OSTEOPOROSIS

Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture

In simple terms a bone thinning diseases which enhanced bone fragility and a consequent increase in fracture risk. A simple fall of even a bump can cause the bone to break.

‘Silent disease’, infact, most people do not now they have osteoporosis till the first bone breaks and by then the disease is advanced.

PREVALENCE OF THIS DISEASE:
80% of people affected by Osteoporosis are women.
80% of the women over the age of 65 have osteoporosis
50% of women will suffer an Osteoporotic fracture in their lifetime
30% of women over the age of 50 have one or more vertebral fractures.
After menopause women loses 1-2 % of bone density each year.
200 million women worldwide today are suffering from osteoporosis
1/3 of women aged 60 to 70
2/3 of women aged 80 or older.
By the age of 80, ½ of the women show on an X- ray that they have had a fracture of the spine.

Osteoporosis is responsible for 1.5 million fractures every year.
Approximately one in five men over the age of 50 will have an osteoporosis-related fracture in their remaining lifetime

Osteoporosis Projections

Economic Burden of Osteoporosis:
Osteoporosis results in more cost than many other diseases

Number of bed days occupied due to Osteoporosis -
701,000 for osteoporosis
891,000 for chronic obstructive pulmonary disease
533,000 for stroke
328,000 for myocardial infarction
201,000 for breast cancer

Every 20 seconds someone in India suffers a hip fracture as a result of osteoporosis

Effects of Osteoporosis
 

Why do we get Osteoporosis?
Bone remodeling occurs throughout an individual’s lifetime. The remodeling is a balance of two special cells working together, the Osteoclast cells (Cells which break downs old bone causing pits) and the Osteoblast cells (Cell which work to fill in this pits with new bone)

In normal adults, the activity of osteoclasts (bone resorption) is balanced by that of osteoblasts (bone formation)
In osteoporosis, the Osteoclast breakdown the bone at a rate the Osteoblast are unable to keep up with resulting in thinning of the bones with increased fragility and increased risk of fracture.

Pathogenesis of Osteoporotic fracture
Non-Modifiable risk factors
  • Age- as age advances the bone breakdown rate becomes greater than the formation, resulting in weaker bone, greater than 70years.
  • Female Sex- females have lesser bone tissue and after menopause the hormonal changes accelerates bone resorption. Specially women having early menopause before 45years are more prone to have advanced osteoporosis
  • Maternal family history of hip fracture – hereditary factor in osteoporosis is also observed.
  • Low birth weight increases the susceptibility to osteoporosis
  • Disease predisposing to osteoporosis (e.g. Hypogonadism, Anorexia Nervosa, Chronic Renal Failure, Transplantation, Rheumatoid Arthritis, Bechterew Disease, Hyperthyroidism, Diabetes Mellitus, tumors like myloma.
Modifiable risk factors
  • History of falls Most of the falls occur in home then outside. We can check certain thing at home to avoid such accidents-
    - Keep the steps levelled
    - Well lit house and also all entrances
    - Avoid curtains in staircases and corridors.
    - Use of non-skid bath mats.
    - Night lamps in bathroom and hall
    - Flash bedside lights.
    - Avoid loose cables in house
    - All carpets well secured with slip resistant backings.
    - Enough space to walk in house from room to room.
    - All light switches near the entrance of the room
    - Keep the floor clean and non-slippery.
    Use of anti-skid rubber sole footwear.
  • Low Body mass index
  • Drug therapy (e.g. corticosteroid, Anticonvulsivants uses etc)
  • Primary or secondary amenorrhea
  • Current Cigarette Smokers
  • Excess Alcohol intake - keeping alcohol consumption to the minimum.
  • Dietary calcium and vitamin deficiency
Components of Fracture Risk

The main morbidity of Osteoporosis is Fractures

Previous fractures are strong predictors of future fractures
Overall: 46% vertebral fractures; 16% hip fractures; 16% wrist fractures

Striking Features of a vertebral fractures
  • Back pain with little or no exertion
  • Acute and severe pain or chronic lower-grade back pain
  • Pain localized to specific vertebra
  • Pain may radiate in-front.
  • Pain associated with limited back mobility
  • Pain relieved by bed rest; worsened when upright, coughing, sneezing
  • Point tenderness over specific vertebra
  • Paravertebral muscles tender to touch secondary to spasm
  • Pain slowly decreases in intensity (weeks to months)
  • Limited back flexion
  • Overall Height loss > 2cm or historical height loss > 4cm
Comparison of verterbrae - Osteoporosis
INcidence rtes for Verterbral, Wrist and Hip Fractures in Woemn over 50

A patient getting an Osteoporotic compression fracture increases the risk of subsequent fractures FIVE fold. When he gets more than one vertebra fracture, the risk increases TWELVE fold.

Diagnosis of Osteoporosis:
  1. DEXA studies
    The gold standard in the diagnosis of osteoporosis. Highest accuracy, Precision, resolution.
    It measures the bone density in all bones.
    It has a short scanning time, reducing the radiation problems.
  2. QCT studies
    Computed quantitative tomography ( QCT ) , is the CT evaluation of the bone mass.
    It calculates the bone mass of Spine, Hip and forearm.
    The amount of radiations are more.
  3. Ultrasound
    The ultrasound attenuation is used to determine the bone density. It’s a good screening test, as it is cheap, no harmful radiation and gives us a rough guidance to select the population at risk.
    It calculates the bone density in Heel, Patella, Tibia and forarm.
  4. High resolution p-QCT
    Takes into account the Tibia and the forarm.
 
WHO guidelines:
  1. The bone density is measured in T score.
    A score above or equal to -1 is normal.
    A score -1 - -2.5 is OSTEOPENIC.
    Anything less then -2.5 is OSTEOPOROSIS
    Less then -2.5 with fracture ESTABLISHED SEVERE OSTEOPOROSIS.
  2. Bone Turnover Markers
    • Bone turnover markers are components of bone matrix or enzymes that are released from cells or matrix during the process of bone remodeling (resorption and formation).
    • Bone turnover markers reflect but do not regulate bone remodeling dynamics.
Osteoporosis - Serum markers of bone turnover

Management of Osteoporosis:
The best way to manage Osteoporosis is to prevent it.

The Goal of management of osteoporosis-
  • Prevent first fragility fracture or future fractures if one has already occurred
  • Stabilize/increase bone mass
  • Relieve symptoms of fractures and/or skeletal deformities
  • Improve mobility and functional status.
Prevention-
Prevention can be done by achieving highest peak bone mass at 20-22years of age.
  • Avoid all risk factors as mentioned before in ‘Modifiable risk factors.’
  • Avoid smoking.
  • Excessive Drinking.
  • Avoid use of unsupervised drugs.
  • Exercise
Exercise-
Exercise remains the most important and un-substitutable treatment in the management of osteoporosis.
  • Exercise can maintain or increase BMD and improve muscle mass, strength, and balance, decreasing risk of hip fracture.
  • Studies have demonstrated a protective effect of previous physical activity on the risk of hip fracture.
  • Caution when prescribing specific exercises for Osteoporotic patients to avoid injury.
  • Exercise programs should be tailored to the individual.
Regular Calcium Intake-
The daily calcium requirements are as follows:
1-3yrs 500mg/day
4-8yrs 800mg/day
9-18yrs 1300mg/day
19-50yrs 1000mg/day
Above 51 1200mg/day

 

Drugs involved in the treatment of osteoporosis:
All post-menopausal women and people at risk need to take Calcium supplements with Vitamin D3 everyday.
Two types
1. Drugs preventing resorption.
2. Drugs stimulating bone formation.

1. Drugs preventing resorption
• Bisphosphonates
  – Alendronate
  – Etidronate
  – Risedronate
  – Ibandronate.
• Calcitonin
  – Nasal / Subcutaneous inj.
• Oestrogen ± progestin
• Selective estrogen receptor modulators (SERMs)
  – Raloxifene

2. Drugs Stimulating new bone formation
(Fluoride)
Parathyroid hormone
Teriparatide- the latest in the series and the most promising results.


The bone quality improvement in 21 months after the teriparatide therapy

3. Mixed mechanism of action
• Vitamin D and metabolites
• Strontium ranelate

 
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