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					Osteoporosis-prevention and treatment
                            DR UMAR FAROOQ
   Systemic skeletal disease characterized by
    low bone mass and micro architectural
    deterioration resulting in increased bone
   WHO---Bone density 2.5 SD below mean for
    young healthy adult of same gender (T-Score)
   Z-score is used to express an idividual’s bone
    density as standard deviation from age
    matched,sex matched and race matched
   1.3 million osteoporotic fractures in US every
   40 % women after 50 years have osteopenia
   7% women after 50 years have osteoporosis
   Increases fracture risk by 4 fold
   After age 90 years 1/3rd women and 1/6th
    men will have osteoporotic fracture
   Hip fracture mortality at 1 year 25%
   Low dietary calcium intake

   Inadequate physical activity

   Low body weight

   Cigarette smoking

   Alcohol

   Excessive exercise (causing functional
   Increasing age

   Female sex

   Race (white or Asian)

   Previous fragility fracture

   Family history of fragility fracture in a first-
    degree relative

   Impaired mobility
   Endocrine disorders: hyperparathyroidism,
    cushing syndrome, hypogonadism,
    hyperthyroidism, prolactinoma, acromegaly

   Hematopoietic disorders: multiple myeloma,
    sickle-cell disease, leukemia, lymphoma

   Connective tissue disorders: osteogenesis
    imperfecta, homocystinuria

   Renal disease: chronic renal failure, renal tubular
    acidosis, hypercalciuria
   Nutritional: malabsorption, total parenteral
   Gastrointestinal disorders: gastrectomy,
    primary biliary cirrhosis, celiac disease
    Medications: corticosteroids,
    anticonvulsants, heparin
   Genetic: Turner syndrome, Klinefelter
   Women age ≥65 years and men age ≥70 years
    (regardless of risk factors)
   Postmenopausal women age <65 years and men
    age <70 years who have at least one risk factor
    for osteoporosis (other than menopause in
   Women or men who have fractures on
    Women or men who are considering therapy for
    osteoporosis and for whom bone mineral
    densitometry test results would influence this
    Radiographic findings suggestive of
    osteoporosis or vertebral deformity

   Corticosteroid therapy for more than 3
    months Primary hyperparathyroidism

   Treatment for osteoporosis (to monitor
    therapeutic response)
   Single photon absorptiometry: can only be
    used at radius and calcaneus (unclear
    attenuation source)

   Dual photon absorptiometry :can be used at
    deeper sites (spine,hip)
   Dual X-ray absorptiometry (DEXA) : most
    popular; precise measurement at clinically
    relevent sites, minimal radiation

   Quantitative CT :similar accuracy to DEXA,
    more radiation

   Ultrasound :same predictive value as DEXA,no
   Indicated when the T-score is below −1 and
    risk factors are present
   Preventive measures include;
   Adequate calcium and vitamin D intake
    Exercise
    Smoking cessation
    Fall prevention
    Limitation of alcohol and caffeine intake
    Use of medications (such as
    bisphosphonates and raloxifene)
Postmenopausal women and men old than 50 who

   Hip or vertebral fracture

   T-score of -2.5or less at femoral neck or spine

   Low bone mass (T-score between -1.0 and -2.5)
    and 10 year probability of major osteoporosis
    fracture of 20% or greater
   Treatment of underlying disorders
   Medical therapy
o    Bisphosphonates
o    Raloxifene
o    Estrogens
o    Parathyroid harmone
   Surgical therapy (vertbroplasty, kyphoplasty)
   Most commonly used, first line agent

   Bind to hydroxyapatite crystals in bone and
    inhibit osteoclast mediated bone resorption

   Alendronate and risedronate and
    zolendronate reduce the risk of both
    vertebral and non-vertebral fractures in men
    and women
   Ibandronate is only used to prevent and treat
    osteoporosis in postmenopausal women

   Usually given for 10 years.

   Osteonecrosis of jaw is potential adverse effect

   Should be taken empty stomach with full glass of
    water and patient should be upright for 45 min
   Most useful in younger postmenopausal
   Provides beneficial effects of estrogen
    without adverse outcome
   Used to prevent osteoporosis in
    postmenopausal women
   Reduces breast cancer risk
   Can cause DVT and hot flushes
   Was once considered first line therapy

   Not currently recommended

   Risk of DVT and stroke
   Only anabolic agent
   Indicated in patients intolerant of previous
    therapy or failed therapy
   Increased risk of osteosarcoma in rats
   Don’t prescribe in patients with increased risk
    of osteosarcoma (paget’s disease,
    unexplained alkaline phosphatase elevations,
    young adults with open epiphyses
   Humanized monoclonal antibody against
    receptor activator of nuclear factor kappa B
    ligand (RANKL) ,mediator of bone resorption

   Indicated in patients with high risk of
    fractures and intolerant to therapy or failed

   First line in patients with autoimmune and
    inflammatory disorders (ulcerative colitis)

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