Osteoporosis

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Osteoporosis

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University Physician Assistant Program

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Osteoporosis

• Affects 25 million Americans
• Causes more than 1 million fractures every year
  in this country usually in the spine, hip or
  wrist.
• 1/2 of all Caucasian women age 50 and older can
  expect to have a bone fracture due to
  osteoporosis
• 1/3 of men have some osteoporosis by age 75

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Definition

• A multifactorial skeletal disease characterized
  by severe bone loss and disruption of skeletal
  micro-architecture sufficient to predispose to
  atraumatic fractures of the
• vertebral column
• upper femur
• distal radius
• proximal humerus
• pubic rami and ribs

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Types of Osteoporosis

• Type I - Postmenopausal
• Type II - Involutional - occurs in both sexes
  over 75 y/oA mixture of Type I II is common
• Idiopathic - rare form of primary osteo. Cause
  unknown, occurs in premenopausal women men(
  prior to age 75)

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Types of Osteoporosis

• Juvenile - A rare form of variable severity
  occurring in prepubertal children. Self-limited
  with cessation of fractures at puberty. Cause
  unknown.

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Types of Osteoporosis

• Secondary - due to extrinsic factors such as
• eating disorders
• steroid excess
• RA
• chronic liver/kidney disease
• malabsorption syndromes
• hyperparathyroidism
• hyperthyroidism
• hypogonadal states
• idiopathic hypercalciuria

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Genetics

• Familial predisposition
• More common in Caucasians and Orientals than in
  black and Latino ethnic groups

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Incidence

• Elderly
• Females Males
• 30-40 cumulatively in women
• 5-15 in men
• Prevalence of idiopathic and juvenile types
  unknown
• Secondary osteoporosis cumulatively 5-10, both
  sexes

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Signs Symptoms

• Back ache/pain acute/chronic
• Kyphosis/scoliosis which leads to pot belly
• Atraumatic fractures
• No peripheral bone deformities
• Sclerae not blue/green/grey
• Loss of height

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Etiology

• Postmenopausal (Type I) Hypoestrogenemia
• Involutional (Type II) Unknown
• Idiopathic Unknown
• Juvenile Unknown
• Secondary - see slide 5

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Etiology

• Bone loss occurs with aging
• Osteoporosis occurs most frequently in
  individuals who fail to achieve optimal skeletal
  mass during development or lose bone rapidly
  thereafter

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Risk Factors

• Dietary -
• inadequate calcium
• excessive phosphate/protein
• inadequate vitamin D intake in the elderly
• Physical - immobilization, sedentary lifestyle
• Social - alcohol, cigarettes, caffeine
• Medical - chronic diseases, malabsorption,
  endocrinopathies

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Risk Factors

• Iatrogenic - corticosteroids, excess thyroid
  hormone replacement, chronic heparin,
  chemotherapy, loop diuretics, anticonvulsants,
  radiation therapy, depro-provera, methotrexate,
  GnRH agonists
• Genetic/familial - suboptimal bone mass at
  maturity, "familial fast bone losers"

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Differential Diagnosis

• Multiple myeloma
• Other neoplasia
• Osteomalacia
• Osteogenesis imperfecta tarda (Type I)
• Skeletal hyperparathyroidism (primary and
  secondary)
• Hyperthyroidism
• Mastocytosis (rare)

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Labs

• CBC - usually normal
• Alk Phosphatase - may be transiently increased
  after a fracture
• Serum /or urine protein
• TFTs urinary cortisol - normal in primary
  types
• Serum osteocalcin - if high, indicates high
  turnover type
• Urine calcium level

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Pathological findings

• Reduced skeletal mass, trabecular bone more so
  than cortical bone. Loss of trabecular
  connections.
• Osteoclast and osteoblast number variable
• No evidence of other metabolic bone diseases and
  no increase in unmineralized osteoid
• Marrow normal or atrophic

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Imaging

• X-ray
• Bone scan
• Bone mineral density (BMD)
• most common is a DEXA scan - lumbar spine,
  forearm upper femur

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33 y/o
55 y/o
72 y/o
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Treatment

• Pain - if a fracture occurs, Physical therapy
• May need to consider joint replacement
• Decrease falls
• Keep moving

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Diet

• Weight - reduce if overweight
• Calcium 1500 mg/day
• 600-1000 IU of Vitamin D a day
• Avoid excess phosphate or protein intake certain
  beverages with phosphoric acid

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Drugs

• HRT
• Calcitonin (miacalcin nasal spray) or injections
• Fosamax Alendronate
• Actonel
• Didronel - inhibit bone resorption
• Evista/Raloxifene
• Miacalcin nasal spray

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Prognosis

• 70 of patients stabilize skeletal
  manifestations increase bone mass, increase
  mobility, and have reduced pain
• 20-30 of upper femoral fractures lead to chronic
  care and/or premature death

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• http//courses.washington.edu/bonephys/opmovies.ht
  ml