2023 Osteoporosis PowerPoint CP2001 .pptx

Osteoporosis CP2001/CP2004 Osteoporosis ‘A progressive, systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue, with consequent increase in bone fragility and susceptibility to fracture.’ WHO 1994. Clinical Guidelines for Prevention and Treat...

Osteoporosis CP2001/CP2004 Osteoporosis ‘A progressive, systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue, with consequent increase in bone fragility and susceptibility to fracture.’ WHO 1994. Clinical Guidelines for Prevention and Treatment Osteoporosis. RCP. July 2000. Altered Bone Architecture Normal Osteoporosis prevalence • 1:2 women • 1:5 MEN • Aged 50 yrs will have an osteoporotic fracture during their remaining lifetime. Fracture Prevalence Osteoporosis causes >1.5 million vertebral and non-vertebral fractures annually Spine, hip, and wrist fractures are most common 15 % 19 % 19 % 46 % Vertebral Hip Wrist Other NIH/ORBD (www.osteo.org), 2000 1950 = 1.66 million 3250 1950 2050 600 629 Total number of hip fractures : 378 400 742 668 A Growing Problem 1950 2050 100 2050 = 6.26 million 1950 2050 1950 2050 Estimated no of hip fractures: (1000s) Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289 Risk of Fracture • Not just decrease in Bone Mineral Density (BMD) that leads to increased fractures - elderly at increased risk of falling. • Other factors Osteoporosis in Ireland Estimated prevalence 300,000 in > 50 year olds More than 2,800 hip fractures annually Average hospital stay 18 days -hospital cost €12,000 each patient Immediate mortality 12% Excess mortality within 6-12 months of hip fracture is 20% 50% unable to walk without assistance 25% require long-term care Only 30% regain their independence Cost of falls and fractures estimated at €400 million annually Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population Report of the National Steering Group on the Prevention of Falls in Older People and the Prevention and Management of Osteoporosis throughout Life, June 2008 (Available online at wwww.hse.ie) Bone mass Two factors affect risk of osteoporosis 1. Peak bone mass attainment 2. Age-related bone loss (accelerated in women post-menopause) Both of these under genetic and environmental influences Peak Bone Mass • Peak bone mass achieved by late 20’s. • 60-70% of maximal peak bone mass laid down in puberty. • After age 40, gradual age-related decrease in bone mass. • In women, accelerated decline after menopause (most bone loss occurs in first year of menopause). Age Related Changes in Bone Mass Bone Mass Attainment of Peak Bone Mass Consolidation Age-related Bone Loss Menopause Men Fracture Threshold Women 0 10 20 30 Age (years) Compston JE. Clin Endocrinol 1990; 33:653–682. 40 50 60 Bone Loss • Oestrogen deficiency causes uncoupling of bone resorption and bone formation. More bone removed by osteoclasts than made by osteoblasts • Age-related bone loss - mainly due to decreased bone formation. failing to match bone resorption. More bone marrow stem cells differentiate into fat cells than into osteoblasts. Peak Bone Mass • Regular, weight-bearing exercise. • Adequate nutrition during growth - energy, protein, calcium, Vitamin D. • Avoid excess caffeine, salt, alcohol and smoking. • Genetics - 80% of the variation in peak bone mass between individuals. Also important in bone turnover and bone size. Polymorphisms may contribute to pathogenesis of OP Osteoporosis -Diagnosis • Osteoporosis usually asymptomatic - only one-third vertebral fractures symptomatic. 80% of women with osteoporosis not aware have OP. • Usually not diagnosed until a fracture occurs. • X-ray performed for other reasons Symptoms and Signs Symptoms • Neck becomes weak and head falls forward • Back pain (can be severe) • Breathing difficulties • Indigestion & gastro-oesophageal reflux • Difficulty with mobility Signs • Deformity -Kyphosis • Abdomen bulges due to loss of space under the ribs • Loss of height 4-16cm due to vertebral fractures. Kyphosis On Examination • Pain of acute vertebral fracture can occasionally radiate to anterior chest or abdominal wall • Local tenderness • Made worse by movement • Height loss (more than 4 cm suggests at least one vertebral fracture) • Dorsal kyphosis • Contact between the ribs and the iliac crests • Range of spinal movement • Abnormal posture • Features of secondary causes • Hip fracture - affected leg shortened and externally rotated However … In most patients, examination will be normal • asymptomatic • Incidental diagnosis on x-ray Fracture risk should be assessed in postmenopausal women and men >/=50 with any of these • • • • • • • • Low trauma fracture Clinical features OP (height loss, kyphosis) Osteopenia on plain X-ray Corticosteroids (7.5mg/day longer than 3 months) Family history Osteoporotic fracture Low BMI (under 19) Early menopause (less than 45) Medical conditions associated with Osteoporosis eg RA, T1 DM,untreated hypogonadism/early menopause (<45yrs), malabsorption or malnutrition, chronic liver disease. Vertebral fracture assessment • Vertebral fracture assessment (1/10 radiation of X-ray) should be considered in postmenopausal women and older men if • 1) Hx loss >/= 4cm • 2) Kyphosis • 3) recent or current long term glucocorticoids Rx • 4) BMD T score </= -2.5 • 5) Hx non vertebral fracture >50yrs Investigations • Bone density • Exclude secondary causes X-ray of spine Exclude obvious bony secondaries (proceed to bone scintiography if doubt)  Urea/electrolytes Exclude renal osteodystrophy  Liver function tests ESR  Elevated in alcohol abuse If elevated, plasma electrophoresis to exclude myeloma in osteomalacia and Calcium/phosphate/ Abnormal bony secondaries alkaline phosphatase Thyroid function Exclude hyperthyroidism and testshypothyroidism  Additional Investigations • Immunoglobulins • Coeliac antibodies • Serum 25 (OH) Vitamin D, calcium • Sex hormones in men and women under 50 ASSESS Fracture risk by using FRAX TOOL Smoking • Detrimental effect on BMD • Associated with early menopause • Associated with increased risk of fracture FRAX® Tool WHO risk assessment tool to determine 10 year probability of major osteoporotic and hip fractures in men and women. Use clinical risk factors and BMI +/- BMD measurements for different age groups and sexes. Web-based tool available online at: www.shef.ac.uk/FRAX National Osteoporosis Foundation recommends treatment in patients with a low bone mass in whom a 10 year probability of a hip fracture is 3% or more or in whom risk of a major OP fracture is 20% or more. Clinical use FRAX & NOGG guidelines. Diagnosis BMD • Should NOT be used for population screening due to low sensitivity • Most fragility fractures occur in women who do NOT have osteoporosis. • 10% of women 65yrs and have a T score of -2 at the hip would be expected to have a fracture over the next 10yrs, AND….if a similar woman had a Colles' fracture, smoked and had prolonged exposure to steroids their risk would be closer to 26% in that same period.(Kumar and Clarke) BMD and DXA Bone mineral density (BMD) is used as a surrogate marker for bone strength Low BMD is a strong predictor of future fracture risk BMD assessed by Dual-energy X-ray Absorptiometry (DXA) - gold standard for the diagnosis of osteoporosis. Based on the principle that calcium in bone attenuates passage of X-ray beams in proportion to the amount of mineral present. Hip and lumbar spine Gives a BMD measurement expressed as grams of hydroxyapatite/cm2. Diagnosis Minimal radiation, quick. BMD reflects the amount of calcified bone present in any particular bone. BMD expressed either as T-score or Z-score. Low BMD has been shown to be an independent predictor of fragility fractures. Plain radiography – approx. 30-80% of bone mineral must be lost before lucency apparent on radiographs. T-score The T-score is the number of standard deviations (SD) BMD is above or below the mean BMD values for a young healthy adult. Used in post-menopausal women and men over 50. For every 1SD decrease in BMD below the mean, fracture risk roughly doubles at the spine and hip. 1994 WHO Criteria www.who.int T-Scores • Normal BMD - T score -1 or greater • Osteopenia - T score of between -1 and 2.5 • Osteoporosis - T score of -2.5 or below • Established Osteoporosis -T score -2.5 or below with one or more associated fractures Z-score The Z-score is the number of standard deviations above or below the mean BMD values for a population of the same age and gender Used in pre-menopausal women, children, and men <50 years. A Z-score >-2.0 is considered ‘within the expected range for age’ and <-2.0 ‘below the expected range for age’* * www.iscd.org Diagnosis of Osteoporosis • A BMD of 2.5 standard deviations or more below normal BMD (T-score ≤ 2.5). • Osteoporosis can also be diagnosed at a higher T -score (-1.5) if a low trauma fracture has already occurred. Relationship Between BMD and Fracture Risk fractures % patients with vertebral 35 30 25 20 15 2x 10 5 –1SD 0 -5 -4 -3 T–score SD – Standard deviation Watts NB. Oral Presentation at ASBMR 2001 -2 -1 0 Fragility Fractures • In Osteoporosis, bone quality is sufficiently abnormal to result in fracture with minimal trauma. • Fracture caused by ‘forces equivalent to a fall from standing height or less.’ (WHO). • Fracture caused by mechanical forces that would not ordinarily cause a fracture (cough, sneeze, turning over in bed, trip or fall). • Most vertebral fractures occur mid-lower thoracic area and upper lumbar area. % with Spine Fractures BMD Alone Misses Vertebral Fractures 30 25 20 15 10 5 0 Osteoporosis Osteopenia Normal WHO Classification (Spine or Hip BMD) • 50% of women with vertebral fractures are not osteoporotic by BMD • 1/3 of women needing Rx are missed using BMD alone Greenspan S et al, J Clin Densitom 2001;4:373-380 Vertebral Fracture Assessment  Imaging techniques that visualise the thoracic and lumbar spines on dual-energy X-ray densitometry -Vertebral Fracture Assessment (VFA) previously termed Lateral Vertebral Analysis (LVA) Involves about 1/10th the radiation of conventional X-rays Measured at the same time as bone densitometry - only takes an extra 3 minutes Cheaper and more convenient than X-rays VFA Patient scanned in the lateral decubitus position to obtain a lateral view of the spine Only one image is required to visualise the spine from T4 to L5 Vertebral fractures can be easily visualised and graded using a semiquantitative visual grading score (Genant et al). The images are digitalised, easily stored and used for follow-up comparisons Images can be viewed on computer or printed VFA Images No Fracture L2 Wedge Fracture Fracture Risk Factors Age Previous fracture Glucocorticoid therapy Parental history of hip fracture (independent of BMD) Risk factors low BMD (OP) Falls Frailty Poor vision Dementia Poor co-ordination -Neuromuscular impairment caused by Vitamin D deficiency increases risk of falls Age, prior fracture history, and BMD are the strongest predictors of fracture risk Predisposing medical conditions Osteoporosis • Endocrine - hyperparathyroidism, hyperthyroidism, diabetes, • Chronic inflammatory diseases Cushing’s disease, acromegaly, (release of pro-inflammatory adrenal insufficiency. cytokines eg TNF which • Male hypogonadism increase bone resorption). RA, (testosterone deficiency causes Ankylosing spondylitis, SLE. increase in bone turnover and uncoupling of bone resorption from • Other- cystic fibrosis, bone formation) homocystinuria, Gaucher’s • Haematological disease - multiple disease, haemochromatosis myeloma, leukemia, lymphoma, sarcoidosis, COAD, HIV/Aids haemophilia, sickle cell disease. Chronic renal disease • GI disorders -inflammatory bowel • Eating disorders -anorexia disease, coeliac disease, chronic nervosa (calcium deficiency, liver disease, Vitamin D or calcium weight loss and hypogonadism) deficiency, malnutrition, malabsorption, gastric bypass surgery. Steroid-induced Osteoporosis • Long-term corticosteroid use (>7.5 mg prednisolone/day for three months or more) Treatment of Osteoporosis Guidelines Who to treat? T score less than -2.5 Fragility vertebral Fracture T score -1.5 and steroidinduced OP Treatment - lifestyle • Lifestyle and dietary measures • Reduce alcohol </=2 u/day • STOP smoking • Ensure adequate Ca (>/=700mgs od) and Vit D intake ideally through dietary intake (if not possible through supplements) Calcium Intake Calculator Bisphosphonates -Inhibit bone resorption Bisphosphonates - stable analogues of inorganic pyrophosphate. High affinity for hydroxyapatite crystals -bind these on bone surface. When osteoclasts attempt to resorb bone containing bisphosphonate, the drug released within the cell and inhibits key signalling pathways essential for osteoclast function -inhibit osteoclast activity and osteoclastic bone resorption. Bone formation also suppressed because of an inhibitory effect on osteoblasts but overall balance of effect on bone turnover favourable Improve mineralisation, increase bone density Bisphosphonates • Increase in spine BMD of about 5-8% and hip BMD of 2-4% during first 3 years of treatment, then plateaus. In the context of multimorbidity & frailty.. In those taking bisphosphonates for osteoporosis for at least 3yrs ..there is no consistent evidence of Continuing for another 3yrs or Harm form stopping after 3yrs Rx SO review stopping …considering patient choice/fracture risk AND life expectancy Preventing fractures in the elderly • Intervention to prevent falls as important as drug treatment • A fragility fracture increases risk future fractures • Calcium and Vitamin D reduce the risk of fractures in elderly in care homes or house-bound New fractures on treatment • A new fracture does not mean treatment failure as even the most effective interventions only reduce fracture risk by 25-50% Prevention of Osteoporosis  Smoking cessation  Avoid excessive alcohol intake  Regular weight-bearing exercise  Avoid immobility  Avoid excessive dieting and exercise resulting in amenorrhoea  Maintain adequate intakes of calcium & vitamins Vitamin D • Sources -oily fish, cod liver, margarine, butter, milk, fortified cereals, eggs. Sunlight UVB 290315 nm. Can only make it April to September, shadow shorter than height. 10am -3pm. Blocked by sunscreen, skin pigment. • Increases calcium absorption, increases urinary re-absorption calcium, increases bone mineralisation. Function is to maintain serum calcium. • Most guidelines recommend a minimum of 400 IU daily Vitamin D Correction of 25(OH) vitamin D more important than increasing Calcium intake Desired 25(OH) vitamin D level of 75nmol/l Ideal daily doses: 1500 mg of Calcium and 800 IU of vitamin D Many post-menopausal women not getting enough vitamin D (52% Europe, 81% Middle East). Many older people in Ireland deficient in Vitamin D Evidence suggests that Vitamin D supplements may have a beneficial effect on BMD, fracture risk and falls. ‘Bone-sparing’ Foods • Countries with highest calcium intake have higher fracture risk. • Fruit and vegetable link to bone health? • PRAL values (Potential renal acid load) • Cheese with high protein content -high PRAL, fruit and vegetables - low PRAL -Bone ‘sparing’ foods Vitamin K • Vitamin K also vital for bone health - produces an amino acid which helps keep the calcium in bone. Preventing Osteoporosis • Eat a varied and healthy diet • Achieve good peak bone mass • Maintain healthy body weight • Keep active • Safeguard Vitamin D status • Avoid bone-thinning behaviors Exercise and other lifestyle recommendations • Thirty minutes weight-bearing exercise suitable for the person’s age. • Decrease caffeine. • Stop smoking. • Decrease alcohol. • Maintain healthy weight. • Decrease fibre if more than 40g/day. • Falls prevention programme. • Avoid immobility • Avoid excessive dieting and exercise resulting in amenorrhoea • Maintain adequate intakes of calcium & vitamin D Osteoporosis in Men • 20% of men will develop Osteoporosis • 50% have an identifiable risk factor (underlying secondary cause) • Alcohol abuse, steroids, hypogonadism, myeloma, renal or liver disease • Lifestyle measures and treating underlying cause essential Pre-menopausal Women Low bone mass defined as Z-score <-2.0 Causes of low bone mass Genetic: reduced peak bone mass acquisition Oestrogen deficiency 20 causes: coeliac, vitamin D deficiency, RA etc. Management Treat 20 causes Look for Oestrogen deficiency Check vitamin D levels Only use antiresorptive drugs if really necessary Conclusion Osteoporosis is important! Preventable Fracture risk should be calculated, and treatment should be aimed at those with high risk of fracture Secondary causes? Effective drugs available with proven fracture risk reduction No drug perfect! Non-compliance a big problem Remember… • A history of fracture more than doubles the possibility of a second fracture compared with a person with the same level of OP by DXA scan but without a prior fracture. • 20% women will have had a fractured hip by age 90. • 25% women over 60 will develop dowager’s hump with progressive rounding of the shoulders. • One in 5 patients with hip fractures require longterm nursing home care.