Everything you should know about Osteoporosis? What is Osteoporosis? Osteoporosis is a disorder of bones characterized by low bone density and a deterioration of bone micro- architecture that enhances bone fragility and increases the risk of fracture Osteoporosis becomes a serious health threat for aging men & postmenopausal women by predisposing them to an increased risk of fracture Do you know that? Osteoporosis is responsible for >1.5 million vertebral and non-vertebral fractures per year Spine, hip, and wrist fractures are most common.

1. Osteoporosis
Prevention and Management

2. What is Osteoporosis?
Osteoporosis is a disorder of bones characterized by low bone density
and a deterioration of bone micro- architecture that enhances bone
fragility and increases the risk of fracture

3. Osteoporosis:
Nightmare Of Post-menopause/ Old Age
Normal vs Osteoporotic Bone

4. Burden of Osteoporosis
• Osteoporosis becomes a serious health threat for aging men &
postmenopausal women by predisposing them to an increased risk of
fracture
• Osteoporotic fractures are associated with substantial morbidity and
mortality in the elderly, especially older women
• In women over 45, osteoporosis accounts for more days spent in hospital
than many other diseases, including diabetes, myocardial infarction and
breast cancer1
• It is estimated that only one out of three vertebral fractures come to clinical
attention2

5. Epidemiology
More common in women than in men & affects 200 million
women worldwide4
 1/3 of women aged 60 to 70
 2/3 of women aged 80 or older
Approximately one in five men over the age of 50 will have
an osteoporosis-related fracture in their remaining lifetime4
Approximately 30% of women over the age of 50 have one
or more vertebral fractures5
Women with vertebral fractures have a 5-fold increased risk
of a new vertebral fracture and a 2-fold increased risk of hip
fracture10, 11
One woman in five will suffer from another vertebral
fracture within a year12

6. 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

7. Common Sites of fracture
Hip
Vertebral column
Wrist

8. Incidence Rates for Vertebral, Wrist & Hip Fractures
in Women after Age 50
50 60 70 80
40
30
20
10
Vertebrae
Hip
Wrist
Age (Years)
Annualincidenceper
1000women
6. Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999

9. 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
250 000
forearm
250 000
hip
Heart
Attack
Stroke Breast
Cancer
Annualincidencex1000
7. Riggs BL, Melton LJ. Bone 1995
8. Heart and Stroke Facts, 1996, American Heart Association
9. Cancer Facts & Figures, 1996, American Cancer Society

10. Morbidity associated with Fractures

11. Projected number of osteoporotic hip
fractures
Total number of
hip fractures:
1950 = 1.66 million
2050 = 6.26 million

12. A Retrospective Study Suggests that
Vertebral Fractures are Under-Diagnosed
934 hospitalised women
with a lateral chest x-ray
0
20
40
60
80
100
120
140
Patients(n)
132
65
23 25
Fracture
identified
by study
radiologists
Fracture
noted in
radiology
report
Fracture
noted in
medical
record
Received
osteoporosis
treatment
Gehlbach et al.,Osteoporos Int 2000, 11:577

13. Osteoporosis in India
• 1 out of 8 males and 1 out of 3 females in India suffers from
osteoporosis, making India one of the largest affected
countries in the world
• Estimated number of osteoporosis patients is approximately 26
million (2003 figures) with the numbers projected to increase
to 36 million by 2013
• Important about osteoporosis in India- high incidence among
men and the lower age of peak incidence compared to
Western countries.
• The incidence of hip fracture is 1 woman to 1 man in India
• Peak incidence of osteoporosis in India is at about 50-60 years
of age, 10-20 years younger than west

14. Osteoporosis: Classification
 Primary Osteoporosis
 Type 1- Post menopausal osteoporosis
 Type 2- Senile/Age related osteoporosis
 Secondary Osteoporosis
 Secondary to various causes
14

15. Post-Menopausal Osteoporosis
 Caused by a lack of estrogens, which helps to regulate, the
incorporation of calcium into bone in women
 There is increased bone resorption
 Resultant disproportionate loss of trabecular bone results in
fractures at skeletal sites containing high levels of trabecular bone
e.g. spine, hip and distal forearms (colle's fracture)
15

16. Age Related/Senile Osteoporosis
• Usually affects people over age 70
• Results from age-related calcium deficiency and an imbalance
between the rate of bone break down and new bone formation
• There is decreased bone formation
• Patients usually present with fractures of the hip and the vertebrae
16

17. Secondary Osteoporosis
Congenital
Conditions
Homocystinuria; hemolytic anemia; hypophosphatasia;
osteogenesis imperfecta
Diet Calcium deficiency; malabsorption syndromes; scurvy;
starvation
Drugs Alcohol; anticonvulsants; cancer chemotherapy; excess thyroid
hormone; glucocorticoids; heparin; methotrexate
Endocrine
Disorders
Cushing's syndrome; growth hormone deficiency;
hypercortisolism; hyperparathyroidism; hyperthyroidism;
hypogonadism
Other Systemic
Disorders
Diabetes mellitus; leukemia; multiple myeloma; renal tubular
acidosis
Rheumatologic
disorders
Ankylosing spondylitis, rheumatoid arthritis
G.I. diseases Gastrectomy, primary biliary cirrhosis, celiac disease
17

18. Non-modifiable/Fixed 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

19. Modifiable Risk Factors
• Alcohol
• Smoking
• Poor nutrition
• Vitamin D deficiency/Lack of sunlight exposure
• Insufficient exercise
• Low calcium intake in food

20. Pathophysiology
• In Osteoporosis imbalance occurs between bone resorption and bone
formation
• This imbalance might occur as a result of one or a combination of the
following factors:
Increased bone resorption
Decreased bone formation
• A negative balance occurs and results in a net loss of bone
20

21. …Pathophysiology
• Bone remodeling depends on surface area
• Trabecular bone with its extensive surface has a more rapid turnover
than cortical bone
• The vertebrae, proximal femur, and distal radius are particularly
prone to osteoporotic fracture because these parts of the skeleton
contain a large proportion of trabecular bone
21

22. Osteoporosis related bone loss
• Osteoclasts erode the bone
• Osteoblasts try to replenish the bone loss
• When bone replacement is incomplete, the trabecular width
decreases
• In osteoporosis, extensive resorption perforates the trabeculae,
leaving fewer surfaces on which to build on & thus spaces within the
bone become larger
22

23. Peak bone mass & Osteoporosis
• Peak bone mass is the maximum mass of bone achieved by an
individual at skeletal maturity, typically between ages 25 and 35
• After peak bone mass is attained, both men and women lose bone
mass over the remainder of their lifetimes
• Because of the subsequent bone loss, peak bone mass is an
important factor in the development of osteoporosis
23

24. Peak Bone Mass in Women
24
10 20 30 40 50 60
•Women achieve lesser peak bone mass than men

25. Stages of Peak Bone Mass in Women
25

26. Determinants Of Peak Bone Mass
Peak Bone Mass
Physical activity Gonadal status
Nutritional statusGenetic factors

27. Signs & Symptoms
• In early stages usually no symptoms
• Therefore also known as silent disease
• There may be back pain due to spinal compression
• First sign may be fractures due to slight trauma or even due to
bending or lifting or rising
• If several vertebrae break, an abnormal curvature of spine (a
dowager's hump) may develop, causing muscle strain and soreness
• A loss of height by 4 to 8 inches may occur
27

28. Osteoporosis related bone loss
Vertebrae, which have a large proportion of trabecular bone, are
commonly the first sites to show bone loss in
Osteoporosis leading
to spine collapse
28

29. Backbone Deformity in Osteoporosis
Three generations of women in
a Korean village. The elderly
women have “hunched back”
which is a sign of vertebral
fractures caused by
osteoporosis

30. Differential Diagnoses
• Myeloma
• Other Problems to Be Considered
• Bony metastases
• Multiple myeloma
• Primary hyperparathyroidism
• Secondary hyperparathyroidism
• Osteomalacia
• Renal osteodystrophy
• Paget disease of bone

31. How is osteoporosis diagnosed
Diagnosis is made on the basis of
• Detailed medical history
• Physical examination
• Investigations

32. Bone Mineral Density (BMD)
• It is a simple test that measures bone
thickness/ density at different parts of
the body, like spine, hip etc
• It employs two x-ray beams of
different energy levels
• Dual energy x-ray absorptiometry
(DEXA) is the best current test to
measure bone density

33. Dual-energy x-ray absorptiometry

34. BMD Tests Other than DEXA
• Quantitative CT vertebral scanning
• Single photon and dual photon absorptiometry
• Peripheral DEXA

35. Indications for Bone Density test
All postmenopausal women <65 yr who have one or more additional risk factors for
osteoporosis, besides menopause
All women >65 yr regardless of additional risk factors
Documenting reduced bone density in a patient with a vertebral abnormality or
osteopenia on a radiograph
Estrogen-deficient women at risk for low bone density, considering use of estrogen
or an alternative therapy, if bone density would facilitate the decision
Women who have been on estrogen replacement therapy for prolonged periods or
to monitor the efficacy of a therapeutic intervention or interventions for
osteoporosis
Diagnosing low bone mass in glucocorticoid-treated individuals
Documenting low bone density in patients with asymptomatic primary or
secondary hyperparathyroidism

36. WHO Classification: T score
Normal
BMD or bone mineral content (BMC) not more than 1 SD
below the young adult mean (T-score above -1)
Osteopenia
BMD or BMC between 1 SD and 2.5 SD below the young
adult mean (T-score between -1 to-2.5)
Osteoporosis
BMD or BMC 2.5 SD or more below the young adult mean
(T-score at or below -2.5)
Severe osteoporosis (or established osteoporosis)
BMD or BMC 2.5 SD or more below the young adult mean in
the presence of one or more fragility fractures
36

37. Primary Prevention
Lifestyle changes may be the best way of preventing
osteoporosis:
 Adequate calcium in diet (roughly 1000-1500 mg/day, but
will depend on age)
 Adequate vitamin D (between 400-800 IU/day)
 Smoking cessation
 Avoiding excess alcohol intake
 Engaging in weight-bearing exercises
 Treat underlying medical conditions that can cause
osteoporosis
 Minimize or change medications that can cause osteoporosis

38. Pharmacological Therapy for Osteoporosis
• The National Osteoporosis Foundation recommends that
pharmacologic therapy should be reserved for postmenopausal
women and men aged 50 years or older who present with the
following:
• A hip or vertebral fracture (Vertebral fracture may clinical or morphometric
[ie, identified on a radiograph alone].)
• Other prior fractures and low bone mass (T-score between -1.0 and -2.5 at
the femoral neck, total hip, or spine)
• T-score less than -2.5 at the femoral neck, total hip, or spine after
appropriate evaluation to exclude secondary causes

39. • Low bone mass (T-score between -1.0 and -2.5 at the femoral neck, total hip,
or spine) and secondary causes associated with high risk of fracture (eg,
glucocorticoid use or total immobilization)
• Low bone mass (T-score between -1.0 and -2.5 at the femoral neck, total hip,
or spine) and (1) 10-year probability of hip fracture of 3% or more or (2) a 10-
year probability of any major osteoporosis-related fracture of 20% or more
based on the US-adapted WHO algorithm

40. Pharmacological Management Osteoporosis
 Calcium
 Vitamin D
 Estrogens/HRT
 Selective Estrogen Receptor Modulator (SERM)
 Raloxifene
 Bisphosphonates
 Teriparatide
 Calcitonin

41. Calcium
• Helps in restoring & maintaining bone mass
• Healthy pre-menopausal women over 30 years need a calcium intake
of about 1000mg/day
• Postmenopausal women need a calcium intake of about 1500 mg per
day
• Calcium absorption decreases in old age

42. Vitamin D
• It stimulates intestinal absorption of calcium
• Suppresses parathyroid hormone, thereby inhibits bone resorption
• Doses:
• 400IU per day until age 60,
• 600-800 IU per day after age 60

43. Oestrogen/ HRT
• Estrogen therapy alone or in combination with another hormone,
progestin, has been shown to decrease the risk of osteoporosis and
osteoporotic fractures in women
• Most effective when bone turnover is high and least effective when
bone turnover is low
• Therefore beneficial when administered soon after menopause when
the bone loss is at its highest

44. Oestrogen/ HRT
• Current recommendations for HRT are that it is most effective at the
time of menopause, or for conditions that confer a high risk of
osteoporosis e.g., premature menopause, gonadal deficiency, and
previous bone disease or corticosteroid therapy
• However, the combination of estrogen with a progestin has been
shown to increase the risk for breast cancer, strokes, heart attacks
and blood clots
• Estrogens alone may increase the risk of strokes

45. Selective Estrogen Receptor Modulators
(SERMs) : Raloxifene
• Approved for the prevention and treatment of postmenopausal
osteoporosis
• Raloxifene decreases spine fractures in women, and is currently
approved for use only in women
• Like estrogen, it decreases the risk of osteoporosis and osteoporotic
fractures in women
• Unlike estrogen they do not have some of the serious side effects
such as breast cancer
• Sometimes they may cause thromboembolism so therapy should be
discontinued temporarily if a person is immobilized for any reason

46. Bisphosphonates
• Used for prevention & treatment of osteoporosis
• Act on osteoclasts to decrease rate & extent of resorption
• Lead to +ve balance during bone remodeling
• There is increase in bone mass over a period of time & they have
been known to decrease the risk of fractures
• They must be taken on an empty stomach with water
• Because they have the potential for irritating the esophagus,
remaining upright for at least an hour after taking these medications
is recommended

47. Calcitonin
• This medication, a hormone made from the thyroid gland, is given
usually as a nasal spray or as an injection under the skin
• It is used for the management of postmenopausal osteoporosis and
helps prevent vertebral fractures
• It also is helpful in controlling pain after an osteoporotic vertebral
fracture
• Calcitonin lowers the calcium level by the inhibiting osteoclasts,
thereby decreasing bone resorption

48. Teriparatide
• Teriparatide is a form of parathyroid hormone that helps stimulate
bone formation
• It is approved for use in postmenopausal women and men at high risk
for osteoporotic fracture
• It is given as a daily injection under the skin and can be used for up to
2 years

49. Strontium Ranelate
 Strontium ranelate has a novel mechanism of action for an
osteoporosis drug
 It acts both on bone resorption to reduce the rate of bone and on
bone formation promoting the growth of new bone
 The recommended dose is 2 g daily and comes in the form of
granules to be taken as a suspension in a glass of water
 Given the slow absorption, it should be taken at bedtime, preferably
at least 2 hours after eating
 Food, milk and derivatives, and medicinal products containing
calcium may reduce bioavailability by 60% to 70% and so should be
avoided for at least 2 hours

50. Osteoporosis Therapy Algorithm
Postmenopausal Women
At Risk/Osteopenia Osteoporosis Severe OsteoporosisSTAGE
LowerHigher
-2.5BMD (T-score)
Raloxifene
PTH
CalcitoninHRT
HRT
During Hot
Flushes
Post Vasomotor Symptoms
Pre fracture
Post Fracture
Risk
of Fracture
AGE
Bisphosphonates Or
Strontium Ranelate
50 55 60 65 70 75 80 85 90

51. Latest in Osteoporosis Treatment
• Carotenoids, Lycopene Reduce Fracture Risk
“…reactive oxygen intermediates may be involved in the bone-
resorptive process and that fruit and vegetable-specific
antioxidants, such as carotenoids, are capable of decreasing
this oxidative stress. Therefore carotenoids may help in
preventing osteoporosis. In particular, an inverse relation of
carotenoids and lycopene with biochemical markers of bone
turnover has recently been demonstrated.”
J Bone Miner Res. 2009 Jun;24(6):1086-94.

52.  Omega-3 Fatty Acids Reduce hs-CRP1
 “This study provides evidence that in healthy individuals, plasma n-3 fatty
acid concentration is inversely related to hs-CRP…”
 “High sensitivity C-reactive protein (hs-CRP) is a marker of low grade
sustained inflammation.”
 “Increased hs-CRP by just 1SD increases fracture risk by an amazing 23
percent2.”
 Consider supplementing the diet with omega-3 fatty acids (fish oil). They’re
a great way to help reduce inflammation, hs-CRP, cardiovascular disease,
and fractures related to osteoporosis.
1. Micallef M A et al., European Journal of Clinical Nutrition, 2009; April 8 [Epub ahead of print].
2. Pasco et al. JAMA. 2006;296(11):1353-1355

53. • Vitamin K Improves Bone Strength and Reduces Fractures
• Review of RCTs showed that vitamin K(1) and vitamin K(2) supplementation
reduced serum undercarboxylated osteocalcin levels regardless of dose but
that it had inconsistent effects on serum total osteocalcin levels and no effect
on bone resorption.”
Iwamoto J et al., Nutrition Research, 2009; 29(4): 221-228.

54. Osteoporosis: Approach of GP
• Patients usually present with c/o back pain
• Treatment would usually be analgesics with calcium/vit D
• Patients with postmenopausal symptoms/ fragility # are usually
referred to specialists

55. What Is The Role of The Gynecologist ?
At Adolescent & Adult Age
 To achieve a peak bone mass
 Late menarche, Menstrual interruptions/irregularities, Pregnancy, Lactation
 To reduce bone loss secondary to drugs
 Gn Rh Analogue, Dopamine Agonist, Glucocortocoied, ??Depo-provera

56. What Is The Role of The Gynecologist ?
At Peri-menopause
 To prevent osteoporosis in high risk group
 Screening, management
At Early Post-menopause
 To treat post-menopausal symptoms
 To prevent osteoporosis
At Late Post-menopause
 To prevent age related osteoporosis (>65y)
 To treat osteoporosis related morbidities (usually with Orthopaedician)

57. Treatment Of Choice in Early Post- menopause:
HRT/SERM?
• As the patient has significant hot flushes and has no
contraindication…..
• HRT may be the option of choice
• As the patient has no significant menopausal signs and has no
contraindication/ women with cured breast cancer
• SERM may be the option of choice

58. Role of Rheumatologists/ Endocrinologists
• Rheumatologists or endocrinologists assist with management and
determination of underlying etiologies in complex cases

59. Role of Orthopaedicians
• Orthopaedicians assist with fracture management
• The goals of surgical treatment of osteoporotic fractures include
rapid mobilization and return to normal function and activities
• Fixation and stabilization of hip or wrist fracture
• Vertebroplasty to reduce vertebral fracture–associated pain
• Kyphoplasty to restore height or to treat the deformity associated with
osteoporotic vertebral fractures

60. Lateral radiograph demonstrates multiple osteoporotic vertebral
compression fractures. Kyphoplasty has been performed at one level

61. Follow-up
• Complications
• Complications resulting from osteoporotic fracture can include chronic pain
from vertebral compression fractures and increased morbidity and mortality
secondary to vertebral compression fractures and hip fractures
• In addition, overall quality of life can be impaired by the presence of these
fractures and their consequences, such as immobility

62. • Prognosis
• Patients with osteoporosis can increase bone mineral density and decrease
fracture risk with the appropriate antiosteoporotic medication
• In addition, patients can decrease their risk of falls by participating in a
multifaceted approach that includes rehabilitation and environmental
modifications, among others

63. • Patient Education
• Patient education is paramount in the treatment of osteoporosis
• Many patients are unaware of the serious consequences of osteoporosis and
only become concerned when osteoporosis manifests in the form of fracture
• Early prevention and treatment are essential in the appropriate management
of osteoporosis

64. References
1. Kanis JA, Delmas P, Burckhardt P, et al. (1997) Guidelines for diagnosis and management of osteoporosis. The European Foundation
for Osteoporosis and Bone Disease. Osteoporos Int 7:390-406.
2. Cooper C, Atkinson EJ, O’Fallon WM, et al. (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in
Rochester, Minnesota, 1985-1989. J Bone Miner Res 7:221-227.
3. The Asian Audit Epidemiology, costs and burden of osteoporosis in Asia 2009. Prepared by the International Osteoporosis
Foundation
4. IOF, 2005 (www.osteofound.org)
5. Dennison E & Cooper C. Epidemiology of osteoporotic fractures. Horm Res. 2000;54 suppl 1:58-63.
6. Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999
7. Riggs BL, Melton LJ. Bone 1995
8. Heart and Stroke Facts, 1996, American Heart Association
9. Cancer Facts & Figures, 1996, American Cancer Society
10. Black et al., J Bone Miner Res 1999
11. Melton et al, Osteoporos Int 1999
12. Lindsay et al., JAMA, 2001
13. Gehlbach et al.,Osteoporos Int 2000, 11:577
14. Osteoporosis Fact Sheet. IOF. Available at http://www.docstoc.com/docs/11026621/OSTEOPOROSIS-FACT-SHEET/ Assessed on 23-
4-10
15. Dana Jacobs-Kosmin & Coburn Hobar. Osteoporosis. Available on: http://emedicine.medscape.com/article/330598-treatment
Assessed on 26-04-10