OSTEO- POROSIS

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OSTEO-POROSIS
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OSTEO-POROSISDr.Abdullah Al-Omran
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• NOTE THIS PRESENTATION DOES NOT REPLACE
  ATTENDANCE OR INFORMATION GIVEN IN THE LECTURE.IT
  IS INTENDED AS A HIGHLIGHT FOR THE TOPIC

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OSTEOPOROSIS

• OSTEOPOROSIS
• DEFINITION
• WHO Definition 1994
• A skeletal disease characterized by low bone mass
  and deterioration of the microarchitecture of
  bone tissue with a consequent increase in bone
  fragility and susceptibility to low trauma
  fractures.
• Why? Imbalance between osteoblast osteoclast
  function

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OSTEOPOROSIS
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OSTEOPOROSIS

• OSTEOPOROSIS
• INCIDENCE 1 in 3 women and 1 in 12 men.
• TYPES
• (postmenoposal) thin trabicular bone
• 55-75y
• fm 61
• Senile thin both trabicular
  cortical bone
• 70-85 y
• 21

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OSTEOPOROSIS

• RISK FACTORS CAUSES !
• I.POST MENOPOSAL SENILE (primary)
• -sessation of estrogen or androgen
• - bad nutritional habits during productive years
  (15-45yr)
• (low calcium content food , smoking,alcohol,sod
  a drinks.
• - genetics (inheritance) race (cocasian
  female)
• II.Secondary
• 1.medications steroids,chronic heparin
  use,anticonvusants,chemotherapy.
• 2.immobilisation
• 3. Medical conditions Anorexia Nervosa, RA,
  Early menopause,Hyperthyroidism,
  hyperparathyroidism, hypogonadism
  Transplantation,
  Cushings disease/syndrome, Chronic kidney, lung
  or GI diseases

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OSTEOPOROSIS

• Clinically
• P?
• P?

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OSTEOPOROSIS
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OSTEOPOROSIS

• INVESTIGATIONS
• History for risk factors
• Physical examination
• X-ray of lumbar and thoracic spine.
  Although gt30 of bone loss
  required to be visible on X-ray, there may be
  some asymptomatic wedge s
• Bone mineral Density measurement
• Blood tests, FBC, ESR, serum biochemistry
• Testosterone and Gonadotrophin levels in men

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OSTEOPOROSIS

• The Gold standard test in clinical practice is
  measurement of Bone Mineral Density (g/cm3), of
  the vertebral spine and the hip. This is as
  recommended by the National Osteoporosis society.
  Only vertebral measurements can be used to assess
  effectiveness of treatment at present.
  
• DEXA scans
  
• Radiographic Absorptiometry
  
• Single Photon X-ray absorptiometry (SPA)
  
• Quantitative Computer tomography
  
• Quantitative Ultrasound

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OSTEOPOROSIS
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OSTEOPOROSIS

• PREVENTATIVE MEASURES
• Aims- to achieve an adequate peak bone mass, by ?

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OSTEOPOROSIS

• TREATMENT OF ESTABLISHED OSTEOPOROSIS
• CALCIUM VIT. D SUPPLEMENTS
• Minimum daily intake of calcium should be
  achieved. Should only be prescribed if this is
  not achieved by diet.
• Vit D in all elderly institutionalized
  osteoporotics is recommended.  
• RDA Calcium 1400 mg
• RDA Vit. D 600-800 IU.

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OSTEOPOROSIS

• HRT (OESTROGEN)
• Prevent osteoporosis and slows or reverses
  progression.
• Given at doses equivalent to 0.625mg of Premarin,
  it will increase bone density by 2 per year.
• Given for 5-10 years almost halves the risk of
  fractures.
• Has a role in corticosteroid induced osteoporosis
  
• Contraindications Endometrial carcinoma, Breast
  cancer, undiagnosed vaginal bleeding.
• Other benefits loss of menopausal symptoms,
  cardiovascular protection.

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OSTEOPOROSIS

• BISPHOSPHONATES
• Synthetic analogues of inorganic pyrophosphate.
  Inhibit bone resorption by osteoclasts
• Alendronate (Fosamax)
• Reduces the incidence of hip, wrist and vertebral
  fractures in postmenopausal women (statistically
  significant)
• Contraindications-Abnormalities of oesophagus,
  renal problems
• Dose -10mg daily at least 30 mins before
  breakfast and sit upright for at least 30 mins
• Disodium Etidronate (Didronel)
• Etidronate is effective in reducing vertebral
  fracture (statistically significant). Dose-
  disodium etidronate 400mg once daily.

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OSTEOPOROSIS

• OESTROGEN RECEPTOR MODULATORS (Raloxifene)
• Work like oestrogen at bone without other harmful
  effects.
• Can increase post menopausal symptoms so not to
  be given within 5 years of menopause  
• CALCITONIN
• Non sex, non steroid hormone
• Reduces resorption of bone
• Nasal form at dosages of 200 units per day
• Can be used for analgesia
• CALCITRIOL (1,25 DIHYDROXYCHOLECALCIFEROL)
• The active metabolite of vit D. 0.25 microg o.d.
  may reduce risk of vertebral . Need monitoring
  of plasma calcium

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RICKETS OSTEOMALACIA

• Def. reduction in bone mineralization !

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OSTEOMALACIA,RICKETS

• Normal bone metabolism
• CALCIUM
  99 in bone.
  
  Main functions- muscle
  /nerve function, clotting.
  Plasma calcium- 50 free, 50 bound to albumin.
• Dietary needs-
  Kids-
  600mg/day,
  Adolesc.-1300mg/day,
  
  Adult-750mg/day,
  Pregnancy-1500mg/day,
  
  Breastfeeding-2g/day,
  Fractures- 1500mg/day
• Absorbed in duodenum (active transport) and
  jejunum (diffusion), 98 reabsorbed in kidney
  prox. tubule, may be excreted in stool.

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OSTEOMALACIA,RICKETS

• Normal bone metabolism
• PHOSPHATE
  85 in bone.
  
  Functions-metabolite and buffer in enzyme
  systems.
• Plasma phosphate mainly unbound.
  Daily requ. 1-1.5g/day

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OSTEOMALACIA,RICKETS

• Regulation of Calcium Phosphate Metabolism
• Peak bone mass at 16-25 years.
• Bone loss 0.3- 0.5 per year (2-3 per year after
  6th decade).
• Parathyroid Hormone (PTH)
• Vitamin D3
• Calcitonin
• Other Hormones
  Estrogen Prevents
  bone loss
  Corticosteroids Increases
  bone loss
  Thyroid hormones Leads
  to osteoporosis
  Growth hormones
  Cause positive calcium balance
  
  Growth factors

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RICKETS, OSTEOMALACIA

• PATHOLOGY
• Sufficient osteoid, poor
  mineralization
• (Rickets is found only in children prior to the
  closure of the growth plates, while OSTEOMALACIA
  occurs in persons of any age. Any child with
  rickets also has osteomalacia, while the reverse
  is not necessarily true).

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RICKETS, OSTEOMALACIA

• CAUSES
• Nutritional deficiency 
• Vit D
• chelators of calcium- phytates, oxalates,
  phosphorous
• Antacid abuse, causing reduced dietary phosphate
  binding
• GI Absorption defects
• Post gastrectomy
• Biliary disease (reduced absorption of Vitamins )
  
• Small bowel disease
• liver disease
• Renal tubular defects
• Renal osteodystrophy
• Miscellaneous causes

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RICKETS, OSTEOMALACIA

• CLINICAL FEATURES
• Rickets  -
  Tetany ,
  convulsions, failure to thrive,
  restlessness, muscular flaccidity.
  Flattening of
  skull (craniotabes),
  Thickening of wrists from epiphyseal
  overgrowth, Stunted growth,
  
  Rickety rosary, spinal curvature,
  Coxa
  vara, bowing, of long bones
• Osteomalacia, - Aches and pains, muscle weakness
  loss of height, stress s.

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RICKETS, OSTEOMALACIA

• XRAY FINDINGS
• RICKETS Thickening
  and widening of physes,
  Cupping of metaphysis, Wide metaphysis,
  Bowing of diaphysis, Blurred trabeculae.

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RICKETS, OSTEOMALACIA

• XRAY FINDINGS
• OSTEOMALACIA
• Loosers zones - incomplete stress with healing
  lacking calcium, on compression side of long
  bones. 
• Codfish vertebrae due to pressure of discs
• Trefoil pelvis, due to indentation of acetabulae
  stress s

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RICKETS, OSTEOMALACIA

• INVESTIGATIONS
• BLOOD TESTS
  Calcium Reduced,
  
  Phosphate reduced
  Alkalline
  Phosphatase increased
  Urinary excretion of calcium
  diminished
  
• Calcium phosphate products ( serum Ca x serum
  PO4) normally 30. In rickets and osteomalacia
  is less than 24

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RICKETS, OSTEOMALACIA

• MANAGEMENT
• Depends on the cause
• Nutritional
  Vitamin D
  deficiency
  Dietary chelators of calcium
  
  
• Phytates
  
• Oxalates
  Phosphorus
  deficiency (unusual)
• Antacid abuse
• Treatment- vitamin D (5000u) and Calcium (3g/day)
  

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RICKETS, OSTEOMALACIA

• MANAGEMENT
• Depends on the cause
• Gastro-intestinal absorption defects
  Post-gastrectomy
  
  Biliary disease
  
  Enteric absorption defects
  
• Short bowel syndrome
• Rapid onset (gluten-sensitive
  enteropathy) Inflammatory bowel
  disease
• Crohns
• Celiac

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RICKETS, OSTEOMALACIA

• MANAGEMENT
• Depends on the cause
• Renal tubular defects
  Vitamin D
  dependant
• type I
• type II
• Treatment High levels of vit D
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  Vitamin D resistant (familial hypophosphatemic
  rickets)
• Treatment Phosphate 1-3 gm
  daily, Vit D3 high dose
  Fanconi syndrome I, II, III
  Renal tubular
  acidosis

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RICKETS, OSTEOMALACIA

• MANAGEMENT
• Depends on the cause
• Renal Osteodystrophy in chronic renal failure
• Miscellaneous
  Hypophosphatasia
  
  Anticonvulsant therapy
• SURGERY
• For deformities

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