Osteoporosis PDF

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Osteoporosis...

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Osteoporosis Case 1  80-year-old female  Presents with sudden pain in the dorsal area  Radiating around both sides Serum Calcium – 2.32 mmol/L [2.2 – 2.6] Serum ALP – 245 IU/L [44 – 147] 1. Diagnosis? 2. Investigations? 3. Management? Case 2    

78-year-old man falls Fractured right hip He is 8 day post hip surgery Mobilising and doing well with physiotherapy

1. Management? Definition  Bone mineral density (T value) 50-years o Women – 18% o Men – 6%  Women lose trabeculae with age  Although there is reduced bone formation in men as they age – trabeculae numbers remain stable  Reduced lifetime risk of fracture

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Risk Factors – SHATTERED 1. Steroid used o Glucocorticoids o > 5mg/d of prednisolone o Excessive thyroxine / hydrocortisone replacement 2. Hyperthyroidism / hyperparathyroidism / hypercalciuria o Primary hyperparathyroidism o Thyrotoxicosis o Hypogonadism o Cushing’s syndrome o Addison’s disease 3. Alcohol & smoking o > 4 units of alcohol / day 4. Thin o BMI < 18.5 5. Testosterone o Reduced 6. Early menopause o < 45-years 7. Renal / liver failure o Chronic liver disease 8. Erosive / inflammatory bone disease o Myeloma o Rheumatoid arthritis o Ankylosing spondylitis 9. Dietary calcium reduced / malabsorption / DMT1 o Coeliac disease o Peptic ulcer surgery Modifiable Risk Factors 1. Alcohol & smoking 2. Long-term severe RA / Coeliac disease / hyperthyroidism 3. Low BMI 4. Ankylosing spondylitis 5. Crohn’s disease 6. Eating disorders 7. Prolonged immobility 8. Untreated premature menopause 9. Long term steroid use

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Investigations 1. X-ray o Low sensitivity / specificity 2. Bone mineral Densitometry (DEXA scan) o Better to scan hip than lumbar spine o Bone mineral density (g/cm2) is compared to that of a young healthy adult o The T score is the number of standard deviations the BMD is from the youthful average o 1 SD decrease in BMD = 2.6-fold increase in risk of hip fracture T score >0 0  -1 -1  -2.5

< -2.5

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Bone mineral density Better than the reference Top 84% No signs of osteoporosis Osteopenia Risk of later osteoporotic fracture Lifestyle advice Optimise RFs Zoledronate infusion – 18 monthly Osteoporosis Lifestyle advice + treatment Repeat DEXA in 2 years

DEXA - Indications 1. Previous low trauma fractures 2. Women >65 + 1/more RFs for osteoporosis 3. Women 75-years

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Management  Possible to reverse loss of BMD in some cases  Age / BMD / RFs  guide pharmacological therapy Primary Prevention 1 Calcium

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Vitamin D

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Exercise Lifestyle modification

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Pharmacological Measures Calcium / Vitamin D 1

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Bisphosphonates

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Selective Oestrogen Receptor Modulator (SERM)

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Hormone replacement therapy (HRT)

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Strontium Ranelate

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1  1.5g / day Loading dose = the deficiency prior to treatment 800u  1200u / day Loading dose = the deficiency prior to treatment Weight bearing exercises increases BMD Stop smoking Reduce alcohol consumption Home bases falls prevention programme

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Rarely used alone for prophylaxis Offer if patient is deficient May increase CV risk Alendronate / Risedronate o Once weekly  Reduce bone resorption by inhibiting osteoclast activity  Increase BMD at hip & lumbar spine  Reduce fractures 30-50%  Prolonged use in atypical fractures  SE; Photosensitivity / GI upset / jaw osteonecrosis (rare)  Raloxifine  Acts similar to HRT but reduced risk of breast cancer  Decreased vertebral fractures  SEs; worsen menopausal symptoms / increased thromboembolism  Can prevent (not treat) osteoporosis in post-menopausal women  Risk of; invasive breast cancer (>10 years use) / stroke / CHD / thromboembolism  Dissociated remodelling o Increases formation o Decreases resorption  Reduces vertebral fractures (early)  Only to be used in patients intolerant

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Teriparatite

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Denosumab

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Calcitonin

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Testosterone

to bisphosphonates and have no CV complications  Recombinant PTH o 34 amino acid fragment  Useful in severe osteoporosis despite other treatment  Subcutaneous route  Bisphosphonates impair anabolic activity  Monoclonal antibody  Inhibitor RANKL o Essential to osteoclast formation / activity  Decreased reabsorption  Subcutaneous every 6 months  Analgesic effect o May reduce pain post fracture  Subcutaneous / nasal route  May help in hypogonadal men  Promote trabecular connectivity

Osteomalacia  Normal amount of bone but the mineral content is low o There is excess uncalcified osteoid and cartilage  This is the reverse of osteoporosis, in which the mineralization is unchanged but there is overall bone loss Rickets  The result if it occurs during the growth phase Osteomalacia  the result if it occurs after the fusion of the epiphyses

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