Secondary Osteoporosis

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Secondary Osteoporosis

• Tuan Van Nguyen and Nguyen Dinh Nguyen
• Bone and Mineral Research Program
• Garvan Institute of Medical Reseach
• Sydney, Australia

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Overview

• Definitions
• Causes
• Corticosteroid Induced Osteoporosis
• Machanism
• Magnitude of the problem
• Patient managements

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Secondary osteoporosis

• Results from chronic conditions that contribute
  significantly to accelerated bone loss.
• Treatment of secondary osteoporosis is more
  complex than that of primary osteoporosis.
• Prognosis depends on the underlying disease.

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Forms of secondary osteoporosis
Endocrine or Metabolic causes
Collagen/genetics disorders
Secondary Osteoporosis
Nutritional disorders
Medications
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Endocrine or metabolic causes

• Hypogonadism
• Hyperparathyroidism
• Cushing-syndrome
• Acidosis
• Diabetes (type I)
• Androgen insensitivity
• Hemochromatosis
• Gauchers disease

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Medications

• Corticosteroids
• Thyroid
• GnRH antagonists
• Anti-neoplastic agents
• Cyclosporin, methotrexate
• Phenobarbital
• Phenothiazines, Phenytoin

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Collagen/genetic disorders

• Ehler-Danlos syndrome
• Glycogen storage diseases
• Homocysturina
• Hypophosphatasis
• Marfan syndrome
• Osteogenesis Imperfecta

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Nutritional

• Alcoholism
• Calcium deficiency
• Chronic liver disease
• Gastric operations
• Malabsorption syndromes
• Vitamin D deficiency

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Corticosteroid-induced Osteoporosis (CIOP)
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Corticosteroid-induced osteoporosis

• CS used in many underlying diseases
• Benefits effects on the underlying disease vs.
  detrimental effects on bone.
• High percentage of osteoporosis and fracture
• Dose-dependent effect ? difficult to define

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CIPO-Epidemiology

• Prevalence of use of oral corticosteroids
• Population 0.5
• Among women aged 55 1.7

• Main indications
• Rheumatoid arthritis
• Polymyalgia
• COPD
• 14 of patients taking any treatment of
  osteoporosis

L J Walsh et al, BMJ 1996313344-6
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CIPO Burden

• Most common of drug-related osteoporosis in men
  and women
• Occur at any age, in both sexes, across races
• Up to 50 patient of chronic steroid therapy
  sustain osteoporotic fractures and/or develop
  osteonecrosis.
• Significant bone loss can occur in as little as 3
  months.
• 50 chance of developing osteoporosis if on
  steroid for 6 mo.

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Corticosteroids-effect on bone
Osteoblast
Inhibition
enhancement
Corticosteroids
increase
Calcium loss
Bone resorption
Inhibition
Inhibition
Gonadal hormone
Calcium absorption
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Who is at high-risk of CIPO?
- Prior fracture - Premature menaupause at lt
45y - Age gt 65 y - Planned or current use CS gt
6 mo- Low weight - Other causes of Osteoporosis
Eastell R et al, J Intern Med 1998244271-92
Tobias JH, Rheumatology 199938198-201
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CIPO and fracture
(Source van Staa TP et al., 2000)
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Patient assessment
After 1 y
In 3-5 y
BMD measurement
High-risk of CIOP?
BMD-Tscores?
or with CS gt15mg/d
or with CS 7.5mg/d x 6mo
gt1
0 to -1.5
lt -1.5

• Thoracic and lumbar spine X-ray
• FBC, ESR S-Electrophoresis if necessary
• Serum Ca, P, AP, Albumin
• Thyroid function
• Men testosterone an women FSH, LH

• Lifestyle
• modification advice
• Smoking
• Alcohol
• Physical activity
• Prevent fall

Eastell R et al, J Intern Med 1998244271-92
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CIOP-Management

• Primary prevention, PP (treatment started at the
  time initiation up to 3 mo of CS therapy)
• Secondary prevention, SP (treatment started gt1y
  after the time initiation of CS therapy)

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Pharmacological therapy
Agent PP SP Dose
Calcium Vit D v v 1000mg/d 50000U/w
Calcitrol v NA 0.6µg/d
Alfacalcidiol v NA 1µg/d
Calcitonin v NA Conflicting results (200U/d, nasal)
Fluoride v v 25mg BID plus Calcium
Etidronate v v marginal effect
Alendronate v v 5mg/d
Pamidronate v v Intermittent IV
Risedronate v v 5mg/d
HRT NA v
Testosterone (men) NA v
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Key messages

• Secondary osteoporosis is common
• Patients on CS therapy should be consider the
  need for therapy to prevent or treat CIOP
• Data on CIOP fracture reduction with treatment
  remain sparse

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L?i C?m t?

• Chúng tôi xin chân thành cám on Công ty Du?c ph?m
  Bridge Healthcare, Australia là nhà tài tr? cho
  h?i th?o.

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Thank you!