Osteoporosis & Its Management

OSTEOPOROSIS
Osteoporosis
Dr Subhajit Mitra
Assistant Professor of Medicine
Gauhati Medical College & Hospital
Osteoporosis: Global burden
 The prevalence of osteoporosis increases with age, from 6% at 50
years to 50% after the age of 80.
 The WHO estimates that osteoporosis is the second-largest

health problem after cardiovascular disease affecting more than
200 million people worldwide.
 According to the ICMR reports it was said that 3% of the Indian

men and 8% of the female population in India are Osteoporotic
 Osteoporosis causes more than 8.9 million fractures annually

worldwide.
 In India, the incidence of osteoporosis is high among men and

peak incidence is at lower age compared to Western countries.
Types ofTypes of Osteoporosis?
Osteoporosis
Primary osteoporosis Secondary osteoporosis
 Postmenopausal  Chronic drug therapy

osteoporosis like Steroids
 Age-related  Calcium and vitamin

osteoporosis D deficiency
 Hyperparathyroidism
What is Osteoporosis?
Osteoporosis is “A systemic skeletal disease”
Pathophysiology characterization –
· Reduced Bone Density
· Micro architectural deterioration
· Increase in bone fragility
· Susceptibility to fracture from
minor trauma
Difference between..
OSTEOPOROSIS ..defect
bone density
 OSTEOPENIA..early stage
 OSTEOMALACIA..defect
bone mineralisation in adults
 RICKET…same as in children
PATHOPHYSIOLOGY cont..…
Bone mass increases during growth to reach a peak
between 20 -45 yrs of age and thereafter falls in both
gender with accelerated phase in women due to
estrogen def.
 The loss of bone with ageing is caused by an
imbalance in the bone remodelling cycle, whereby the
amount of new bone formed by osteoblasts cannot keep
pace with the amount that is removed by osteoclasts
STAGES OF BONE REMODELLING
Clinical Features
 Osteoporosis is a “silent disease” which does not
become clinically apparent until a fracture occurs.
 The term ‘fragility fracture’ is used to describe a
fracture that occurs as the result of a fall from standing
height or less.
These are typical of osteoporosis
 Patient may complain of back pain.
 Vertebral fractures may result in spinal deformity.

Changes in Bone Mass with age
Quality
Osteoporosis & qualityof
ofLife
life
 Limitations in the ability to work
 Difficulties in performing the activities of
daily life
 Loss of independence
 Acute or chronic pain
 Anxiety and depression
 Reduced self image
Risk Factors Risk Factors
Screening
 X-ray of spine, hip, wrist
 Measure bone mineral density (DEXA)
 C.T scan- Sensitive
 Blood investigation: Serum calcium, phosphorous,

alkaline phosphatase.
Bone Mineral Density- Gold standard
DEXA SCAN
T score Inference
0 to -1 Normal
-1 to –2.5 Osteopenia
-2.5 OR Lesser Osteoporosis
<-2.5 with trauma Severe osteoporosis
Blood Investigations
Complication Complications
of Osteoporosis
Low Bone Mass Poor Bone Quality Trauma
Hip fractures, vertebral fractures, wrist fractures

Glucocorticoid induced
Glucocorticoid induced Osteoporosis
The risk of osteoporosis is related to dose and duration of
glucocorticoid therapy and increases substantially in
patients who have taken more than 7.5mg of prednisolone
daily for more than 3 months (or an equivalent dose of
another glucocorticoid)
Role of Estrogen in Bone Health
Management Goals
 Preserve bone mass
 Prevent fractures
 Decrease pain
 Maintain function
Management: Lifestyle Intervention
ManagementManagement
of Osteoporosis
 Currently, no treatment can completely reverse established osteoporosis. Early
intervention can prevent osteoporosis in most people.
 For patients with established osteoporosis, medical intervention can halt its
progression.
 If secondary osteoporosis is present, treatment for the primary disorder

should be provided.
 Patients identified as at risk for osteoporosis (including children and

adolescents) should undergo preventive measures, including adequate calcium
intake, vitamin D intake, and exercise.
 Patients should be counseled to avoid tobacco and excessive alcohol use.

Who should be treated?
The National Osteoporosis Foundation
recommends reserving pharmacologic
therapy for postmenopausal women and
men aged 50 years or older who present
with the following :
 Fragility fracture: a hip or vertebral

fracture
 T-score of –2.5 or less at the femoral
neck, total hip, spine
 Low bone mass -T-score of –1.0 to –
2.5 at the femoral neck or spine
Management: Pharmacological
Management of Osteoporosis intervention
1. Antiresorptive agent
• Bisphosphonates eg Zolendronic acid, alendronate,
ibadronate
• RANKL Antibodies eg Denosumab
• Selective estrogen receptor modulators (SERMs)
• Calcitonin
2. Anabolic agents : PTH analogues like teriperatide ,

Abaloparatide
3. Dual Acting (Both antiresorptive & Anabolic
agents): Romosozumab
Hormonal Replacement
Management Therapy (HRT)
of Osteoporosis
 It is used as a prophylactic measure and has shown to reduce
the frequency of Osteoporotic fractures.
 Estrogens may reduce the risk of fractures by increasing

mobility and dexterity.
 Cyclic HRT with estrogen & Progesterone is an effective

treatment & prevents post menopausal bone loss and reduces
risk of vertebral and non-vertebral fractures.
 Meta-analysis has reported that with the use of HRT, there

was a 33% reduction in the vertebral fractures and a 27%
reduction in non-vertebral fractures Biomedical & Pharmacology Journal, June 2021. Vol. 14(2), p. 567-575
EXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1379, 2021
https://emedicine.medscape.com/article/330598-treatment#d8
When to do surgery..
 Orthopaedic surgery with internal fixation is
frequently required to reduce and stabilise osteoporotic
fractures.
 Patients with intracapsular fracture of the femoral
neck generally need hemi-arthroplasty or total hip
replacement in view of the high risk of osteonecrosis.
 Vertebroplasty is sometimes used in the treatment of
painful vertebral compression fractures.
 Kyphoplasty is used under similar circumstances.
Conclusion
Management of Osteoporosis
• Osteoporosis is becoming a lifethreatening health issue in recent times
due to its increase in fracture risk.
• Among the various treatments for osteoporosis that are currently in use,
pharmacological therapy is the most efficient and accessible, and has
been rigorously studied
• Currently used therapies include those that inhibit bone resorption,

promote bone formation and dual‑action therapies
• Pharmacological therapies are used in patients with osteoporosis to

reduce the risk of fracture and increase BMD
• Estrogen therapy is available for the prevention and treatment of

Osteoporosis. Calcium and vitamin D intake from fruits and vegetables is
also recommended with extra supplementation to increase the bone
mineral density.

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OSTEOPOROSIS

 The WHO estimates that osteoporosis is the second-largest

 According to the ICMR reports it was said that 3% of the Indian

 Osteoporosis causes more than 8.9 million fractures annually

 In India, the incidence of osteoporosis is high among men and

Primary osteoporosis Secondary osteoporosis

 Postmenopausal  Chronic drug therapy

 Age-related  Calcium and vitamin

Osteoporosis is “A systemic skeletal disease”

 Patient may complain of back pain.

 Vertebral fractures may result in spinal deformity.

 X-ray of spine, hip, wrist

 Measure bone mineral density (DEXA)

 C.T scan- Sensitive

 Blood investigation: Serum calcium, phosphorous,

Low Bone Mass Poor Bone Quality Trauma

Hip fractures, vertebral fractures, wrist fractures

 If secondary osteoporosis is present, treatment for the primary disorder

 Patients identified as at risk for osteoporosis (including children and

 Patients should be counseled to avoid tobacco and excessive alcohol use.

 Fragility fracture: a hip or vertebral

2. Anabolic agents : PTH analogues like teriperatide ,

 Estrogens may reduce the risk of fractures by increasing

 Cyclic HRT with estrogen & Progesterone is an effective

 Meta-analysis has reported that with the use of HRT, there

• Currently used therapies include those that inhibit bone resorption,

• Pharmacological therapies are used in patients with osteoporosis to

• Estrogen therapy is available for the prevention and treatment of

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