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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 – PowerPoint PPT presentation

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Title: Secondary Osteoporosis


1
Secondary Osteoporosis
  • Tuan Van Nguyen and Nguyen Dinh Nguyen
  • Bone and Mineral Research Program
  • Garvan Institute of Medical Reseach
  • Sydney, Australia

2
Overview
  • Definitions
  • Causes
  • Corticosteroid Induced Osteoporosis
  • Machanism
  • Magnitude of the problem
  • Patient managements

3
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.

4
Forms of secondary osteoporosis
Endocrine or Metabolic causes
Collagen/genetics disorders
Secondary Osteoporosis
Nutritional disorders
Medications
5
Endocrine or metabolic causes
  • Hypogonadism
  • Hyperparathyroidism
  • Cushing-syndrome
  • Acidosis
  • Diabetes (type I)
  • Androgen insensitivity
  • Hemochromatosis
  • Gauchers disease

6
Medications
  • Corticosteroids
  • Thyroid
  • GnRH antagonists
  • Anti-neoplastic agents
  • Cyclosporin, methotrexate
  • Phenobarbital
  • Phenothiazines, Phenytoin

7
Collagen/genetic disorders
  • Ehler-Danlos syndrome
  • Glycogen storage diseases
  • Homocysturina
  • Hypophosphatasis
  • Marfan syndrome
  • Osteogenesis Imperfecta

8
Nutritional
  • Alcoholism
  • Calcium deficiency
  • Chronic liver disease
  • Gastric operations
  • Malabsorption syndromes
  • Vitamin D deficiency

9
Corticosteroid-induced Osteoporosis (CIOP)
10
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

11
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
12
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.

13
Corticosteroids-effect on bone
Osteoblast
Inhibition
enhancement
Corticosteroids
increase
Calcium loss
Bone resorption
Inhibition
Inhibition
Gonadal hormone
Calcium absorption
14
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
15
CIPO and fracture
(Source van Staa TP et al., 2000)
16
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
17
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)

18
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
19
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

20
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.

21
Thank you!
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