Description and management of osteoporosis.

1. Department of
Orthopaedics & Traumatology,
Rajshahi Medical College Hospital

2. Definition
National Osteoporosis Foundation:
“a disease characterized by low bone mass an
micro-architectural deterioration of bone
tissue, leading to bone fragility and an
increased susceptibility to fractures.”

3. Definition
World Health Organization
bone mineral density T-score greater than –2.5
standard deviations from the mean peak
adult bone mass.

4. Osteoporosis
Definition:
It is a disease where
• decrease in the density of bone
• decreasing its strength and
• resulting in fragile bones.

6. 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.

8. Composition of bone…

10.  Bone Homeostasis:
 the situation when the body
requires and achieves an equal
amount of bone resorption and
bone formation
 the amount of bone eroded by
osteoclasts is equal to the
amount of bone produced by
osteoblasts, thereby producing
a stable net mass of bone in the
body
Homeostasis

11. Healthy bone balance

12.  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.

15. Prevalence
Osteoporosis, “the silent thief of your bone”

16. 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…

17. Prevalence…
Approximately 1 in 2 women and 1 in 4 men over
age 50 will have an osteoporosis related fracture
in their remaining lifetime.

18. Risk factors
of
Osteoporosis

19. 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

20. “Forty is the old age of youth,
fifty is the youth of old age. “
Risk factors…
Older age

21. • 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…

22. • Diet
– Low calcium intake
– Low vitamin D intake
– Excessive intake of protein,
sodium and caffeine
• Inactive lifestyle
• Smoking , Alcohol abuse
Risk factors…

23. • Certain medications
– steroid, anticonvulsants etc
• Certain diseases
– anorexia nervosa, rheumatoid arthritis,
gastrointestinal diseases and others
Risk factors…

24. How does
Osteoporosis presents ?

25. presentations
•People may not know that
they have osteoporosis until
they break a bone.

26. presentations
Persistent, unexplained back pain

27. • 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…

28. Diagnosis
• Bone mineral density (BMD) tests can measure bone
density in various sites of the body.
• BMD test is done to diagnose and predict fracture risk
and to monitor therapy.
• For patients on pharmacotherapy, it is typically performed
2 years after initiating therapy and every 2 years
thereafter; however, more frequent testing may be
warranted in certain clinical situations.

29. 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 per cent of bone
tissue must be lost before a recognizable abnormality can
be detected on spinal radiographs.

30.  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.
• Validated in many clinical trials.
• Available in Bangladesh.

31.  Dual-energy X-ray Absorptiometry (DXA) Scan
Classification T-score
Normal -1 or greater
Osteopenia Between -1 and -2.5
Osteoporosis -2.5 or less
Severe Osteoporosis
-2.5 or less
and fragility fracture

32. Diagnosis
Painless, non-invasive, effective
diagnostic tool

33. Complications
FRACTURE ,
The most serious complication of
Osteoporosis that leads to
 Increased morbidity
 Increased mortality
 Decreased quality of life

34. 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.

35. Management

36. Beat The Break

37. • 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

38. Life style modification

40. Page 40
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

41. • 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

42. 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.

43. • Alendronate-
• prevention -5 mg daily and 35 mg weekly
tablets.
• treatment -10 mg daily tablet, 70 mg weekly
tablet, 70 mg weekly tablet.
• Alendronate is also used in treatment of
osteoporosis in men and women taking
glucocorticoids.

44. • 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.

45. • 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.

46. 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

47. How to prevent
complication
of
osteoporosis ??

48. 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

49. Exercise

50. Fall prevention

51. Eat a health diet
lean meat, fish, green leafy vegetables, and oranges and
Off course Plenty Milk

52. Avoid smoking, alcohol and excess soft drink and coffee

53. Get moving

54. Be active
Being active really
helps our bones by :
• slowing bone loss
• improving muscle strength
• helping your balance

55. • 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.