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OSTEOPOROSISBy. Dr. Bambang SN, Sp.PD
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METABOLIC BONE DISEASE
a. The condition produces diffusely
decreased bone density
(osteopenia) and diminished bonestrength
b. Histologic appearance:
-osteoporosis (common), bone matrixand mineral are decreased
-Osteomalacia(unusual), bone matrix
intact, mineral is decreased
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OSTEOPOROSIS
An excess of resorptive over formative bone cellactivities, result in loss of bone mass and
eventually bone fragility and fractures.
Resorption occurs principally in trabecular bone
and from endosteal surfaces.
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OSTEOPOROSIS
The most common metabolic bonedisease
Estimated to cause 1.5 million fractures
anually in US, mainly of the spine
Rate of bone formation is often normal,
rate of bone resorption is increased
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FACTORS INFLUENCING BONE FORMATION AND
RESORPTION
PROCESS FACTORS THATINCREASE
FACTORS THATDECREASE
LABORATORYINDICES OF THE
PROCESS
Bone formation Physical activity,
stress on bones
Growth
Bone repair following
fracture or surgical
cure of
hyperparathyroidism
with bone lesionsPharmacologic and
therapeutic agents
Immobilization,
disuse, bed rest
Aging
Growth hormone
deficiency
Glucocorticoid
excess (Cushings
syndrome)Hypophosphatasia
Bone-derived
serum alkaline
phosphatase
Urinary non
dialyzable
hydroxyproline
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PROCESS FACTORS THAT
INCREASE
FACTORS THAT
DECREASE
LABORATORY
INDICES OF
THE PROCESS
Bone resorption Ageing
Gonadal hormonedefciency
(postmenopausal,
hypogonadism in male
or female)
Hyperpharathyroidism
(primary or secondary)
Vit. D excess
Calcium or phosphate
deficiency (dietary,
malabsorption or renal
loss)
Osteolytic neoplasm
Glucocorticoid excess(Chusings syndrome)
Prostaglandin E2,
osteoclastactivating
factor, and other
osteolytic agents
secreted by
nonosseous neoplasm
Adequate dietary
calcium andphosphate
Hypoparathyroidism
Magnesium
deficiency
Pharmacological
and therapeutic
agents
Serum calcium
Urinary calciumTotal urinary
hydroxyproline
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TYPES AND CAUSES OF
OSTEOPOROSIS
1. Primary Osteoporosis
Naturally occured, cause by decreasing level of sex
hormone and by aging
a. Post menopause osteoporosis
- started onmenopause until aged of 65 years
- decreasing of estrogen hormone
- loss of bone density 3 % / year
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TYPES AND CAUSES OF
OSTEOPOROSIS
b. Senile Osteoporosis
- occured on male and female after aged of 65 years
- often cause by less intake of calcium and vitamin D
2. Secondary Osteoporosis
Cause by:
- chronic condition,
- medication effect or
- under nutrition.All cause less bone density
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CONDITION AND RISK FACTORS TO
OSTEOPOROSIS
1. Menstruation
- Early menopause (Hysterectomy)
- Irregularly menstruation
2. Ras
- white and Asia are easier than black
- Peak bone density on black more than white
3. Family history
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CONDITION AND RISK FACTORS TO
OSTEOPOROSIS
4. Posture, underweight more risky than normoweight andoverweight
5. Smoker
cigarrete influences of bone strength
6. Alcoholic
alcohol decreases bone formation andddecreases calcium resorption
7. Corticosteroid
increases bone resorption and decreases bone
formation
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CONDITION AND RISK FACTORS TO
OSTEOPOROSIS
8. Breast cancer
cancer medication suppress estrogen effect
9. Less calsium and vitamin D intake
10. Life style
- less contain of calcium in nutrition
- less exercise and physical activity
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ETIOLOGIC CLASSIFICATION OF
OSTEOPOROSIS1. Hormone deficiency
Estrogen
Androgen
2. Hormone Excess Cushings syndrome / glucocorticoid
administration
Thyrotoxicosis Hyperparathyroidism
3. Immobilization
4. Tobacco Use
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5. Alcoholism
6. Malignancy especially multiplemyeloma
7. Genetic disorders
8. Miscellaneous
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SYMPTOMS & SIGNS OF
OSTEOPOROSIS
Usually asymptomatic, until fractures accured
May present as : - backache of varying degrees
- spontaneous fractures- colaps of a vertebra
Loss of height is common
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IMAGING OF OSTEOPOROSIS
Demineralization areas : spine, pelvis, femoral
neck and head Demineralization is less marked in the skull and
extremities
Compression of vertebrae is common
Bone densitometry, screening for osteopenia
CT densitometry of vertebrae, highly accurate
and reproducible
Dual energy xray absorptiometry (DEXA), candetermine the density of any bone (quite
accurate)
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TREATMENT OF OSTEOPOROSIS
1. Education and prevention
2. Exercise and rehabilitation
3. Medicamentous therapies
a. Sex hormone
b. Biphosphonates
c. Selective Estrogen Receptor Modulators
(SERMs)
d. Calcitonin
e. Calcium and vit. D
4. Surgical
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EDUCATION AND PREVENTION
The diet should be adequate in protein,total calories, calcium, vit. D
Pharmacologic glucocorticoid doses
should be reduced or discontinued ifpossible
High impact physical activity increasesbone density in men and women
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MEDICAMENTOUS THERAPIES1. Sex hormone
Estrogen for female Testoteron for male
2. Biphosphonates
Inhibit osteoclast bone resorption
Must be taken in the morning 30 minutes beforeconsumption of anything else, to ensure intestinal
absorption
Must remain upright after taking alendronate, to
reduce the risk of esophagitis Alendronate dose :10 mg/d orally, effective for
increasing bone density and reducing fracture risk
Ses : esophagitis, gastritis, anorexia, weight loss
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Residronate dose : 5 mg / d orally, has a
lower incidence of GI side effects
All patients should receive some
supplementation with oral calcium and vit. D
Pamidronate, a parenteral biphosphonate :
60 mg, by i.v infusion in normal saline every 3months
Zoledronate is third generation bihosphonate,
is a potent osteoclast inhibitor
Can be given 24 mg i.v. ly every 612
months
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SELECTIVE ESTROGEN RECEPTOR
MODULATORS (SERMs)
Raloxifene 60 mg / d / orally, can be used for post
menopausal women, prevention of osteoporosis
Raloxifene :
reduces LDL cholesterol, not rises in HDL cholesterol
like seen with estrogen
No direct effect on coronary plaque
Not reduces hot flushes (often intensifies)
Not relieves vaginal dryness
Does not cause endometrial hyperplasia, uterinebleeding, cancer, breast sourness
Increases risk for thromboembolism
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CALCITONIN
Nasal spray of calcitonin salmon (miacalcim)
2200 units/mL in 2 mL metereddose bottles Usual dose is one puff (0.09mL, 200 IU) once
daily by alternating nostril
Nasal administration causes significanly lessnausea and flushing than parenteral route
Rhinitis, epitaxis, accure commonly
Less common adverse reactions include flu like
symptoms, allergy, arthralgias, back pain orheadache
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CALCIUM AND VITAMIN D
Adequate oral intake of calcium and vit. D are
required throughout life in order to maintain peakbone mass and reduced the risk of subsequent
osteoporosis and osteomalacia
Supplements are recommended for patients at
high risk for osteoporosis and for those with
established osteoporosis
Vit. D reduces the risk of breast cancer, calcium,
supplements may reduce the risk of coloncancer
Calcium citrate 0.40.7 g/d, calcium carbonate
11.5 g/d, vit. D 4001000 IU daily
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