By Siraya KitiyodomBy Siraya Kitiyodom

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BONEBONE

By Siraya KitiyodomBy Siraya Kitiyodom

Management

• Brain symptoms

• Prevalence

• Mood

• Estrogen as an neuromodulator

• Depression

• Vasomotor symptom

• Definition

• Physiology

• Management

• Bone

• Nonhormonal in menopause

• Hormone replacement therapy

Scope

• Definition

• Pathogenesis

• Evaluate & Diagnosis

• Treatment

DefinitionDefinition

• Osteoporosis is defined

as a skeletal disorder

characterized by compromised

bone strength predisposing a

person to an increased risk of

fracture.

• Bone strength primary

reflects the integration of

bone density and quality

NIH Concensus Development Panel an Osteoporosis , 2001

Bone StrengthNIH Consensus Statement 2001

Bone StrengthNIH Consensus Statement 2001

BoneQualityBone

Quality BoneStrength

++++

Architecture and geometryDegree of mineralizationProperties of collagen/mineral matrixDamage accumulation Turnover/ remodeling rate

Architecture and geometryDegree of mineralizationProperties of collagen/mineral matrixDamage accumulation Turnover/ remodeling rate

BoneDensity

NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95

Scope

• Definition

• Pathogenesis

• Evaluate & Diagnosis

• Treatment

Bone BiologyBone Biology

• TYPE OF BONE

Bone can be divided into 2 major types • Cortical

- Outer shell of all bones

- 75% of total bone mass

• Trabecular

- Spongy, open architectural structure

- Most of the volume in bone

- 25% of total bone mass

Larger surface area

Higher turn over rate

Show early bone loss

First respond to therapy

ACOG Practice Bulletin. 2004; NO. 50: 203-216

• Bone mass peaks at approximately age 30 years in both men and women

• After reaching peak bone mass, approximately 0.4% of bone is lost per year in both sexes

• Women lose approximately 2% of cortical bone and 5% of trabecular bone per year for the first 5–8 years after menopause

ACOG Practice Bulletin. 2004; NO. 50: 203-216

Bone BiologyBone Biology

Osteoblast

Bone formation

Osteoclast

Bone resorption

OsteocyteOsteoblast that trap in

matrix

Calcium deficiencyPrimary Vit D deficiencyPrimary 1.25-(OH)2D3

deficiency / resistanceParathyroid hyperplasia

Hormone deficiency(estrogen, testosterone, 1.25 (OH)2D3, GH, IGF)

Muscle strength Sense of balance

Mental status Reflexes Mobility

Secondary

hyperparathyroidism

Low bone mass

Bone strength Tendency to fall

Fractures

OSTEOPOROTIC FRACTUREOSTEOPOROTIC FRACTURE

Type I Type II

Type II

EndocrineEndocrine-Cushing-Thyroid/parathyroid-hypogonadism

DrugDrug -glucocorticoid-heparin, warfarin-phenytoin, phenobarb-CA drug

Systemic diseaseSystemic disease-renal disease-liver disease-malabsorb-rheumatoid-CA

Scope

• Definition

• Pathogenesis

• Evaluate & Diagnosis

• Treatment

Risk factor

• Non modificationNon modification - Age > 65 - asian - early menopause (< 45 year) - small body built - Hx fragility fracture - Family Hx – osteoporosis/osteoporosis Fx

• ModificationModification - low intake calcium - sedentary lifestyle - smoking, alcohol, caffeine - BMI < 19kg/m2 - estrogen deficiency

Evaluate

• Risk assessment of

osteoporosis fracture (FRAX)

• LAB

• Bone strength assessment

• Biochemical marker of

bone turnover

FRAX

Evaluate

• Risk assessment of

osteoporosis fracture (FRAX)

• LAB

• Bone strength assessment

• Biochemical marker of

bone turnover

LAB

• CBC

• Calcium, phosphate, albumin

• Liver function test

• Renal function

• X-ray – Lateral TL spine or AP hip

(suspected fracture)

Evaluate

• Risk assessment of

osteoporosis fracture (FRAX)

• LAB

• Bone strength assessment

• Biochemical marker of

bone turnover

Bone strength assessment

• Plain X-ray (BMD<30%)

• Semi-quantitative method

(high intra & inter observer)

• Bone mass measurement

-> axial dual energy X-ray

absorptiometry (axial DXA)

Bone mass measurement

• IndicationIndication - Age > 65 - Age < 65 - early menopause - estrogen deficiency > 1 yr - on glucocorticoid - BMI < 19 kg/m2 - parent hip Fx history - X-ray find osteopenia/vertebral fracture - fragility fracture - decrease height - screening -> high risk – OSTA score 0.2 X (BW – Age) > -1 low risk < -1 to > -4

moderate risk < -4 high risk

Bone mass measurement

WHO Study Group. Osteoporos Int,1994;4:368-381.

Scope

• Definition

• Pathogenesis

• Evaluate & Diagnosis

• Treatment

NORMAL NORMAL OSTEOPOROSISOSTEOPOROSIS FRACTURESFRACTURES MORTALITY MORTALITY & MORBIDITY& MORBIDITY

“Prevention”“Prevention” “Treatment”“Treatment” “Surgery & Rehabilitation”

“Surgery & Rehabilitation”

Stategy

Prevention

• Strategy to maximize peak bone mass• Strategy to prevent bone loss - weight bearing exercise - life style modification - nutrition – Calcium Daily intake of calcium.

Women < 50 years : 1,000 mg Women > 50 years : > 1,200 mg In dietary ~ 500-600 mg. calcium/day

Calcium supplement Divided dose, with meal, and single dose< 1,000 mg

– Vitamin D (800 iu) - prevent fall

Treatment

• IndicationIndication

- Primary indication

- Menopause – Fragility fracture (vertebrae or hip)

– BMD T score < -2.5

Treatment

• IndicationIndication

- Secondary indication - BMD – 2.5 < T score < -1 with - major fragility Fx e.g. ankle, wrist, pelvis - use glucocorticoid - secondary osteoporosis e.g.

thyrotoxicosis - FRAX (no BMD) 10 yr probability of hip Fx > 3% other Fx > 20% - clinical risk factor - parent Hx hip Fx - Premature menopause - smoking / alcohol

DRUG

• Hormonal

• Bisphosphonate

• Calcitonin

• Parathyroid hormone

• Strontium ranelate

• Vitamin K2

• New drug

www.umich.edu/news/Release/2005/Feb05/bonehtml

Inhibit bone resorptionInhibit bone resorptionHRT HRT Bisphosphonate Bisphosphonate SERM SERM Calcitonin Calcitonin

Stimulate bone formationStimulate bone formationPTH PTH

Strontium ranelateStrontium ranelate

Vitamin kVitamin k22

Effects of Medication on Bone Remodeling

Inhibit bone resorption & Inhibit bone resorption & Stimulate bone formationStimulate bone formation

DRUG

• Hormonal

• Bisphosphonate

• Calcitonin

• Parathyroid hormone

• Strontium ranelate

• Vitamin K2

• New drug

HRT

• Estrogen therapy (ET) - prevention of bone loss and

fractures in postmenopausal women with or without established osteoporosis

- FDA approved only for the prevention of postmenopausal osteoporosis

- reduce vertebral and non vertebral fracture

- effect are exerted through estrogen receptors (present on monocyte lineage and osteoblasts)

- anti bone resorption

THE END