OSTEOPOROSIS

Dr. Zulfan, SpPD

Bagian Penyakit Dalam FK Universitas YARSI

EPIDEMIOLOGY
Osteoporosis is a major public health problem, and postmenopausal osteoporosis constitutes as a major part of the problem.
Claus Christiansen, Am J Med 1993

Hip fractures will increase sharply in the next half century, especially in Asia, making osteoporosis a truly global issue.
WHO 1998

Introduction
Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhance bone fragility and a consequent increase in fracture risk (WHO)

Osteoporosis is a skeletal disorders compromised bone strength, predisposing in an increase risk of fracture

Rigg and Nelson divided into :

A/. Primary osteoporosis 1. Post menopause osteoporosis 2. Senile osteoporosis B/. Secondary osteoporosis Osteoporosis due to other condition of disease such as metabolic, endocrine or malignancy

Post menopausal osteoporosis Most common in woman 15 20 year after menopause

Mostly affects trabecular bone, increasing patient

susceptibility to vertebral compression fractures, distal radial fractures and intertrochanteric fractures. Esterogen deficiency plays a primary role

Senile Osteoporosis
Occurs in men and women over the age of 70 years with female to male ratio of 2:1 It affects : cortical and trabecular bone equally, predisposing patient to multiple wedges vertebral and femoral neck fractures Aging and long-term calcium deficiency is more important.

Primary osteoporosis mostly are old and elderly people complaining of mild backache but may also a sudden pain with only a mild injury due to a compression fractures of the vertebrae.

Before it reaches the threshold of fractures,

usually the height of patient reduces beside

deformity (kyphotic deformity)

It is a silent disease, meaning there is no significant signs and symptoms caused by osteoporosis

Etiology :
General factor predictive of osteoporosis :
1. Peak bone mass at maturity :
General / familial Nutritional Physical (activity status, exercise, etc) Life style (alcohol, cigarettes, caffeine) Medical (chronic disease, hypogonadal states, etc) Iatrogenic (corticosteroid, anticonvulsant, etc)
Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889

Bone Mass Development

Peak Bone Mass

Bone Loss

Bone Mass

male

Menopause

female

20

40

60

80

age

Age (year)

2. Post menopausal bone loss

Accelerated trabecular bone loss for 3 to 10 years post menopausal Due to increased bone resorption secondary to estrogen loss Loss of normally 1 to 2% per year to a maximum of 10%
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Age-related (involutionall) bone loss

Starts at age 35 40 years in both sexes, continues for 30 to 40 years Subtle uncoupling of rates of bone formation and resorption Both cortical and trabecular bone affected Loss normally less than 0.5% per year to a maximum of 20 %
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Risk factors Genetic, life style, Medical, Iatrogenic

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Risk factors for bone loss :

1. Genetic :

- Female sex - Caucasian / Asian ethnicity - Family history of osteoporosis

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

2. Life Style
-

Low calcium intake Excessive alcohol use Cigarette smoking Excessive caffeine use Extreme or insufficient athlecity Excessive acid ash diet (high protein / soft drink intakes)

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Medical :
Early menopause Gonadal hormone deficiency states Eating disorders Chronic liver / kidney disease Malabsorption syndrome

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Iatrogenic
-

Corticosteroids Excessive thyroid hormone Chronic heparin therapy Radiotherapy to skeleton Long-term anticonvulsants Loop diuretics

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Bone is the most dynamic tissue. Metabolism of catabolism and anabolism as the activity of osteoclast and osteoblast as a process of bone remodeling or

bone turn over

Degeneration occurs as an aging process where the activity of osteoclast is not able to compensate by the activity of osteoblast. As a result bone mineral density decrease

The main problem of osteoporosis lies in the effectiveness of interventionprevention and treatment

Osteoporosis is preventable if prevention starts during the childhood and adolescence when bone reaches maturity at the end

of 3rd decade to achieve maximum

Peak Bone Mass

After the 3rd decade all organ include skeletal / bone will degenerate, the speed of degeneration, differs for different organ.

In general organ will loose function

1% every year (the rule of 1% of Andreas and Tobin)

Diagnosis should include differential diagnosis of primary and secondary osteoporosis by : o Taking a good history o Physical examination o Laboratory examination o Imaging examination

DIAGNOSIS
History :
o ras, sex and age
o health status o life style (alcohol, smoking) o physical activity (sports) o history of previous disease including administration of

drugs, previous fracture.

Physical Examination : Body weight and height (BMI) Extremities and spine including : deformity, MMT and ROM

Laboratory findings :
o blood serum o hormone

o Urine

LABORATORY FINDINGS :
Routine: - Serum : - Complete blood counts - Electrolytes, creatinine, blood urea, nitrogen calcium - Phosphorus, protein, albumin, alkaline phosphatase, liver enzyme - Protein electrophoresis - Thyroid function tests - Testoterone (men only) - 24 hours urine : - calcium - Pyridinium cross-links

LABORATORY FINDINGS : Spesial :

- Serum:
- 25 hydroxyvitamin D3 - 1,25 hydroxyvitamin D3

- intact parathyroid hormone

- osteocalcium (bone Gla protein) - Urine : - Immunoelectrophoresis - Bence-Jones protein

IMAGING :
Radiology : plain X-ray (especially the spine, hip and wirst) The spine : - the ballooning disc

- deformity of vertebral body

(wedge, fish tail) The Hip The Wirst : : - Singh Index - Porotic / thinning cortex

The general diagnostic categories established in woven : (WHO working group)

Normal : Bone Mass Density (BMD)or Bone Mineral Content (BMC) -1 SD from T Score of the young adult reference mean Osteopenia : BMD or BMC 1 SD to 2.5 SD Osteoporosis : BMD or BMC 2.5 SD (severe osteoporosis when there is followed a fracture)

Prevention and Treatment

T-score > +1 -1 s/d 0 - 1 s/d +1 -1s/d -2,5 < - 2,5 no fracture < - 2,5 With fracture Fracture risk very low low low midle high Teatment no treatment densitometry with indication no treatment densitometry after 5 years no treatment densitometry after 2 years prevention densitometry after 1 years osteoporosis treatment continue prevention densitometry after 1 years osteoporosis treatment continue prevention surgery with indication densitometry after within 6 month 1 years

very high

Prevention
Aging process is a natural process of a person getting old
3 steps of osteoporosis prevention : I. Up to the end of 3rd decade where Peak Bone Mass should be achieved II. After the 3rd decade up to menopause / Andropause III. Senile, prevent from minor injury / accident

Goal of Osteoporosis Prevention

Optimising skeletal development Nutrition Physical activity Life style changes Minimize medical / iatrogenic factors Minimize postmenopausal bone loss Early identification of patients at risk Reduced risk factors Hormone replacement therapy (HRT) Other agents pre-emptively if HRT contraindicated raloxifene, alendronate

Minimize age-related bone loss Identification of patients at risk Reduce risk factors Full prevention and exercise program (physical therapy)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

1st Prevention :

Good nutrition Life style and physical exercise

To achieve maximum Peak Bone Mass

2nd Prevention

Early diagnose of osteoporosis The same prevention as 1st prevention In female patient after menopause with HRT Prevention of the use of medication consist steroid etc

3rd Prevention

Prevent from accident (minor injury could cause fracture) Care giver especially after fracture Operative intervention and bracing

Treatment
Nowadays there is a lot of medication For osteoporosis such as : - calcium and vitamin D - calcitriol - calcitonin - bisphosphonate : generation : I III such as (clorodronate, alendronate, and risedronate (actonel)) - hormone : - anabolic - sex hormone - SEMs (Selective Modulator) - SERM (Selective Estrogen Reseptor Modulator : Raloxifene (analogue of tamosifene) SURGERY

Calcium

: 1500 mg / day

Vitamin D : 500 mg / day Calcitonin (myacalcic : Nasal spray: 200 mg / daily)

HRT

: establish approach for osteoporosis prevention

and treatment. But what after WHI report ????

SERM : Raloxifene : Evista : 60 mg/daily - the goal is to increase bone benefits and decrease deletterious affects on breast and endometrim. - decrease breast cancer : 76 %

- 60 % women, 2 years : BMD increase 1-2 %

Dr. C. Deeply

 DIET CUKUP KALSIUM DAN VIT. D 4 SEHAT 5 SEMPURNA

KEBUTUHAN KALSIUM
Balita Remaja Dewasa Hamil Menyusui Sebelum menopause Selama menopause Setelah menopause 400 700 1000 1500 750 1000 1500 2000 800 1000 1000 1200 1200 1500 mg mg mg mg mg mg mg mg / / / / / / / / hari hari hari hari hari hari hari hari

BAHAN MAKANAN
Per Ons Per Ons Per Ons 40 gr Per Ons Per Ons Per Ons er Ons Per Ons Per Ons Per Ons 1 gelas 1 gelas 1 gelas 1 gelas 1 gelas 20 gr Teri nasi mengandung 1000 mg Kalsium Kepiting 210 mg Kerang 133 mg Dencis kaleng 200 mg Kuning telur ayam 147 mg Tempe 129 mg Tahu 124 mg Emping 100 mg Bayam merah 347 mg Kacang panjang 347 mg Daun singkong 165 mg Susu kental manis 275 mg Susu segar 380 mg susu krim penuh 290 mg Susu non fat 480 mg yurgort 200 mg keju 100 mg

PREPARAT KALSIUM YANG TERSEDIA DI PASARAN No.Jenis Kalsium 1. Kalsium karbonat Nama Dagang Ca-C 100 Sandoz Calsan Caxon-F Calsium Sandoz Epocaldi Ca-C 1000 Sandoz Calcidin Calsium Sandoz Calcidin Calcalcin Kalsium(mg) 327 1250 250 300 400 1000 100 2940 200 800

2. Kalsium Laktas

3. Kalsium fosfat

Catatan :

Kalsium karbonat mengandung 40 % kalsium Kalsium laktas mengandung 13 % kalsium Kalsium fosfat mengandung 25 % kalsium