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CNSLF Med - Osteoporosis (i) (Intro (hip + vertebral insufficiency…
CNSLF Med - Osteoporosis (i)
Intro
hip + vertebral insufficiency fractures are a major cause of morbidity in older women (+ men)
hip fractures have 100% mortality @ 6 months untxed
hip fractures have 25% mortality @ 1yr if txed
increased nursing home admissions
vertebral fractures
kyphosis (hunched forward, can affect COG - falls forward + the ability to look ahead)
changes in lung structure
reduced height
low bone mass + micro architectural deterioration of bone tissue with a consequence increase in bone fragility + susceptibility in fracture risk
bone mineral density (BMD) T score < -2.5 (2.5 Cds below normal for a 30 y/o female - i.e. peak density in women)
estimates fracture risk
reduced density + interconnectivity of trabecular bone
progression: dorsal kyphosis then hip fracture
compression fractures in thoracic + lumbar vertebrae
progressive kyphosis + shortening of spine (not arms + legs)
osteopenia = bones are weaker than normal but donuts break easily (OP hallmark) - although fractures do occur in osteopenia
age-related bone loss occurs in men + women > 30
women's bones don't strengthen as much as men's in early life - reach OP threshold faster on decline (lower peak)
menopause: sudden drop in sex hormones
a/w atraumatic fractures (incidence increases with age)
in the future OP will be dxed by 10 yr fracture risk not T-score (individualised patient fracture risk stratification)
big threat to post-menopausal women
1 in 2 women >50 willl have an osteoporotic fracture in their lifetime
large risk group: glucocorticoids
male osteoporosis is a significant consideration - 15% of osteoporosis are men
Risk factors
female
caucasian/asian
hx of maternal hip fracture
genetics
sex hormone deficiency
low body mass (obesity actually protective)
lifelong low Ca intake)
sedentary lifesyle, immobility
astronauts (gravity not strengthening their bones)
excessive alcohol use + cig smoking
prior low trauma fracture
Secondary causes of diminished bone density (not true OP)
endocrine disorders
Cushing's syndrome
hyperparathyroidism
hyperthyroidism
prolactinoma
hypogonadism
coeliac disease + other causes of malabsorption
vit D deficiency (osteomalacia)
hep or renal dysfunction (renal bone disease)
genetic disorders e.g. osteogenesis imperfecta
systemic inflamm disease (e.g. RA, IBD - also they are txed with steroids
anorexia nervosa (low BMI + malnutrition)
malignancies (e.g. multiple myeloma - increased bone turnover)
corticosteroids
WHO dx criteria for OP in post-menopausal women + men > 65
normal: T score >/= -1
osteopenia: T score -1 - -2.5
OP: T score </= -2.5
severe OP: T score </= -2.5 with fragility fractures
Factors increasing absolute fracture risk
older age
lower T scores
prior fracture
multiple risk factors
Glucocorticoid-induced OP
regardless of age or gender
dose related (oral glucocorticoid dose strongly correlates to fracture risk)
longterm use in chronic diseases
asthma
COPD
RA
IBD
SLE
significant bone loss can occur in as little as 3 months (fastest in 1st 3 months)
up to 50% of patients taking 7.5+ mg/day prednisolone will fracture
pathogenesis
inhibits blasts, IGF1, testosterone, oestrogen
increased clasts
remodelling imbalance - rapid bone loss
less Ca (reduced absorption from diet + increased excretion) - causes secondary parathyroidism further increasing bone resorption
for any bone density the risk of fracture is high (esp T scores of -1.5 or less)
spine fracture incidence higher - trabcelular bone loss effect