This document provides information on osteoporosis from Dr. Ashutosh. It defines osteoporosis as a reduction in bone strength that increases fracture risk. The WHO defines it as a bone density 2.5 standard deviations below young adults of the same sex. Postmenopausal women with bone density between -1 and -2.5 SD also have increased fracture risk. Non-pharmacological prevention includes nutrition, lifestyle modifications, fall prevention, and hip protectors. Pharmacological management includes calcium and vitamin D supplementation, hormonal therapy, antiresorptive drugs, anabolic drugs, and drugs with dual actions.

1. OSTEOPOROSIS
Presenter: Dr. Ashutosh
Date: 30/04/2018

2. DEFINITION
Osteoporosis is defined as a reduction in the strength of bone that
leads to an increased risk of fractures.
The World Health Organization (WHO) operationally defines
osteoporosis as a bone 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.

4. Postmenopausal women who fall at the lower end of the young
normal range (a T-score <–1.0) are defined as having low bone
density and are also at increased risk of osteoporosis.
Although risk is lower in this group, more than 50% of fractures
among postmenopausal women, including hip fractures, occur in
this group with low bone density, because the number of
individuals in this category is so much larger than that in the
osteoporosis range.
As a result, ongoing attempts to identify individuals within the low
bone density range who are at high risk of fracture should be
made as they might get benefit from pharmacologic intervention.

5. The actual prevalence of osteoporosis remains unknown because
of its asymptomatic nature.
In India it has been presumed that 35% of postmenopausal women
are at the risk of developing osteoporosis.
Osteoporotic bone fractures commonly occur at the vertebrae, hip
and wrist.
On an average a post-menopausal woman has 40% to 50% chance
of developing a fracture including 15% chance of hip fracture in her
lifetime.
More than 10% of hip fracture victims die within one year from
various complications and nearly 50% of the survivors are
incapacitated, some of them permanently.
Epidemiology

7. In women it is 3 times more common than men as
1. Low peak bone mass (PBM)
2. Hormonal changes at menopause

8. Constituents of Bone
Composition
Cells
OsteoclastOsteoblastOsteocyteOsteoprogenitor
Calcium Phosphorus
Inorganic
Mucopolysaccharides
Non Collagenous
Proteins
Collagen
Organic
Matrix

9. CELLS
1.OSTEOCYTES-
Are mononuclearcells in mineralized matrix
Under inf luenceof PTH, participate in bone resorption and
calcium ion transport.
2.OSTEOBLASTS-
Mesenchymal cells derived from marrow stromal cells.
Responsible for mineralization of bone matrix.
Resonsible forsecretion of type 1 collagen and large numberof
non collagenous bone proteins.

10. 3.OSTEOCLASTS-
Exclusively bone resorbing cells.
Appearat sitesof high bone turnover.
Contain characteristic TRAP(tartrate resistant acid phosohatase)
and carbonicanhydrase.

11. Mainlyconsists of collagenousand non collagenous matrix-
A.TYPE 1 COLLAGEN-
Forms a scaffold on which mineralization occurs.
Produced byosteoblasts.
Makes upto 80% of unmineralized bone matrix.
Matrix
B. NON COLLAGENOUS PROTEINS-
Osteopontin, osteonectin, osteocalcin, alkaline phosphate
Function is regulationof bone cells and matrix
mineralisation.

12. C.BONE MORPHOGENIC PROTEINS-
A collection of growth factor proteins.
Important in inducing differentiationof progenitorcells.
Used in treatment of bone defects, non unions , delayed unions.

13. Pathophysiology
1. Peak Bone Mass
2. Bone Remodeling

14. 1.Peak bone mass & Osteoporosis
Peak bone mass is the maximum massof boneachieved byan
individual at skeletal maturity, typically between ages 25 and 35
Afterpeak bone mass is attained, both men and women lose
bone massoverthe remainderof their lifetimes
Becauseof the subsequent bone loss, peak bone mass is an
important factor in thedevelopmentof osteoporosis
13

15. Determinants Of Peak Bone Mass
Peak Bone Mass
Physical activity Gonadal status
Nutritional statusGenetic factors

16. Peak Bone Mass in Women
10 20 30 40 50 60
•Women achieve lesserpeak bone mass than men
15

17. 2.BONE MODELING AND REMODELING
MODELLING- During growth, the skeleton increases in size by
linear growth and by apposition of new bone tissue on the outer
surfaces of the cortex.
REMODELLING- It is a cellular process of bone activity by which
both cortical and cancellous bone are maintained.

18. Osteoporosis results a from bone loss due to age related changes
in bone remodelling as well as extrinsic and intrinsic factors that
exagerate this process.
Bone remodelling has two main functions-
1.to repair micro damage within skeleton to maintain skeletal
strength.
2.To supply calcium to maintain serum calcium levels.
Bone remodeling is also regulated by several circulating hormones,
including
estrogens, androgens, vitamin D, and parathyroid hormone (PTH),
as well as locally produced growth factors such as IGF-I and
immunoreactive growth hormone II (IGH-II), transforming growth
factor β (TGF-β), parathyroid hormone–related peptide (PTHrP),
interleukins (ILs), prostaglandins, and members of the tumor
necrosis factor (TNF) superfamily.

19. RANK – RANKL receptor pathway for bone remodeling
RANK L( receptor activated nuclear factor kappa ligand)-
the cytokine responsible for communication between osteoblasts
and other marrow cells and osteoclasts.
Secreted by osteoblats and certain cells of immune system.
RANK- receptor present on osteoclast.
Activation of RANK by RANKL is final common pathway for
osteoclast differentiation and functioning.
Osteoprotegerin is humoral decoy for RANK secreted by
osteoblasts.

20. Estrogens are pivotal in modulating secretion of osteoprotegerin
(OPG) and perhaps also RANKL.
In young adults, resorbed bone is replaced by an equal amount of
new bone tissue. Thus, the mass of the skeleton remains
constant after peak bone mass is achieved in adulthood.
After age 30–45, however, the resorption and formation
processes become imbalanced, and resorption exceeds
formation.
This imbalance may begin at different ages and varies at different
skeletal sites; it becomes exaggerated in women after
menopause.
Excessive bone loss can be due to an increase in osteoclastic
activity and/or a decrease in osteoblastic activity.

24. Hormones & Growth factors regulating bone formation
Factor Target cells & tissue Effect
Interleukins
(IL-l, IL-3, lL-6, IL-ll)
Bone marrow, osteoclasts Stimulate osteoclast
formation & resorption
Tumor necrosis factor
(TNF-a) ;
Granulocyte macrophage
stimulating factor
(GM-CSF)
Osteoclasts Stimulates bone resorption
Leukemic inhibitory Factor Osteoblasts, osteoclasts Stimulates osteoblast and
Osteoclast formation in
marrow

25. Factor Target cells Effect
Parathyroid Hormone
(PTH)
Kidney & Bone Stimulate production of Vit-D &
helps resorption of calcium
Calcitonin Bone osteoclasts Inhibits resorptive action of
osteoclasts: lowers
circulating Calcium.
Calcitriol Bone Osteoblasts -Stimulates collagen, osteopontin,
(1.25-dihydroxy vit-D3) osteocalcin synthesis;
Bone Osteoclasts, -stimulates cell differentiation;
Kidney, -Stimulates Calcium retention
Intestine -Stimulates calcium absorption
Estrogen Bone Stimulates formation of calcitonin
receptors, inhibiting resorption,;
Stimulate bone formation
Testosterone Muscle, Bone Muscle growth, placing stress on
bone to stimulate bone formation
Prostaglandins Osteoclasts Stimulate resorption and bone
formation
Bone
Morphogenic
protein
Mesenchyme Stimulate cartilage protein & bone
matrix formation; replication

26. Clinically, osteoporosis has been classified into two categories

28. Patients with osteoporosis are asymptomatic until a fracture occurs.
Osteoporotic spinal fracture may present with acute back pain or
gradual onset of height loss and kyphosis with chronic pain.
The pain of acute vertebral fracture can occasionally radiate to the
anterior chest or abdominal wall and be mistaken for a myocardial
infarction or intra-abdominal pathology, but worsening of pain by
movement and local tenderness both suggest vertebral fracture.
Peripheral osteoporotic fractures present with local pain,tenderness
and deformity, often after an episode of minimal trauma.
In patients with hip fracture, the affected leg is shortened and
externally rotated.
Many patients present with incidental osteopenia on an X-ray
performed for other reasons.
Clinical Features

29. Diagnosis

30. WORK UP FOR SECONDARY OSTEOPOROSIS
ROUTINE LABORATORY EVALUATION
A general evaluation that includes complete blood count, serum and 24-
h urine calcium, renal and hepatic function tests, and a 25(OH)D level is
useful for identifying selected secondary causes of low bone mass,
particularly for women with fractures or very low T-scores.
An elevated serum calcium level suggests hyperparathyroidism or
malignancy, whereas a reduced serum calcium level may reflect
malnutrition and osteomalacia.
In the presence of hypercalcemia, a serum PTH level differentiates
between hyperparathyroidism (PTH↑) and malignancy (PTH↓), and a
high PTHrP level can help document the presence of humoral
hypercalcemia of malignancy.

31. A low urine calcium(<50 mg/24 h) suggests osteomalacia, malnutrition,
or malabsorption; a high urine calcium (>300 mg/24 h) is indicative of
hypercalciuria and must be investigated further.
Hypercalciuria occurs primarily in three situations:
(1) a renal calcium leak, which is more common in males with
osteoporosis;
(2) absorptive hypercalciuria, which can be idiopathic or associated with
increased 1,25(OH)2D in granulomatous disease; or
(3) hematologic malignancies or conditions associated with excessive
bone turnover such as Paget’s disease, hyperparathyroidism, and
hyperthyroidism.

32. Imaging

33. X-
rayPost menopausal osteoporosis :Trabecular resorption and cortical
resorption
Senile osteoporosis: Endosteal resorption
Hyperparathyroidism: Sub periosteal resorption
Note:
Osteoporosis produces increased radiolucency of vertebral bone.
Approximately 30 to 80 per cent of bone tissue must be lost before a
recognizable abnormality can be detected on spinal radiographs.

34. INDICATIONS FOR VERTEBRAL IMAGING
•In all women age 70 and older and all men age 80 and older if
bone mineral density (BMD) T-score is –1.0 or below
• In women age 65–69 and men age 75–79 if BMD T-score is –1.5
or below
• In postmenopausal women age 50–64 and men age 50–69 with
specific risk factors:
o Low-trauma fracture
o Historical height loss of 1.5 in. or more (4 cm)
o Prospective height loss of 0.8 in. or more (2 cm)
o Recent or ongoing long-term glucocorticoid treatment

35. CONVENTIONAL RADIOGRAPHY
LS SPINE-
 Generalized osteopenia
 Thining and accentuation of cortex
 Accentuation of primary trabeculae and thinning of secondary
trabaculae.
 Vertically striated appearance vertebral body.

36. KLEER KOPER score
Osteoporosis produces increased radiolucency of vertebral bone.
Approximately 30 to 80 per cent of bone tissue must be lost before a
recognizable abnormality can be detected on spinal radiographs.
Lesions less than 2cm may escape detection.

37. Disadvantages-
 Subjective
 Affected by body habitus , exposure, positioning.
 >30% bone loss should be present.

38. BONE MINERAL DENSITY

39. INDICATIONS FOR BMD TESTING
• Women age 65 and older and men age 70 and older, regardless
of clinical risk factors
• Younger postmenopausal women, women in the menopausal
transition and men age 50–69 with clinical risk factors for fracture
• Adults who have a fracture after age 50
• Adults with a condition (e.g., rheumatoid arthritis) or taking a
medication (e.g., glucocorticoids in a daily dose ≥5 mg prednisone
or equivalent for ≥3 months) associated with low bone mass or
bone loss

40. Sites of measurement are the spine, the hip, calcaneum
and the wrists.

41. DEXA SCAN
 Commercially introduced in 1987.
 Principle – 2 x ray of 70Kvand 140kvare fired on siteof
measurementwith lag time 0f 4ms.
 Detectordetectsaccentuationof 2 beams.
 Data is fed intocomputerpowered with complex
algorithm and calculates BMD.
 SITES-
 Central dexa- lumbarspine, hip.
 Peripheral dexa- forearm , calcaneum.

42.  BMD within 1.0 SD – Normal
 BMD between 1.0 and 2.5 SD – Osteopaenia
 BMD below 2.5 SD or more – Osteoporosis
 BMD beyond 2.5 SD with one or – Severe osteoporosis
more fragility fractures

43. Contraindications-
 Pregnancy.
 Recent administration of contrast agent, nuclear medicine scan.
 Radiopaque implant in measurement area.
 Marked obesity.

44. BONE TURN OVER MARKERS

45. BIOCHEMICAL MARKERS OF BONE
TURNOVER
1.Predict the risk of fracture independently of bone
density in untreated patients
2.Predict rapidity of bone loss in untreated patients
3.Predict extent of fracture risk reduction when repeated after 3-6
months of treatment with FDAapproved therapies
4.Predict magnitude of increase in BMD with FDA approved
therapies

46. WHO FRAX SCORING TOOL
 A web based algorithm designed to calculate the 10 year
probability of major osteoporosis related fracture based on clinical
risk factors and BMD.
 Results evaluated are given in % of risk of patient developing
fracture in next 10 years.

47. FRAX

48.  Following assessment of fracture risk using FRAX, the patient
can be classified as:
 Low risk – reassure, give lifestyle advice and reassess in
≤5 years depending on the clinical context.
 Intermediate risk - measure BMD and recalculate the fracture
risk to determine whether the individual's risk
lies above or below the intervention threshold.
–
 High risk - can be considered for treatment without the need for
BMD, although BMD measurement may sometimes
be appropriate, particularly in younger
postmenopausal women.

49. BONE BIOPSY
Tetracycline labeling of the skeleton allows determination of the
rate of remodeling as well as evaluation for other metabolic bone
diseases.
The current use of BMD tests, in combination with hormonal
evaluation and biochemical markers of bone remodeling, has
largely replaced the clinical use of bone biopsy, although it
remains an important tool in clinical research and assessment of
mechanism of action of medication for osteoporosis.

50. MANAGEMENT

51. Who should be considered for treatment?
Postmenopausal women and men age 50 and older
presenting with the following should be considered-
 A hip or vertebral fracture (clinically apparent or found on vertebral
imaging).
 T-score ≤−2.5 at the femoral neck, total hip, or lumbar spine.
 Low bone mass (T-score between −1.0 and −2.5 at the femoral
neck or lumbar spine)
 a 10-year probability of a hip fracture ≥3 % or a 10-year probability
of a major osteoporosis-related fracture ≥20 %(by FRAX score).

52. 1.NON PHARMACOLOGICAL – PREVENTION OF OSTEOPOROSIS AND
OSTEOPOROTIC FARCTURE.
A. NUTRITION
B. LIFE STYLE MODIFICATIONS
C. PREVENTION OF FALL
D. HIP PROTECTORS
2. BASIC THERAUPETIC MEASURES
A. VIT D AND CALCIUM SUPPLEMENTATION
B. ESTEROGEN AND HRT
3.ANTI RESORBTIVE AGENTS
A. CALCITONIN
B. BISPHOSHPHANTES
C. SERM
D. DONESUMAB
4. DRUGS STIMULATE BONE FORMATION
A. SODIUM FLOURIDE
B. EXOGENOUS PTH
C. VIT D ANALOGUES
5. DRUGS WITH DUAL ACTION
STRONTIUM RANELATE

53. 1.NonPharmacologicTreatment
A. Diet changes/Nutriton :
For all individual, a well balanced diet with
adequate calcium and vitamin D is essential
for healthy bone.
Calcium contributor - Dairy products like
milk, yogurt, cheese, ice cream, cottage
cheese, and fortified orange juice or soy
products. Certain cereals, waffles, snacks,
juices, and crackers. Green leafy vegetables
and nuts, particularly almonds, are also
sources of calcium
Most vitamin D comes from sun induced skin
conversion
Vitamin D contributors - fatty fish, few
unfortified foods.

54. Other nutrients such as salt, high animal protein intakes, and
caffeine may have modest effects on calcium excretion or
absorption.
Adequate vitamin K status is required for optimal carboxylation of
osteocalcin. States in which vitamin K nutrition or metabolism is
impaired, such as with long-term warfarin therapy, have been
associated with reduced bone mass.
Although dark green leafy vegetables such as spinach and kale
contain a fair amount of calcium, the high oxalate content reduces
absorption of this calcium (but does not inhibit absorption of
calcium from other food eaten simultaneously).

55. Magnesium is abundant in foods, and magnesium deficiency is
quite rare in the absence of a serious chronic disease.
Magnesium supplementation may be warranted in patients with
inflammatory bowel disease, celiac disease, chemotherapy,
severe diarrhea, malnutrition, or alcoholism.
Dietary phytoestrogens, which are derived primarily from soy
products and legumes (e.g., garbanzo beans[chickpeas] and
lentils), exert some estrogenic activity but are insufficiently potent
to justify their use in place of a pharmacologic agent in the
treatment of osteoporosis.

56. B. LIFESTYLE MODIFICATIONS-
a.Physical activity-weight bearing and muscle strengthing
exercises.
Exercise improves bone strength by 30%to 50%.
Exercise should be life long.
b. Cessation of smoking,alcohol,high caffeine intake.
c. Adequate sunexposure

57. C. Prevention of falls
a. Exercises like balance training, lower limb strengthing exercises
b. Correction of sensory impairment like correction of low vision and
hearing impairments
c. Reduce environmental hazards
d. Appropriate reduction of medications
e. Education of individual in behavior strategies

58. D. HIP PROTECTORS-
PREVENT DIRECT IMPACT ON PELVIS.
1.Energyabsorption type
2.Energyshunting types
3.Crash helmet type
4.Airbag type

59. 2. PHARMACOLOGICAL PREVENTION
OF OSTEOPOROSIS

60. Pharmacologic therapy
 All patients being considered for treatmentof
osteoporosisshould also be counseled on risk factor
reduction including the importanceof calcium,
vitamin D, and exerciseas partof any treatment
program forosteoporosis.
 Prior to initiating treatment, patients should be
evaluated forsecondarycausesof osteoporosisand
have BMD measurements bycentral DXA, when
available, and vertebral imaging studieswhen
appropriate.
 Biochemical marker levelsshould be obtained if
monitoring of treatmenteffects is planned.

61. VIT D
recommended daily intakes of
200 IU for adults <50 years of age,
400 IU for those 50–70 years, and
600 IU for those >70 years.
 Treatment of vitamin D deficiency-
Adults should be treated with 50,000 IU once a week or the
equivalent daily dose (7000 IU vitamin D2 or vitamin D3) for8–12
weeks to achieve a 25(OH)D blood level of approximately 30 ng/ml.
This regimen should be followed by maintenance therapy of 1500–
2000 IU/day.
The Institute of Medicine report suggests that it is safe to take up to
4000 IU/d.

63. Estrogens
A large body of clinical trial data indicates that various types of
estrogens (conjugated equine estrogens, estradiol, estrone,esterified
estrogens, ethinyl estradiol, and mestranol) reduce bone turnover,
prevent bone loss, and induce small increases in bone mass of the
spine, hip, and total body.
Dose of Estrogen:
For oral estrogens, the standard recommended doses have been
0.3 mg/d for esterified estrogens,
0.625 mg/d for conjugated equine estrogens, and
5 μg/d for ethinyl estradiol.
For transdermal estrogen, the commonly used dose supplies 50 μg
estradiol per day, but a lower dose may be appropriate for some
individuals.

64. Epidemiologic databases indicate that women who take estrogen
replacement have a 50% reduction, on average, of osteoporotic
fractures, including hip fractures.
The beneficial effect of estrogen is greatest among those who start
replacement early and continue the treatment; the benefit declines
after discontinuation to the extent that there is no residual protective
effect against fracture by 10 years after discontinuation.
WHI(Women’s Health Initiative) showed that combined estrogen-progestin
treatment increases risk of fatal and nonfatal myocardial infarction by ~29%,
confirming data from the HERS(Heart and Estrogen-Progestin Replacement study)
study.
Other important relative risks included a 40% increase in stroke, increase risk of
venous thromboembolic disease, and a 26% increase in risk of
breast cancer.
Subsequent analyses have confirmed the increased risk of stroke and, in a
substudy, showed a twofold increase in dementia. Benefits other than the
fracture reductions, includes a 37% reduction in the risk of colon cancer.

65. Nonetheless, there is reluctance among women to use
estrogen/hormone therapy, and the U.S. Preventive Services task Force
has specifically suggested that estrogen/hormone therapy not be used
for disease prevention.

66. SERMs (Selective Estrogen Receptor Modulator)
Two SERMs are used currently in postmenopausal women:
Raloxifene (Ceost/Ronal 60mg) which is approved for the
prevention and treatment of osteoporosis as well as the prevention
of breast cancer, and
Tamoxifen, (Entax/Valedox 10mg)
which is approved for the prevention and treatment of breast cancer
A third SERM, bazedoxifene, has been complexed with conjugated
estrogen, creating a tissue selective estrogen complex (TSEC).
This agent has been approved for prevention of osteoporosis.

67. Tamoxifen reduces bone turnover and bone loss in
postmenopausal women compared with placebo groups.
There are limited data on the effect of tamoxifen on fracture
risk, but the Breast Cancer Prevention Study indicated a possible
reduction in clinical vertebral, hip, and Colles’ fractures.
The major benefit of tamoxifen is on breast cancer occurrence.
Tamoxifen increases the risk of uterine cancer and increases
risk of venous thrombosis, cataracts, and possibly stroke in
postmenopausal women, limiting its use for breast cancer
prevention in women at low or moderate risk.

68. Raloxifene (60 mg/d) has effects on bone turnover and bone mass that are very
similar to those of tamoxifen, indicating that this agent is also estrogenic on the
skeleton.
The effect of raloxifene on bone density is somewhat less than that seen with
standard doses of estrogens.
Raloxifene reduces the occurrence of vertebral fracture by 30–50%, but
reduction of other site fracture is still doubtful
Raloxifene, like tamoxifen and estrogen, has effects in other organ systems.
The most beneficial effect appears to be a reduction in invasive breast cancer
(mainly decreased ER-positive) occurrence.
In a head-to-head study, raloxifene was as effective as tamoxifen in preventing
breast cancer in high-risk women, and raloxifene is now FDA approved for this
indication.
In a further study, raloxifene had no effect on heart disease in women with
increased risk for this outcome. In contrast to tamoxifen, raloxifene is not
associated with an increase in the risk of uterine cancer or benign uterine
disease.

69. Raloxifene increases the occurrence of hot flashes but reduces
serum total and low-density lipoprotein cholesterol, lipoprotein(a),
and fibrinogen.
Raloxifene increases the risk of deep vein thrombosis and may increase
the risk of death from stroke among older women.
Consequently, it is not usually recommended for women over 70 years
of age.
The main advantage of the bazedoxifene/conjugated estrogen
compound is that the bazedoxifene protects uterine tissue from the
effects of estrogen and makes it possible to avoid taking a progestin,
while using an estrogen primarily for control of menopausal symptoms.
The TSEC (tissue selective estrogen complex) prevents bone loss
somewhat more potently than raloxifene alone and appears safe for the
breast.

70. Bisphosphonates
MODE OF ACTION
Bisphosphonates are structurally related to pyrophosphates,
compounds that are incorporated into bone matrix.
Bisphosphonates specifically impair osteoclast function and reduce
osteoclast number, in part by inducing apoptosis.
Recent evidence suggests that the nitrogen-containing
bisphosphonates also inhibit protein prenylation, one of the end
products in the mevalonic acid pathway, by inhibiting the enzyme
farnesyl pyrophosphate synthase.
This effect disrupts intracellular protein trafficking and ultimately
may lead to apoptosis.

71. Bisphosphonates
Alendronate, risedronate, ibandronate, and zoledronic
acid are approved for the prevention and treatment of
Postmenopausal osteoporosis.
Alendronate, risedronate, and zoledronic acid are also approved
for the treatment of steroid-induced osteoporosis,
and risedronate and zoledronic acid are approved for prevention
of steroid-induced osteoporosis.
Alendronate, risedronate, and zoledronic acid are approved for
treatment of osteoporosis in men.

72. Alendronate- (Alendrate/Osteofos/Alenost 70mg)
Trials comparing once-weekly alendronate, 70 mg, with daily 10-mg dosing have
shown equivalence with regard to bone mass and bone turnover responses.
Consequently, once-weekly therapy generally is preferred because of the low
incidence of gastrointestinal side effects and ease of administration.
Alendronate should be given with a full glass of water before breakfast, because
bisphosphonates are poorly absorbed.
Because of the potential for esophageal irritation, alendronate is contraindicated
in patients who have stricture or inadequate emptying of the esophagus.
It is recommended that patients remain upright for at least 30 min after taking
the medication to avoid esophageal irritation.
 prevention -5 mg daily and 35 mg weekly tablets.
 treatment -10 mg daily tablet, 70 mg weekly tablet,
Alendronate is also used in treatment of osteoporosis in men and women taking
glucocorticoids.

73. Etidronate (Etifem 200mg) was the first bisphosphonate to be
approved, initially
for use in Paget’s disease and hypercalcemia.
This agent has also been used in osteoporosis trials of smaller
magnitude than those performed for alendronate and risedronate
but is not approved by the FDA for treatment of osteoporosis.
Etidronate probably has some efficacy against vertebral fracture
when given as an intermittent cyclical regimen (2 weeks on, 2.5
months off).

74. Ibandronate(Bonerise/Iban plus 150mg)-
Ibandronate is the third amino-bisphosphonate approved in the United
States.
Ibandronate (2.5 mg/d) has been shown in clinical trials to reduce
vertebral fracture risk by ~40% but with no overall effect on
nonvertebral fractures.
In clinical trials, ibandronate doses of 150 mg/month PO or 3 mg
every 3 months IV had greater effects on turnover and bone mass than
did 2.5 mg/d.
Patients should take oral ibandronate in the same way as other
bisphosphonates, but with 1 hr elapsing before other food or drink
(other than plain water).
Risedronate(Risofos/Gemfos 35 & 150mg)-
prevention and treatment -5 mg daily tablet; 35 mg weekly tablet ,150
mg monthly tablet.

75. Zoledronic acid (Zoledron/Zoldria 4mg inj)
Zoledronic acid is a potent bisphosphonate with a unique
administration regimen (5 mg by slow IV infusion annually).
It is highly effective in fracture risk reduction.
In the treated population, there was an increased risk of transient
postdose symptoms (acute-phase reaction) manifested by fever,
arthralgia, myalgias, and headache. The symptoms usually last less
than 48 h.
An increased risk of atrial fibrillation and transient but not permanent
reduction in renal function was seen in comparison to placebo.
Detailed evaluation of all bisphosphonates failed to confirm that these
agents increased the risk of atrial fibrillation.

76. Drug administration-
Zoledronic acid, 5 mg in 100 ml is given by intravenous Infusion
over at least 15 min.
Patients should be well hydrated and may be pre- treated
with acetaminophen to reduce the risk of an acute phase reaction
(arthralgia, headache, myalgia, fever).

77. Drug safety
Side effects for all oral bisphosphonates gastrointestinal problems
such as difficulty swallowing and oesophagitis and gastritis.
All bisphosphonates are contraindicated in patients with estimated
GFR below 30–35 ml/min.
osteonecrosis of the jaw (ONJ) can occur with long- term use of
bisphosphonates (>5year).
Although rare, low-trauma atypical femur fractures may be
associated with the long-term use of bisphosphonates (e.g., >5
years of use).

78. Calcitonin (Unicalcin 100 IU inj)
Calcitonin is a polypeptide hormone produced by the thyroid gland
MODE OF ACTION
Calcitonin suppresses osteoclast activity by direct action on the
osteoclast calcitonin receptor.
Osteoclasts exposed to calcitonin cannot maintain their active
ruffled border, which normally maintains close contact with
underlying bone.
Treatment of osteoporosis in women who are at least 5 years
postmenopausal when alternative treatments are not suitable.
 200 IU delivered as a single daily intranasal spray/i.m./s.c.
 Intranasal calcitonin can cause rhinitis, epistaxis, and allergic
reactions.
 Very small increase in the risk of certain cancers.

79. Calcitonin preparations are approved by the FDA for Paget’s disease,
hypercalcemia, and osteoporosis in women >5 years post menopause.
Concerns have been raised about an increase in the incidence of
cancer associated with calcitonin use.
Initially, the cancer noted was of the prostate, but an analysis of all
data suggested a more general increase in cancer risk.
In Europe, the European Medicines Agency (EMA) has removed the
osteoporosis indication, and an FDA Advisory Committee has voted for
a similar change in the United States.
Injectable calcitonin produces small increments in bone mass of the
lumbar spine.
However, difficulty of administration and frequent reactions, including
nausea and facial flushing, make general use limited.
Calcitonin is not indicated for prevention of osteoporosis and is not
sufficiently potent to prevent bone loss in early postmenopausal women.

80. DENOSUMAB [RANKL INHIBITOR]-
(Prolia 60mg)
Dose- 60mg/6months S.C
Denosumab was approved by the FDA in 2010 for the treatment
of postmenopausal women who have a high risk for osteoporotic
fractures, including those with a history of fracture or multiple risk
factors for fracture, and those who have failed or are intolerant to
other osteoporosis therapy.
Denosumab is also approved for the treatment of osteoporosis in
men at high risk, men with prostate cancer on GnRH agonist
therapy, and women with breast cancer on aromatase inhibitor
therapy..

81. MODE OF ACTION
Denosumab is a fully human monoclonal antibody to RANKL, the final
common effector of osteoclast formation, activity, and survival.
Denosumab binds to RANKL, inhibiting its ability to initiate formation of
mature osteoclasts from osteoclast precursors and to bring mature
osteoclasts to the bone surface and initiate bone resorption.
Denosumab also plays a role in reducing the survival of the osteoclast.
Through these actions on the osteoclast, denosumab induces potent
antiresorptive action, as assessed biochemically and histomorphometrically,
and may contribute to the occurrence of osteonecrosis of the jaw (ONJ).
Atypical femur fractures have also been noted.
Serious adverse reactions include hypocalcemia, skin infections (usually
cellulitis of the lower extremity), and dermatologic reactions such as
dermatitis rashes, and eczema.
The effects of denosumab are rapidly reversible.
If it is stopped, bone will be lost rapidly if another agent is not used.

82. PTH, teriparatide (Bonemax/Bonotide)
Endogenous PTH is an 84-amino-acid peptide that is largely
responsible for calcium homeostasis
Although chronic elevation of PTH, as occurs in
hyperparathyroidism, is associated with bone loss (particularly
cortical bone), PTH when given exogenously as a daily injection
exerts anabolic effects on bone.
Teriparatide (1-34hPTH) is approved for the treatment of
osteoporosis in both men and women at high risk for fracture.
It is also approved for treatment in men and women at high risk of
fracture with osteoporosis associated with sustained systemic
glucocorticoid therapy.

83. MODE OF ACTION
Exogenously administered PTH appears to have direct actions on
osteoblast activity, with biochemical and histomorphometric evidence of
de novo bone formation early in response to PTH, before activation of
bone resorption.
Subsequently, PTH activates bone remodeling but still appears to favor
bone formation over bone resorption.
PTH stimulates Wnt signaling, IGF-I, and collagen production and
appears to increase osteoblast number by stimulating replication,
enhancing osteoblast recruitment, and inhibiting apoptosis.
Unlike all other treatments, PTH produces a true increase in bone
tissue and an apparent restoration of bone microarchitecture

84.  DOSE-20 μg daily subcutaneous injection
 Duration not to exceed 18 to 24 months.
When treatment is stopped, bone loss can be rapid and alternative
agents should be considered to maintain BMD.
It is best administered as monotherapy and followed by an
antiresorptive agent such as a bisphosphonate.
 SIDE EFFECTS- leg cramps, nausea, and dizziness, increase risk
of osteosarcoma

85. Fluoride (D flour/ Fluoritop)
Fluoride has been available for many years and is a potent
stimulator of osteoprogenitor cells when studied in vitro.
It has been used in multiple osteoporosis studies with conflicting
results, in part because of the use of varying doses and
preparations.
Despite increments in bone mass of up to 10%, there are no
consistent effects of fluoride on vertebral or nonvertebral fracture;
the latter may actually increase when high doses of fluoride are
used.

86. Strontium Ranelate (Stronat granules 2gm)
Strontium ranelate is approved in several European countries for the
treatment of osteoporosis.
It increases bone mass throughout the skeleton; in clinical trials, the
drug found to reduced the risk of fractures.
It appears to be modestly antiresorptive while at the same time not
causing as much of a decrease in bone formation
Strontium is incorporated into hydroxyapatite, replacing calcium, a
feature that might explain some of its fracture benefits.
Small increased risks of venous thrombosis, sometimes severe
dermatologic reactions, seizures, and abnormal cognition is seen.
An increase in risk of cardiovascular disease has also been associated
with use of strontium, such that the EMA has restricted its use at

87. Other Potential Anabolic Agents
Several small studies of growth hormone (GH), alone or in combination with
other agents, have not shown consistent or substantial positive effects on
skeletal mass.
Many of these studies have been relatively short term, and the effects of GH,
growth hormone–releasing hormone, and the IGFsare still under investigation.
Anabolic steroids, mostly derivatives of testosterone, act primarily as
antiresorptive agents to reduce bone turnover but also may stimulate
osteoblastic activity.
Effects on bone mass remain unclear but appear weak in general, and use is
limited by masculinizing side effects.
Several observational studies suggested that the statin drugs, used to treat
hypercholesterolemia, may be associated with increased bone mass and
reduced fractures, but conclusions from clinical trials have been largely
negative.
Early studies with sclerostin antibodies, which inhibit sclerostin, activate
Wnt, and might be highly anabolic to bone, are under development.
Odanacatib is a mixed antiresorptive, partial bone formation stimulator
that is currently in the late stages of development.

88. Duration of therapy and monitoring response
Oral bisphosphonates are usually given on a long-term basis for
osteoporosis with periodic review of the continued need for therapy at 5-
yearly intervals.
Alendronate and risedronate appear to be safe and effective for up to 10
years in most patients.
Studies with intravenous zoledronic acid have shown that 3 years’
treatment give equal protection from fractures as 6 years’ treatment.
Other drug treatments, such as HRT, raloxifene and denosumab, need
to be given continuously for a beneficial effect.
The optimal duration of treatment for strontium has not been
established.
For anabolic drugs such as PTH, a 2-year course of treatment is given
and followed by long-term antiresorptive therapy.

89. PREVENTATION TREATMENT
Calcium 500mg to 1500 mg 1000 to 1500
Vit – D 400IU 400IU – 800IU
Bi phosphonates
1. Alendronate 5mg/day 10mg/day
2. Ibandronate - 150mg/month
3. Rsidronate - 5mg/day
4. Zolendronic acid 5mg/2 year 5mg/ 1 year
SERMS
Rolaxifen 5mg/day 10mg/day
Calcitonin 200 IU 200IU
Parathyroid harmone 20ug/d 20-40ug/d
Donesumab - 60mg/6 months

90. Role of Orthopaedicians &surgical
management
The goals of surgical treatment of osteoporotic fractures include
 rapid mobilization and return to normal function and activities
 Avoid too much manipulations
 Progressive physio therapy

91. Recent in Osteoporosis treatment
1. Romosozumab
Canonical Wnt signaling plays a pivotal role in maintaining bone
homeostasis by enhancing osteoblastic bone formation and
inhibits bone resorption via direct and indirect mechanisms.
Although Wnt signaling affects almost all types of cells, Wnt–β-
catenin signaling in bone is controlled by sclerostin, a glycoprotein
selectively secreted from osteocytes.
Sclerostin is an inhibitor of Wnt signaling and potently inhibits bone
formation.
Romosozumab is a humanized monoclonal antibody against
sclerostin. Romosozumab is under clinical development, and
a phase 3 study demonstrated that romosozumab was shown to
markedly increase the BMD of lumbar spine by 13.3% and
proximal femur by 6.8% in just 12 months and prevent vertebral
and clinical fractures in postmenopausal women with
Osteoporosis.

92. 2. Abaloparatide
Abaloparatide is a synthetic analog of the 34 N-terminal amino acid region of
PTH-related protein (PTHrP).
PTH and PTHrP bind to the same PTH1 receptor through their N-terminal
portions.
PTHR1 can take two conformations, R(0) and RG; R(0) binding results in
prolonged signaling, whereas RG binding causes more transient
responses.
Abaloparatide binds more preferably to the RG conformation and is shown to
cause a more transient response than does teriparatide.
The more transient action of abaloparatide via binding to the RG conformation
of PTHR1 appears to favor the anabolic effect of abaloparatide with fewer bone
resorptive effects.
Abaloparatide is currently under development and is in phase 3 clinical study
and was shown to increase BMD and reduce vertebral and non-vertebral
fractures in postmenopausal women with osteoporosis over 18 months.
The effects of abaloparatide on the increase in BMD of lumbar spine and
proximal femur were shown to be greater than those of teriparatide.
Hypercalcemia was lower in the abaloparatide than the teriparatide group.

93. 3.Carotenoids, Lycopene Reduce Fracture Risk (Antioxidants)
“…reactive oxygen intermediates may be involved in the bone-
resorptive process and that fruit and vegetable-specific
antioxidants, such as carotenoids, are capable of decreasing this
oxidative stress. Therefore carotenoids may help in preventing
osteoporosis.
The Journal of Bone and Mineral Research (JBMR), (American society of bone and
mineral research)

95. REFERENCES:
Harrisons Principles of Internal Medicine, 19Ed
Davidsons Principles and practice of medicine_22Ed
API Textbook of Medicine, 9th Edition
Apley's System of Orthopaedics and Fractures 9th ed