Osteoporosis: Best EvidenceHitesh Gopalan U

Clinical Assistant Prof,Visiting Lecturer, McMaster University, CA

Classification

WHO DefinitionBone density that falls 2.5 standard

deviations (SD) below the mean for young healthy adults of the same sex—also referred to as a T-score of –2.5

LabSerum CaPTH25(OH) Vit DUrine Ca

High serum Ca (Hyperparathyroidism Vs Malignancy)

Low serum Ca (Osteomalacia)

HypercalciURIA: males with osteoporosis, Hyperparathyroidism, Paget’s disease, Hyperthyroidism

Secondary OsteoporosisHypogonadal States: Turner, KlinefleterEndocrine conditions: Thyrotoxicosis,

Cushing’sGI conditions: Gastrectomy, Liver diseaseRheumatological: RA, ASHematologic Disorders: Multiple MyelomaInherited Conditions: OI, Marfan

DEXACT ScanX-rays

TreatmentEstrogen- beneficial- ↑ risk of Endometrial

Ca

Estrogen + Progesterone= ↑ Risk of heart disease/stroke

Tibolone

What we Know

SERMRaloxifene

Reduces risk of vertebral fractures

Reduced incidence of Ca Breast, Cardiovascular and Cerebrovascular Events

BisphosphonatesAlendronate

Ibandronate

Risedronate

Zolendronic Acid

BisphosphonatesOsteonecrosis of Jaw, Atypical

Subtrochanteric Fractures

? Ca oesophagus

Perthe’s Disease, Osteogenesis Imperfecta, AVN

Accumulates in the Body

Bisphosphonates- # HealingIncrease BMD at # site- Single Dose

Does not interfere with fracture healing

Odvina et al.. J Clin Endocrinol Metab2005;90(3):1294–301.van der Poest Clement E, J Bone Miner Res 2000;15(3):586–93.

TeriparatideRecombinant PTH

Daily injection

Cost

Osteogenic Ca

CalcitoninNasal Spray

Paget’s Disease

Kyphoplasty Vs Sham

Denosumab

FREEDOMFracture Reduction Evaluation of Denosumab

in Osteoporosis Every 6 Months (FREEDOM) Trial

No major adverse effects

Supported by AMGEN

DenosumabHigher incidence of infections

Contraindicated in Hypocalcemia

VEGF-A

Hierarchy of Evidence

Randomized Trials

Prospective Cohort Studies

Retrospective Case Series

Case Control Studies

Opinion

Meta-analysis

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“EBM Begins and Ends with the Patient”

Evidence Cycle