Osteoporosis new horizons

OSTEOPOROSIS DIAGNOSISNEW PARADIGMS

Dr.maninder ahujaAhuja nursing home&infertility centre526, sector 17 faridabad

Dr.ManinderAhuja chairperson geriatric gynecology committe

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DR.MANINDER AHUJACHAIRPERSON GERIATRIC GYNE.COMMITTEFOGSI

TO DIAGNOSE OSTEOPOROSIS WE HAVE ALWAYS TO KEEP IT

IN MIND WHEN TREATING AGING WOMEN !

2Dr.ManinderAhuja chairperson geriatric gynecology committe

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What is changing?

• The life span of a woman has increased from 23 years in the Roman era to 65 years in India and 80 years in developed countries

• Age of menopause is 46&52

• 1/3rd of a woman’s life is spent after Menopause and no of women in menopause is increasing.

• Source: US Dept of Health and Human Services; 1999;47(28).

Year

1850 1900 1950 20000

20

40

80

60Age

(Year)


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NUMBER OF AGING WOMEN IS INCREASING

1990 2030

World wise population 470million 1.2 billion

Developing countries 40% 24%

Developed countries 60% 76%


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New Age Approach--Quality Of Life

• Early diagnosis and assessment of problems

• Prevention of problems main stay is life style modifications

• New treatment modalities


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Magnitude of problem in India

• 1 out of 3 females in India suffers from osteoporosis, largest affected.

• 26 million with the numbers projected to increase to 36 million by 2013.(Osteoporosis Society of India (2003)

• By 2050 1 out of 2 hip fractures would occur in Asia

• A woman’s risk of developing an osteoporosis-related hip fracture is equal to her combined risk of developing breast uterine and ovarian cancer.


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Osteoporotic Fracture1,200,000

Heart Attack513,000

Strokes228,000

BreastCancer 1,84,000

1 million

> 2.0 x

> 4.4 x

> 5.5 x

OSTEOPOROSIS IN WOMEN : CONCERN


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Osteoporosis – the silent diseaseUnder diagnosed and most common

Osteoporosis – the silent diseaseUnder diagnosed and most common

35 yrs onwards you lose bone mass at 0.5 to 1% per yr(initial quality Imp)

Around menopause loss is upto 4-5 % per year

You also lose muscle mass from 35 years onwards

vitamin D receptor, estrogen receptor, transforming growth factor, interleukin-6, interleukin-1 receptor 2, type I collagen genes, and collagenases are for genetic causes


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Sarcopenia and osteoporosis go hand in hand


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Beginning in the fourth decade of life, adults lose 3 % to 5% of muscle mass per decade,rate of decline increases to 1% to 2% per year after age 50 years( RED ALERT FAT)

N

sarcopenia

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Osteoporosis defined

“A systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue with a resultant increase in fragility and risk of fracture.”

New definiton: A skeletal disorder characterized by compromised bone

strength predisposing a person to an increased risk of fracture.

Bone strength reflects the integration of three main features: Bone density, Bone structure Bnd bone quality

Euler’theorem


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DIAGNOSED BY BMD MEASUREMENTS

By DXA SCAN

• BMD is compared to two norms - healthy young adults ( T-score)

• age-matched ( Z-score)

• WHO CLASSIFICATION:• Normal A T-score within 1 SD (+1 or

-1) of the young adult • Osteopenia A T-score of 1 to

2.5 SD below the young adult mean (-1 to - 2.5 SD)

• Osteoporosis A T-score of 2.5 SD or more below the young adult mean (> - 2.5 SD)

• It takes about 10 years for change of 1 SD


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For each standard deviation decrease in femoral neck BMD,there is an approximate 2.5-fold increased risk of hip fracture.

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ADVANTAGES DEXA

– High Accuracy (Error < 1%)

– Diagnose both osteopenia & osteoporosis

– Predicts risk of fractures

– Evaluates response to therapy

– Low Radiation

– Can assess both central as well as peripheral osteoporosis

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LUMBAR SPINE

• AP Lumbar Spine most widely used for evaluation

• BMD value in spine: extent of osteoporosis

• BMD value in hip:

predicts fracture


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Other methods of Diagnosis Radiologic Procedure Rating Comments RRL*

DXA PA spine 9 Min

DXA proximal femur and femoral neck and total hip

9 Min

QCT spine 8 Preferred method of evaluation if DXA not available or cannot be performed.

Min

QUS heel 4 Can be used for preliminary evaluation of patients at risk for fracture. If abnormal, DXA may follow.

None

DXA forearm 3 Only if hip/spine or hip/hip can't be done or patient over the table limit for weight. Primary site for patients with hyperparathyroidism.

Min

SXA/DXA heel 3 Min

QCT proximal femur 3 Limited clinical experience. Currently, primarily a research tool.

Min

pQCT 2 Min

X-ray thoracic or lumbar spine

2 Useful for diagnosing stress fractures, not osteoporosis. Low

Radiographic absorptiometry 1 Min

Rating Scale: 1=Least appropriate, 9=Most appropriate *Relative Radiation Level


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Micro and high-resolution MRI

Strengths Limitations• A noninvasive approach• No ionizing radiation• 3-dimensional assessment

of cortical and trabecular structure

• Can use clinically available MRI available

• Treatment related effects can be assessed

• Limited to appendicular skeleton

• Reference data limited• technically demanding


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300,000 hip fractures20% die within 6months approximately 10% have a second fracture within a year of the incident hip fracture 60% of those who survive hip fracture do not regain the same level of independence

200,000 broken wristsLimited movement Quality of life impaired

Most of time undiagnosed 500,000 spinal fractures,compression or wedge fractures,

Losing height .>2cms Back pain Kyphosis,inc.mortality &morbidity In extreme cases chest compression Abdominal space reduced and problems of eating and

digestion

COMMON SITES OF FRACTURES

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Dental health and osteoporosis

• A correlation between lower BMD and/or postmenopausal osteoporosis and parameters of periodontal disease, such as alveolar crestal bone height, tooth loss and, to a lesser degree, gum recession.

• Hormone replacement therapy has been associated with reduced tooth loss in several observational studies.


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In Diabetics• "In type 2 diabetes mellitus patients, impaired bone quality may • result from the deterioration of microarchitecture rather than a • decrease in bone mass,

• In Diabetics BMD by QUS is lower and by DXA higher

• Still fracture rate is higher

• Guang Ning and colleagues from Shanghai Jiao-tong University School of Medicine, China


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Risk factors

• Female

• Over 50 years old

• Low estrogen

• Body mass index<19kg/m2

• bone mass low

• History of fragility fractures in self or family

• Poor nutrition (with deficient calcium and vitamin D intake)

• Smoking,active and passive

• Excessive alcohol use>3 drinks /day

• sedentary lifestyle

• Rheumatoid arthritis

Sources: Chan, KM, Anderson M, Lau EM. Exercise interventions: defusing the world’s osteoporosis time bomb. Bulletin of the World Health Organization 2003;81:827-830.

National Osteoporosis Foundation: Fast Facts. Available at: www.nof.org/osteoporosis/disease facts.htm. . 19Dr.ManinderAhuja chairperson geriatric gynecology committe

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http://www.nof.org/osteoporosis/disease%20facts.htm

Medications causing ostoeoporosis

• Glucocorticoids>5mg /day predenisolone for > 3months• Long acting progestins/inj depoprovera• Aromatase inhibitors• GnRh agonists• Anticonvulsants• Cytotoxic drugs• Long term anticoagulation• Lithium• Proton pump inhibitors• SSRIs


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Heridity or genetics Is very Imp.

• Up to 80% of the variability in peak bone density might be attributable to genetic factors.

• Female children of women who have osteoporotic fractures have lower BMD

• First-degree relatives (ie, mother, sister) of women with osteoporosis also tend to have lower BMD than those with no family history.

• In one large study of postmenopausal women from five ethnic groups (white Americans, African Americans, Asian Americans, Hispanic Americans, and Native Americans),African Americans had the highest BMD, while Asian Americans had the lowest.


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Effects of osteoporotic fractures

• Psychological trauma• Physical disabilities • Morbidity• Huge costs of treatment

• So to diagnose and prevent we have to keep it in mind.


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•90% - 95% of patients go home without a bone density test

•Fragility Fracture Patients Are Rarely Evaluated for Osteoporosis

•Counselling should be done whenever you get an opportunity

•Aim is to assess by risk factors so that first fracture is prevented

•After first fracture treat her so that you can prevent a second fracture!!

FACTS

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NOF 2008 Recommendations for BMD Testing

• All women ≥ 65 years and all men ≥ 70 years, • Postmenopausal women < 65 and men aged 50 to 70 with a

concerning clinical profile • Perimenopausal women with a particular risk factor • Anyone under consideration for osteoporosis medication • Any adult taking high-risk medication or who has a high-risk

condition for bone loss • Any adult >50 years who sustains a fracture • Postmenopausal women who are coming off estrogen • Anyone in whom knowledge of low BMD would lead to

pharmacotherapy • To monitor effectiveness for those on treatment


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10-year Probability of Fracture in Women by Age and FN T-Score-

”age and BMD are independent predictors”


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A new paradigm -FRAX

• 10-year risk for hip and other major fractures. The model, called "FRAX," incorporates BMD, age, sex, body-mass index, and seven other risk factors, family H/O fragility fracture, rheumatoid arthritis, alcohol intake ,smoking, glucocorticoids, secondary osteoprosis

• Model does allow the identification of those in the low BMD range (T-score –1 to –2.5) who have the highest risk of fracture and would benefit for treatment,but they should not be on treatment for osteoporosis

• This model can be seen at following web site.• http://www.shef.ac.uk/FRAX.


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http://www.shef.ac.uk/FRAX

Prior fracture

• A prior fracture has been associated with an 84% increased risk of a future fracture. For example, a prior wrist fracture has led to a 50% greater risk of a future hip fracture.

•

• Roux C. Joint Bone Spine. 2009;76:1-3.

• FRAX® WHO Fracture Risk Assessment Tool. Available at: http://www.shef.ac.uk/FRAX. Accessed June 2, 2009

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Risk should be >3%for hip#&>20% for all major #


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Bone turnover markers(For determining response to treatment)

Bone formation(serum)

• Osteocalcin(OC)• Bone specific

alk.phosphotase(BAP)• Amino-terminal type 1

collagen(PINP)• Carboxy terminal

type1 collagen(PICP)• increase when

response to anabolic agents

Bone resorption(urine)

• Pyridinoline(pvr)• Deoxypyridinoline(Dvd)• Aminoterminaltelopeptide

(NTx)• Carboxyterminal

telopeptide(CTx)• decrease when response

to antiresorptive agents,


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OTHER BIOCHAEMICAL TESTS

• For Secondary osteoporosis

• fasting serum calcium,

• 24-hour urinary calcium,

• serum 25-OH-D (vitamin D).

• Anti-tTG (tissue TransGlutaminase) antibodies.An anti-tTG test is the most sensitive lab test for celiac disease

• Serum creatinine

• Complete blood count;• • Measurement of phosphorous, • alkaline phosphatase,

• Thyroid-stimulating hormone,

• Hepatic enzyme levels


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Role of Vit D • Serum 25 D should be 80 nmol/L or higher

• Low levels of vitamin D are highly prevalent• • Vitamin D plays a key role in normalizing PTH levels

• Vitamin D deficiency is associated with increased risk of falls and fractures,

• vitamin D intakes much higher than are currently recommended are quite safe.

• Raising serum 25(OH)D from 50 to ~80 nmol/L improves Ca absorption, raises BMD, and reduces both fall and fracture risk


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Vit D Def & Risk Of Falls


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Genetic Tests in near future• Two variants — one in a protein governing bone

formation (LRP5), and another in a receptor involved in bone resorption (TNFRSF11B) — were linked to increased risk for osteoporosis or a history of clinical low-impact fractures.

• “Can be measured with near-perfect precision ... years before the age at which fractures tend to occur — which could provide ample lead-time for preventive measures."


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Conclusion

• Dexa scan is Gold standard for diagnosis• Fracture risk is now calculated by FRAX MODEL• Age and BMD are independent risk factors• Biochemical markers have place in determining

response to treatment.• We should always assess by risk factors• Aim is to avoid first fracture• After first fracture treat and prevent second fracture.• Role of calcium 1200-1500 mg/day and Vit 800 IU is

undisputed


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Acknowledgements

• Dr.Sonal Bathla• Dr.shekhar Agarwal

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CHAIRPERSON GERIATRIC GYNAECOLOGY COMMITTEE (FOGSI)

[email protected]

Osteoporosis new horizons

Health & Medicine

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