maintain bone
health after romosozumab treatment,
patients are typically switched to a bone-
stabilizing medication like a
Newer treatment
83. Be active
Being active really
helps our bones by :
• slowing bone loss
• improving muscle strength
• helping your balance
84. • Building strong bones in childhood and adolescence,
best defense
• A balanced diet rich in calcium and Vitamin D
• Weight bearing exercise
• Avoidance of tobacco smoking and
excessive alcohol intake
• Bone density testing and medication
when appropriate.
85. “Forty is the old age of youth,
fifty is the youth of old age. “
Older age
#65:In considering the patient with risk for osteoporotic fracture, review of non-pharmacologic and pharmacologic interventions provide a holistic approach.
Lifestyle modifications1,2
Minimizing factors that contribute to falls: According to the National Osteoporosis Foundation (NOF), falls may reflect impaired balance and neuromuscular weakness. Increased strength training may mitigate future falls and risk for low trauma fracture. In addition, the NOF recommends developing strategies for fall prevention.
Modification of risk factors: Risk factors that may be modifiable include tobacco and excessive alcohol use, low calcium and vitamin D intake, low endogenous estrogen, and low physical activity.
Therapeutic Interventions3-5
Improving Medication Adherence: Medication adherence with treatment for postmenopausal osteoporosis, including weekly oral bisphosphonates, is low.
A recent study associated decreased adherence to bisphosphonates with increased risk for osteoporotic fracture.
Bone microarchitecture and bone density are key components of bone strength and therefore important to mitigate fracture risk.
Slowing/stopping bone loss: Antiresorptive therapies, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, work by decreasing bone remodeling, thus permitting preservation of existing bone. In contrast, teriparatide increases new bone formation.
NAMS Position Statement. Menopause. 2006;13:340-367.
National Osteoporosis Foundation. Available at: www.nof.org. Accessed July 15, 2007.
Heaney, RP. Bone. 2003;33:457-465.
NIH Consensus Development Panel on Osteoporosis. JAMA. 2001;285:785-795.
Siris ES, et al. Mayo Clin Proc. 2006;81:1013-1022.
