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Osteoporosis is a skeletal disorder
characterized by compromised bone
strength predisposing individuals to an
increased fracture risk.
postmenopausal osteoporosis,
 age related steoporosis
 secondary osteoporosis.
Refer to textbook
Many patients are unaware that they have
osteoporosis and only present after fracture. Fractures
can occur after bending, lifting, or falling, or
independent of any activity.
The most common osteoporosis-related fractures
involve the vertebrae, proximal femur, & wrist. 2/3 of
patients with vertebral fractures are asymptomatic;
the remainder present with moderate to severe back
pain that radiates down a leg after a new vertebral
fracture. The pain usually subsides significantly after 2
to 4 wks, but chronic, low-back pain may persist.
Multiple vertebral fractures decrease height &
sometimes curve the spine with or without significant
back pain.
Patients with a non vertebral fracture
frequently present with severe pain,
swelling, & reduced function & mobility
at the fracture site.
Major risk factor (<127 lb in postmenopausal women),
history of osteoporotic fracture in a first-degree
relative, and personal history of low-trauma fracture
as an adult. age, high bone turnover, low BMI index
(<19 kg/m2), RA, & glucocorticoid use.
Complete physical examination
BMD of central hip & spine
T score: Normal bone mass is a T-score greater than –
1, osteopenia is –1 to –2.4, & osteoporosis is at or
below –2.5.
low trauma fracture
The primary goal of osteoporosis management is
Optimizing skeletal development & peak bone mass
accrual in childhood, adolescence, and early
adulthood will reduce the future incidence of
Once osteopenia or osteoporosis develops, the
objective is to stabilize or improve bone mass and
strength and prevent fractures.
Goals in patients who have already suffered
osteoporotic fractures include reducing future falls
and fractures, improving functional capacity,
reducing pain and deformity, and improving quality
of life.
balanced diet with adequate intake of
calcium & vitamin D or , calcium
 caffeine increases calcium excretion,
caffein intake should be limited to two
servings per day.
 Smoking cessation
 Weight-bearing aerobic and strengthening
exercises improving muscle strength,
coordination, balance, & mobility.
Intake should increase, with vit D, calcium
carbonate is the best choice b/c it is high with
Ca content, less expensive,
Constipation is most common SE.
Vitamin D
Maximize intestinal Ca absorption, intake
should be 800-1000 u/d
Not FDA approved, short-term in patient with
menapusal symptoms ,oral and transdermal
estrogens at equivalent doses and continuous
or cyclic HT regimens have similar BMD effects.
Has many CI.
Not FDA approved, should not be used alone,
may reduce bone loss in patient with
hypogondal symptoms , evaluate patient
every 1-2m, then 3-6m.
Thiazide diuretics
Thiazide diuretics increase urinary calcium
reabsorption; should not be used alone, best
in patient how require diuretic or with
glucocorticiod use
Bisphosphonates Bisphosphonates bind to hydroxyapatite in bone and
decrease resorption by inhibiting osteoclast
adherence to bone surfaces. All bisphosphonates
become incorporated into bone, giving them long
biologic half-lives of up to 10 years. provide the
greatest BMD increases & fracture risk reductions.
Fracture reductions are demonstrated as early as 6 m,
with the greatest fracture reduction seen in pts with
lower initial BMD and in those with the greatest BMD
changes with therapy.
BMD increases are dose dependent and greatest in
the first 6 -12 m of therapy. Small increases continue
over time at the lumbar spine but plateau after 2 to 5
years at the hip. After d/c, the increased BMD is
sustained for a prolonged period that varies
depending on the bisphosphonate used.
Alendronate, risedronate, oral ibandronate
are FDA approved for prevention & treatment of
postmenopausal osteoporosis.
IV ibandronate & zoledronic acid are indicated only
for treatment of postmenopausal women.
Risedronate & alendronate are also approved for
male & glucocorticoid-induced osteoporosis.
poorly absorbed (BA1-5%)
Each oral tablet should be taken in the morning with
at least 6 oz of plain tap water (not coffee, juice,
mineral water, or milk) at least 30 minutes (60 minutes
for oral ibandronate) before consuming any food,
supplement, or medication. The patient should
remain upright (sitting or standing) for at least 30
minutes after alendronate & risedronate & 1 h after
ibandronate administration to prevent esophageal
irritation & ulceration.
Most patients prefer once-weekly or once-monthly
administration over daily therapy. If a patient misses
a weekly dose, it can be taken the next day. If more
than 1 day has elapsed, that dose is skipped
until the next scheduled ingestion. If a patient misses
a monthly dose, it can be taken up to 7 days before
the next scheduled dose.
SE: GI, flu like symptoms. Osteonecrosis of
the jaw occurs rarely; if it develops, oral chlorhexidine
washes, systemic antibiotics, and systemic analgesics
are used based on severity.
Mixed Estrogen
Raloxifene is an estrogen agonist on bone but an
Agonists/Antagonists antagonist on the breast & uterus. It is approved
for prevention and treatment of postmenopausal
osteoporosis. Less effective, less breast cancer
risk, SE: hot flashes, bleeding, CI:
is released from the thyroid gland when serum
calcium is elevated. Salamon calcitonin is used
b/c more potent & long lasting, indecated 5
years past menopause, 3rd line agent, can
produce pain relief in vertebular fracture,
intranasal dose 200 u/d
recombinant product representing the first 34 amino
acids in human parathyroid hormone. Teriparatide
increases bone formation,
the bone remodeling rate, and osteoblast number and
activity. Both bone mass & architecture are improved.
• Teriparatide is FDA approved for postmenopausal
women & men who
are at high risk for fracture. Candidates for therapy
include patients with a history of osteoporotic fracture,
multiple risk factors for fracture, very low bone density
(e.g., T-score <–3.5), or those who have failed or are
intolerant of previous bisphosphonate therapy.
The drug reduces fracture risk in postmenopausal
women, but no fracture data are available in men.
Lumbar spine BMD increases are higher than with any
other osteoporosis therapy. Although wrist BMD is
decreased, wrist fractures are not increased.
• D/C of therapy results in a decrease in BMD, but some
antifracture efficacy appears to be maintained.
Sequential therapy with teriparatide followed by an
antiresorptive agent (e.g., bisphosphonate) should be
considered to maintain BMD gains.
The dose is 20 mcg administered SC in the thigh or
abdominal area. The initial dose should be given with the
patient either lying or sitting, in case orthostatic
hypotension occurs. Each prefilled 3-mL pen device
delivers a 20-mcg dose each day for up to 28 days; the
pen device should be kept refrigerated.
• Transient hypercalcemia rarely occurs. A trough serum
ca conc is recommended 1 m after initiation of therapy.
• Teriparatide is CI in patients at baseline increased risk
for osteosarcoma (e.g., Paget’s bone disease,
unexplained alkaline phosphatase elevations, pediatric
patients, young adults with open epiphyses, or patients
with prior radiation therapy involving the skeleton).
Guidelines for managing corticosteroidinduced osteoporosis recommend measuring
BMD at the beginning of chronic therapy
(prednisone 5 mg or more daily or equivalent
for at least 6 months) and follow up monitoring
with DXA in 6 to 12 months. BMD should be
measured in patients taking chronic therapy
whose baseline values were not obtained.
All patients starting or receiving long-term
systemic glucocorticoid therapy should receive
at least 1,500 mg elemental calcium and 800
to 1,200 units of vitamin D daily and practice a
bone-healthy lifestyle.