Presented by:

Siti Noraisah Bt Kifli

 OUTLINES
• INTRODUCTION
• STATISTICS IN MALAYSIA
• PATHOPHYSIOLOGY
• CLASSIFICATIONS
• RISK FACTORS
• SYMTOMPS
• DIAGNOSIS
• PREVENTION
• MANAGEMENT
 ::introduction::
• Osteoporosis is a disease in which bones become fragile and
more likely to break. If not prevented or if left untreated,
osteoporosis can progress painlessly until a bone breaks.

• These broken bones, also known as fractures, occur typically in

the hip, spine, and wrist.

• Any bone can be affected, but of special concern are fractures

of the hip and spine. A hip fracture almost always requires
hospitalization and major surgery.

• It can impair a person's ability to walk unassisted

• may cause prolonged or permanent disability or even death.

• Spinal or vertebral fractures also have serious consequences,
including loss of height, severe back pain, and deformity

• Osteoporosis makes your bones weak and more likely to break.

• Anyone can develop osteoporosis, but it is common in older women.

• As many as half of all women and a quarter of men older than 50

will break a bone due to osteoporosis
 STATISTICS of
OSTEOPOROSIS IN
MALAYSIA
Osteoporosis-related fractures have been
recognized as a major health problem,
particularly in the elderly. In 1997, the
incidence of hip fracture in Malaysia among
individuals above 50 years of age was 90
per 100 000. Hip fractures are associated
with a high morbidity and mortality rate of
up to 20% in the first year.
 
The majority who survive are disabled and
only 25% will resume normal activities. The
direct hospitalization cost for hip fracture in
1997 is estimated conservatively at RM 22
million.
 PATHOPHYSIOLOGY OF OSTEOPOROSIS
• As a result of physical stresses experienced
during activities of daily living micro fractures can
occur. If left unattended, these micro fractures can
become clinically evident as fractures.

•Osteoclasts and osteoblasts are in charge of

repairing the micro fractures. These two cells
originate in the bone marrow from a common
precursor.

•As a result of endocrine signals that are poorly understood and in the
presence of a number of growth factors and cytokines the osteoclasts are
recruited and create a "resorption pit" where bone is digested (see Figure
1).

•Thereafter, the osteoclasts abandon the pit while osteoblasts settle within it
to deposit new bone. When resorption and deposition are coupled there is
no net change in the amount of bone present. Following menopause and
after some pathological processes the coupling is altered in favor of
increased resorption and as a result there is a loss in bone mass.
 CLASSIFICATION OF OSTEOPOROSIS

PRIMARY
SECONDARY

idiopathic Drugs Others

Postmenopausal •Glucocorticoids •Nutritional
osteoporosis •Heparin •Multiple myeloma
•Anticonvulsants and maglinancy
Age-related (phenytoin •Osteogenesis
•Immunosuppressants imperfects

Chronic Dx
Endocrine •Renal impairment
•Cushing’s syndrome
•Liver cirrhosis
•Hypogonadism
•Malabsorption
•Thyrotoxicosis
•Chronic inflammatory
•hyperparathyroidism
polyarthropaties
 ::Who is at RisK ??::

Risk factors you cannot change include:

• Gender. Women get osteoporosis more often than men.

• Age. The older you are, the greater your risk of osteoporosis.

• Body size. Small, thin women are at greater risk.

• Ethnicity. White and Asian women are at highest risk. Black and
Hispanic women have a lower risk.

• Family history. Osteoporosis tends to run in families. If a family

member has osteoporosis or breaks a bone, there is a greater
chance that you will too.
Other risk factors are:
• Sex hormones. Low estrogen levels due to missing menstrual periods or to
menopause can cause osteoporosis in women. Low testosterone levels can
bring on osteoporosis in men. [During menopouse,bone loss can range from 4
to 8%]

• Calcium and vitamin D intake. A diet low in calcium and vitamin D makes
you more prone to bone loss. [In Malaysia most people hate drinking milk and
hence increase their probability towards osteoporosis]

• Medication use. Some medicines increase the risk of osteoporosis.

• Too Much acidity in Food. As the blood must be a neutral pH, your body pulls
calcium from the bones to neutralize the acidity. This is often the major factor
in the development of osteoporosis
• Activity level. Lack of exercise or long-term bed rest can cause weak
bones.
• Smoking. Cigarettes are bad for bones, heart, and lungs.
• Drinking alcohol. Too much alcohol can cause bone loss and
broken bones.
• Lack of magnesium may be the cause of osteoporosis.
Calcitonin relies on magnesium to function properly. When we lack
magnesium, the balance between PTH and calcitonin tilts too far toward
PTH. This results in excessive stimulation of osteoclasts, which causes
net bone loss. Magnesium suppresses the hormone that tells your body to
pull calcium from the bones, and stimulates the hormone that tells the
body to put calcium in your bones.
 ::SyMPTOmpS::
Osteoporosis is called the
"silent disease“
because bone is lost with no signs. You
may not know that you have osteoporosis
until a strain, bump, or fall causes a bone
to break.
 ::DiagnosiS::
•Common clinical presentations
Increasing dorsal kyphosis (Dowager’s hump)
Low trauma fracture
Loss of height
Back pain

•Diagnosis
Primary osteoporosis is made after excluding secondary causes of bone loss
BMD measurement with dual energy x-ray absorptiometry (DEXA)
 PREVENTION
1. Enough calcium intake daily; 800-1000 mg,
also other important nutrients; proteins, zinc, mg
& vitamin D for healthy and strong bone
Vitamin D is important in absorption of Ca
from food and incorporate it into bones
1 glass of high Ca milk = 500 mg Ca

2. Bone examination – free during World

Osteoporosis Day – access risk of loss of mass of
bone

3. Exercises but not excessive!!! (3-4 times a week)

Exercise alters hormonal balances, favoring the
hormones that protects bone
So, walk rather than ride,
climb the stairs rather than using lift,
stand rather than sit when appropriate :P
4. Importance of good posture
 Proper way to sit - Support your lower back
with a pillow or by a straight high-backed chair. When
driving or reading, avoid bending the neck
forward. When rising from a chair, do it slowly.
 Proper way to walk and stand - Keep
your head high, look forward with the chin in. Pull your
shoulders back, pull your stomach in to maintain the natural
arch of the lower back, and tighten your buttocks. Wear low-
heeled shoes with rubber soles
 Proper way to lift - You must bend your
knees when lifting heavy objects to avoid backstrain and
further compression fractures. Use your Leg
muscles rather than your back!
5. Avoid taking too much coffee,
tea or chocolate, because they help
in loss of Ca.
6.High protein will reduce the ability of
Ca resorption.
7.Alcohol destroys cells forming bone.
8.Smoking reduces estrogen
• It is important to remember that we cannot
avoid hormonal and genetic factor
thus, we control the environment and
diet factor, so that we can overcome
the osteoporosis problem.
 •Proper nutrition
•Calcium & Vit D supplementation if needed to achieve adequate intakes
•Optimal physical activity
•Healthy social habit
•Fall & trauma prevention

Consider treating without measuring BMD
•Men & women w/ increase risk
+ a fragility fracture
•Men & women taking chronic
systemic corticosteroids
Population appropriate for BMD testing
•All women >65 yo
•Women aged 60-64 y,w/ increased
risk for osteoporotic fracture
•Men at high risk

Hip osteoporosis
T-score< -2.5 T-score< -2.0
Normal BMD
T-score> -1
Treat w/ biophosphonate Spine osteoporosis only
T-score< -2.5 osteopenia
T-score of -1 to -2.5
Biophosphonate Workup for 2o osteoporosis
intolerant •PTH Treatmet options
•TSH •Biphosphonate
Treatment option •25-OH Vit D •Raloxifene
•CBC Monitor DXA every
•Parenteral biophosphonate •calcitonin
•Chemistry panel 1-5 yrs
•Teriparatide
•Raloxifene •Condition-specific tests
•Calcitonin
Treat underlying cause BONE HEALTH THERAPEUTIC ALGORITHM
if present PHARMACOTHERAPY HANDBOOK
 MANAGEMENT OF OSTEOPOROSIS

• Hormone replacement therapy

• Selective Estrogen Receptor Modulators
(SERMs)
• Biphosphonates
• Calcitonin
• Calcium
• Vitamin D
 Hormone replacement therapy (HRT)
• Beneficial in the prevention & tx of postmenopausal osteoporosis

• Estrogens ↓ osteclast recruitment & activity,inhibit PTH peripherally,

↑calcitriol concentrations & intestinal calcium absorption and
decrease renal calcium excretion

• Max benefit to the bone when estrogen is started at menopause and

continued for 10 yrs or more

• Other benefits; relief of vasomotor symptoms, psychological

problems, vaginal dryness and reduction in risk of primary
cardiovascular disease. Emerging potential benefits include a
decreased incidence of colonic cancer, macular degeneration,
prevention and delay in Alzheimer’s Disease and a positive effect on
alveolar dentition
 Effective Bone Protective Doses of Estrogen

Type of estrogen Dose

Conjugated Equine Estrogen 0.625mg

Estradiol Valerate 2.0 mg

Transdermal estradiol 50-100µg

Micronised Estradiol 1mg

Tibolone 2.5mg

• HRT do not prevent primary or secondary CVS disease and may even
increase events within the 1st years of use.
• C/I: undiagnosed vaginal bleeding, severe liver dx & a hx of VTE within
• the past 12 months
 Selcetive Estrogen Receptor Modulators
(SERMs)
Raloxifene
• MOA: affects some of the same receptors that estrogen
does, but not all, and in some instances, it antagonizes
or blocks estrogen

• acts like estrogen to prevent bone loss and has the

potential to block some estrogen effects in the breast
and uterine tissues.

• decreases bone resorption, increasing bone mineral

density and decreasing fracture incidence. decreases
bone resorption, increasing bone mineral density and
decreasing fracture incidence.
• Common s/e: hot flashes and cramps

• Associated w/ a threefold increased risk of VTE,

similar to the risk with estrogen

• should be discontinued at least 72 hours prior to

and during prolonged immobilization (e.g., post-
surgical recovery, prolonged bed rest), and
patients should be advised to avoid prolonged
restrictions of movement during travel because
of the increased risk of venous thromboembolic
events
 Bind to hydroxyapatite in bone and decrease
resorption by inhibiting osteclast adherence to
bone surfaces

common side effects are nausea, GI irritation,

perforation,ulceration and/ or bleeding Risedronate

Biphosphonates
Postmenopasal:
5mg OD or 35 mg
once weekly or one
Alendronate Etidronate 75 mg tablet taken
on 2 consecutive
Dosage: 400mg/day days once a month
Dosage: 5 mg daily for 2 weeks, followed
(prevetion); 10 mg by 13-week period Male: 35 mg once
daily,70mg weekly with no weekly
(treatment) etidronate,then
repeat cycle Glucocorticoid-
induced: 5 mg OD
 Calcitonin
• a polypeptide hormone secreted by the parafollicular cells of the
thyroid gland in mammals and by the ultimobranchial gland of birds
and fish.

• MOA: antagonizes the effects of parathyroid hormone. Directly

inhibits osteoclastic bone resorption; promotes the renal excretion of
calcium, phosphate, sodium, magnesium, and potassium by
decreasing tubular reabsorption; increases the jejunal secretion of
water, sodium, potassium, and chloride

• As a second line tx (reduces fracture risk to a lesser extent than

other osteporosis medications)

• Dosage: injection solution (I.M., S/C): 100 units/every other

day;Intranasal: 200 units (1 spray) in one nostril daily
 Calcium
• Should be ingested in edequate amounts to prevent
hyperparathyroidism and bone destruction

• Combination of calcium & Vit D decreases nonvertebral, vertebral &

hip fractures

• According to NOF;
-Adults under age 50 need 1,000 mg of calcium and 400-800 IU of vitamin D daily.
-Adults 50 and over need 1,200 mg of calcium and 800-1,000 IU of vitamin D
daily.

• best absorbed when taken in amounts of 500 – 600 mg or less

 Vitamin D
•promoting absorption and utilization of calcium and phosphate and for
normal calcification of bone.

•Along with parathyroid hormone and calcitonin, it regulates serum

calcium concentrations by increasing serum calcium and phosphate
concentrations as needed.

•stimulates calcium and phosphate absorption from the small intestine

and mobilizes calcium from bone.

Activated Vitamin D calcitriol

alfacalcidol
• Calcitriol:
-act by binding to a specific receptor in the cytoplasm of the
intestinal mucosa and subsequently being incorporated into the
nucleus, probably leading to formation of the calcium-binding protein
that results in increased absorption of calcium from the intestine
-decreases excessive serum phosphatase levels, parathyroid
hormone levels, and decreases bone resorption
-increases renal tubule phosphate resorption
dosage: Initial: 0.25 mcg/day, range: 0.5-2 mcg once daily

• Alfacalcidol:
-rapidly converted to 1,25-dihydroxycholecalciferol in the liver→most
active form
dosage: Initial: 1 mcg/day. Maintenance: 0.25-1 mcg/day.
 REFERENCES

• Clinical Practice Guidelines on the Maganement of

Osteoporosis 2002
• Drug Information handbook,17th Edition 2008-2009
• Well, G. B., DiPiro, J., T., Schwinghammer, T., L. & Hamilton,
C. W. 2006.Pharmacotherapy Handbook,6th Editon
• National Osteoporosis Foundation
• Johann D. Ringe.Alfacalcidol in Prevention and Treatment of
All Major Forms of Osteoporosis and Renal Osteopathy
• www.drugs.com