OSTEOPOROSIS

Definition Low bone mass and bone density with microarchitectural deterioration of bone
tissue
Increased bone resorption and reduced bone formation
Enhanced bone fragility brittle and porous bone
Increased risk of fracture
But normal bone mineralisation

WHO classification
Normal BMD within 1 SD of young adult reference range
T score > -1

Osteopenia BMD more than 1 SD but less than 2.5 SD below

the young adult mean
T score between -1 and -2.5

Osteoporosis BMD value of 2.5 SD or more below the young

adult mean
T score < -2.5

Severe/established BMD value of 2.5 SD or more below the young

osteoporosis adult mean with the presence of 1 or more
fragility fractures

Pathogenesis Increased bone breakdown by osteoclast

Reduced bone formation by osteoblast
Bone mass decreases with age
Classification
Primary Osteoporosis Secondary Osteoporosis
Postmenopausal OP Endocrine
-accelerated bone loss Cushings syndrome
related to oestrogen Hypogonadism
deficiency. Thyrotoxicosis
Hyperparathyroidism
Age-related osteoporosis
-occurs in both men and Drugs
women. Glucocorticoids
Heparin
Idiopathic (rare). Anticonvulsants (phenytoin)
Immunosuppressants

Chronic Diseases
Renal impairment
Liver cirrhosis
Malabsorption/ post-
gastrectomy
Chronic inflammatory
polyarthropathies (e.g.
rheumatoid arthritis)

Others
Nutritional
Multiple myeloma and
malignancy
Osteogenesis imperfecta

RF Non - Modifiable RF
Advancing age
Ethnic group (Oriental & Caucasian)
Female gender
Premature menopause (< 45 years) including surgical menopause
Slender build
Family history of osteoporosis in first degree relative

Modifiable RF
Low calcium intake
Sedentary lifestyle
Cigarette smoking
Excessive alcohol intake
Excessive caffeine intake
CF Most patients are asymptomatic
Increasing dorsal kyphosis (Dowagers hump)
Low trauma fracture : colles fracture, proximal femur fracture
Loss of height : compression fracture
Back pain

Ix Gold standard for dx of osteoporosis: measurement of BMD using DEXA.

The main aims of investigation are

1. to confirm the diagnosis of osteoporosis
2. to assess fracture risk
3. to exclude secondary causes

IX
Full blood count and ESR
Serum calcium, phosphate, albumin
Alkaline phosphatase
Renal function
Plain X-rays*- lateral thoraco-lumbar spine or hip (as indicated)

*Osteoporosis is apparent in plain X-rays only after 30% of bone loss has
occurred.
Other investigations may be done as indicated (FT4, TSH, testosterone,
FSH, LH, urine Bence Jones protein, serum protein electrophoresis)

Specific Ix Densitometry
BMD measurement - accurate reflection of bone mass
Important to use race-specific reference ranges when available.

BMD results are reported as T-scores (comparison with the young adult mean)
and Z-scores (comparison with the mean of individuals of the same age)

The risk of fracture is increased 2 fold for each SD reduction in BMD.

Currently available techniques in Malaysia for measuring BMD include:
a) Dual energy X-ray absorptiometry (DEXA)
b) Quantitative computed tomography (QCT)
c) Single energy X-ray absorptiometry (SXA)

DEXA
-measures areal bone density (mineral per surface area)
-precise, accurate, use low radiation dose
-BMD measurement at the lumbar spine and proximal femur remain the gold
standard and fracture prediction is site specific.
-When site-specific measurements are not available, other
skeletal sites can be used to provide an adequate estimation of fracture risk.
 QCT
-allow distinction between trabecular and cortical bone
-more expensive, higher radiation
-offers no clinical advantage

Indication for DEXA

scanning Presence of strong Oestrogen deficiency
RF Premature menopause (< 45 years of
age) including surgical menopause
Prolonged secondary amenorrhoea
Hypogonadism
Glucocorticoid therapy (equivalent to > 7.5 mg
prednisolone daily for > 1 year)
Maternal family history of hip fracture
Low body mass index (<19 kg/m2)
Other conditions associated with osteoporosis
Anorexia nervosa
Malabsorption
Hyperparathyroidism
Hyperthyroidism
Prolonged immobilisation
Cushings syndrome

Radiological
osteopenia and/or
vertebral deformity

Previous low Hip, spine and/or wrist

trauma fractures -proximal femur, compression #, colles #

Loss of height,
thoracic kyphosis
Postmenopausal
women who are
considering
treatment for
osteoporosis

Tx To reduce risk of #

Prevention of Osteoporosis
 Nutrition
Calcium Calcium intake is positively correlated to bone mass at all ages
Daily intake of 600mg is needed throughout life
Postmenopausal women : 800-1000mg
Established osteoporosis: 1200mg

A sustained high calcium intake in children and adolescents higher peak

bone mass reduce risk of osteoporosis in later life
Increased calcium intake potentiates the effect of vitamin D and HRT

Current calcium intake in the Malaysian diet is 300-400 mg daily

Vitamin D Exposure to sufficient sunlight (> 15min/dy) adequate Vitamin D level

Elderly who are institutionalised, immobile, lack outdoor activities and
have a poor diet will benefit from 800 IU Vitamin D supplementation daily
Vitamin D and calcium reduce non vertebral osteoporotic #

S/E: Excessive intake of calcium and/or vitamin D supplement may

encourage the formation of renal stone. (consume adequate fluids)

Body Weight Low body weight and excessive dieting is associated with low bone mineral
status and increased fracture risk.
Maintenance of BMI not less than 19 kg/m2 is recommended for
prevention of osteoporosis
Nutritional Status Maintenance of adequate protein and energy intake is important esp in
children and elderly.

Exercise Regular physical activity, in particular weight-bearing exercise 30 minutes 3

times/week
maximise peak bone mass
decrease age-related bone loss
maintain muscle strength and balance

Pharmacological HRT, selective estrogen receptor modulators (SERMs) and

agents bisphosphonates have been shown to be effective in prevention of

Prevention of falls Most osteoporosis-related fractures, especially in the elderly, are a

consequence of decreased BMD and fall
Factors that may lead to a fall :
poor balance, reduced muscle strength, poor vision
diseases of nervous and musculoskeletal systems
excessive alcohol consumption
certain medications (sedatives, anti-hypertensives)
 hazards in home (steps, inadequate lighting, slippery floors)
Physiotherapy and assessment of home safety is important

Pharmacological Tx
-treatment with efficacy at all major # site is preferable

Bisphosphonate -synthetic analogue of bone pyrophosphate, bind to hydroxyapatite, and

-first line drug inhibit osteoclast
-alendronate at 5 mg daily was shown to prevent postmenopausal bone
(Alendronate loss with similar efficacy to HRT
5mg daily or -useful alternative for women unable or unwilling to take HRT.
70mg weekly) -in established osteoporosis, the recommended daily dose of alendronate
is 10 mg.

S/E
: GI-nausea, esophagitis.
: used in caution in patient with CKD
: osteonecrosis of jaw is rarely seen following high dose IV nitrogen-
containing bisphosphonate in pt with malignant dz.
: prolonged suppression of bone turnover atypical femoral # NB to
reassess tx after 5-10 yrs

Proper administration of alendronate will reduce the small risk of

oesophagitis or oesophageal ulceration. Oral bisphosphonate taken in
fasting state with large drink of water, while patient is standing or sitting
upright. Pt should remain upright and avoid food and drink for at least 30
min.

Strontium -weak anti resorptive activity

ranelate -stimulate osteoblast bone formation
-reduces risk of vertebral , hip and other non-vertebral # in
postmenopausal women with OP
-2g daily, given as granules dissolved in water ON

S/E : N,D, headache, small risk of VTE, risk of arrhythmia

HRT -Oestrogen therapy is beneficial in the prevention and treatment of

postmenopausal osteoporosis
-The maximum benefit to the bone: oestrogen started at menopause and
continued for 10 years or more.
-Oestrogen can be started at any time from the perimenopausal period till
late postmenopausal.

-For women with an intact uterus, progestins for a minimum of 10-12 days
 monthly must be given together with oestrogen.

Benefits Studies shown 30-50 % reduction in fracture

risk in the spine and hip with
long term use of oestrogen

Relief of vasomotor symptoms, psychological

problems, vaginal dryness Reduction in risk of
primary cardiovascular disease

Emerging potential benefits include:

-decreased incidence of colon ca, macular
degeneration, prevention and delay in
Alzheimers Disease and a positive effect on
alveolar dentition

Prior to starting HRT Full gynaecological assessment prior to

starting HRT and at regular intervals A breast
examination should be conducted annually
and mammography at 1-3 yearly intervals.
SBE is advised

Absolute Undiagnosed vaginal bleeding

contraindications Severe liver disease and a history of VTE
within the past 12 months
HRT and Ca The association between HRT and breast
cancer remains inconclusive.
Epidemiological studies suggest that
oestrogen use does not cause an
increased risk of breast cancer in the first 5
years, but this risk may
increase after 5 years or more of treatment

SERM Selective estrogen receptor modulators

-activate estrogen receptors in bone, no effect on endometrium
(Raloxifene -Improves and preserves bone density at both the spine and hip
-60 mg daily)
-Reduction incidence of ER+ve breast cancer in women treated up to 4 yrs
-Suitable alternative for women who are unable/unwilling to take HRT.
S/E: hot flushes and leg cramps, slightly increased risk of DVT

Calcitonin -Prevent bone resorption

-Daily intranasal dose of 200 IU, will increase lumbar spine BMD by 1%
-1.5% over 5 years and reduce vertebral fracture rates by 36-38%
-S/E: nausea, flushing, vomiting and nasal irritation

Calcium -Calcium supplementation can potentiate other treatment modalities

Vitamin D -Vitamin D supplementation at 800 IU/day in combination with calcium
has been shown to reduce fracture in elderly populations with vitamin D
deficiency

Activated -Increase BMD in those with established OP and reduce vertebral #

Vitamin D -The reduction in fracture risk of spine and in those with mild to moderate
(Calcitriol or osteoporosis
Alfacalcidol)
-All patients on activated Vitamin D should avoid taking excessive calcium
to reduce the risk of hypercalcemia and renal stone disease.
-Serum and urinary calcium should be monitored periodically, 6 weeks
after initiation of therapy and at 3 to 6 monthly intervals thereafter.

Patients such as those over 65 years of age with multiple risk factors who are at sufficiently
high risk for osteoporosis, can be started on treatment even without BMD measurement.