rmt ostp dr blondina 2009

OSTEOPOROSIS

Blondina Marpaung

Rheumatology DivisionInternal Department

Medical Faculty USU - Medan

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 Occurs in men and women over the age of 70

years with female to male ratio of 2:1years with female to male ratio of 2:1 It affects : cortical and trabecular bone It affects : cortical and trabecular bone

equally, predisposing patient to multiple equally, predisposing patient to multiple wedges vertebral and femoral neck fractures wedges vertebral and femoral neck fractures

Aging and long-term calcium deficiency is Aging and long-term calcium deficiency is more important.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 %



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


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)


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


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


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 Treatment

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

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

33rdrd Prevention Prevention

Prevent from accidentPrevent from accident (minor injury could cause fracture)(minor injury could cause fracture) Care giver especially after fractureCare giver especially after fracture Operative intervention and bracingOperative intervention and bracing

TreatmentTreatment

Nowadays there is a lot of medicationFor osteoporosis such as :- calcium and vitamin D- calcitriol- calcitonin- bisphosphonate : generation : I – III such as (clorodronate, alendronate, and risedronate (actonel))- hormone : - anabolic - sex hormone - SEMs (Selective Modulator) - SERM (Selective Estrogen Reseptor Modulator : Raloxifene (analogue of tamosifene)SURGERY

Calcium : 1500 mg / day

Vitamin D : 500 mg / day

Calcitonin (myacalcic : Nasal spray: 200 mg / daily)

HRT : establish approach for osteoporosis prevention

and treatment.

But what after WHI report ????

SERM : Raloxifene : Evista : 60 mg/daily

- the goal is to increase bone benefits and decrease

deletterious affects on breast and endometrim.

- decrease breast cancer : 76 %

- 60 % women, 2 years : BMD increase 1-2 %

Dr. C. Deeply

CALSIUM DAN VITAMIN D RICH DIET “ 4 SEHAT 5 SEMPURNA “

CALSIUM NEEDED

Child 400 700 mg / dayTeen ager 1000 1500 mg / day

Adult 750 1000 mg / day Pregnant 1500 mg / day lactation 2000 mg / day

Premenopause 800 1000 mg / day Intra menopause 1000 1200 mg / day Post menopause 1200 1500 mg / day

Food ingredient100 g Teri nasi consist of 1000 mg Kalsium

Kepiting 210 mg Kerang 133 mg

40 g Dencis kaleng 200 mg 100 g Kuning telur ayam 147 mg

Tempe 129 mg Tahu 124 mg

Emping 100 mg Bayam merah 347 mg Kacang panjang 347 mg Daun singkong 165 mg

1 gelas Susu kental manis 275 mgSusu segar 380 mg

susu krim penuh 290 mg Susu non fat 480 mg yurgort 200 mg20 gr keju 100 mg

PREPARAT KALSIUM YANG TERSEDIA DI PASARAN

No.Type of Calsium Brand name Calsium(mg)

1. Calcium Carbonate Ca-C 100 Sandoz 327Calsan 1250Caxon-F 250Calsium Sandoz 300Epocaldi 400

2. Calcium Lactate Ca-C 1000 Sandoz 1000Calcidin 100Calsium Sandoz 2940

3. Calcium Phosphate Calcidin 200Calcalcin 800

Note : Calcium carbonate mengandung 40 % kalsiumCalcium lactate mengandung 13 % kalsiumCalcium phospate mengandung 25 % kalsium

rmt ostp dr blondina 2009

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