Download OSTEOPOROSIS

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INTERNAL MEDICINE CONGRESS 1382
OSTEOPOROSIS
Rheumatology Research Center
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DEFINITION
• Systemic Skeletal Disease
• Low Bone Mass
• Micro Architectural Deterioration
– Increase in Bone Fragility
– Susceptibility to Fracture
Am J Med 1993;94:644-650
• Bone Densitometry
– t score: –2.5SD
WHO 1990
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EPIDEMIOLOGY
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EPIDEMIOLOGY
• USA (NHANESS III 1997)
– Women
– Men
• IRAN
13 - 18%
1 - 4%
4,575,000 - 7,150,000
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FRACTURE RISK
50 YEARS AND OVER
WOMEN
MEN
• Femur
17.5%
6.0%
• Spine
15.6
5.0
• Wrist
16,0
2.5
• Any Fracture
39.7
13.1
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BONE
PHYSIOLOGY
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BONE PHYSIOLOGY
• Bone Resorption
– Osteoclast
• Bone Formation
– Osteoblast
• Bone Remodeling
Unit
– Positive < age 30
– Negative > age 30
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
10
15
20
25
30
35
40
45
50
55
60
65
70
75
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OSTEOBLAST
• Origin:
Mesenchymal Cell
• Activation:
PTH, Vitamin D
• Function
– Matrix Formation
– Bone Mineralization
– Matrix Degradation
 RANK L
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OSTEOCLAST
• Origin
– Blood Mononuclear Cells
Cl
• Differentiation
H2O + CO2
– CSF-1
– RANK L
HCO3
• Lymphocyte
• Osteoblast
• Action
– Acidification
– Protein Degradation
H+
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BONE REMODELING UNIT
.
Resorption
. . . . . . ..
Formation
Completion
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BONE RESORPTION
PTH
Vit D
PTH
Vit D
M-CSF
IL-1
TNF-
IL-6
IL-11
IL-1
TNF-
IL-6
IL-11
RANK
STIMULATION
STIMULATION
RANK
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PTH
Vit D
IL-1
TNF-
IL-6
IL-11
BONE FORMATION
ANDROGEN
CALCITONIN
ESTROGEN
ILGF
PROGESTERONE
INHIBITION
ESTROGEN
PTH
Vit D
INHIBITION
STIMULATION
RANK
STIMULATION
COUPLING FACTOR
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CLINICAL
MANIFESTATIONS
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CLINICAL MANIFESTATIONS
• Symptoms
Non
• Complications
Fractures
– Macroscopic
• Vertebra
• Femoral Neck
• Wrist
• Others
– Microscopic
• Vertebrae: Mechanical Pain, Spine Deformity
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DIAGNOSIS
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OLD DAYS
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20th CENTURY
• X-RAY
• BONE BIOPSY
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NOWADAYS
BONE DENSITOMETRY
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D E X A
ual
nergy
-ray
bsorptiometry
(Gold Standard)
• NON INVASIVE
– Irradiation: 1/100 Chest X-ray
– 1 h. Sun Exposure
• SENSITIVITY
1.0%
• ACCURACY
2.8%
• REPEATABLE
• LONGITUDINAL STUDY
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BONE MINERAL DENSITY
• SPINE
• FEMUR
• FOREARM
• OTHERS
– Whole Body
– Heel
– hand
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RESULT
• BMD
0.857
• Comparison To Young Adult
– %
76%
– t Score -2.4
• Comparison To Same Age
– %
101%
– z Score +0.1
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SPINE
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SPINE
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FEMUR
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FEMUR
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FOREARM
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FOREARM
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DIFFERENT STANDARDS
• COUNTRIES and ETHNICITIES
• MACHINES
– Hologic
– Lunar
– MediLink
– Norland
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AMERICAN STANDARD
PBM
1124 mg
Female - Spine
Standardized BMD
1006 mg
Osteopenia
829 mg
Osteoporosis
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IRANIAN STANDARD
PBM
1097 mg
Female - Spine
Standardized BMD
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COMPARISON
PBM diff
2.5%
Female - Spine
Standardized BMD
1006 mg
Osteopenia
829 mg
Osteoporosis
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DEFINITIONS
• NORMAL BONE
– 1.0 to -1.0 SD over/bellow PBM
• OSTEOPENIA
– -1.0 to -2.4 SD bellow PBM
• OSTEOPOROSIS
– -2.5 SD bellow PBM
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BMD REPORT
• FRACTURE RISK
Spine
Neck
– t = -1 SD
2.2
2.6
– t = -2 SD
5.0
7.0
– t = -3 SD
11.0
18.0
• Comparison Iranian Standard
• Advice
– Evaluation
– Prevention/Treatment
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PURPOSE and APPLICATION
• DIAGNOSIS
– Osteoporosis
– Osteopenia
– Normal Bone
• CALCULATION
– Time to Osteopenia
– Time to Osteoporosis
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BONE LOSS
Spine – Iranian Women
%
22% Loss 35-65 Y
Age
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INDICATION
(People at Risk)
• Menopause
• Inflammatory Diseases
• Endocrine Disorders
• Predisposing Drugs
• Familial History
• Fracture
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BONE TRABECULA
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BONE TRABECULA
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BONE TRABECULA
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PREVENTION
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PREDISPOSING FACTORS
• Genetic
– Stature
– Vitamin D Receptor: DD, Dd, dd
• Alimentation
– Calcium, Protein
• Physical Activity
• Habits
– Coffee, Alcohol, Smoking
• Disease
– Endocrine, Inflammatory Diseases, Renal Disorders
• Drugs
– Steroids, Cytotoxic, Anti-epileptic, Heparin, Thyroxine
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PREVENTION
(Normal Person, Normal BMD)
• Young
– Alimentation
– Sport
• Mid Age (up to menopause)
– Habits
• Menopause
– HRT (Allendronate?), Calcium, Exercises
• Senile
– Exercises
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PREVENTION
(Disease or Medication, Normal BMD)
• Same as for Normal Person
• Adequate Management of the Disease
– Minimum Required Dose of Predisposing Drug
• Medication
• Calcium
• Exercise
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DRUGS
• Bone Forming
– Synthetic PTH
– Fluoride
20-40 mg/daily + Ca + Vit D
– Progesterone
– Anabolic agents
Nandrolone Decanoate
• Resorption Preventing
– Estrogen & Analogs
ERT, HRT, Ralloxiphen
– Calcitonin
Injectable, Nasal Spray
– Bisphosphonate
Etidronate, Allendronate
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ALLENDRONATE
• Osteofos
• Prevention
– 5 mg daily
• Treatment
– 10 mg daily
• Precautions
– 30 Minutes Before Breakfast
– Upright Position
• Side Effects
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INTERNAL MEDICINE CONGRESS 1382
Rheumatology Research Center