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Osteopenia:

Osteoporosis &
Osteomalacia

Definitions
Osteopenia is decreased bone mass and is
primarily caused by two conditions.
inosteoporosis,bone mass decreases but the ratio
of bone mineral to bone matrix is normal
this is characterised by micro-architectural deterioration
of bone tissue and an increased fracture risk

Osteoporos
is

Normal
bone
matrix

inosteomalacia,the ratio of bone mineral to bone


matrix is low

The Bone Cycle

Changes in bone mass


with age

M
en

Osteoporotic fragility fractures are common in the vertebrae, wrists,


and hips.
lifetime risk of fracture in women is 20% for spine, 15% for wrist
and 18% for hip
there is an exponential increase in fractures over 50 years
Peak bone mass

en
om
W

Bone
mass

10

20

M
en
op
au
se

30
40
Age (years)

50

60

70

80

Aetiology of Osteoporosis
Non-modifiable risk
factors:

Female gender
Increasing age
Family history
White or East Asian
ethnicity
Small stature
Early menopause

ACCES

Additional risk
factors:
Excess alcohol
intake
Cigarette smoking
Anorexia
Oophorectomy
Sedentary lifestyle
Insufficient calcium
intake
Low testosterone
levels
(hypogonadism in

1 & 2 Disease
Idiopathic osteoporosis (type I)
Postmenopausal osteoporosis
Occurs in women aged 50-65
years
Characterised by a phase of
accelerated bone loss, primarily
from trabecular bone
Fractures of the distal forearm
and vertebral bodies common
Senile osteoporosis (type II)
Occurs in women and men older
than 70
Represents bone loss associated
with aging
Fractures occur in cortical and
trabecular bone of the hips

Secondary osteoporosis
Hypogonadal states
Genetic/congenital
Endocrine disorders
Deficiency states
Inflammatory diseases
Hematologic and
neoplastic disorders
Medications

Investigations
Initial investigations:
FBC and ESR or CRP
U&E, LFTs, TFTs, serum calcium/vitamin D
Testosterone/gonadotrophins in men
Gold standard for diagnosis:
DEXA (dual-energy X-ray absorptiometry)
scan to measure BMD (bone mass density)
Other imaging: USS and CT

DEXA
(dual-energy X-ray absorptiometry)
The lumbar spine (L1-4) and
femoral neck, total hip, or
forearm BMD is measured.
The spine, which has a
greater cancellous bone
content and a larger surface
area, is the best site for
monitoring response to
treatment because of its
greater rate of change in
BMD.

DEXA Interpretation
T-score: this number shows
the amount of bone
compared with a young adult
of the same gender with
peak bone mass.
Z-score: this number
reflects the amount of bone
you have compared with
other people in the same
age group and of the same
size and gender.
Both of them is expressed as
SD numbers

The FRAX algorithm is available online at


http://www.shef.ac.uk/FRAX

Who to treat?
Postmenopausal women and men age 50 and older
presenting with the following should be considered
for treatment:
A hip or vertebral fracture .
T-score -2.5 at the femoral neck or spine after
appropriate evaluation to exclude secondary causes .
Low bone mass (T-score between -1.0 and -2.5 at the
femoral neck or spine) with risk factors (prevention)
10-year probability of a hip fracture 3% or a 10-year
probability of a major osteoporosis-related fracture 20%
based on the patient country-adapted WHO.

Prevention and Treatment


Non-pharmacological & health advice
for all:
Diet
Physical exercise
Other lifestyle modifications (e.g. fall prevention)

Pharmacological management:
Anti-resorptive (Biphosphonates, Raloxifen,
Calcitonin)
Anabolic (Calcium, Vitamin D, Teriparatide)

Vitamin D

Vitamin D :

Chief dietary sources of vitamin D :


Vitamin D-fortified milk (400 IU per quart) .
Cereals (40 to 50 IU per serving), egg yolks,
salt-water fish and liver.
Some calcium supplements and most
multivitamin tablets also contain vitamin D.
Individuals older than age 65 should aim
to take 10 micrograms (400 IU) daily.

Encourage sun exposure of 20-30min


twice weekly if possible .

Sunlight can be the most efficient method

Osteomalacia
Decalcification and softening of the bone in adult.
similar to rickets in children

Caused mainly by vitamin D deficiency


**Vitamin D is required for the absorption of calcium from the
intestine and calcium is responsible for mineralisation of bone
Caused mainly by:
Decreased availability of vitamin D
Insufficient sunlight exposure
Nutritional deficiency of vitamin DMalabsorption; aging, excess wheat bran,
bariatric surgery, pancreaticenzymedeficiency
Liver disease
Chronic kidney disease
Kidney transplantation
Medications: anti epileptics (phenytoin,carbamazepine, orbarbituratetherapy)

Presentation
Initially asymptomatic
Eventually, bone pain, simulating fibromyalgia
Painful proximal muscle weakness (especially pelvic girdle)
due to calcium deficiency
Pathologic fractures with little or no trauma (although rare)
Vitamin D deficiency has been associated with a possible
increased risk of

Multiple sclerosis
Rheumatoid arthritis
Diabetes mellitus and hypertension
Psoriasis
Depression

Diagnosis
Bloods
Decreased serum calcium or
phosphate
Decreased serum 25hydroxyvitamin D
Elevated alkaline phosphatase

X-rays
Show Loosers transformation
zone

ribbons of decalcification in

Treatment and Prevention


Vitamin D and Calcium
Individuals older than age 65 should aim to
take 10 micrograms (400 IU) daily.
Encourage sun exposure of 20-30min twice
weekly if possible.
Sunlight can be the most efficient method
of obtaining vitamin D, and can eliminate
the need for tablets.
Where vitamin D deficiency is confirmed or
likely a daily dose of 20 micrograms (8001000 IU) is recommended.
Recommended calcium intake for the

Thank You