Diagnosis Dan Terapi

Osteoporosis Dengan
Ibandronat

Objectives
1. To understand BMD in osteoporosis.
2. To calculate fracturerisk (using FRAX).
3. To understand the use of
bisphosphonate in osteoporosis
treatment.

Osteoporotic

fracture
Vertebrae
>66% trabecular

Distal radius
>95% cortical
Femoral neck
75% cortical 25%
trabecular

The most frequent site of fracturedue to

osteoporosis

Bone Density & Age vs. Fracture Ri

Age

50
40
Ten Year

30

Fracture
Probability 20
(%)

80
70
60
50

10
0
1.
0

0.5
-1.5 -2.5 - 0.0
3.0
3.5 4.0
0.5 1.0 2.0
Femoral Neck T- score

Probability of first fracture of hip, distal forearm, proximal humerus, a

symptomatic vertebral fracture in women of Malm, Sweden.
Adapted from Kanis JA et al. Osteoporosis
Int. 2001;12:989-995.

Risk factor for osteoporosis

Bone Mineral Density

(BMD)

Is early diagnosis
of osteoporosis
possible?

DXA Technology
Detector (detects 2 tissue types and

- bone

soft tissue)
Very low radiation to patient.

Patient
Photons

Very little scatter radiation to

technologist

Collimator
(pinhole for pencil beam, slit for fan
beam)

X-ray Source
(produces 2 photon energies with different attenuation profiles)

Region of interest (ROI)

Spine L1-

Femoral Neck
L4

El Maghraoui A. Interpreting aDXA scan in clinical practice. In : Dual energy x-ray absorptiometry. InTech,2012.

Distal Forearm

Total Body
Vertebral Fracture
Assessment

T-score
Patients BMD - Young-Adult Mean BMD
1 SD of Young-Adult Mean BMD
Example:
T-score =

0.7 g/cm2 - 1.0 g/cm2

= - 3.0
0.1 g/cm2

WHO Diagnostic Classification

Classification
Normal
Osteopenia

Osteoporosis
Severe
Osteoporosis

T-score
-1.0 or greater
Between -1.0 and -2.5

-2.5 or less
-2.5 or less and fragility
fracture

Indications For Bone Density Testin

All women age 65 and older
All menage 70 and older
Adults with a fragility fracture
Adults with a disease or condition associated with low
bone density
Adults taking medication associated with low bone density
Anyonebeing treated for low bone density to monitor treatment
effect
Anyone not receiving therapy, in whom evidence of bone loss
would lead to treatment
Women discontinuing treatment should be considered for bone
density testing according to the indications listed above.
ISCD Position Development Conference 2003

Calculating fracture
risk
(using FRAX )

Osteoporotic

fracture

BMD is major determinant for fracture

The role of FRAX for treatment

Ten year probability of fracture

Major osteoporotic fracture > 20%
Hip fracture > 3%

The used of bisphosponate

Skeletal disorder in children (e.g.
osteogenesis imperfecta)
Postmenopausal
osteoporosis

Glucorticoid-induced
osteoporosis

Bone metastases
Paget disease of the bone
Hypercalcemia
Multiple myeloma
Osteoarthritis (?)

Bisphosphonate

Basic structure of Bisphosphonate

Bone cells

Osteoclast and osteoblast play majorrole

in bone metabolism.
Role of osteocytes?

Osteoclast-targettedtherapy

Scanning electron micrograph on an

osteoclast resorbing bone

Role of calcium and vitamin

Assuring adequate vitamin D and
calcium intake before and after starting
bisphosphonate therapy
- Optimal serum level of 25-OH-vit D :
30
ng/ml (75 nmol/L)
- Calcium intake recommendation
< 50 years : 1000 mg/day
> 50 years : 1200 mg/day

Oral bisphosphonate
Poor absorption (generally < 1%)
Short-term bioavailability
Esophageal irritation
Prevention :
- upright posture for 30-60
minutes after
ingestion
- afull glass of water
- empty stomach
- do nottake together with calcium or
other drugs

3 Montly i.v. ibandronate (Bonviva)

Quarterly IV ibandronate injection:

lumbar spine
7.0

n=254

3mg quarterly IV injection (n=413

2.5mg daily (n=422)

Year
Note the published years 1 and 2, PP population data are not directly comparable with the ITT
population data presented here; At 2 years
*p<0.001 vs 2.5mg daily; p<0.0001 vs DIVA baseline
Lewiecki M, et al. Bone 2007;40(Suppl. 2):S301 (Abstract 307Th)

Quarterly IV ibandronate injection:

proximal femur
Total hip

Femoral neck

3.3*

3.1*

n=251

n=251

Year

Year
Trochanter
5.1*

3mg quarterly IV injection (n=410)

2.5mg daily (n=481)

n=251

Year
ITT population; *p<0.0001 for change from DIVA baseline; At 2 years
Lewiecki M, et al. Bone 2007;40(Suppl. 2):S301 (Abstract 307Th)

Bone micro-architecture

Bisphosphonate therapy increases bone density and reduces

fracture risk by improve trabecular connectivity and increase
bone structural unit thatreacha maximum degree of
mineralization.
Boivin GY et al. Bone 2000

Ibandronate and bone markers

Clinical concerns to
bisphosphonate therapy

Osteonecrosis of the jaw

Atrial fibrillation
Oversuppression of bone turnover
Hypocalcemia
Acute inflammatory response
Musculoskeletal pain
Diffuse osteolytic lesions on panoramic view
in patient with osteonecrotic of jaw
(mandible)

Take Home Messages

Clinical conditions and risk factors are
important in interpreting BMD test.
Decision to treat can be based on
BMD (T-score) and/or FRAX assesment
Bisphosphonate is drug of choice for
treatment of osteoporosis .
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