OSTEOPOROSIS

Dr. FAIZAL DRISSA HASIBUAN, SpPD

Bagian Penyakit Dalam FK UNIV.YARSI JAKARTA

2013

Osteoporosis is a major public health problem, and postmenopausal osteoporosis constitutes as a major part of the problem.

Claus Christiansen, Am J Med 1993

Hip fractures will increase sharply in the next half century, especially in Asia, making osteoporosis a truly global issue.

WHO 1998

EPIDEMIOLOGY

IntroductionIntroduction

Osteoporosis is a disease characterized Osteoporosis is a disease characterized by low bone mass and microarchitecturalby low bone mass and microarchitecturaldeterioration of bone tissue, leading to deterioration of bone tissue, leading to enhance bone fragility and a consequentenhance bone fragility and a consequentincrease in fracture riskincrease in fracture risk

(WHO)(WHO)

Osteoporosis is a skeletal disordersOsteoporosis is a skeletal disorders

compromised bone strength, compromised bone strength,

predisposing in an increase riskpredisposing in an increase risk

of fractureof fracture

Rigg and Nelson divided into :Rigg and Nelson divided into :

A/. Primary osteoporosisA/. Primary osteoporosis 1. Post menopause osteoporosis1. Post menopause osteoporosis 2. Senile osteoporosis2. Senile osteoporosis

B/. Secondary osteoporosisB/. Secondary osteoporosis Osteoporosis due to other conditionOsteoporosis due to other condition of disease such as metabolic,of disease such as metabolic, endocrine or malignancy endocrine or malignancy

Post menopausal osteoporosis

• Most common in woman 15 – 20 year after menopause

• Mostly affects trabecular bone, increasing patient

susceptibility to vertebral compression fractures,

distal radial fractures and intertrochanteric fractures.

• Esterogen deficiency plays a primary role

Senile OsteoporosisSenile Osteoporosis•Occurs in men and women over the age of 70 years

with female to male ratio of 2:1• It affects : cortical and trabecular bone equally,

predisposing patient to multiple wedges vertebral and femoral neck fractures •Aging and long-term calcium deficiency is more

important.

Primary osteoporosis mostly are old and

elderly people complaining of mild

backache but may also a sudden pain

with only a mild injury due to a

compression fractures of the vertebrae.

Before it reaches the threshold of fractures,

usually the height of patient reduces beside

deformity (kyphotic deformity)

It is a silent disease, meaning there isIt is a silent disease, meaning there is

no significant signs and symptoms no significant signs and symptoms

caused by osteoporosiscaused by osteoporosis

Etiology :Etiology :

General factor predictive of osteoporosis :General factor predictive of osteoporosis :

1. Peak bone mass at maturity :1. Peak bone mass at maturity : General / familialGeneral / familial Nutritional Nutritional Physical (activity status, exercise, etc)Physical (activity status, exercise, etc) Life style (alcohol, cigarettes, caffeine)Life style (alcohol, cigarettes, caffeine) Medical (chronic disease, hypogonadal states, etc)Medical (chronic disease, hypogonadal states, etc) Iatrogenic (corticosteroid, anticonvulsant, etc)Iatrogenic (corticosteroid, anticonvulsant, etc)

Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889

20 40 8060

Bon

e M

ass

Peak Bone Mass

male

female

Menopause

Bone Loss

Bone Mass Development

ageAge (year)

2. Post menopausal bone loss2. Post menopausal bone loss

Accelerated trabecular bone loss for 3Accelerated trabecular bone loss for 3 to 10 years post menopausalto 10 years post menopausal Due to increased bone resorptionDue to increased bone resorption secondary to estrogen losssecondary to estrogen loss Loss of normally 1 to 2% per year to Loss of normally 1 to 2% per year to a maximum of 10%a maximum of 10%

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Age-related (involutionall) bone loss3. Age-related (involutionall) bone loss

Starts at age 35 – 40 years in both sexes,Starts at age 35 – 40 years in both sexes, continues for 30 to 40 yearscontinues for 30 to 40 years Subtle uncoupling of rates of bone formationSubtle uncoupling of rates of bone formation and resorptionand resorption Both cortical and trabecular bone affectedBoth cortical and trabecular bone affected Loss normally less than 0.5% per year to aLoss normally less than 0.5% per year to a maximum of 20 %maximum of 20 %

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Risk factors4. Risk factors

Genetic, life style, Medical, IatrogenicGenetic, life style, Medical, Iatrogenic

Risk factors for bone Risk factors for bone loss :loss :

1. Genetic : 1. Genetic :

- Female sex- Female sex- Caucasian / Asian ethnicity- Caucasian / Asian ethnicity- Family history of osteoporosis- Family history of osteoporosis

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

2. Life Style : 2. Life Style :

- Low calcium intake- Low calcium intake- Excessive alcohol use- Excessive alcohol use- Cigarette smoking- Cigarette smoking- Excessive caffeine use- Excessive caffeine use- Extreme or insufficient athlecity - Extreme or insufficient athlecity

- Excessive acid ash diet (high protein /- Excessive acid ash diet (high protein / soft drink intakes)soft drink intakes)

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Medical : 3. Medical :

- Early menopause- Early menopause- Gonadal hormone deficiency - Gonadal hormone deficiency

statesstates- Eating disorders- Eating disorders- Chronic liver / kidney - Chronic liver / kidney

diseasedisease- Malabsorption syndrome- Malabsorption syndrome

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Iatrogenic :4. Iatrogenic :

- Corticosteroids- Corticosteroids- Excessive thyroid hormone- Excessive thyroid hormone- Chronic heparin therapy- Chronic heparin therapy- Radiotherapy to skeleton- Radiotherapy to skeleton- Long-term anticonvulsants- Long-term anticonvulsants- Loop diuretics- Loop diuretics

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Bone is the most dynamic tissue.Bone is the most dynamic tissue.

Metabolism of catabolism and anabolismMetabolism of catabolism and anabolism

as the activity of osteoclast and osteoblastas the activity of osteoclast and osteoblast

as a process of bone remodeling or as a process of bone remodeling or

bone turn overbone turn over

Degeneration occurs as an aging processDegeneration occurs as an aging process

where the activity of osteoclast is not ablewhere the activity of osteoclast is not able

to compensate by the activity of osteoblast.to compensate by the activity of osteoblast.

As a result bone mineral density decreaseAs a result bone mineral density decrease

The main problem of osteoporosisThe main problem of osteoporosis

lies in the effectiveness of intervention-lies in the effectiveness of intervention-

prevention and treatmentprevention and treatment

Osteoporosis is preventable if preventionOsteoporosis is preventable if prevention

starts during the childhood and adolescencestarts during the childhood and adolescence

when bone reaches maturity at the end when bone reaches maturity at the end

of 3of 3rdrd decade to achieve maximum decade to achieve maximum

Peak Bone MassPeak Bone Mass

After the 3After the 3rdrd decade all organ include decade all organ include skeletal / bone will degenerate, the speed skeletal / bone will degenerate, the speed of degeneration, differs for different of degeneration, differs for different organ. organ.

In general organ will loose function In general organ will loose function

1% every year (the rule of 1% of Andreas 1% every year (the rule of 1% of Andreas and Tobin) and Tobin)

Diagnosis should include differential diagnosis of

primary and secondary osteoporosis by :

o Taking a good history

o Physical examination

o Laboratory examination

o Imaging examination

DIAGNOSIS

History :

o ras, sex and age

o health status

o life style (alcohol, smoking)

o physical activity (sports)

o history of previous disease including administration of

drugs, previous fracture.

Physical Examination :

Body weight and height (BMI)

Extremities and spine including :

deformity, MMT and ROM

Laboratory findings :

o blood serum

o hormone

o Urine

LABORATORY FINDINGS :

Routine:

- Serum :

- Complete blood counts

- Electrolytes, creatinine, blood urea, nitrogen calcium

- Phosphorus, protein, albumin, alkaline phosphatase,

liver enzyme

- Protein electrophoresis

- Thyroid function tests

- Testoterone (men only)

- 24 hours urine :

- calcium

- Pyridinium cross-links

LABORATORY FINDINGS :

Spesial :

- Serum:

- 25 hydroxyvitamin D3

- 1,25 hydroxyvitamin D3

- intact parathyroid hormone

- osteocalcium (bone Gla protein)

- Urine :

- Immunoelectrophoresis

- Bence-Jones protein

IMAGING :

Radiology : plain X-ray

(especially the spine, hip and wirst)

The spine : - the ballooning disc

- deformity of vertebral body

(wedge, fish tail)

The Hip : - Singh Index

The Wirst : - Porotic / thinning cortex

The general diagnostic categoriesThe general diagnostic categoriesestablished in woven : (WHO working group)established in woven : (WHO working group)

Normal :Normal : Bone Mass Density (BMD)or Bone Mass Density (BMD)or Bone Mineral Content (BMC)Bone Mineral Content (BMC) -1 SD from T Score of the young-1 SD from T Score of the young adult reference meanadult reference meanOsteopenia :Osteopenia : BMD or BMC –1 SD to –2.5 SD BMD or BMC –1 SD to –2.5 SD Osteoporosis :Osteoporosis : BMD or BMC –2.5 SD BMD or BMC –2.5 SD

(severe osteoporosis when there is followed a fracture)(severe osteoporosis when there is followed a fracture)

Prevention and TreatmentT-score Fracture risk Teatment

> +1 very low • no treatment• densitometry with indication

-1 s/d 0 low • no treatment• densitometry after 5 years

- 1 s/d +1 low • no treatment• densitometry after 2 years

-1s/d -2,5 midle • prevention• densitometry after 1 years

< - 2,5 high • osteoporosis treatmentno fracture • continue prevention

• densitometry after 1 years

< - 2,5 very high • osteoporosis treatment With fracture • continue prevention

• surgery with indication • densitometry after within 6 month –1 years

T-score Fracture risk Teatment

> +1 very low • no treatment• densitometry with indication

-1 s/d 0 low • no treatment• densitometry after 5 years

- 1 s/d +1 low • no treatment• densitometry after 2 years

-1s/d -2,5 midle • prevention• densitometry after 1 years

< - 2,5 high • osteoporosis treatmentno fracture • continue prevention

• densitometry after 1 years

< - 2,5 very high • osteoporosis treatment With fracture • continue prevention

• surgery with indication • densitometry after within 6 month –1 years

PreventionPrevention

Aging process is a natural process of a personAging process is a natural process of a person getting oldgetting old

3 steps of osteoporosis prevention :3 steps of osteoporosis prevention : I. Up to the end of 3I. Up to the end of 3rdrd decade decade where Peak Bone Mass should be where Peak Bone Mass should be achievedachieved II. After the 3II. After the 3rdrd decade up to menopause / decade up to menopause / AndropauseAndropause III. Senile, prevent from minor injury / III. Senile, prevent from minor injury / accidentaccident

Goal of Osteoporosis PreventionGoal of Osteoporosis Prevention

Optimising skeletal development Nutrition Physical activity Life style changes Minimize medical / iatrogenic factors

Minimize postmenopausal bone loss Early identification of patients at risk Reduced risk factors Hormone replacement therapy (HRT) Other agents pre-emptively if HRT contraindicated raloxifene, alendronate

Minimize age-related bone loss Identification of patients at risk Reduce risk factors Full prevention and exercise program (physical therapy)Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

11stst Prevention : Prevention :

Good nutrition Good nutrition

Life style and physical exerciseLife style and physical exercise

To achieve maximum Peak Bone MassTo achieve maximum Peak Bone Mass

22ndnd Prevention Prevention

Early diagnose of osteoporosisEarly diagnose of osteoporosis The same prevention as 1The same prevention as 1stst prevention prevention In female patient after menopause with HRTIn female patient after menopause with HRT Prevention of the use of medicationPrevention of the use of medication consist steroid etcconsist steroid etc