Clinical manifestations and diagnosis of osteoporosis

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Clinical manifestations and diagnosis of
osteoporosis
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• INTRODUCTION Osteoporosis is the most common
  bone disease.
• DEFINITION Osteoporosis is a skeletal disorder
  characterized by two elements
• low bone mass
• and microarchitectural disruption.

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• There are fewer bony spicules in osteoporotic
  bone and they are thinner
• But the bone that is present is normally
  mineralized,

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• EPIDEMIOLOGY
• It is estimated that over 1.3 million
  osteoporotic fractures in the United States.
• One-half are vertebral fractures,
• One-quarter are hip fractures,
• And one-quarter are Colles' fractures.
• Among subjects age 90 years, 33 percent of women
  and 17 percent of men will have a hip fracture .
• After age 50 years, a woman is three times more
  likely than a man to have a vertebral or hip
  fracture

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• Risk Factors For Osteoporosis
• Age.
• Sex.
• Organs Failure.
• Certain drugs include glucocorticoids,
  heparin, cyclosporine, medroxyprogesterone
  acetate, vitamin A and certain synthetic
  retinoids, Anxiolytic, anticonvulsant, or
  neuroleptic drugs.
• Organ transplantation .
• Cancer treatment.
• Vitamin B12 deficiency

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• Previous fracture between the ages of 20 and 50.
  years
• History of fracture in a first degree relative.
• Cigarette smoking .
• Inflammatory bowel disease.
• Sedentary life style.
• Consumption of large amounts of caffeine.
• Above average height.
• Low body weight or weight loss.
• Type 2 diabetes mellitus .

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Clinical Manifestations

• Osteoporosis has no clinical manifestations until
  there is a fracture.
• many patients with achy hips or feet do not have
  osteoporetic fractures but they have osteomalacia
  .
• Vertebral fracture
• Vertebral fracture is the most common
• Most of these fractures (about two-thirds) are
  asymptomatic

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• Osteoporotic fracture can lead to the acute onset
  of pain.
• Successive fractures lead to increased thoracic
  (dorsal) kyphosis with height loss "dowager's
  hump and complain of "getting fat" without any
  change in weight.
• Their abdomen becomes protuberant.
• The distance from the occiput to the wall
  (normally 0 cm).
• The size of the gap between the costal margin and
  the iliac crest (normally three finger breadths).

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• Other fractures
• Hip fractures are relatively common in
  osteoporosis, affecting 15 percent of women and
  five percent of men by 80 years of age.
• RADIOGRAPHIC FEATURES
• Plain radiographs show detectable changes when
  bone loss exceeds 30 percent.
• An early manifestation is "codfish" vertebrae.

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• DIAGNOSIS
• MEASUREMENT OF BONE DENSITY
• Several different methods are used to measure
  bone density
• Single-photon absorptiometrywich can be used
  only at peripheral sites (radius and calcaneus).
• Dual-photon absorptiometry (DPA) that measure
  bone density at the spine and hip

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•  Dual x-ray absorptiometry(DEXA)
• The two photons are emitted from an x-ray tube
  instead of a radioactive source.
• DXA is the most popular method for measuring bone
  density at the spine and hip and some times at
  distal of radious bone.

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•  Ultrasonography
• Potential advantages include lower expense,
  portability, and lack of radiation exposure.
• Measurements are usually made at the patella or
  calcaneus (heel).
• Quantitative ultrasound is a good predictor of
  fracture risk especially in pregnancy.
• A major limitation to using is that the criteria
  for diagnosing osteoporosis and recommending
  treatment are not yet well established.

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Which Skeletal Sites Should Be Measured?

• Some Patients
• Forearm (33 Radius)
• If hip or spine cannot be measured
• Hyperparathyroidism
• Very obese

• Every Patient
• Spine
• L2-L4
• Hip
• Total Proximal Femur
• Osteoporosis
• Femoral Neck
• Trochanter

Use lowest T-score of these sites
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Indications For Bone Density Testing

• All women age 55 and older
• All men age 65 and older
• Adults with a fragility fracture
• Adults with a disease or condition associated
  with low bone density
• Adults taking medication associated with low bone
  density
• To monitor treatment effect

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DEFINITIONS

• Osteopenia
• Bone mineral density (BMD) measurement at any
  site gt 1 but ? 2.5 standard deviations below the
  young adult standard
• T score lt -1 but ? -2.5

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Definitions

• Osteoporosis
• BMD measurement at any site gt 2.5 standard
  deviations below the young adult standard with or
  without previous fracture
• T score of lt -2.5

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Diagnostic Classification
Classification T-score
Normal -1 or greater
Osteopenia Between -1 and -2.5
Osteoporosis -2.5 or less
Severe Osteoporosis -2.5 or less and fragility fracture
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SCREENING FOR SECONDARY CAUSES

• Disease Recommended Laboratory Tests
• (bolded items are recommended routinely)
• Cushings disease Electrolytes, 24-hour urinary
  cortisol
• Hyperthyroidism TSH, T4
• Hypogonadism Bioavailable testosterone
• Multiple myeloma CBC, serum electrophoresis,
  urine electrophoresis
• Osteomalacia Alkaline phosphatase, 25(OH)D
• Pagets disease Alkaline phosphatase
• Primary hyperparathyroidism Calcium, PTH

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Treatment Guidelines
Summary of recommendations for pharmacologic
therapy according to T-score from the National
Osteoporosis Foundation (NOF) and the American
Association of Clinical Endocrinologists (AACE)
Patient Profile T-score T-score
NOF AACE
No Risk Factors Less than -2.0 -2.5 or less
Risk Factors Less than -1.5 -1.5 or less
Fragility fracture, family history of fracture,
cigarette smoking, low body weight (lt127 lbs.),
etc.
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RISK FACTORS FOR POSTMENOPAUSAL WOMEN

• Early menopause
• White or Asian race
• Sedentary life style
• Smoking
• Small frame
• Alcohol abuse
• Primary hyperparathyroidism
• Hyperthyroidism
• Glucocorticoid use

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CALCIUM VITAMIN D

• Calcium and vitamin D maintain or increase bone
  density help prevent hip and nonvertebral
  fractures
• Men 65 years and older postmenopausal women
  should ingest a total of 800 IU of vitamin D and
  1200 mg / day of calcium daily.
• Higher doses are required if they have
  malabsorption or rapid metabolism of vitamin D

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Estrogen/progestin therapy

• Estrogen-progestin therapy is no longer a
  first-line approach because of Increased risk of
  
• Breast cancer,
• Stroke,
• Venous thromboembolism,
• And perhaps coronary disease.
• HRT Prevents bone loss at hip spine when
  initiated within 10 years of menopause

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• Possible indications for estrogen-progestin in
  postmenopausal women include persistent
  menopausal symptoms and
• women with an indication for antiresorptive
  therapy who cannot tolerate the other drugs or
  because of side effects.
• There was a significant 33 percent reduction in
  clinical vertebral fractures and a 23 percent
  reduction in other osteoporotic fractures.

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Bisphosphonates

• Alendronate (10 mg/day or 70 mg once weekly) or
  risedronate (5 mg/day or 35 mg once weekly), are
  good choices for the treatment of women with
  established osteoporosis.
• These drugs increase bone mass and reduce the
  incidence of vertebral and nonvertebral fractures
  (even in women who already have fractures).

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• The beneficial effects of alendronate persist
  over several years after treatment is stopped,
• When given, alendronate or risedronate should be
  taken with precautions to avoid pill-induced
  esophagitis.
• Alendronate appears to be well tolerated and
  effective for at least ten years .

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OTHER BISPHOSPHONATES

• Residronate (Actonel)
• Approved for osteoporosis prevention treatment
  of osteoporosis 5 mg / day
• In comparison with placebo
• ? bone density of spine hip
• ? new vertebral fracture rate
• GI side effects
• Zolindronic acid(Aclasta)
• Only infusible drug approved for treatment of
  osteoporosis and the most strong members.
• Use for idiopathic osteoporosis only if other
  treatments are ineffective or conterindicated.

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SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs)

• Act as estrogen agonists in bone and heart.
• Act as estrogen antagonists in breast and uterine
  tissue
• Potential for preventing osteoporosis without the
  increased risk of breast or uterine cancer

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SERMs RALOXIFENE

• Rationale
• Approved for osteoporosis prevention treatment
  in postmenopausal women
• In comparison with placebo
• ? vertebral fractures by 60
• ? breast cancer (relative risk 0.24)
• ? bone turnover maintained hip total body
  bone density
• ? total cholesterol and LDL levels
• Side effects
• Flu-like symptoms, hot flushes, leg cramps
• Peripheral edema

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Calcitonin

• A less popular choice for treatment of
  osteoporosis is nasal calcitonin, 200 IU/day.
• It is a weak drug for treatment and because of
  tachyphylaxis has a little effect on density.
• There is one exception,most use calcitonin as
  first-line therapy in patients who have
  substantial pain from an acute osteoporotic
  fracture.
• Dosing
• Subcutaneous injection
• Nasal spray (fewer reported side effects,

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Monitoring of treatment

• Bone density measurement can be repeated after
  one year of therapy.
• If BMD is stable or improving, that would be
  evidence for treatment response.
• However, if BMD declines at one year, compliance
  with drug, calcium and vitamin D should be
  verified, and some evaluation for secondary
  causes of bone loss should be performed .
• If the patient is otherwise well and taking the
  drug and supplements correctly, the correct
  action is controversial.

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• Some physicians believe that the decrease in BMD
  truly reflects a treatment failure and would
  consider modification of the primary treatment
  for the osteoporosis.
• Others believe that the decline in BMD is not
  necessarily reflecting inadequate therapy, but
  could be ascribed to measurement error and would
  repeat BMD one year later, taking action only if
  the decline is reaffirmed.

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