OSTEOPOROSIS By : Widjayanti, S.

Ked
DEFINITION
Osteoporosis is characterized by low bone mass with micro architectural
deterioration of bone tissue leading to enhance bone fragility, thus increasing the
susceptibility to fracture. Osteoporosis is a silent disease and does not produce any
symptoms until the time of fracture. Osteoporosis is very common in postmenopausal
women. Osteoporotic fragility fractures typically involve vertebrae, the femoral
neck, and the distal radius but may occur in any other area.
RISK FACTORS
The risk factors for osteoporosis include:
•Advanced age •Alcoholism
•Female gender •Endocrine conditions (hyperthyroidism,
hyperparathyroidism, hypogonadism)
•Caucasian or Asian ethnicity
•Rheumatic conditions (rheumatoid arthritis,
•Family history ankylosing spondylitis)
•Low calcium intake •Drugs (glucocorticoids, heparin,
•Low body weight anticonvulsants, aromatase inhibitors)
•Smoking
CLASSIFICATION
PATOPHYSIOLOGY
the principal cell types of bone are osteoclasts, osteoblasts, and osteocytes:
1. Osteoclasts, the cells responsible for resorption of bone, are derived from hematopoietic
stem cells.
2. Osteoblasts, derived from local mesenchymal cells, are responsible for bone formation.
3. Osteocytes, also derived from mesenchymal cells, are the most numerous cells in the bone
and may be involved in signaling to osteoclasts and osteoblasts and help regulate their
functioning.
In the normal adult bone, new bone laid down by osteoblasts exactly matches osteoclastic
bone resorption; that is, bone formation and bone resorption are closely coupled.
Osteoporosis occurs as a result of an alteration in bone turnover from an imbalance between
the activity of osteoclasts and osteoblasts.
SYMPTOMS
Early, detectable signs of bone loss are rare. Often people don’t know
they have weak bones until they’ve broken their hip, spine, or wrist. When
the bone has deteriorated significantly more, you may start to experience
more obvious symptoms, such as:
1. Loss of height: Compression fractures in the spine can cause a loss of
height. This is one of the most noticeable symptoms of osteoporosis.
2. Fracture from a fall: A fracture is one of the most common signs of
fragile bones. Fractures can occur with a fall or a minor movement such
as stepping off a curb. Some osteoporosis fractures can even be
triggered by a strong sneeze or cough.
3. Back or neck pain: Osteoporosis can cause compression fractures
of the spine. These fractures can be very painful because the
collapsed vertebrae may pinch the nerves that radiate out from
the spinal cord. The pain symptoms can range from minor
tenderness to debilitating pain.
4. Stooped posture or compression fracture: The compression of the
vertebrae may also cause a slight curving of the upper back. A
stooped back is known as kyphosis, or more commonly, widow’s
hump. Kyphosis can cause back and neck pain and even affect
breathing due to extra pressure on the airway and limited
expansion of your lungs.
RADIOGRAPHIC FINDINGS
Dual-energy X-ray absorptiometry (DEXA) is the most widely used
bone density measurement technique. In DEXA, bone mineral
density is reported as a comparison to age-, race- and sex-
matched reference ranges (Z score) and as a comparison to mean
bone mass of young (30-year-old) adult normal individuals (T
score). It can be used to measure bone mass at various sites, but
the hip and spine are typically the measured locations.
The World Health Organization (WHO) defines osteoporosis as a
T score < -2.5 and osteopenia as T score between -1 and -2.5.
TREATMENT
Goals of osteoporosis treatments are :
1. Control pain from the disease
2. Slow-down or stop bone loss
3. Prevent the bone fractures with medicines that strengthen bone
4. Minimize the risk of falls that can be might cause fractures
NON PHARMACOLOGY
EXERCISE AND REHAB
1. Improve Strength, Endurance, Posture
2. Maintain Bone Density
3. Prevent Falls
4. 30 Minutes Moderate Intensity Daily
5. Post Fracture Rehab May Reduce Future Fracture
PHARMACOLOGY
Antiresorptive agents
• Prevent bone loss and preserve architecture
• Improve quality of bone
• Reduce the risk of vertebral fractures (all agents)
• e.g. bisphosphonates, calcitonin, esterogen, calcium and
vit.D
Anabolic agent: rhPTH [1-34] (teriparatide)
• Increases bone density and size
• Improves quality of bone
• Reduces the risk of vertebral and nonvertebral fractures
 Bisphosphonates
Alendronate, Risedronate, Ibandronate, and Zoledronic Acid

• Alendronate: 10 mg daily (tablet) or 70 mg weekly (tablet or liquid) for treatment, 5

mg daily or 35 mg weekly for prevention

• Risedronate: 5 mg daily or 35 mg weekly (tablet); 150 mg monthly (tablet)

• Ibandronate: 150 mg monthly by tablet; 3 mg intravenously over 15 to 30 seconds

every 3 months

• Zoledronic acid: 5 mg by intravenous infusion over a minimum of 15 minutes once

every year for treatment—and every other year for prevention
 Calcitonin
• Calcitonin (200 units daily by nasal spray)
• Skeletal effects:
– Decrease in biochemical markers of 20%
– Small effect (1% to 2%) on bone density in spine
– Reduced incidence of vertebral fractures (36%) in women with pre-existing
vertebral fractures
– No effect on nonvertebral or hip fractures has been observed
• Adverse effects
– Nasal stuffiness
– Possible increased cancer risk
 Estrogen Treatment (ET)
• Several approved oral and transdermal preparations
• Treats symptoms of estrogen deficiency
• Skeletal effects:
–Decrease in biochemical markers of 50% to 60%
–Decreased incidence of vertebral and hip fractures (34%) after 5 years in the
Women’s Health Initiative (WHI)
–Effects in women with osteoporosis have not been evaluated in randomized
controlled trials
• Concern about adverse effects
• Long-term use not recommended
 Calcium Intake Recommendations From the IOM
Estimated Recommended Dietary Upper Level Intake
Life Stage Group Requirement (mg/day) Allowance (mg/day) (mg/day)
Infants 0 to 6 months * * 1,000
Infants 6 to 12 months * * 1,500
1–3 years old 500 700 2,500
4–8 years old 800 1,000 2,500
9–13 years old 1,100 1,300 3,000
14–18 years old 1,100 1,300 3,000
19–30 years old 800 1,000 2,500
31–50 years old 800 1,000 2,500
51–70 year-old male 800 1,000 2,000
51–70 year-old female 1,000 1,200 2,000
>70 years old 1,000 1,200 2,000

* For infants, adequate intake is 200 mg/day for 0 to 6 months of age and 260 mg/day for 6 to 12 months of age.
 Vitamin D Intake Recommendations From the IOM
Estimated Avg Recommended Upper Level Intake
Requirement Dietary Allowance (IU/day)
Life Stage Group (IU/day) (IU/day)
Infants 0 to 6 months * * 1.000
Infants 6 to 12 months * * 1,500
1–3 years old 400 600 2,500
4–8 years old 400 600 3,000
9–13 years old 400 600 4,000
14–18 years old 400 600 4,000
19–30 years old 400 600 4,000
31–50 years old 400 600 4,000
51–70-year-old male 400 600 4,000
51–70-year-old female 400 600 4,000
>70 years old 400 600 4,000

* For infants, adequate intake is 400 IU/day for 0 to 6 months of age and 400 IU/day for 6 to 12 months of age.
 Teriparatide: rhPTH [1-34]
• The only treatment agent that is anabolic—stimulates bone
formation rather than inhibiting bone resorption
• 20 μg daily (subcutaneously) for no more than 2 years
• Indication: treatment of men and postmenopausal women
with osteoporosis who are at high risk for fracture
• Effects:
–Increased bone density in spine by 9% and hip by
3% vs placebo over 18 months
–Reduced incidence of vertebral fractures (65%) and
nonvertebral fragility fractures (53%) in women with
pre-existing vertebral fractures
–Studies too small to evaluate effect on hip fractures
• Adverse reactions: arthralgia, pain, nausea
CONCLUSION
Osteoporosis is a progressive systemic skeletal disease characterizedby
reduced bone mass/density and microarchitectural deterioration of bone
tissue. It is a “silent disease” as there are no symptoms prior to a fracture.The
prevalence of osteoporosis increases markedly with age. DEXA is regarded as
the gold standard technique for diagnosis of osteoporosis.Treatment for
osteoporosis should include lifestyle measures including nutrition, exercise and
measures to reduce falls. Adequate calcium intake and vitamin D should be
provided. Effective pharmacological management strategies should always be
implemented where necessary including bisphosphonate asAlendronate,
Etidronate, Risedronate, andraloxifene, strontium ranelate and teriparatide.
The prevention of osteoporosis should be considered in early life and should
be continued by regular physical activity and a balanced diet.
thankyou