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OSTEOPOROSIS

INTERNAL MEDICINE CONGRESS 1382. OSTEOPOROSIS. R heumatology R esearch C enter. R. R. 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

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OSTEOPOROSIS

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  1. INTERNAL MEDICINE CONGRESS 1382 OSTEOPOROSIS RheumatologyResearchCenter

  2. R R C

  3. 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

  4. EPIDEMIOLOGY

  5. EPIDEMIOLOGY • USA (NHANESS III 1997) • Women 13 - 18% • Men 1 - 4% • IRAN 4,575,000 - 7,150,000

  6. FRACTURE RISK50 YEARS AND OVER WOMENMEN • Femur 17.5% 6.0% • Spine 15.6 5.0 • Wrist 16,0 2.5 • Any Fracture 39.7 13.1

  7. BONE PHYSIOLOGY

  8. 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 BONE PHYSIOLOGY • Bone Resorption • Osteoclast • Bone Formation • Osteoblast • Bone Remodeling Unit • Positive < age 30 • Negative > age 30

  9. OSTEOBLAST • Origin: Mesenchymal Cell • Activation:PTH, Vitamin D • Function • Matrix Formation • Bone Mineralization • Matrix Degradation  RANK L

  10. Cl H2O + CO2 HCO3 H+ OSTEOCLAST • Origin • Blood Mononuclear Cells • Differentiation • CSF-1 • RANK L • Lymphocyte • Osteoblast • Action • Acidification • Protein Degradation

  11. . . . . . . . . . . . . . . . . . . . Resorption Formation Completion BONE REMODELING UNIT

  12. 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 RANK STIMULATION STIMULATION

  13. BONE FORMATION PTH Vit D ANDROGEN ESTROGEN CALCITONIN ESTROGEN PTH Vit D ILGF IL-1 TNF- IL-6 IL-11 PROGESTERONE INHIBITION INHIBITION STIMULATION RANK STIMULATION COUPLING FACTOR

  14. CLINICAL MANIFESTATIONS

  15. CLINICAL MANIFESTATIONS • Symptoms Non • Complications Fractures • Macroscopic • Vertebra • Femoral Neck • Wrist • Others • Microscopic • Vertebrae: Mechanical Pain, Spine Deformity

  16. DIAGNOSIS

  17. OLD DAYS

  18. 20th CENTURY • X-RAY • BONE BIOPSY RRC

  19. NOWADAYS BONE DENSITOMETRY

  20. Dual Energy X-ray Absorptiometry(Gold Standard) • NON INVASIVE • Irradiation: 1/100 Chest X-ray • 1 h. Sun Exposure • SENSITIVITY 1.0% • ACCURACY 2.8% • REPEATABLE • LONGITUDINAL STUDY

  21. BONE MINERAL DENSITY • SPINE • FEMUR • FOREARM • OTHERS • Whole Body • Heel • hand

  22. RESULT • BMD 0.857 • Comparison To Young Adult • % 76% • t Score -2.4 • Comparison To Same Age • % 101% • z Score +0.1

  23. SPINE

  24. SPINE

  25. FEMUR

  26. FEMUR

  27. FOREARM

  28. FOREARM

  29. DIFFERENT STANDARDS • COUNTRIES and ETHNICITIES • MACHINES • Hologic • Lunar • MediLink • Norland

  30. AMERICAN STANDARD PBM 1124 mg Female - Spine Standardized BMD 1006 mg Osteopenia 829 mg Osteoporosis

  31. IRANIAN STANDARD PBM 1097 mg Female - Spine Standardized BMD

  32. 1006 mg Osteopenia 829 mg Osteoporosis COMPARISON PBM diff 2.5% Female - Spine Standardized BMD

  33. 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

  34. BMD REPORT • FRACTURE RISK SpineNeck • 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

  35. PURPOSE and APPLICATION • DIAGNOSIS • Osteoporosis • Osteopenia • Normal Bone • CALCULATION • Time to Osteopenia • Time to Osteoporosis

  36. % 22% Loss 35-65 Y Age BONE LOSS Spine – Iranian Women

  37. INDICATION(People at Risk) • Menopause • Inflammatory Diseases • Endocrine Disorders • Predisposing Drugs • Familial History • Fracture

  38. BONE TRABECULA

  39. BONE TRABECULA

  40. BONE TRABECULA

  41. PREVENTION

  42. 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

  43. PREVENTION(Normal Person, Normal BMD) • Young • Alimentation • Sport • Mid Age (up to menopause) • Habits • Menopause • HRT (Allendronate?), Calcium, Exercises • Senile • Exercises

  44. 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

  45. TREATMENT

  46. 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

  47. ALLENDRONATE • Osteofos • Prevention • 5 mg daily • Treatment • 10 mg daily • Precautions • 30 Minutes Before Breakfast • Upright Position • Side Effects

  48. INTERNAL MEDICINE CONGRESS 1382 RheumatologyResearchCenter

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