OSTEOPOROSIS

Mohd Fikri bin Mustapa

DEFINITIONS
Osteoporosis : skeletal disorder characterised by
compromised bone strength that
increased risk of fracture.

Bone strength : integration of bone density and bone
quality.

Bone density (g/cm2) : determined by peak bone mass
and amount of bone loss.

Bone quality refers to the architecture, turnover, damage
accumulation, and mineralisation of the bone.
CLASSIFICATION
Primary Osteoporosis
Postmenopausal osteoporosis.
Age-related osteoporosis.
Idiopathic (rare)
Secondary Osteoporosis
Risk factors
Osteoporosis is a silent disease until
fractures have occurred.

screening is not cost effective

identification of risk factors will help in
case finding
Clinical Presentation
Most patients are asymptomatic and
diagnosis is made only after a fracture.

Common clinical presentations include:
Increasing dorsal kyphosis (Dowagers hump)
Low trauma fracture
Loss of height
Back pain
The common sites of fracture are the
spine, wrist and hip.
Diagnosis
primary osteoporosis is made after
excluding secondary causes.

patient with a low trauma fracture,
osteoporosis is a presumptive diagnosis.

BMD measure with dual energy x-ray
absorptiometry (DXA) is a the gold
standard
Fracture Risk Assessment Tool
(FRAX)
FRAX is used to evaluate the 10-year
probability of hip and major osteoporotic
fracture risk that integrates clinical risk
factors and bone mineral density at the
femoral neck
If FRAX is not accessible, individuals over
65 years of age with risk factors, can be
started on treatment.
Screening
BMD measurement is recommended for
all women above 65 and men above 70
years old.

based on age and weight, Osteoporosis
Self-Assessment Tool for Asians (OSTA),
was developed for postmenopausal Asian
women.
Radiological osteopenia is apparent in
plain X-rays only after more than 30% of
bone loss has occurred.
Densitometry

BMD is an accurate reflection of bone mass

T-scores (comparison with the young adult
mean)

Z-scores (comparison with the mean of
individuals of the same age)

The risk of fracture is increased two fold for each
SD reduction of T-score in BMD

Currently available methods in Malaysia
for measuring BMD include:
a) Dual energy X-ray absorptiometry (DXA)
b) Quantitative computed tomography (QCT)

DXA
The gold standard
measured at the hip and lumbar spine.

Indications for BMD Measurement*
Quantitative computed tomography (QCT)

is an alternative technique for measuring bone
density in the axial skeleton.

It is able to measure vertebral volumetric bone
density.

The main limitations
the lack of availability in Malaysia
higher radiation dose compared to DXA
Quantitative Ultrasound (QUS)

not recommended.
Problems
diversity of techniques,
the lack of standardisation

The criteria for diagnosis not well established.

Women with low QUS results should be referred
for BMD measurement.
Bone Turnover Markers (BTM)
useful to identify patients at high risk of future
fractures.

used to evaluate treatment efficacy and
compliance to therapy.

not for the diagnosis

Changes in level of BTM can be seen within 3-6
months after initiation of drug therapy
Currently available biochemical
markers
Monitoring of Therapy
to assess the response to treatment.

two separate baseline need followed by
one repeat 2-3 months after initiating
therapy and yearly thereafter

These measurements should be taken at
the same time of the day to minimise the
effect of diurnal variation
PREVENTION OF OSTEOPOROSIS
Nutrition

Suggested Daily Calcium Intake
When dietary intake is insufficient, calcium
supplementation may be needed.

For optimal absorption, calcium should not
exceed 500 to 600 mg per dose
Vitamin D
Vitamin D supplementation at 800 IU/day in combination
with calcium

Activated Vitamin D
calcitriol 0.25 g bd,
alfacalcidol 1 g od
avoid taking more than 800 mg of calcium supplements
to reduce the risk of hypercalcemia and renal stone
disease.
Serum and urinary calcium monitored 6 weeks after
initiation of therapy and at 3 to 6 monthly intervals
thereafter
Body Weight
Low body weight associated with low bone
mineral status and increased fracture risk.

BMI of not less than 19 kg/m2 is
recommended for prevention of
osteoporosis
Caffeine intake
should less than 1 to 2 servings (240 to
360 ml in each serving) per day.

leads to slight decrease in intestinal
calcium absorption and an increase in
urinary calcium excretion
Smoking
Cigarette smoking increases osteoporotic
fracture risk and thus should be avoided.

Alcohol intake
Excessive intake of alcohol should be
avoided because alcohol has detrimental
effects on fracture risk.
Exercise
Regularly, in particular weight-bearing exercise
to maximise peak bone mass, decrease age-
related bone loss, maintain muscle strength and
balance

Prevention of falls
Most osteoporosis-related fractures, especially
in the elderly, are a consequence of decreased
BMD and falls

Recommendations for Hormonal Therapy

not be used solely for the prevention of osteoporosis

recommended in women with premature menopause

not recommended in women with breast cancer,
coronary heart disease or stroke

used for the shortest duration (< 5years), in the lowest
possible dose
Bisphosphonates
They inhibit the cells that break down bone
(osteoclasts) and allow the cells that rebuild
bone (osteoblasts) to work more effectively.
Alendronate
Risedronate
Ibandronate



Two adverse effects have been noted in
bisphosphonate therapy:
1. Atypical femoral shaft fractures
2. Osteonecrosis of the jaw (ONJ)
Atypical Femoral Shaft Fractures
The risk of atypical femoral shaft fracture
increased duration of bisphosphonate use.

Although this is a useful process to
prevent bone loss and fractures, there are
concerns that over a prolonged period of
time, this may result in bones becoming
older and more brittle.
Osteonecrosis necrosis of the jaw (ONJ)
some of the cells die in the affected bone
in the jaw and delayed healing

mostly very high doses of bisphosphonate
given intravenously zoledronate for cancer
treatment

Fosamax is very unlikely affecting
between 1 in 10,000 people per year
taking the treatment for osteoporosis.
Use of bisphosphonates in Chronic Kidney Disease (CKD)

CKD Stages 1-3
Bisphosphonates can be used safely
Patients should be well hydrate
nephrotoxic drugs (NSAIDs), should be avoided

CKD Stages 4-5
not recommended for patients with an estimated
GFR < 30 ml/min
MANAGEMENT OF OSTEOPOROTIC
FRACTURES
The goals are early mobilisation and a return to normal activities.

Conservative management of hip fractures is discouraged because
patient at risk of
respiratory problems,
thromboembolic disease,
pressure ulcers
further bone loss.

The majority of osteoporotic vertebral fractures are stable.
Operative intervention is indicated for those fractures complicated by
spinal cord or nerve root compression.
OSTEOPOROSIS IN MEN

Osteoporosis is increasingly recognised in older men.

Men account for up to 30% of hip fractures and 42% of
clinical vertebral fractures.

Fifty to sixty percent of cases are due to secondary
causes

For every one SD reduction in age-matched mean BMD
(Z score), fracture risk increases two-fold
Strontium Ranelate

reduces bone resorption while promoting
bone formation
Available as Protelos
Dose 2g sachet of tasteless powder to be
mixed in a glass of water
Denosumab

human monoclonal antibody (IgG2) that
inhibits the formation,function and survival
of osteoclasts by preventing RANK
(receptor activator of nuclear factor kappa-
B) thus reducing bone resorption.

denosumab 60mg given 6 monthly
subcutaneously,
Calcitonin
Daily intranasal dose of 200 IU calcitonin,

Calcitonin has also been shown to have
an analgesic effect for acute pain in
osteoporosis related vertebral fractures.

Side effects of calcitonin include nausea,
flushing, vomiting and nasal irritation.
Teriparatide (r-PTH)

effective in the treatment of osteoporosis in men.

Recombinant human PTH 1-34 (r-PTH), teriparatide, is a potent
anabolic agent.

indicated for severe osteoporosis or osteoporosis not responsive to
other therapy.

Subcutaneously administered r-PTH at 20 micrograms daily for 21
months

Current recommendation is up to 24 months
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