Osteopenia refers to decreased bone mass. Osteoporosis refers to osteopenia (reduced bone strength/mass) that is severe enough to increase the risk of fracture. According to WHO, osteoporosis is defined as bone mineral density that falls 2.5 standard deviation below mean for young healthy adult of same sex and race. Osteoporosis associated fractures : These are adulthood fractures of any bones (chiefly hip and vertebral fractures) in the setting of trauma less than or equal to fall from standing height with exception of fingers, toes, face and skull. Drugs associated with osteoporosis Alcohol Glucocorticoids Anticoagulants Anticonvulsants Chemotherapy Excess thyroxine Endocrine disorders Cushing syndrome Hyperparathyroidism Thyrotoxicosis Diabetes mellitus (both type I and II) Acromegaly CATEGORIZATION OF OSTEOPOROSIS A.Primary Idiopathic Postmenopausal Senile/age related B. Secondary (Diseases) Hypogonadal state, endocrine disorders, nutritional and gastrointestinal disorders, rheumatologic disorders, hematological disorders/malignancy, inherited disorders and others. Usually asymptomatic until fracture occurs Vertebral and hip fracture common by simple fall Loss of height due to multiple vertebral fracture and other deformities like lordoisis, kyphoscoliosis. Fracture of femur neck, pelvis or spine causes deep vein thrombosis and pulmonary embolism, pneumonia. INVESTIGATIONS FOR OSTEOPOROSIS DXA (Dual energy X-ray absorptiometry) Quantitative CT Ultrasound Urea, creatinine and electrolytes Liver function test and albumin Renal function test Full blood count, ESR Serum calcium and phosphate Serum vitamin D and alkaline phosphate Serum PTH Thyroid function test Testosterone, estrogen and gonadotropins Serum cortisol Bone biopsy Plain radiography not diagnostic Following non pharmacological approaches are taken: Exercise Appropriate calcium and vitamin D intake (Calcium 1000mg/day and vitamin D 800 IU/daily) Cessation of smoking Limit/ Quit alcohol intake Get up and go exercise Hip protectors to reduce the risk of fracture. Pharmacological agents Bisphosphonates ( decrease osteoclast activity) Postmenopausal hormone replacement therapy Denusumab (anti- RANKL antibody) Anti- sclerostin antibodies Cathepsin k antibodies

1. OSTEOPENIA AND OSTEOPOROSIS
Medical MADE EASY

2. OSTEOPENIA AND OSTEOPOROSIS
Osteopenia refers to decreased bone mass.
Osteoporosis refers to osteopenia (reduced bone strength/mass) that is severe enough to increase the risk of fracture.
According to WHO, osteoporosis is defined as bone mineral density that falls 2.5 standard deviation below mean for young
healthy adult of same sex and race.
Modifiable risk factors od osteoporosis
 Cigarette smoking
 Estrogen deficiency( most common-
postmenopausal)
 Low calcium and vitamin D diet
 Alcoholism
 Inadequate physical exercise

3. EPIDEMIOLOGY
 Most common bone disease.
 Approximately 8.9 million fractures occur annually worldwide and most of them are osteoporosis
associated fractures.
 1/3 of women and 1/5 of men after the age of 50 suffer from such fracture.
 Most common are postmenopausal and senile osteoporosis.
 Occurs mostly in elderly female but can occur in both sexes with underlying disease and risk factors.
 In women, loss of ovarian function after menopause( > 50 years of age) leads to rapid bone loss
with risk of osteoporosis by the age of 70-80.
Endocrine disorders
 Cushing syndrome
 Hyperparathyroidism
 Thyrotoxicosis
 Diabetes mellitus (both type
I and II)
 Acromegaly
Selected inherited disorders
 Osteogenesis imperfecta
 Marfans’s syndrome
 Hemochromatosis
 Glycogen storage disease
 Homocystinuria
 Ehlers- Danlos syndrome
 Epidermolysis bullosa
CATEGORIZATION OF OSTEOPOROSIS
A. Primary
1. Idiopathic
2. Postmenopausal
3. Senile/age related
B. Secondary (Diseases)
Hypogonadal state, endocrine disorders,
nutritional and gastrointestinal disorders,
rheumatologic disorders, hematological
disorders/malignancy, inherited disorders and
others.
Drugs associated with
osteoporosis
 Alcohol
 Glucocorticoids
 Anticoagulants
 Anticonvulsants
 Chemotherapy
 Excess thyroxine
Hypogonadal states
 Turner’s syndrome
 Klinefelter’s syndrome
 Hypothalamic amenorrhea
 Anorexia nervosa
 Hyperprolactinaemia
Hematological disorders/ malignancy
 Multiple myeloma
 Lymphoma and leukemia
 Mastocytosis
Nutritional and gastrointestinal disorders
 Malnutrition
 Malabsorption syndrome
 Gastrectomy
 Parenteral nutrition
 Pernicious anemia
 Biliary cirrhosis
Others
 Immobilization
 COPD
 Pregnancy and lactation
 Sarcoidosis and amyloidosis
 Multiple sclerosis
Rheumatologic disorders
 Rheumatoid arthritis
 Ankolysing spondylitis

4. PATHOPHYSIOLOGY
Peak bone mass or bone mineral density (BMD) is determined by hereditary
factors, physical exercise, muscle strength, diet and hormonal status.
Following are the well known theories regarding the pathogenesis of
osteoporosis.
a. Age related changes (senile):
Osteoblasts of older individuals are less active than that of younger
population. So there is diminished bone matrix formation in elderly people.
This is known as senile osteoporosis.
b. Reduced physical exercise :
Experimentally, it is seen that reduced physical exercise increases the rate of
bone loss.
There is bone loss in :
- Elderly people with diminished physical work
- Immobilized or paralyzed part of body
- Astronauts in zero gravity for prolonged time.
There is high bone mineral density in athletes.
It is seen that load magnitude of physical exercise increases bone density
than the number of load cycles. It implies that weight training are more
effective for increasing bone mass than repetition of exercise.
c. Genetic factor
 Defect in LRP5 gene
 Over expression of RANKL and RANK receptor and less
expression of osteoprotegerin stimulates osteoclast
formation and recruitment leading to bone resorption.
d. Calcium and vitamin D nutritional state
Lack of calcium and vitamin D during growing age of life
increases the risk of osteoporosis in later life. Lack of calcium,
increases PTH and reduced vitamin D level contribute to
osteoporosis.
e. Hormonal influence
Postmenopausal osteoporosis is due to estrogen deficiency as a
result of cessation of ovarian function. Decreased level of
estrogen increases the release of inflammatory cytokines like IL-
1, IL-6, TNF that in turn, increases the production of RANKL,
RANK receptor and reduces the expression of osteoprotegerin,
increasing osteoclast formation and recruitment.

5. CLINICAL FEATURES OF OSTEOPOROSIS
 Usually asymptomatic until
fracture occurs
 Vertebral and hip fracture
common by simple fall
 Loss of height due to
multiple vertebral fracture
and other deformities like
lordoisis, kyphoscoliosis.
 Fracture of femur neck,
pelvis or spine causes deep
vein thrombosis and
pulmonary embolism,
pneumonia.

6. INVESTIGATIONS FOR OSTEOPOROSIS
 DXA (Dual energy X-ray absorptiometry)
 Quantitative CT
 Ultrasound
 Urea, creatinine and electrolytes
 Liver function test and albumin
 Renal function test
 Full blood count, ESR
 Serum calcium and phosphate
 Serum vitamin D and alkaline phosphate
 Serum PTH
 Thyroid function test
 Testosterone, estrogen and gonadotropins
 Serum cortisol
 Bone biopsy
 Plain radiography not diagnostic
ALGORITHM FOR THE INVESTIGATION OF PATIENTS WITH OSTEOPOROSIS
Osteopenia
Screen for
secondary
cause
Age >50
Low trauma fracture
Age>50
Fracture risk> 10%
DXA spine and hip
Age<50
Very strong risk
factors
Normal
Reassess at later
date
Correct
modifiable risk
factors
Correct
modifiable
factors + give
drugs
Osteoporosis

7. TREATMENT AND PREVENTION OF OSTEOPOROSIS
Aim is to reduce the risk of fractures.
Following non pharmacological approaches are taken:
1. Exercise
2. Appropriate calcium and vitamin D intake (Calcium 1000mg/day and vitamin D 800 IU/daily)
3. Cessation of smoking
4. Limit/ Quit alcohol intake
5. Get up and go exercise
6. Hip protectors to reduce the risk of fracture.
Surgical approach
 Orthopedic surgery with internal
fixation to stabilize osteoporotic
fractures.
 Hemiarthroplasty or total hip
replacement
 Vertebroplasty
Pharmacological agents
 Bisphosphonates ( decrease osteoclast activity)
 Postmenopausal hormone replacement therapy
 Denusumab (anti- RANKL antibody)
 Anti- sclerostin antibodies
 Cathepsin k antibodies