OSTEOPOROSIS AND OSTEOPOROSIS AND OSTEOMALACIAOSTEOMALACIA

OSTEOPOROSIS AND OSTEOPOROSIS AND OSTEOMALACIAOSTEOMALACIA

Prof. Mohamad S. Al-HadramyProf. Mohamad S. Al-HadramyProfessor of Medicine/ConsultantProfessor of Medicine/Consultant

King Abdulaziz UniversityKing Abdulaziz UniversityJeddah, Saudi ArabiaJeddah, Saudi Arabia

Prof. Mohamad S. Al-HadramyProf. Mohamad S. Al-HadramyProfessor of Medicine/ConsultantProfessor of Medicine/Consultant

King Abdulaziz UniversityKing Abdulaziz UniversityJeddah, Saudi ArabiaJeddah, Saudi Arabia

F. 19-year-old presented with difficulty F. 19-year-old presented with difficulty in walking for many years, especially in walking for many years, especially going upstairs. She felt parasthesia going upstairs. She felt parasthesia in hands & feet and occasional in hands & feet and occasional spasm. P/E: waddling gait.spasm. P/E: waddling gait.

Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125).(0.7-1.4). Alk Phos: 562 ( - 125).

• What other test results you need?What other test results you need?

F. 19-year-old presented with difficulty F. 19-year-old presented with difficulty in walking for many years, especially in walking for many years, especially going upstairs. She felt parasthesia going upstairs. She felt parasthesia in hands & feet and occasional in hands & feet and occasional spasm. P/E: waddling gait.spasm. P/E: waddling gait.

Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-1.4). Alk Phos: 562 ( - 125).(0.7-1.4). Alk Phos: 562 ( - 125).

• What other test results you need?What other test results you need?

Alb: Urea: PTHAlb: Urea: PTHAlb: Urea: PTHAlb: Urea: PTH

1.1. What signs for low Ca What signs for low Ca would you look for?would you look for?

ChovestickChovestick

Trouseau 4 min.Trouseau 4 min.

1.1. What signs for low Ca What signs for low Ca would you look for?would you look for?

ChovestickChovestick

Trouseau 4 min.Trouseau 4 min.

OSTEOMALACIAOSTEOMALACIAOSTEOMALACIAOSTEOMALACIA

• Raised bone turnoverRaised bone turnover• + Failure of mineralization+ Failure of mineralization• Most common cause: Most common cause:

decreased Vitamin Ddecreased Vitamin D• Darker skin more susceptibleDarker skin more susceptible

• Raised bone turnoverRaised bone turnover• + Failure of mineralization+ Failure of mineralization• Most common cause: Most common cause:

decreased Vitamin Ddecreased Vitamin D• Darker skin more susceptibleDarker skin more susceptible

Less common:Less common:

Heriditary resistance to Vitamin DHeriditary resistance to Vitamin D

1 1 αα-hydroxylase def.-hydroxylase def.

Familial X-linked hypophosphatemiaFamilial X-linked hypophosphatemia

Mesynchymal tumours produce Mesynchymal tumours produce phosphatoninphosphatonin

Less common:Less common:

Heriditary resistance to Vitamin DHeriditary resistance to Vitamin D

1 1 αα-hydroxylase def.-hydroxylase def.

Familial X-linked hypophosphatemiaFamilial X-linked hypophosphatemia

Mesynchymal tumours produce Mesynchymal tumours produce phosphatoninphosphatonin

RadiologyRadiologyRadiologyRadiology

Subperiosteal resorption of Subperiosteal resorption of phalangesphalanges

Looser zonesLooser zones

Brown cystsBrown cysts

Subperiosteal resorption of Subperiosteal resorption of phalangesphalanges

Looser zonesLooser zones

Brown cystsBrown cysts

Chemistry:Chemistry:Chemistry:Chemistry:

Decreased corrected CaDecreased corrected Ca

(40-Alb) x 0.02 + Ca(40-Alb) x 0.02 + Ca

Decreased P; Why?Decreased P; Why?

Decreased urinary CaDecreased urinary Ca

Decreased 25 (oH) Vit. DDecreased 25 (oH) Vit. D

Decreased corrected CaDecreased corrected Ca

(40-Alb) x 0.02 + Ca(40-Alb) x 0.02 + Ca

Decreased P; Why?Decreased P; Why?

Decreased urinary CaDecreased urinary Ca

Decreased 25 (oH) Vit. DDecreased 25 (oH) Vit. D

TreatmentTreatmentTreatmentTreatment

1000 – 2000 IU Vitamin D/day + 1000 – 2000 IU Vitamin D/day + 500 – 1000 mg of Ca/day. 500 – 1000 mg of Ca/day. Rarely 50,000 – 100,000 u/d or Rarely 50,000 – 100,000 u/d or 1 1 αα 0.5 – 2.5 0.5 – 2.5 μμg/day ·.· shorter g/day ·.· shorter acting to decrease tox.acting to decrease tox.

Check Ca Q 2-4 weeksCheck Ca Q 2-4 weeks

Phosphate for hypophosph Phosphate for hypophosph RicketsRickets

1000 – 2000 IU Vitamin D/day + 1000 – 2000 IU Vitamin D/day + 500 – 1000 mg of Ca/day. 500 – 1000 mg of Ca/day. Rarely 50,000 – 100,000 u/d or Rarely 50,000 – 100,000 u/d or 1 1 αα 0.5 – 2.5 0.5 – 2.5 μμg/day ·.· shorter g/day ·.· shorter acting to decrease tox.acting to decrease tox.

Check Ca Q 2-4 weeksCheck Ca Q 2-4 weeks

Phosphate for hypophosph Phosphate for hypophosph RicketsRickets

OSTEOPOROSIOSTEOPOROSISSOSTEOPOROSIOSTEOPOROSISS

• Low bone densityLow bone density• Microarchitectural Microarchitectural

deteriorationdeterioration• ↑ ↑ fracturesfractures

• Low bone densityLow bone density• Microarchitectural Microarchitectural

deteriorationdeterioration• ↑ ↑ fracturesfractures

Balance between bone Balance between bone formation and bone formation and bone resorptionresorption

Balance between bone Balance between bone formation and bone formation and bone resorptionresorption

Max bone mass at 25 – 35 Max bone mass at 25 – 35 yearsyears

Increased by exercise and Increased by exercise and good Ca intake. Later bone good Ca intake. Later bone mass ↓, especially with mass ↓, especially with ↓oestrogens (Menopause).↓oestrogens (Menopause).

Max bone mass at 25 – 35 Max bone mass at 25 – 35 yearsyears

Increased by exercise and Increased by exercise and good Ca intake. Later bone good Ca intake. Later bone mass ↓, especially with mass ↓, especially with ↓oestrogens (Menopause).↓oestrogens (Menopause).

Dx: T score. What is it?Dx: T score. What is it?Dx: T score. What is it?Dx: T score. What is it?

Normal T ± 1Normal T ± 1Osteopenia -1> T ≥ -2.5Osteopenia -1> T ≥ -2.5Osteoporosis T < - 2.5Osteoporosis T < - 2.5Severe osteoporosis T <-Severe osteoporosis T <-

2.5 with 1 or more 2.5 with 1 or more fragility, fracturesfragility, fractures

Normal T ± 1Normal T ± 1Osteopenia -1> T ≥ -2.5Osteopenia -1> T ≥ -2.5Osteoporosis T < - 2.5Osteoporosis T < - 2.5Severe osteoporosis T <-Severe osteoporosis T <-

2.5 with 1 or more 2.5 with 1 or more fragility, fracturesfragility, fractures

Chemistry: normalChemistry: normalWhy Why ↑alk, but not persistent↑alk, but not persistentChemistry: normalChemistry: normalWhy Why ↑alk, but not persistent↑alk, but not persistent

Primary OsteoporosisPrimary OsteoporosisPrimary OsteoporosisPrimary Osteoporosis

Senile or post-menopausal – Senile or post-menopausal – 95%95%

IndiopathicIndiopathic

Senile or post-menopausal – Senile or post-menopausal – 95%95%

IndiopathicIndiopathic

Secondary OsteoporosisSecondary OsteoporosisSecondary OsteoporosisSecondary Osteoporosis

Endocrine: Endocrine: Cushing + exog steroidsCushing + exog steroidsHyperthyroidismHyperthyroidismHypogonadismHypogonadismHyperparathyroidismHyperparathyroidismDMDM

ProclatinomaProclatinomaAcromegalyAcromegalyPreg & lactationPreg & lactation

Endocrine: Endocrine: Cushing + exog steroidsCushing + exog steroidsHyperthyroidismHyperthyroidismHypogonadismHypogonadismHyperparathyroidismHyperparathyroidismDMDM

ProclatinomaProclatinomaAcromegalyAcromegalyPreg & lactationPreg & lactation

Connective Tissue:Connective Tissue:Connective Tissue:Connective Tissue:

Osteogenesis inperfectaOsteogenesis inperfecta

MarfanMarfan

HomocystinuriaHomocystinuria

Osteogenesis inperfectaOsteogenesis inperfecta

MarfanMarfan

HomocystinuriaHomocystinuria

Drugs:Drugs:Drugs:Drugs:

HeparinHeparin

SteroidsSteroids

Anti-convulsantsAnti-convulsants

HeparinHeparin

SteroidsSteroids

Anti-convulsantsAnti-convulsants

RenalRenalRenalRenal

C R FC R FC R FC R F

Nutrition and GITNutrition and GITNutrition and GITNutrition and GIT

Malabsorption, CeliacMalabsorption, CeliacGastrectomyGastrectomyT P NT P NHepatobiliary diseaseHepatobiliary diseaseChronic hypophosphatemiaChronic hypophosphatemia

Malabsorption, CeliacMalabsorption, CeliacGastrectomyGastrectomyT P NT P NHepatobiliary diseaseHepatobiliary diseaseChronic hypophosphatemiaChronic hypophosphatemia

Elite female athletes Elite female athletes and anorexia nervosaand anorexia nervosaElite female athletes Elite female athletes and anorexia nervosaand anorexia nervosa

Risk increased by:Risk increased by:Risk increased by:Risk increased by:

F – sexF – sexMenopauseMenopauseDecreased CaDecreased CaSmokingSmokingAlcoholAlcoholInactivityInactivityLeannessLeannessWhite Race (White Race (↓ black)↓ black)

F – sexF – sexMenopauseMenopauseDecreased CaDecreased CaSmokingSmokingAlcoholAlcoholInactivityInactivityLeannessLeannessWhite Race (White Race (↓ black)↓ black)

Signs & Symptoms:Signs & Symptoms:Signs & Symptoms:Signs & Symptoms:

Asymptomatic unless #Asymptomatic unless #Back painBack pain↓ ↓ HeightHeightKyphosisKyphosisEffect especially in:Effect especially in:

DorsalvertsDorsalvertsFemoral neckFemoral neckDistal radiusDistal radius

Asymptomatic unless #Asymptomatic unless #Back painBack pain↓ ↓ HeightHeightKyphosisKyphosisEffect especially in:Effect especially in:

DorsalvertsDorsalvertsFemoral neckFemoral neckDistal radiusDistal radius

DD: Lytic lesionsDD: Lytic lesionsDD: Lytic lesionsDD: Lytic lesions

Ca breast, Lung, Kidney, Ca breast, Lung, Kidney, ThyroidThyroid

Prostate Prostate wall sclerosis wall sclerosis

MM MM generalized thinning generalized thinning

Ca breast, Lung, Kidney, Ca breast, Lung, Kidney, ThyroidThyroid

Prostate Prostate wall sclerosis wall sclerosis

MM MM generalized thinning generalized thinning

Prevention:Prevention:Prevention:Prevention:

ExerciseExercise

Good Ca intakeGood Ca intake

Non-smokingNon-smoking

ExerciseExercise

Good Ca intakeGood Ca intake

Non-smokingNon-smoking

Screening:Screening:Screening:Screening:

Screen post-menopausalScreen post-menopausal

F >64 or with multiple risk F >64 or with multiple risk factors (e.g., factors (e.g., ↓weight, ↓weight, fragility fracturesfragility fractures

Frag #: of limb or spine post fall Frag #: of limb or spine post fall from standing height or lessfrom standing height or less

Screen post-menopausalScreen post-menopausal

F >64 or with multiple risk F >64 or with multiple risk factors (e.g., factors (e.g., ↓weight, ↓weight, fragility fracturesfragility fractures

Frag #: of limb or spine post fall Frag #: of limb or spine post fall from standing height or lessfrom standing height or less

TREATMENT:TREATMENT:TREATMENT:TREATMENT:

Ca 1200 mg/dayCa 1200 mg/dayVitamin D:- 400-2000 IU / dayVitamin D:- 400-2000 IU / dayHRTHRTBiphosphonatesBiphosphonatesCalcintoninCalcintoninS E R M SS E R M SParathyroid hormoneParathyroid hormone

Ca 1200 mg/dayCa 1200 mg/dayVitamin D:- 400-2000 IU / dayVitamin D:- 400-2000 IU / dayHRTHRTBiphosphonatesBiphosphonatesCalcintoninCalcintoninS E R M SS E R M SParathyroid hormoneParathyroid hormone