Osteoporosis

Osteoporosis
Introduction
Osteoporosis is a systemic skeletal disease characterizes by low bone mass and micro-architectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis is a generalized reduction in bone density that results when the rate of bone resorption exceeds the rate of bone formation. It is most commonly associated with the aging process in which the bone formation generally proceeds at the normal rate but bone removal occurs at an increased rate. Under abnormal conditions the reduction in bone density may represent the failure of the protein matrix in which the calcium is laid down. Osteoporosis thus is a disturbance of tissue metabolism, not calcium metabolism. Not enough matrix is laid down by osteobalsts (bone cells), but whatever is formed is calcified. In osteoporosis the (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety ofproteins in bone is altered.
Osteoporosis is defined by the (WHO) in women as a bone
mineral density 2.5 below peak bone mass (20-year-old healthy female average) as measured by the term "established osteoporosis" includes the presence of a Osteomalacia on the other hand is a condition of adults characterized by softening of bones because of an accumulation of osteoid tissue, the bone matrix that fails to mineralize. The most common cause of osteomalacia is Vitamin D deficiency. Incomplete fractures may cause acute onset of localized pain and tenderness. Fractures are usually multiple and heal with an abundant callus (new bone) formation, consisting chiefly of osteoid, so that union is markedly delayed. It results in deformities, particularly of weight bearing structures, including the leg, the thigh and spine. Generalized bone pain and tenderness results.
Epidemiology
Though there are no large epidemiological studies, it is now believed that it may be more prevalent in the Indian men. Dr. Balu Sankaran’s study as well as our experience at ISIC suggests that there may be a higher male to female ratio in the Indian population. As per US statistics one out of every two women and one in eight men over 50 will have an osteoporosis- related fracture in their lifetime. Estimated national direct expenditures for osteoporosis and related fractures is $14 billion each year. Since the incidence of femoral neck fractures in the Indian males is the highest in the age group 51-60 and that of Intertrochanteric fractures in the age group 61-70, it is presumed that Indian men get osteoporosis at a younger age compared to their Western counter-parts.
Osteoporosis increases the risk of fractures, especially those of the back, wrist and hip. It can also lead to hunched back, loss of height and pain in part or in whole of back. Most often, osteoporosis is a silent disease and presents with fracture. Fractures are most common in the vertebra resulting in wedged vertebra. This wedging can make the back start curving and have a “hunched” deformity. This not only looks ugly, it also makes breathing difficult. It lowers the height and causes the abdomen to bulge. The second most common site of fracture is the hip.
As per International Osteoporosis Foundation, Indians show the highest prevalence of osteoporosis, Indian men seem to have equal if not more susceptibility to osteoporosis and Indians get osteoporosis at a younger age then their western counter parts.
Amongst the risk factors for osteoporosis are those which we can't change (female gender, advanced age, small body size, Caucasian and Asian ethnicity and family history) and those which we can change (inactive lifestyle or extended bed rest, premature menopause, a lifetime diet low in calcium and vitamin D, use of certain medications, such as steroids or some anticonvulsants, cigarette smoking and excessive use of alcohol).
Symptoms
The osteoporosis condition can be present without any symptoms for decades, because osteoporosis doesn't cause symptoms unless bone fractures. Some osteoporosis fractures may escape detection until years later. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. Then the symptoms are related to the location of the fractures. Fractures of the spine can cause severe "band-like" pain that radiates around from the back to the side of the body. Over the years, repeated spine fractures can cause chronic as well as loss of height or curving of the spine, which gives the individual a hunched-back appearance of the upper back, often called a "dowager hump." A fracture that occurs during the course of normal activity is called a minimal trauma fracture or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb. Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality.
These fractures can be slow to heal or recur if osteoporosis is not treated. The other symptoms thus can be • Neck becomes weak and head falls forward • Stomach bulges because of the loss of space under the ribs Risk Factors

Osteoporosis results if the bone stock is deficient. Thus neglect of any point of time can result in
reduced overall bone stock and predispose to osteoporosis. Thus in general we should be aware
about it through out our life time. However if there are some risk factors for osteoporosis we should be more careful. The risks factors are as under:  Gender – Your chances of developing osteoporosis are greater if you are a woman. Women have less bone tissue and lose bone more rapidly than men because of the changes involved in menopause.
 Age - The older you are, the greater your risk of osteoporosis. Your bones become less  Body size – Small, thin-boned women are at greater risk.
 Ethnicity – Caucasian and Asian women are at highest risk. African-American and Latino women have a lower but significant risk.
 Family history – Susceptibility to fracture may be, in part, hereditary. People whose parents have a history of fractures also seem to have reduced bone mass and may be at  Sex hormones: abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause) and low testosterone level in men.
 Anorexia.
 A lifetime diet low in calcium and vitamin D.
 Use of certain medications, such as glucocorticoids or some anticonvulsants.
 An inactive lifestyle or extended bed rest.
 Cigarette smoking.
 Excessive use of alcohol.
• Advanced age • Sedentary lifestyle• Low calcium intake• Early menopause Drugs which are known to predispose to osteoporosis are as under: • Antiepileptics (Phenytoin) • Glucocorticoids• Chronic anticoagulant use (Coumarin, Heparin)• Immunosuppressants (methotrexate or cyclosporin)• Gonadotropin releasing hormones analogues (used to treat endometriosis) In general women without any risk factors should be more careful in the perimenopausal period Diagnosis
A routinecan reveal osteoporosis of the bone, which appears much thinner and lighter than normal bones. Unfortunately, by the time x-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, x-rays are not accurate indicators of bone density. The appearance of the bone on x-ray is often affected by variations in the degree of exposure of The National Osteoporosis Foundation, the and other major medical organizations are recommending (DXA, formerly known as DEXA) for diagnosing osteoporosis. DXA measures bone density in the hip and the spine. The test takes only 5 to 15 minutes to perform, uses very little(less than one tenth to one hundredth the amount used on a standard, and is quite precise. The bone density of the patient is then compared to the average peak bone density of young adults of same sex and race. This score is called the "T score," and it expresses the bone density in terms of the number of standard deviations (SD) below peak young adult bone mass. Osteoporosis is defined as bone density T score of -2.5 SD or below.
Osteopenia (between normal and osteoporosis) is defined as bone density T score between -1 and -2.5 SD Early diagnosis is important in order to have best results of treatment. In fact it is better if we can take suitable steps to prevent osteoporosis since once it sets in it is not easy to revert the changes.
Prevention
Building strong bones during childhood and adolescence can be the best defense against developing osteoporosis later. The average woman has acquired 98% of her skeletal mass by 30 years of age.
There are four steps to prevent osteoporosis. No one step alone is enough to prevent osteoporosis. Eat a balanced diet rich in calcium and vitamin D. Engage in weight-bearing exercise. Adopt a healthy lifestyle with no smoking or excessive alcohol intake. Take medication to improve bone density when appropriate.
1. Exercise, quitting cigarettes and curtailing alcohol.
2. Dietary counseling for management and prevention.
3. Lifestyle changes.
4. Fall risk evaluation with prevention and management.
5. Osteoporosis Methods to prevent osteoporosis include changes of lifestyle. However, there are medications that can be used for prevention as well. As a different concept there are osteoporosis ortheses which help to prevent spine fractures and support the building up of muscles. Fall prevention can help prevent osteoporosis complications.
Exercises role:has a wide variety of beneficial health effects. However, exercise does
not bring about substantial increases in bone density. The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved and/or muscle strength is increased. Research has not yet determined what type of exercise is best for osteoporosis or for how long. Multiple studies have shown that aerobics, weight bearing, and resistance exercises can all maintain or increase BMD in postmenopausal women. Many researchers have attempted to pinpoint which types of exercise are most effective at improving BMD and other metrics of bone quality, however results have varied. Treadmill walking, gymnastic training, endurance, and strength exercises all resulted in significant increases of L2- L4 BMD in osteopenic postmenopausal women. Strength training elicited improvements specifically in distal radius and hip BMD.Exercise combined with other pharmacological treatments such as hormone replacement therapy (HRT) has been shown to increases BMD more than HRT alone. Additional benefits for osteoporotic patients other than BMD increase include improvements in balance, gait, and a reduction in risk of falls. A word of caution about exercise: it is important to avoid exercises that can injure already weakened bones.
Lifestyle: Lifestyle prevention of osteoporosis is in many aspects inversions from potentially
modifiable risk factors. As tobacco smoking and unsafe alcohol intake have been linked with
osteoporosis, smoking cessation and moderation of alcohol intake are commonly recommended in the prevention of osteoporosis.
Nutrition: Proper nutrition includes a diet sufficient in calcium and vitamin D. Patients at risk for
osteoporosis (e.g. steroid use) are generally treated with vitamin D and calcium supplements and often with bisphosphonates. In renal disease, more active forms of Vitamin D such as paracalcitol or (1,25-dihydroxycholecalciferol or calcitriol which is the main biologically active form of vitamin D) is used, as the kidney cannot adequately generate calcitriol from calcidiol (25-hydroxycholecalciferol) which is the storage form of vitamin D. High dietary protein intake increases calcium excretion in urine and has been linked to increased risk of fractures in research studies. Other investigations have shown that protein is required for calcium absorption, but that excessive protein consumption inhibits this process. No interventional trials have been performed on dietary protein in the prevention and treatment of osteoporosis.
Medications: Just as for treatment, bisphosphonate can be used in cases of very high risk.
Other medicines prescribed for prevention of osteoporosis include raloxifene, a selective
estrogen receptor modulator (SERM). Estrogen replacement therapy remains a good treatment for prevention of osteoporosis but, at this time, is not recommended unless there are other indications for its use as well. There is uncertainty and controversy about whether estrogen should be recommended in women in the first decade after the menopause. In hypogonadal men testosterone has been shown to give improvement in bone quantity and quality, but, as of 2008, there are no studies of the effects on fractures or in men with a normal testosterone level.
Fall risk Evaluation and management: following points will be taken care of,
• Application of a dim light in bed room at night.
• Use of non slippery slipper in bathroom and wetland areas especially in rainy season.
• No obstacles and hurdles in living area.
• Overall prevent oneself from fall.

Treatment
The treatment of osteoporosis includes pharmacological and non-pharmacological treatment. Non pharmacologic management is equally, if not more important component of management and includes dietary management, a healthy lifestyle with adequate exercises and removal of predisposing factors. Dietary management includes a balanced diet with adequate amount of calcium. Exercises build and maintain strong bones as a result of adequate calcium deposition, results in better balance, muscles strength and agility thus reducing the risk of falls and fractures and boost the appetite resulting in adequate intake of nutrition and calcium.
PHARMACOLOGICAL MANAGEMENT
Inhibitors of bone resorption.
2. Calcitonin 3. Estrogen ± progestin Selective estrogen receptor modulators (SERMs) Stimulators of bone formation
Mixed mechanism of action
Medication:
1. Alendronate: In clinical trials, Alendronate increased the bone mass as much as 8
percent and reduced fractures as much as 30 percent to 40 percent, depending on skeletal site.
To avoid damage to the esophagus, Alendronate should be taken according to the instructions. These instructions include taking the drug in the morning upon waking up and at least half an hour before eating. The drug should be taken with a glass of water, and the person should remain upright for half an hour after taking it. Alendronate should not be taken by people who cannot stand or sit upright or who have disorders that prevent esophageal emptying into the stomach.
2. Risedronate:, a more recently introduced bisphosphonate (marketed as Actonel by
Aventis) is more potent and has fewer upper gastrointestinal side effects than Alendronate. Alendronate and risedronate are approved for prevention of bone loss in recently menopausal women, for treatment of post menopausal osteoporosis, and for prevention (risedronate) and treatment (alendronate and risedronate) of glucocoricoid – induced osteoporosis. Alendronate is also approved for the treatment of osteoporosis in men.
Both alendronate and risdronate are now available as weekly tablets which has facilitated the patient compliance to treatment together with a decreased occurrence of gastro- The use of intravenous bisphosphonates such as Zoledronate, Ibandronate and Pamidronate remains limited to special indications such as intolerance to oral formulations and treatment of patients with bone metastasis.
Since bisposphonates have an effect on non-vertebral fractures as well, reduce the risk of fractures quickly (risk of clinical verteberal fractures is reduced after 1 year of treatment with risedronate) and have fewer and less serious side effects, they may be considered the first line of treatment for osteoporosis. However, it is to be specified that drug therapy alone is not sufficient and a healthy, active lifestyle with adequate exercises and calcium supplementation should be advised.
3. Calcitonin: is not a bisphosphonate but a hormone that plays a role in calcium and bone
metabolism. When used regularly it can slow the loss of bone. Calcitonin increases bone mineral density in early postmenopausal women and men with idiopathic osteoporosis. Calcitonin is also beneficial in reducing the bone pain associated with fractures. Available for many years as an injection, calcitonin treatment became much easier with availability 4. Raloxifene: may not be taken by all women who are post menopausal. Raloxifene is
probably most useful in women who have osteoporosis (T score less than or equal to 2.5) or who are at risk (T score less than -1.5 with clinical risk factors) in the middle menopausal period (age 55-65) or in the early menopausal period in women who have no significant hot flushes. At this stage in life, vertebral fractures are common, but hip fractures are not. Therefore, women who take raloxifene can expect a reduction in the likelihood of having a vertebral fracture, and possibly breast cancer. The lack of definitive efficacy against hip fracture is not a major deterrent to use of this agent in this age group because hip fracture risk is very low. Raloxifene might not be the treatment of choice for elderly women who are at particularly high risk of hip fracture.
Raloxifene does increase the risk of venouse thromoembolic disease (blood clots in the veins of legs) and is thus contraindicated in women with previous history of venous thromboembolism or those who are at significantly increased risk.
5. Teriparatide (Forteo) is the first treatment that stimulates new bone growth to increase
bone mass. All other drugs approved for osteoporosis treatment act by slowing the turnover of bone, rather than stimulating new bone formation. Teriparatide is a portion of human parathyroid hormone, which works in the body to regulate the metabolism of calcium and phosphate in bones. The treatment is given in daily injections and is approved for postmenopausal women who are at high risk for bone However, there is a strong caution to its use. In the pre-approval studies of Teriparatide using rats, there was an increase in the incidence at osteosacroma, a rare but serious cancer of the bone. Because it’s possible that women treated with Teriparatide could have increased risk for developing this cancer, doctors are advised to discuss this risk with their patients and be sure that it’s the best treatment. Because individuals with growing bones (children and adolescents) and patients with Paget’s disease of the bone have a higher risk for developing osteosarcoma, it should not be used in these groups. Further more individuals with hypercalcamia, women who are pregnant or are nursing or those who have ever been diseased with bone cancer should not use this. Most other adverse effects are mild and include nausea, diginess and leg cramps.
Teriparatide supposedly increases bone mineral density at most sites and decreases non- vertebral fractures more than aledronate.
It is also effective for treatment of men with primary or hypogonadal osteoporosis who are at high risk for fracture. It should however be used in patients who have failed a treatment course with bisphosphonates (men) or with bisphosphonates and SERM (women) or are intolerant to side effects of bisphosphonates/SERMS. Since long term effectiveness and safety are not known, therapy for more than two years is not recommended. **********************

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