Osteoprosis and Osteomalacia

Supervised byDR. Leena Abdulla

Family Medicine Consultant.By

Dr Khalid Al-Karbi PGY 2

Osteoporosis

• Case history: 68-year-old white woman

• Presents to accident and emergency department with right wrist pain, swelling, and displacement following a fall onto outstretched hand on the stairs at home

History

• Past medical history – asthma since childhood (treated with corticosteroids aged 50–55), gastric ulcer aged 45, menopause age 59, left wrist fracture aged 67

• Family history – stroke in sister aged 65, hip fracture in mother aged 78. Mother diagnosed with osteoporosis

• Social history – lives alone, 2 children, retired, smokes 5 cigarettes per day, occasional alcohol, takes no exercise, fully mobile and able to complete all ADLs (activities of daily living)

Examination

• On examination – wrist displaced, swollen, no open wound

• No loss of sensation or vascular compromise

• X-ray – Colles’ fracture of distal radius present

A tip to remember

• N.B. The most common osteoporotic fractures are vertebrae, wrists, and hips. Lifetime risk of fracture in white women is 20% for spine, 15% for wrist, and 18% for hip. There is an exponential increase in fracture over 50 years

Osteomalasia

F. 19-year-old presented with difficulty in walking for many years, especially going upstairs. She felt parasthesia in hands & feet and occasional spasm. P/E: waddling gait.

Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125).

• What other test results you need?

Educational Objectives :

• Understand the difference between osteomalacia and

Osteoprosis.

• Identify the following aspects of osteomalacia and osteoprosis.

- Pathophysiology

- Risk factors

- Clinical picture

- Diagnosis

- Prevention and Treatment.

Terms to remember

• Osteoclasts: bone resorption, stimulated by PTH

• Calcitonin: inhibits osteoclastic bone resorption

• Pathophysiology:• Slow down of bone build up: osteoporosis seen

in older women and men (men after age 70)• Accelerated bone breakdown: postmenopausal• Normal loss 0.5% per year after peak in 20s• Up to 5% loss/year during first 5 years after

menopause

What is Osteoporosis?

• “Systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in Fracture risk”

• True Definition: bone with lower density and higher Fracture risk

• WHO defines Osteoporosis as; Bone Mineral Density as definition (T score <-2.5); surrogate marker

Changes in bone mass with age

Bone mass

Age (years)

Wom

en

0 10 20 30 40 50 60 70 80Adapted from J Compston 1990

Menopause

Peak bone mass

Men

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Osteoporosis

Osteoporotic bone

The Epidemiology and the Burden of the

disease.• In the U.S., more than 10 million persons over

age 50 are affected by osteoporosis, and approximately 33.6 million have osteopenia.

• The lifetime risk of osteoporotic fractures is approximately 50% for women and 30% for men.

• However, the mortality rate following all types of fractures is much higher in men than in women

Annual Incidence of Osteoprosis in comparison to major morbidities affecting

elder women

Consequences of bone Fragility

Osteoporotic fracture probability is country

specific

Etiology

• Risk factors (non-modifiable) • Female gender• Increasing age• Family history• White or Asian ethnicity• Small stature• Early menopause

Etiology

• Risk factors (cont’d) • Excess alcohol intake• Cigarette smoking• Anorexia • Oophorectomy• Sedentary lifestyle• Insufficient calcium intake• Low testosterone levels (hypogonadism in men)

Falls

AgeBone density

Smoking

Parent broke their hip

Body mass index

Previous fragility fracture

Corticosteroids

Other diseases/conditions

Alcohol >3 units daily

Rheumatoid arthritis

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Risk of a fragility fracture

Epidemiology

• Females are at greater risk of developing osteoporosis.

• The frequency of postmenopausal osteoporosis is highest in women aged 50-70 years.

• Senile osteoporosis is most common in persons aged 70 years or older.

• Wrist fractures are usually the 1st presentation (6th decade of life).

• The majority of hip fractures happens by the 9th decade of life.

Types ?

Types ?

• Secondary osteoporosis :

- Hypogonadal states

- Genetic/congenital

- Endocrine disorders

- Deficiency states

- Inflammatory diseases

- Hematologic and neoplastic disorders

- Medications

- Miscellaneous

Physical examination

• A prominent finding in patients with fractures is point tenderness

• Low body weight (< 127 lb [58 kg]) associated with increased risk.

• Physical examination may show signs of vertebral compression, such as kyphosis, height loss (>1.5 cm), or a protruding abdomen

• Findings such as a thyroid nodule, jaundice, hepatic enlargement, and cushingoid features may point to secondary causes of osteoporosis

Physical examination

Laboratory Evaluation

Laboratory Evaluation

Imaging studies

• DXA • An imaging technique that measures areal BMD

(g/cm²).

• The gold standard in measuring the lumbar spine (L1-4) and femoral neck, total hip, or forearm BMD.

• The spine, which has a greater cancellous bone content and a larger surface area, is the best site for monitoring response to treatment because of its greater rate of change in BMD

Interpretation

• T-score - This number shows the amount of bone compared with a young adult of the same gender with peak bone mass.

• Z-score - This number reflects the amount of bone you have compared with other people in the same age group and of the same size and gender.

• Both of them is expressed as SD numbers

Osteoporosis Definition According to the WHO

Guidelines

Other Imaging Techniques

• Quantitative Computed Tomography (CT) :

Can be used as an alternative to DXA, however, its not recommended due to the exposure hazards associated with.Q

• Quantitative Ultrasound:

- Can be used if DXA is not available.

- Lower risk associated compared to CT.

SO FAR ,YOU HAVE ASSESSED :

• 1) Risk Factors.

• 2) BMD

• 3) What’s Next..?

• Fracture Risk Assessment for 10 years (FRAX® score).

• The FRAX® models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia.

Fracture Risk Assessment for 10 years

(FRAX® score).

• The FRAX®algorithm is available online at http://www.shef.ac.uk/FRAX

Screening Recommendations

• Screening criteria vary because of gaps in evidence and differences in the way guidelines are formulated (i.e., evidence-based versus expert opinion).

Evidence-based: The U.S. Preventive Services Task Force (USPSTF)

• Screening DEXA in all women 65 years and older.

• AS well as in women 60 to 64 years of age who have increased fracture risk.

• Insufficient evidence to recommend for or against screening in postmenopausal women younger than 60 years.

Screening Recommendations

Expert opinion :The National Osteoporosis Foundation (NOF)

o Women age 65 and older and men age 70 and older, regardless of clinical risk factors .

o Younger postmenopausal women and men age 50 to 69 about whom you have concern based on their clinical risk factor profile.

o Women in the menopausal transition if there is a specific risk factor associated with increased fracture risk such as low body weight, prior low-trauma fracture or high risk medication .

o Adults who have a fracture after age 50.  

Interventions used for prevention and treatment of Osteoprosis

I. Non-Pharmacologic & health advice for all :

Diet

Physical exercise

Other lifestyle modifications

II. Pharmacological management :

Anti-resorptive (Biphosphonates, Strontium ranelate ,Raloxifen,Calcitonin)

Anabolic (Calcium , Vit.D, Teriparatide , …….

Interventions used for prevention and treatment of Osteoprosis

Non-Pharmacologic & health advice for all :

1. Diet :

Calcium : Recommended : at least 1,200 mg per day for elderly

people. Supplements should be added if the dietary intake is

not sufficient . Advice to use rich calcium diet like : milk , yogurt ,

solid cheese . Use supplementation most of the time is required to

complete the recommended intake (Ca Co3 or citrate ).Calcium carbonate 1.25 g (500 mg calcium)

Vitamin D

Vitamin D : Chief dietary sources of vitamin D : Vitamin D-fortified milk (400 IU per quart) . Cereals (40 to 50 IU per serving), egg yolks, salt-water fish and

liver. Some calcium supplements and most multivitamin tablets also

contain vitamin D. Individuals older than age 65 should aim to take 10

micrograms (400 IU) daily. Encourage sun exposure of 20-30min twice weekly if

possible . Sunlight can be the most efficient method of obtaining

vitamin D, and can eliminate the need for tablets . Where vitamin D deficiency is confirmed or likely a daily

dose of 20 micrograms (800-1000 IU) is recommended.

2)REGULAR EXERCISE :

Regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures

Improve agility, strength, posture and balance, which may reduce the risk of falls. In addition, modestly increase bone density.

NOF strongly endorses lifelong physical activity at all ages .

Weight-bearing exercise (in which bones and muscles work against gravity as the feet and legs bear the body’s weight) includes walking, jogging, Tai-Chi, stair climbing, dancing and tennis.

Muscle-strengthening exercise

Other life-style modifications :

FALL PREVENTION :

Checking and correcting vision and hearing, evaluating any neurological problems, reviewing prescription medications for side effects that may affect balance and providing a checklist for improving safety at home.

Wearing undergarments with hip pad protectors may protect an individual from injuring the hip in the event of a fall.

Hip protectors may be considered for patients who have significant risk factors for falling or for patients who have previously fractured a hip.

Pharmacologic therapy

For Prevention :

• Patients with osteopenia should be considered for pharmacological intervention based upon fracture risk.

• The risk factors that are best validated include advanced age, prior fragility fracture, parental history of hip fracture, glucocorticoid use, excess alcohol intake, rheumatoid arthritis, and current cigarette smoking.

• Patients with the highest probability of fracture are most likely to benefit from drug therapy.

• Bisphosphonates or Raloxifene as first-line choices (Grade 2B).

Who to treat???

Postmenopausal women and men age 50 and older presenting with the following should be considered for treatment:

A hip or vertebral (clinical or morphometric) fracture .

T-score ≤ -2.5 at the femoral neck or spine after appropriate evaluation to exclude secondary causes .

Low bone mass (T-score between -1.0 and -2.5 at the femoral neck or spine) with risk factors (Prevention)

10-year probability of a hip fracture ≥ 3% or a 10-year probability of a major osteoporosis-related fracture ≥ 20% based on the patient country-adapted WHO.

Treatment

• Bisphosphonates : (Alendronate, Alendronate plus D, Ibandronate,

Risedronate, Risedronate with 500 mg of calcium carbonate and Zoledronic acid)

• Hormonal : Calcitonin, Estrogens (Estrogen and/or hormone

therapy), (raloxifene) and Parathyroid hormone [PTH(1-34), teriparatide]

Management of premenopausal osteoporosis

Referral

Referral crieteria

I. Patient experiences problems or side effects with medication.

II. Patient shows inadequate response to therapy .

III. A secondary cause of osteoporosis is identified.

References

• Maxine A. Papadakis, Stephen J. McPhee, Eds. Michael W. Rabow, Associate Ed.Current Medical Diagnosis & Treatment 2013.

• National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010.

• The National Institute for Health and Clinical Excellence (NICE) guidelines on the prevention of fragility fractures in postmenopausal women with osteoporosis [NICE, 2010b; NICE, 2011a; NICE, 2011b]

• AuthorsHillel N Rosen, MDMarc K Drezner, MD Uptodate .Osteoprosis management and prevention .

• Franklin D. Shuler, MD, PhD; Jacob Conjeski, MD; DavidKendall, MA; Jonathon Salava, MD Understanding the Burden of Osteoporosis and Use of the World Health Organization FRAX

- Up to date .com

- Medscape.com

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OSTEOMALACIA

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Osteomalacia

Decalcification and softening of the bone in adult.

• Caused mainly by: vitamin D deficiency

**Vitamin D is required for the absorption of calcium from the intestine and calcium is responsible for mineralization of bone

Caused mainly by:

Vitamin D deficiency.

Dietary calcium deficiency.

Phosphate deficiency.

Inhibitors of mineralization 

Disorders of bone matrix 

Osteomalacia

• Decreased availability of vitamin D  

• Insufficient sunlight exposure  

• Nutritional deficiency of vitamin D  Malabsorption; aging, excess wheat bran, bariatric surgery, pancreatic enzyme deficiency  

• Liver disease 

•  Chronic kidney disease 

•  Kidney transplantation  

• Medications: Anti epileptics (Phenytoin, carbamazepine, or barbiturate therapy)

Osteomalacia

•  Initially asymptomatic

•  Eventually, bone pain, simulating fibromyalgia

•  Painful proximal muscle weakness (especially pelvic girdle) due to calcium deficiency

•  Pathologic fractures with little or no trauma

•  Vitamin D deficiency has been associated with a possible increased risk of

– Multiple sclerosis

– Rheumatoid arthritis

– Diabetes mellitus – Hypertension –Psoriasis

Diagnosis

• Blood work• Decreased serum calcium or phosphorus• Decreased serum 25-hydroxyvitamin D• Elevated alkaline phosphatase

• X-Rays• Show loose’rs transformation zone –

• ribbons of decalcification in bone

Treatment and Prevention

• Vitamin D and Calcium