OSTEOPOROSISDr Ramin RafieiAlzahra HospitalRheumatology Department

DEFINITION

Osteoporosis is defined by

systematic skeletal disorder

low bone density

deterioration of microarchitecture

bone strength reduction

increase fragility fracture risk

What are fragility fractures?

occur spontaneously or following minimal trauma

falling from a standing height or less

EPIDEMIOLOGY

most common metabolic bone disease

recognized as a global concern

Osteoporotic fractures

are common may have devastating consequences may be associated with increased mortality (hip and vertebral fractures)

Osteoporosis or osteopenia occurs in 55 percent of the population age 50 and over

prevalence

European Union in 2010

27.6 million

Americans older than 50 years

10 million (estimated to be 14 million in 2020)

34 million are at risk for the disease

OSTEOPOROSIS PREVALENCE IN IRAN

Osteoporosis 17%

Men 12%

postmenopausal women 19%

Osteopenia 35%

men 33%

postmenopausal women 40%

OSTEOPOROSIS PREVALENCE IN ISFAHAN

Bonakdar et al 2008

Salamat et al 2009

Sex Menoupause

Mean age(year)

Prevalence of Osteoporosis

Prevalance of Osteopenia

spinal Femur Spinal Femur

Female

Mix 44 9% 3% 25% 27%

Sex Menoupause Mean Age (yaer)

Prevalence of Osteoporosis

Prevalance of Osteopenia

spinal Femur spinal Femur

Female post 51.8 5% 40% 50% 45%

HEALTH IMPACT Mortality

increases the number of vertebral fractures leads to increased risk for death

CVD and pulmonary disease

9% In-hospital mortality

25% mortality within first year after a hip fracture

elevated mortality persists for up 10 years for hip fracture

excess mortality for 5 years after a vertebral fracture

relative risk of dying after a vertebral fracture is as high as 8.6

main predictors of higher mortality after fragility fractures

male sex

increasing age

coexisting illness

poor prefracture functional status

Smoking

low BMD

HEALTH IMPACT (MORBIDITY)

Hip fracture

leads to reduced function and loss of independence

Disability is 6 times that accounted for by hip fracture alone

physical performance had decreased by 51%

decreased Social function by 26%

40% are still unable to walk independently for 1 year

HEALTH IMPACT (MORBIDITY)

60% requiring assistance in at least one essential activity of daily living

80% are unable to perform at least one instrumental activity (driving or shopping)

patients are susceptible to the development of acute complications

pressure sores

bronchopneumonia

urinary tract infections

HEALTH IMPACT (MORBIDITY)

vertebral fracture

most are precipitated by routine daily activities

bending

lifting light objects

Leads to

loss of height

kyphosis

reduced pulmonary function (each fracture decreases FVC by 9%)

increased risk for back pain

disability

estimates of the prevalence of vertebral fractures

19% of women aged 75 to 79 years

22% of women aged 80 to 84 years

41% of those 85 years and older

osteoporotic fracture

increases as BMD declines

3-fold increase in fracture for each standard deviation fall in BMD

inverse correlation between BMD and the severity of fracture

3.5 million fragility fractures occur every year in the European Union

combined direct and indirect annual costs for hip fracture

$21,000 per patient

cost of osteoporosis in the European Union

€37 billion in yaer

RED:>300 FX/100000ORANGE:200-300 FX/100000GREEN:<200 FX/100000

BONE REMODELING

Bone is continually undergoing renewal called remodeling

bone laid down by osteoblasts

bone resorption is done by osteoclast

bone formation and bone resorption are closely coupled

BONE REMODELING

Bone remodeling follows an ordered sequence bone remodeling unit (BMU)

This cycle of coupling of bone formation and resorption is vital for skeletal integrity

Key regulators of osteoclastic bone resorption

RANK ligand (a member of the tumor necrosis factor

ligand family)

its two known receptors

RANK (Receptor activator of nuclear factor kappa-B)

osteoprotegerin (OPG)

DETERMINANTS OF BONE MASS

Genetic factors

Nutrition

calcium

phosphorus

vitamin D

other dietary factors

magnesium

vitamin C and K

Alcohol and smoking

Physical activity

Chronic diseases and medications

CLINICAL MANIFESTATIONS

Osteoporosis has no clinical manifestations

Vertebral fracture most common clinical manifestation of osteoporosis two-thirds are asymptomatic diagnosed as an incidental finding on chest or abdominal x-ray pain, usually subside gradually within 2 to 6 weeks loss of height greater than 3 cm in men and 4 cm in women Non–spine-related fractures level of trauma needed is relatively low Hip fractures relatively common in osteoporosis distal radius fractures (Colles fractures)

DOWAGER’S HUMP CORRESPONDINGNRADIOGRAPH

CLINICAL EXAMINATION

variable degrees of kyphosis of the thoracic spine

flattened (reduced) lumbar lordosis

loss of trunk height

Tenderness

Mobility of the spine is restricted

Painful spinal movements

CLASSIFICATION

primary

95% of cases in women

70% to 80% in men

Secondary

SECONDARY CAUSES

DIFFERENT PARAMETER IN BONE DENSITOMETRY REPORT T-score

number of SD the patient is below or above mean value for young (30 year old) normal subjects

Z-score

number of SD the patient is below or above the mean value for age-matched normal subjects

Absolute BMD

actual BMD expressed in g/cm2

the value that should be used to calculate changes in BMD during longitudinal follow-up

change of 1 standard deviation in either the T or Z score correlates

approximately 0.06 g/cm2

approximately 10% of BMD

SKELETAL SITE SELECTION World Health Organization (WHO) recommendation using T-score measured by DXA at the femoral neck

National Osteoporosis Foundation (NOF) the International Society for Clinical Densitometry (ISCD) using the lowest T-score of the lumbar spine (L1-L4) total proximal femur femoral neck following areas In the hip should not be used for diagnosis Ward's area trochanter other regions

WHAT ESTIMATES OF BONE LOSS AND FRACTURE RISK