MANAGEMENT OF OSTEOPOROSIS

1
MANAGEMENT OF OSTEOPOROSIS

• Dr SANJAY KALRA
• D.M. (AIIMS)
• BHARTI HOSPITAL, KARNAL

2
OSTEOPOROSIS

• A major health problem
• Inadequate Ca intake
• Increasing longevity
• Postmenopausal state
• Morbidity FRACTURES
• Mortality
• Osteopenia is common in healthy Indians as well

The auntyji next door
3
Normal bone
4
Osteoporotic bone
5
Osteomalacic bone
6
MALACIA vs POROSIS

• MALACIA
• Anatomic bone volume unchanged
• Volume of specific bone tissue unchanged
• Less mineral content
• Increased organic matter

• POROSIS
• Bone size unchanged
• Cortical and trabecular thinning
• Bone tissue reduced, fat tissue increased
• Ratio of mineral to organic matter unchanged

Cement mein rait
7
OSTEOMALACIA VS. POROSIS

• MALACIA
• Defective mineralization
• Vit D deficiency predominates
• Proximal myopathy
• Painful bones
• Low Ca, high ALP
• Check renal status

• POROSIS
• Defective bone formation
• Ca def predominates
• Asymptomatic until fracture occurs
• Back pain (paraspinal)
• Loss of height
• Low Ca, P, ALP

8
OSTEOMALACIA VS. POROSIS

• MALACIA
• Evenly distributed abnormalities of vertebral
  shape
• Lumbar spine
• Superior and inferior margins equally affected in
  biconcave deformity smooth appearance

• POROSIS
• One or more abnormal vertebrae separated by
  several normal ones
• Thoracic spine
• Irregular involvement of endplates

9
MECHANISM

• Anti-remodelling anti-resorptive
• Pro-remodelling strontium, teriparatide
• Pro-modelling strontium, teriparatide
• Shift from anti-resorptive to anabolic
• Shift from re-active to pro-active
• Shift from static to active

10
DIAGNOSIS

• Bone densityDEXA, USG, Plain Xrays
• Trabecular vs. cortical bone
• Lumbar spine, hip, wrist
• Biochemistry serum, urine

11
MANAGEMENT STRATEGIES

• ANTI RESORPTIVE
• Bisphosphonates
• SERMs
• Calcitonin

• ANABOLIC
• Calcium
• Vitamin D
• Teriparatide PTH fragment
• Strontium
• HRT

12
2 1 0 -1 -2 -2.5
Normal Do not treat
BMD T SCORE (SDs)
Osteopenia Treat if fracture
Osteoporosis Treat
50 55 60 65 70 75 80
HRT
Raloxifine
Bisphosphanates
Parathyroid Hormone
Calcium
Vitamin D
13
WHY TREAT ?

• Treatment reduces risk of vertebral
• Trabecular bone
• Up to 50 for anabolic therapies
• Reduces risk of non-vertebral (hip)
• Mixed trabecular cortical bone
• Up to 10
• Not much effect on radius
• Cortical bone

14
CALCIUMHOW MUCH TO GIVE?

• Indian RDA 400 mg
• US RDA 800 1200 mg in males
• In osteoporosis 1500 to 2000 mg/d
• Premenopausal women 1000 mg/d
• Postmenopausal women 1500 mg/d

15
DIETARY CALCIUM
16
DIETARY CALCIUM
17
WHY SUPPLEMENT ?

• Intestinal absorption of Ca is not efficient,
  especially with cereal-based diet
• Intake of dairy Ca is usually inadequate
• Exposure to sunlight is limited, especially in
  indoor workers
• Vit D synthesis is less in dark-skinned persons
• Vit D, Ca levels, and bone density are low in
  Indians

18
WHAT TO GIVE ?

• Calcium phosphate (25 Ca)
• Calcium carbonate (40 Ca)
• Calcium lactate (13 Ca)
• Calcium chloride (27 Ca)
• Calcium gluconate (9 Ca)
• Calcium bionate (6.5 Ca)
• Calcium citrate
• Calcium citrate malate
• Active absorbable calcium (AACa)
• Active absorbable algal calcium (AAACa)

19
WHAT TO GIVE ?

• PHOSPHATE use in hypophosphatemia, avoid in
  renal failure, may act as laxative, only 25 Ca
• CARBONATE 40 Ca bioavailable, absorbed in
  acidic medium, causes constipation, gastric
  irritation commonest prep in India, needs to be
  taken with meals

• CITRATE better absorbed, less gastric
  irritation, commonest prep in USA, does not need
  gastric acid for absorption
• CITRATE MALATE better absorbtion, more
  expensive, more effective at reducing bone loss

20
WHAT TO GIVE ?

• AACa active absorbable Ca oyster shell heated
  to 800 C at reduced oxygen pressures to break
  tough molecular bonds of CaCO3 to CaO and CaOH,
  then treated at 100 C to produce free Ca, which
  is absorbed easily, independent of gut pH

• AAACa active absorbable algal calcium treated
  seaweed Cystophyllum fusiforme added (HAI
  heated algal ingredient. Contains aminoacids
  which improve absorption at intestinal villi and
  provide a neutral coat for ve ionic Ca

21
WHEN TO GIVE ?

• Immediately after meals, to utilize acidic pH
• Immediately after meals, to minimize gastric
  irritation
• Away from meals, to avoid phytate complex
  formation

22
WHEN TO GIVE ?

• Not with tea, to prevent tannic acid chelation
• Not with iron, to prevent chelation
• At night, to achieve maximal PTH suppression and
  to reduce bone resorption

23
HOW MUCH TO GIVE ?

• 150 mg to 900 mg/day
• Divided doses are better
• Higher dose at night
• Vit D usually not necessary with AAACa
• Monitor se Ca, ionized Ca, urine for Ca crystals,
  24 hr urine Ca, urine pH
• Monitor se ALP in osteomalacia/rickets

• Try bone density annually
• DEXA, pQCT are best methods of measuring density
• Trabecular bone distal radius
• Cortical bone mid-radius, lumbar spine
• Se Vit D, PTH levels not measured routinely

24
VITAMIN D

• Sunlight
• Cholecalciferol
• Injectable 6 lakh U
• Oral 60 000 U
• 1(OH) Vit D
• 0.25, 1.0 µg
• 1,25(OH)2 Vit D
• 0.25, 1.0 µg

• Essential for absorption of calcium from GIT, for
  assimilation into bone
• Suppresses PTH
• Most Indians are Vit D deficient

25
VITAMIN D WHICH TO USE ?

• Healthy individuals cholecalciferol
• Renal-impaired (OH) Vit D
• Hepatic-impaired (OH)2 Vit D
• Early action needed active metabolites
• Long action injectable Vit D
• Compliance/cost injectable Vit D
• Risk of hypercalcemia/calciuria low dose

26
BISPHOSPHONATES

• ORAL
• Alendronate
• Daily
• Weekly
• Risedronate
• IV
• Pamidronate
• Ibandronate
• Zolandronate

• Antiresorptive
• GI side effects
• Commonly used
• Sequential use after anabolic therapy
• Use prior to anabolic therapy ? results

27
TERIPARATIDE

• N(1-34) PTH fragment
• Daily SC injection hs
• Follow up with antiresorptives
• Limit Ca to 1500 mg/day
• Monitor serum Ca, urinary Ca at 1 month
• Se uric acid may rise
• Dizziness

28
TERIPARATIDE

• Most effective in reducing rate
• May use up to 2 years
• Cost-effective for patients with pre-existing ,
  BMD T score lt 2.5
• Do not give with alendronate
• May use with estrogen, calcium (up to 1500 mg,
  strontium

29
STRONTIUM RALENATE

• Divalent cation
• Enters bone matrix
• Improves BMD (50 actual benefit, 50
  artefactual)
• 1 2 g/ day
• Few side effects
• Administer apart from antacids, calcium
• Avoid with quinolones, tetracyclines

30

• The imperative to treat increases with
• Increasing age.
• Declining BMD.
• Prior fracture.
• Family history of osteoporosis.
• Risk factors for bone loss (e.g,
  hyperparathyroidism, corticosteroid
  therapy,immobilisation, chronic illness)
• High levels of bone remodelling markers.

31

• Treatment summary
• If BMD is gt - SD ,do not treat if BMD is -1 to
  -2.5 SD, treat if fracture is present and, if
  BMD is lt -2.5 SD ,treat whether or not a fracture
  is present.
• Consider hormone replacement therapy around
  menopause if the patient has postmenopausal
  symptoms.
• Raloxifene or one of the bisphosphonates is
  appropriate in the later postmenopausal years.
• Use bisphosphonates in women aged over 75 years
  when the main concern is preventing hip fracture.
• Parathyroid hormone should be considered in
  patients with severe osteoporosis and fractures.
• Give calcium supplements in people aged over 65
  years, and vitamin D if deficiency is present or
  likely.

32
DRUG AUDIT Bharti Hospital
33
CONCLUSIONS

• TREAT AGGRESSIVELY
• REDUCE FRACTURE RISK
• Anabolic therapy Vit D calcium
• Follow up with anti-resorptive therapy
• BE PRO-ACTIVE
• IMPROVE BONE HEALTH

34
(No Transcript)