silent bone disease osteoporosis -hidden facts,red flags,prevention & treatment dr.sandeep c...

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com!

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OSTEOPOROSIS :!PREVENTION,DIET & TREATMENT

Dr.Sandeep C Agrawal Consultant Orthopedic Surgeon

MS,DNB

Agrasen Hospital Gondia

Maharashtra

India www.agrasenortho.com

[email protected]

09960122234

OSTEOPOROSIS: Red Flags & Preventive Cares

http://www.agrasenortho.com


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www.uc-osteoporosis.com



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Selected Risk Factors

“Red flags” that can mean you could be at high risk for weak bones.



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❑ I’m older than 65

❑ I’ve broken a bone after age 50

❑ My close relative has osteoporosis or .has broken a bone

❑ My health is “fair” or “poor”

❑ I smoke

❑ I am underweight for my height 5

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Selected Risk factors



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❑ I started menopause before age 45

❑ I've never gotten enough calcium

❑ I have more than two drinks of alcohol .several times a week

❑ I have poor vision, even with glasses

❑ I am prone to fall

❑ I'm not active 6

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I have one of these medical conditions: ❑ Hyperthyroidism ❑ Chronic lung disease ❑ Cancer ❑ Inflammatory bowel disease ❑ Chronic liver or kidney disease ❑ Hyperparathyroidism ❑ Vitamin D deficiency ❑ Cushing's disease ❑ Multiple sclerosis ❑ Rheumatoid arthritis

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I take one of these medicines: ❑ Oral glucocorticoids (steroids) ❑ Cancer treatments (radiation, chemotherapy) ❑ Thyroid medicine ❑ Antiepileptic medications ❑ Gonadal hormone suppression ❑ Immunosuppressive agents

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�Strategies for prevention of osteoporosis: 1. High risk strategy: To identify women at risk & offer intervention 2. Global strategy: Population based, where the aim is to modify the

risk factors in the general community

ABOUBAKR ELNASHAR



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ABOUBAKR ELNASHAR



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• Types of prevention of osteoporosis. 1. Primary: Aims at reaching at adolescent age a peak bone

mass as high as possible. Should begin in childhood& continue throughout the

life span to maximize bone mass. E.g. sufficient calcium intake, omit risk factors 2. Secondary: Aims at reducing bone loss peri & postmenopausal E.g. estrogens/gestagens, bisphosphonates

&SERMs. 3. Tertiary: With manifest osteoporosis aims at preventing

fractures.

ABOUBAKR ELNASHAR



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Bone mass •35% of cortical & 50% of cancellous bone mass are lost over a lifetime •The peak bone mass attained is a major determinant of subsequent bone mass& fracture risk in later life (Bonjour et al,1997).

ABOUBAKR ELNASHAR



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�5 steps for maximizing peak bone mass (National osteoporosis foundation)

Most important for women who haven't reached their maximum peak bone mass, which usually occurs around the age of 30. Step 1: Daily recommended amounts of ca & vitamin D Step 2: Regular wt-bearing exercises Step 3: Avoid smoking& excessive alcohol intake Step 4: Risk factor assessment of developing osteoporosis. To institute strategies to maximize peak bone mass and minimize loss before it is too late to prevent the disease. Step 5: When indicated, BMD test to see if medication is needed ABOUBAKR ELNASHAR



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�5 steps to minimizing bone loss especially after menopause (National osteoporosis foundation)

Step 1: Balanced diet Regular exercise program Adequate intake of calcium in diet, Regular sunlight exposure Step 2: Stop smoking and reduce alcohol consumption Step 3: Risk factor assessment & screening test Step 4: If required, medication for osteoporosis prevention Step 5: Avoid certain medications ABOUBAKR ELNASHAR



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Prevention Steps Are Simple

National Osteoporosis Foundation (NOF) : ! FIVE simple steps to improve bone health and prevent osteoporosis.



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Pyramid for Osteoporosis Prevention and Treatment

Pharmacotherapy(antiresorptives and anabolics)

Address Secondary Factors(drugs and diseases)

Lifestyle Changes(nutrition, physical activity, and fall prevention)

What does this mean for your patients?

Leading the Effort to Help Prevent and Treat Osteoporosis



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OSTEOPOROSIS CARE:ABCDE

Alcohol…No !BMD Check up !Calcium supplements: Cigarette(Smoking)..No !Drug therapy,Diet & Doctor consultation !Exercise



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Steps 1 + 2

1.Daily recommended calcium and vitamin D.

2. Regular weight-bearing exercise



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• FDA uses “Percent Daily Value” (% DV) to describe amount of calcium needed daily

• 100% DV for calcium = 1,000 mg

• Look for this label: – “Nutrition Facts” on foods – “Supplement Facts” on

vitamin/mineral supplements

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Get enough calcium and vitamin D :



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Example of “Daily Value”

If a food or supplement has 200 mg of calcium per serving, the “Nutrition Facts” or “Supplement Facts” panel shows:

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20% DV for calcium (200 mg ÷ 1,000 mg = 20%)



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2. Vitamin D Essential for intestinal absorption of calcium.

The recommended intake for women is 400 IU/d for ages 51 to 70, 600 IU/d over age 70, and 800 IU/day for all high-risk women (homebound, institutionalized, on chronic glucocorticoids, or who live in northern latitudes and therefore have limited exposure to sunlight) Sources of vitamin D include sunlight, vitamin D–fortified foods, fish oils, and supplements. Multivitamins typically contain 400 IU of vitamin D. Adequate calcium and vitamin D supplementation is key to ensure prevention of progressive bone loss.

Calcium and vitamin D alone are insufficient to prevent fracture in those with osteoporosis.

ABOUBAKR ELNASHAR



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Step 3

Avoid smoking and excessive alcohol.



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Cessation of smoking

• accelerates bone loss • smoking one pack per day throughout adult

life was associated with a 5 to 10 percent reduction in bone density

• negate the beneficial effect of estrogen therapy in postmenopausal women by acceleration of the metabolism of estrogen



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Steps 4 & 5

4.Doctor Consultation !

5. Bone density test

and medication when appropriate.



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TESTS AND DIAGNOSIS

▪ Osteopenia refers to mild bone loss that isn't severe enough to be called osteoporosis, but that increases the risk of osteoporosis. !

▪ The best screening test is dual energy X-ray absorptiometry (DEXA) – measures the density of bones in the spine, hip and wrist and it's used to accurately follow changes in these bones over time.

▪ Ultrasound

▪ Quantitative CT scanning

Dual energy X-ray absorptiometry



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•T score ≥ -1

•T score -1 to -2.5

•T score < -2.5

Normal

Osteopenia

Osteoporosis

WHO Classification of BMD using DEXA

•T score < -2.5 + H. of fracture Severe Osteoporosis

T score represents the number of SD a patient is above or below the mean BMD of a young adult. ABOUBAKR ELNASHAR



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DEXA

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ABOUBAKR ELNASHAR

DEXA Scan



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Interpreting DEXA Results T scores (comparison with the young adult mean): relates to absolute fracture risk Z scores (comparison with reference values of the same age): related to the individual’s relative risk for their age.

ABOUBAKR ELNASHAR



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Low Z-score: Evaluate for secondary causes of osteoporosis

z Hypogonadism– Estrogen deficiency: menstrual history– Testosterone deficiency: serum testosterone

z Vit. D deficiency/ intestinal malabsorption– 24-h urine calcium– serum 25-hydroxy vitamin D– serum PTH

z Primary hyperparathyroidism: serum calcium and PTHz Hyperthyroidism: serum TSHz Idiopathic hypercalciuria: 24-h urine calciumz Myeloma: SPEP



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DEXA– Flaws?• DEXA overestimate bone mineral density

of taller subjects and underestimate bone mineral density of smaller subjects.

• In DEXA: bone mineral content is divided by the area of the site being scanned.

• DEXA calculates BMD using area (aBMD: areal Bone Mineral Density), it is not an accurate measurement of true bone mineral density, which is mass divided by a volume.



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• A repeat BMD measurements should be done on the same machine each time, or at least a machine from the same manufacturer.

• Error between machines, or trying to convert measurements from one manufacturer's standard to another can introduce errors large enough to wipe out the sensitivity of the measurements.

• DEXA results need to be adjusted if the patient is taking strontium, and calcium supplements.

• Metallic artifacts in cloths or pockets cause errors.

• Osteomalacia, Osteoarthritis of spine, old Fractures of spine and hip, aortic calcification affect BMD readings.



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FRAX- 10 year risk of fragility fracture

• Age, Sex, Height, Weight, • Previous fracture, • Family history of fracture, • Smoking, Alcohol, • Rheumatoid, Corticosteroid, • Secondary Osteoporosis • BMD

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The FRAX® tool has been developed by WHO to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck. The FRAX® models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia. In their most sophisticated form, the FRAX® tool is computer-driven and is available on this site. Several simplified paper versions, based on the number of risk factors are also available, and can be downloaded for office use. The FRAX® algorithms give the 10-year probability of fracture. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).

ABOUBAKR ELNASHAR



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II. Tests other than DEXA (peripheral bone densitometry devices

(ACOG guideline, 2004)

1. Quantitative US (QUS) . 2. Single-energy x-ray absorptiometry. 3. Peripheral DEXA 4. Peripheral quantitative computed tomography 9less expensive

9low radiation exposure

¾low precision& accuracy.

¾Measure peripheral bone only.

Cannot replace DEXA scans .

ABOUBAKR ELNASHAR



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BMD Role??• Osteoporosis is an arbitrary point on a scale, • Process of micro-architectural deterioration • Accelerated bone resorption exists throughout

postmenopausal life, whereas osteoporosis does not.

• Bone densitometry measures bone density, not bone turnover or bone stability.

• 85% of the rise in risk of fracture in ageing women is attributable to something other than the loss of BMD.

• Age is a better predictor of hip fracture than radial bone density.

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BMD Monitoring Role??

Normal bone Osteoporosis

Microarchitectural deterioration

Low bone density

ABOUBAKR ELNASHAR



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DRUG THERAPY


FDA-APPROVED MEDICATIONSINDICATIONS

Postmenopausal Osteoporosis

Glucocorticoid-induced Osteoporosis

Men

Drug Prevention Treatment Prevention Treatment

Estrogen 9

Calcitonin(Miacalcin®, Fortical®)

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Raloxifene(Evista®)

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Ibandronate (Boniva®)

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Alendronate (Fosamax®) 9 9 9 9

Risedronate (Actonel®)

9 9 9 9 9

Zoledronic acid(Reclast®)

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Teriparatide(Forteo®)

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Pharmacologic TreatmentTargets

Osteoclast

Inhibition of resorption

Osteoblast

Stimulation of formation



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Bone marrow precursors

OsteoblastsOsteoclast

Lining cells

Stimulators of Bone Formation Fluoride PTH analogs Sr Ranelate (?)

Inhibitors of Bone Resorption Estrogen, SERMs Bisphosphonates Calcitonin

Inhibitors of RANKL

Cathepsin K

Therapeutic strategies



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Whom to treat ?

Prior Hip/Vertebral Fracture

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T Score < -2.5

orT Score -1 to -2.5 & 10 yr risk (FRAX) :

HIP Fracture > 3 % or major osteoporotic Fracture> 20 %

Postmenopausal women /men > 50 yrs

with



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Australian Family Physician, 2004 ABOUBAKR ELNASHAR



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Exercise

• Any weight-bearing exercise regimen, including walking

• Women with osteoporosis should exercise for at least 30 minutes three times per week

• Improvements in bone density • reduced risk of hip fracture in older women



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What keeps bones healthy



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II. Regular exercise •In children& adolescents: Wt-bearing physical activity e.g.walking or running contributes to higher peak bone mass. •In postmenopausal: weight-bearing exercise produces small increases in bone density at the hip and improvement in balance& strength. Exercise in postmenopausal: resistance training {improve muscle mass, strength and balance} balance training which should be performed three times/w •Women with established osteoporosis: Activities that place an anterior load on the vertebral bodies e.g. forward flexion exercises: increased incidence of new vertebral deformities, and patients should be advised to avoid them.

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VI. Fall reduction •Falls are the direct cause of more than 90% of osteoporotic hip fractures, and the tendency to fall increases with age. •Some studies have shown that, for women over age 70, the most important predictors of hip fractures are fall-related factors

such as poor cognitive function, slow gait and otherwise impaired mobility, poor vision, drugs that impair alertness or balance, and history of falls. In women over 75, age and slow gait are equal to low BMD of the femoral neck as predictors of hip fracture. Unfortunately, labeling women as osteopenic or osteoporotic can cause fear of falling and lack of activity, leading to further acceleration of bone loss.

ABOUBAKR ELNASHAR



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TOP CALCIUM SOURCES

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Be happy when alone. Let happiness be your quality. And when you move from aloneness into involvement, into communication, relationship, carry that quality of happiness which was in loneliness — carry that.



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References

. IOF web site

.“Osteoporosis and Bone Physiology” web site, 1999 - 2006 http://courses.washington.edu/bonephys of Dr. Susan Marie Ott, MD. .Some slides are from teaching slides of British Medical Journal.

• JAMA 2004;291(16):1999 • J Clin Densitom 2004;7(1):1-6 • J Am Acad Orthop Surg 2006;14:347 • National Osteoporosis Foundation (http://www.nof.org) • NEJM 2003;348:1187 • NEJM 2004;350(12):1189-99 • Osteoporosis Int 1998;8:1

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http://www.nof.org/

http://www.nof.org/


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.!Information contained and transmitted by this presentation is based on review of literature from internet and form Institute of Medicine summary on DRI for Vitamin D & Calcium,BJD AAOS,National Osteoporosis Foundation websites.!. Graphics,Images and jpeg files are taken from Google and yahoo Image to heighten the specific points in this presentation. !!• If there is any objection/or copyright violation, please inform

[email protected] for prompt deletion. !!

• It is intended for use only by the doctors and orthopaedicians.!!

. Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. !!• Every body is allowed to copy or download and use the material

best suited to him. !!

There is no financial involvement.!! • For any correction or suggestion please contact [email protected] or www.agrasenorth.com.

silent bone disease osteoporosis -hidden facts,red flags,prevention & treatment dr.sandeep c...

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