OSTEOPOROSIS
Prof. Dr. Ülkü Akarırmak
Metabolic Bone Diseases

Osteosclerosis

Osteolysis

Osteoporosis is the most common metabolic
bone disease
Vertebral Body
Normal
Osteoporotic
Definition of Osteoporosis
A systemic skeletal disease
- characterized by low bone mass
- microarchitectural deterioration of bone
tissue
- with a consequent increase in bone
fragility and susceptibility to fracture
Osteoporosis
1. Low bone mass and
2. Reduced bone quality
Result: Increased risk of fracture
Bone structure

Cortical and
trabecular bone

Bone cells
Bone function
Bone Turnover
- Osteoclasts - Bone resorption
- Osteoblasts - Bone formation
- Osteocytes
Formation=Resorption
Bone Turnover
Osteocytes
Osteoclasts
Osteoblasts
Monocytes
Bone Metabolism
Bone Metabolism
Local factors: Growth factors
3 Systemic hormones: - Parathormone
- Vitamin D
- Calcitonin
3 Involved systems: - Bone
- Intestines
- Renal
Peak Bone Mass
Genetic factors 70%
Nutrition
PBM
Exercises
Hormones
Risk Factors for Fracture

Age
 Female sex
 Family fx
 Previous fx
 Glucocorticoids
Risk Factors for Osteoporosis
Modifiable
 Inadequate exercise
 Inadequate nutrition
- calcium
- vitamin D
- balanced diet
 Medications
- glucocorticoids
- excess thyroid - etc.
 Smoking
 Excessive alcohol intake
Risk Factors for Osteoporosis 2
Nonmodifiable

Genetics
 Gender
 Race
 Age
Classification
I. Primary OP
1- Postmenopausal
2- Senile
II. Secondary OP
Sec.
OP
Osteoporosis
Fractures: Mortality –
Morbidity
 Pain


Deformity
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Loss of quality of life
Clinical Picture
The traditional picture of an
individual with osteoporosis:
An elderly woman with a curved back and
stooped posture, a woman who has lost height
and who appears small and frail
Major Osteoporotic Fractures
Type
Colles Vertebral Hip
Typical age
55
65
75
Female:male ratio
4:1
3:1
2:1
Femur fx
Peripheral fx
Forearm fx
Spinal Osteoporotic Fractures

Acute – chronic pain

Kyphosis
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Nontraumatic - low energy fx
Progressive loss of height;
Development of kyphosis
Spinal Fx
Pathogenesis of Osteoporotic Fracture
LOW PEAK
BONE MASS
POSTMENOPAUSAL AGE-RELATED
BONE LOSS
BONE LOSS
Low Bone Mass
Nonskeletal
factors
Other risk factors
FRACTURE
Increased risk of falls
Poor bone quality
Hip Fx
Femoral Fractures

Mortality in 20% of patients over 60 years
of age

Morbidity in 50%
Clinical Results of Osteoporotic Fractures

Pain
 Reduction in physical activity
 Deformity
 Muscle weakness
 Social isolation
 Loss of independence
 Increased mortality
Evaluation of Osteoporosis

Identify risk factors for OP

Identify contributing factors
Medical history: Secondary OP

Physical examination

DXA

X-ray
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Laboratory Evaluation
Radiographic Evaluation
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0 Normal
1 End plate deformity
2 Fish vertebrae
3 End plate fracture
4 Wedge vertebrae
5 Compression
fracture
X-Ray of Thoracic Spine
Diagnosis of Osteoporosis

Osteodensitometry DXA
DXA = Dual X- ray Absorptiometry
Bone Mineral Density BMD
Indications for Bone Densitometry






Female patients > 65 years
Patients with osteoporosis risk factors
Vertebral abnormalities and/or osteopenia on x-rays
Long – term glucocorticoid therapy
Primary hyperparathyroidism or other diseases with
high risk of OP
Patients being treated for OP, to monitor changes in
bone mass
Diagnosis Based on BMD (WHO)
BMD
T-score
Normal
0 - (-1)SD
Osteopenia
(-1) - (-2.5)SD
Osteoporosis
<(-2.5)SD
Established OP
‘’
+ fracture
Recommendations Based on BMD
BMD
Normal
Osteopenia
OP
Establ OP
Risk of Fx
Very low
Low
High<(-2.5)SD
Very high
Action
Prevention
Prevention
Treatment
Treatment
Osteodensitometry is the most
important method for diagnosis

Fracture risk may be assessed
 Low BMD is associated with increased fracture
risk
ROI
Laboratory Tests
- Routine Biochemistry
Serum calcium
Phosphorus
Alkaline phosphatase
Creatinine
Total protein,albumin,and globulin
25(OH)Vitamin D
- Complete blood count
- Sedimantation rate
- Biochemical markers of bone turnover
Differential Diagnosis
Metastasis
Multiple Myeloma
Osteoporotic
Fx
Osteoporosis is a….

Preventable
 Treatable disease

Recommendations
 1. Nutrition
2. Activity
3. Vitamin D
Approaches for Management of Osteoporosis:
Pharmac&Nonpharmacologic

Prevent fractures
- Medical therapy
- Prevention of falls

Improve physical function

Improve quality of life
Therapeutic Agents Used in Osteoporosis
Osteoclast
Inhibition of Resorption
Osteoblast
Stimulation of
Formation
Inhibitors of Bone Resorption
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Calcium
HT: Estrogens +/- progestogens
SERMs
Bisphosphonates
Alendronate
Zoledronate
Risedronate
Ibandronate
Calcitonin
Stimulators of Bone Formation

Parathyroid hormone injections
Dual Action

Strontium ranelate

Vitamin D and active derivatives

Ipriflavon

Anabolic steroids
Calcium – Vitamin D
Calcium - Adults : 1000 mg
Increased: Over 65 years, after menopause,
pregnancy, stilling
Vitamin D :
Adults : 400-800 IU
Over 70 years: >800 IU
HRT: Estrogen

Reduces the rate of bone loss
 Reduces fracture risk in
postmenopausal women
Adverse effects; WHI
Limited time
Calcitonin

Reduces bone loss in postmenopausal
women- bone quality

Effective on spinal fractures

Opt.dose: 200 IU/daily nasal spray

High tolerability
Bisphosphonates: Gold Standard
Indication:
PMO
Male OP
GIO
Decrease fracture incidence
ALN: 70mg/w
ZOL: 5mgIV/yearly infusion
RIS: 35mg/w-75/mo IBN:150mg/mo - 3mg 3mo inf
Contraindication: Oesaphageal irritation
Strategies for Reducing Falls and
Fractures
- Maintain physical activity
- Provide a safe home environment
- Balance training
- Ambulatory support when appropriate
- Avoid sedative medications
- Minimize other contributing medical problems
- Hip pads in the frail elderly
Hip Pads

Prevention of hip fractures in patients with
high fracture risk - shock absorbing effect
Decrease Risk of Falls
Questions
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