..

4. COPD is a multidimensional disease, associated with
different comorbidities &systemic consequences, which
further impair functional status, reduce quality of life, and
increase mortality.
Of these, osteoporosis is increasingly being appreciated
as a major comorbidity in COPD, is often under-diagnosed
& associated with poor health status.

5. The World Health Organization defined osteoporosis as
‘‘a disease characterized by low bone mineral density
(BMD) &micro-architectural deterioration of bone tissue,
leading to enhanced bone fragility and a consequent
increase in fracture risk.’’
Osteoporosis is a silent disease unless it is complicated
by fractures.

6. Patients with osteoporosis are at an increased risk of
fracture, particularly fragility fractures.
Fragility fractures are caused by injury that would be
insufficient to break a normal bone.
Osteoporosis-related fractures are divided into vertebral
fractures (predominantly at the thoracolumbar spine)
and nonvertebral or peripheral fractures, including
hip fractures.

7. The most common type of osteoporosis-induced fracture is
the vertebral compression fractures (VCFs).
Since most cases (About 60–70%) of vertebral compression
fractures remain asymptomatic,
Underdiagnosis of VCFs is a common occurrence , this
leads to the under treatment of osteoporosis, resulting in
its progression.

8. Prevalence of Osteoporosis in COPD
In COPD patients, the prevalence of osteoporosis is about
two- to fivefold higher than that in age-matched subjects
without airflow obstruction .
It has been reported that the prevalence of VCF in COPD
patients is high (24% to 63%), depending on the population
studied. , and is correlated with COPD severity

9. Vertebral compression fractures should be of major
concern in COPD, even when remaining asymptomatic.
Osteoporosis may cause vertebral compression
fractures (VCF) that can deteriorate pulmonary function.
VCFs are associated with back pain and kyphosis.
Kyphosis can cause loss of height, resulting in impaired
lung function.

10. In average for each thoracic vertebral fracture a 9 % fall
in forced vital capacity (FVC) can be expected. , any FVC
decrease implies a FEV1 decrease, aggravating the
airflow reduction in COPD patients in a sort of vicious
circle that could be easily Prevented
Total lung capacity becoming progressively reduced as
the number of vertebral fractures increases.

11. Spine fractures & rib fractures may impair an already
limited respiratory capacity and make maintaining an
effective cough effort more difficult.
Hip fractures may also lead to immobility and trigger a
downward spiral of decreased exercise capacity and
breathlessness.
Osteoporotic fractures in COPD may further decrease the
mobility of the patients, thereby, predisposing them to
the risk of deep venous thrombosis (DVT) & pulmonary
embolism.

12. The presence of COPD in patients with hip fractures carries
a poor prognosis.
A previous fracture is a well-known risk factor for new
vertebral and nonvertebral fractures, indicating that their
diagnosis is important.
Diagnosis & prevention of osteoporosis should be an
important goal in the management of patients with COPD.

13. Risk Factors for Osteoporosis in COPD:
1. Smoking
2. Older age
3. Physical inactivity
4. Increased alcohol intake
5. Vitamin D deficiency
6. Malnutrition
7. low body-mass index (BMI)
8. Treatment with corticosteroids (high doses of inhaled
corticosteroids as well as courses of oral steroids).
9. Hypogonadism (reduced levels of sex hormones)
10. Systemic inflammation

14. COPD itself may be a risk factor for osteoporosis &this
may be related to spillover of inflammatory mediators
from the lung, as a systemic inflammation.
Several inflammatory mediators, including TNF-a, IL-1b
and IL-6 act as stimulants of osteoclasts, which cause
bone resorption

15. Barnes PJ (2010) Chronic Obstructive Pulmonary Disease: Effects beyond the Lungs.
Mechanism linking COPD to systemic manifestations

17. Several studies have shown a very high prevalence of
osteoporosis and low bone mineral density in patients
with COPD, even with milder stages of disease
In a cross-sectional study the prevalence of osteoporosis
was 75% in patients with GOLD stage IV disease & was
strongly correlated with reduced fat-free mass, especially
in women.

18. Predictors of osteoporosis in COPD patients include low
BMI, low fat-free mass index (FFMI), severity of COPD,
and treatment with glucocorticoid therapy, both inhaled
and oral..
Osteoporosis may be more closely associated with
emphysema than other subgroups of COPD.
(Osteoporosis is more often associated with decreased
body mass index and low fat-free mass.)

19. Impact of COPD Exacerbations on Osteoporosis
Exacerbations also cause deterioration in several risk
factors for osteoporosis, such as physical inactivity and
augmentation of systemic inflammation and the use of
systemic corticosteroids during exacerbations may
accelerate BMD loss
Osteoporosis progression should be evaluated in COPD
patients, especially in those with a history of frequent
exacerbations.

23. Diagnostic Imaging of Osteoporosis:
Measurement of BMD by dual-energy x-ray absorptiometry
(DEXA) scan is the gold standard for the diagnosis of
osteoporosis. It is also used to monitor the response to
treatment .
A bone mineral density (BMD) measurement, provides a
very useful estimate of fracture risk.

25. 25

26. Prevention&Treatment of Osteoporosis in COPD Patients
Osteoporosis should be treated according to usual
osteoporosis guidelines.
There is no evidence that osteoporosis should be treated
differently in the presence of COPD.
COPD should be treated as usual, as there is no evidence
that stable COPD should be treated differently in the
presence of osteoporosis

27. Non-pharmacological management
1) Cigarette smoking is a reversible risk factor for osteo-
porosis, and smoking cessation results in the improvement
in BMD.
2) Pulmonary Rehabilitation Programs in moderate to severe
COPD, such as counselling on fall prevention, are useful.
3) A weight-bearing and strengthening exercise performed at
least 3 times per week may be effective for skeletal health
4) In addition, excessive alcohol intake should be avoided.

28. Pharmacological management
Pharmacological interventions consist of calcium and
vitamin D supplementation and anti-resorptive therapy.
Vitamin D and calcium supplementation is an integral part
in the prevention and treatment of osteoporosis.
Combination therapy is the best for fracture prevention.
Vitamin D without calcium supplementation is ineffective
in preventing fractures

29. As a general rule, everyone COPD man with or without
diagnosed osteoporosis should receive calcium
(1000 mg/day) and vitamin D (800 IU/day) as a standard
supplementation, considering that calcium and vitamin D
have been shown to reduce fracture risk in men and women
(target serum level of 25-OHD ≥30 ng/mL)
These supplements should be taken with a meal However,
compliance with supplements is essential, with no long-
lasting benefits once calcium and vitamin D have been
discontinued.

30. Antiresorptive Therapy
Bisphosphonates are the most commonly prescribed drugs
for the prevention and treatment of osteoporosis.
Maximum effect of bisphosphonates becomes obvious in
three to six months, and with continued treatment

31. 31
Flow diagram summarizing risk assessment, diagnosis, and therapy of osteoporosis in COPD

32. Pharmacologic therapy is indicated in the following
conditions:
1) COPD with documented fragility hip or vertebral
fractures,
2) T-score below −2.5 SD
3) T-score −2.5, T-score ,−1 and one major criterion

33. Precautions
Anti-resorptive therapy should be started early during corti-
costeroid treatment as the bone loss starts quite early and
fracture risk is independent of BMD.
Overuse of ICS in COPD must be avoided. ICS use should
be restricted to COPD patients with forced expiratory volume
(FEV1) less than 50% of predicted.

34. Precautions
Unnecessary prolonged use of oral steroids during COPD
exacerbations should be avoided.
A five-day course of oral prednisone (at 40 mg daily) was
similar to conventional 14-day course of prednisone with
regard to re-exacerbation within six months of follow-up.
Therefore, most patients with AEs-COPD can be treated with
a five-day course of prednisone or equivalent (40 mg daily).

35. Monitoring
In otherwise healthy individuals treated for osteoporosis, an
interval of 2 years between DXA scan measurements is
usually recommended.
COPD patients treated with oral corticosteroids develop
osteoporosis at an accelerated pace and is recommended to
have annual repeat DXA scans
It is recommended, therefore, that all COPD patients treated
with oral glucocorticoids should have annual repeat DXA
scans irrespective of the initial DXA scan result.

37. Osteoporosis is a common comorbidity in COPD patients
and is associated with significant morbidity.
An osteoporotic fracture increases the risk of subsequent
fractures
As fractures may further compromise lung function and
decrease mobility,the early identification of osteoporosis
is important to avoid excess physical impairment in COPD .

38. A large fraction of glucocorticoid treated COPD patients
are not being evaluated for osteoporosis and may develop
severe osteoporosis and repeat fractures without being
diagnosed.

39. In fact, more than 50% of patients with COPD have
osteoporosis and a high risk for fracture. "screening for
osteoporosis should be performed even in moderate COPD
patients.“
COPD patients are at increased risk of osteoporosis and
should therefore be evaluated for the condition by DXA
scan.

40. BMD should be measured, either by Dexa or CT, in all
patients with GOLD grade III and IV, particularly in
patients with a low FFM.
The goal is to detect bone loss early and intervene
appropriately to reduce risk of fracture .

41. Osteoporosis is an undertreated entity in COPD patients
as 82% of osteoporotic COPD patients were not prescribed
any specific treatment .
Thus professionals treating COPD patients, especially
medical pulmonologists and general practitioners (GPs),
need to routinely and regularly assess the osteoporosis risk
in patients with COPD .

42. All patients with COPD should be examined & investigated
for co-morbidities, and conversely, patients with any of
the known co-morbidities should be screened for COPD
Early recognition and early intervention should improve
outcomes.

43. Look for
Look for
COPD Comorbidities
If Smoker

44. 44

45. 45