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RR C INTERNAL MEDICINE CONGRESS 1382 OSTEOPOROSIS Rheumatology Research Center R RR RC C RR C 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 RR C EPIDEMIOLOGY RR C EPIDEMIOLOGY • USA (NHANESS III 1997) – Women – Men • IRAN 13 - 18% 1 - 4% 4,575,000 - 7,150,000 RR C 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 RR C BONE PHYSIOLOGY RR C 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 RR C OSTEOBLAST • Origin: Mesenchymal Cell • Activation: PTH, Vitamin D • Function – Matrix Formation – Bone Mineralization – Matrix Degradation RANK L RR C OSTEOCLAST • Origin – Blood Mononuclear Cells Cl • Differentiation H2O + CO2 – CSF-1 – RANK L HCO3 • Lymphocyte • Osteoblast • Action – Acidification – Protein Degradation H+ RR C BONE REMODELING UNIT . Resorption . . . . . . .. Formation Completion RR C 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 RR C 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 RR C CLINICAL MANIFESTATIONS RR C CLINICAL MANIFESTATIONS • Symptoms Non • Complications Fractures – Macroscopic • Vertebra • Femoral Neck • Wrist • Others – Microscopic • Vertebrae: Mechanical Pain, Spine Deformity RR C DIAGNOSIS RR C OLD DAYS RR C 20th CENTURY • X-RAY • BONE BIOPSY RRC RR C NOWADAYS BONE DENSITOMETRY RR C 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 RR C BONE MINERAL DENSITY • SPINE • FEMUR • FOREARM • OTHERS – Whole Body – Heel – hand RR C RESULT • BMD 0.857 • Comparison To Young Adult – % 76% – t Score -2.4 • Comparison To Same Age – % 101% – z Score +0.1 RR C SPINE RR C SPINE RR C FEMUR RR C FEMUR RR C FOREARM RR C FOREARM RR C DIFFERENT STANDARDS • COUNTRIES and ETHNICITIES • MACHINES – Hologic – Lunar – MediLink – Norland RR C AMERICAN STANDARD PBM 1124 mg Female - Spine Standardized BMD 1006 mg Osteopenia 829 mg Osteoporosis RR C IRANIAN STANDARD PBM 1097 mg Female - Spine Standardized BMD RR C COMPARISON PBM diff 2.5% Female - Spine Standardized BMD 1006 mg Osteopenia 829 mg Osteoporosis RR C 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 RR C 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 RR C PURPOSE and APPLICATION • DIAGNOSIS – Osteoporosis – Osteopenia – Normal Bone • CALCULATION – Time to Osteopenia – Time to Osteoporosis RR C BONE LOSS Spine – Iranian Women % 22% Loss 35-65 Y Age RR C INDICATION (People at Risk) • Menopause • Inflammatory Diseases • Endocrine Disorders • Predisposing Drugs • Familial History • Fracture RR C BONE TRABECULA RR C BONE TRABECULA RR C RR C BONE TRABECULA RR C PREVENTION RR C 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 RR C PREVENTION (Normal Person, Normal BMD) • Young – Alimentation – Sport • Mid Age (up to menopause) – Habits • Menopause – HRT (Allendronate?), Calcium, Exercises • Senile – Exercises RR C 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 RR C RR C 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 RR C ALLENDRONATE • Osteofos • Prevention – 5 mg daily • Treatment – 10 mg daily • Precautions – 30 Minutes Before Breakfast – Upright Position • Side Effects RR C INTERNAL MEDICINE CONGRESS 1382 Rheumatology Research Center