unusual osteoporosis
TRANSCRIPT
UNUSUAL OSTEOPOROSIS
Case 1
∗ 73 year old man presented with recent onset of back pain and weight loss.
∗ X-rays showed multiple vertebral fractures.
∗ PMH AF controlled with amiodarone.∗ Non smoker, little alcohol.
∗ Differential diagnosis?
Case 1
∗ FBP∗ Admission profile, bone profile, PSA∗ ESR / CRP∗ PPE, Bence Jones∗ Testosterone∗ TFTs, 24hr urinary cortisol∗ Coeliac screen
Case 1 Investigations
∗ T4 96.9 pmol/L∗ TSH < 0.02 mu/L
∗ Hyperthyroidism secondary to amiodarone
Case 1 Diagnosis
∗ Increased frequency of bone remodelling∗ Shortened cycle with bone formation
shortened more than resorption∗ Leads to loss of bone with each cycle
∗ relative increased Ca -- decreased PTH-- decreased 1-25 Vit D -- decreased Ca
absorption and increased Ca excretion
Hyperthroidism and Bone
∗ Increased fracture rateX 3 to 4 increased rate & only in part related
through BMD.
Hyperthyroidism and Fracture
∗ BMD increases on average 4% in first year.∗ BMD returns to normal range within 3-5 yrs. ∗ But there remains an increased fracture rate
for up to 5 years.∗ Therefore in severe osteoporosis use
antiresorptive therapy for 3-5 years.
Correction of HyperthyroidismBone response
Case 2
∗ 51 year old man # elbow after fall off bicycle, March 2017
∗ Keen club cyclist∗ Previous #s in falls off bike
∗ Hip 2007∗ Pubic ramus 2013
Case 2
∗ FBP∗ Admission profile, bone profile, PSA∗ ESR / CRP∗ PPE, Bence Jones∗ Testosterone∗ TFTs, 24hr urinary cortisol and calcium∗ Coeliac screen∗ All normal
Case 2 Investigations
∗ Sherk et al. (2014)14 cycling (F)>1 year of competition history26–41Longitudinal (1 year) BMD of the hip decreases 1–2% after a year of training and competition.
∗ Gómez-Bruton et al. (2013) 20 cycling19 control (M)10 h/wk16.4Cross-sectional Lower BMD of young cyclists in some places.
∗ Guillaume et al.(2012)29 cycling (M)25,000–30,000 km/year26–5 Descriptive ND between groups on calcium and vitamin D intake
∗ Nichols et al.(2011)19 cycling18 control (M)11.1 h/wk4.5 h/wk50–57Longitudinal (7 years) Cycling has not demonstrated positive effects on BMD. High rate of osteopenia/osteoporosis in cyclists (84.2% and 89.5% after seven years)
∗ Abe et al.(2014) 14 cycling (masters)13 moderately active youngsters (M)17 years of training 20–71 Cross-sectional BMD lower in femoral neck of cyclists versus control. ND in BMD of lumbar spine.
∗ Olmedillas et al. (2011)21 cycling23 control (M)10 h/wk 4 h/wk15–21 Cross-sectional Lower BMD of the hip, leg and pelvis of cyclists versus control
∗ Campion et al. (2010)30 cycling30 control (M)22–25 h/wk<1 h/wk29 ± 3 28 ± 4 Cross-sectional Professional cycling affected negatively BMD (femoral neck: −18%)
∗ Penteado et al.(2010)31 cycling28 control 21 h/wk20–30 Cross-sectional ND in BMD versus control
∗ Barry et al.(2008)14 cycling (M)>450 h/y27–44 Two groups: low and high doses of calcium supplementation during one year Both groups decreased BMD of the hip and sub-regions, regardless of calcium intake
∗ Rector et al.(2008) 27 cycling 18 marathon (M)≥6 h/wk≥6 h/wk20–59 Cross-sectional 63% of cyclists had lumbar spine osteopenia and were 7-fold times more likely to have osteopenia
Cycling and BMD
∗ Is low BMD in cyclists associated with higher
fracture rate?
∗ Why low BMD?
∗ Effect of Skeletal loading on osteocyte
∗ Lazy Bones may be right !
∗ Advise weight bearing exercise
Cycling and Fracture
Case 3
∗ 68 year old man presented with tiredness
after small CVA.
∗ PMH of AF.
∗ Lower thoracic back pain
Case 3
∗ FBP∗ Admission profile, bone profile, PSA∗ ESR / CRP∗ PPE, Bence Jones∗ Testosterone∗ TFTs, 24hr urinary cortisol and calcium∗ Coeliac screen∗ Testosterone 2.8 (6.7-25.7)
Case 3 Investigations
∗ Very aware of postmenopausal bone loss. but
hypogonadism in men?
∗ Studies suggest up to 50% of osteoporosis in men is
secondary.
∗ Alcohol probably accounts for half of this and
hypogonadism ? a quarter.
Hypogonadism and Osteoporosis
∗ Testosterone(T) has direct effect on bone cells through androgen receptor.
∗ T has indirect effect through peripheral conversion of T to oestrogen via aromatase in fat tissue.
∗ Stronger correlation between oestrogen and BMD and fractures than T in men.
∗ Low T could be linked to increased fracture rate through reduced muscle strength and falls
Testosterone and bone
∗ Treat hypogonadism in men when it is symptomatic.
∗ Treat osteoporosis with bisphosphonates (Denosumab) as per guidelines.
∗ Treat osteoporosis with testosterone replacement when there is no alternative therapy available.
Treatment
∗ Aromatase inhibitors∗ Treat when T score is less than -2.0
∗ Androgen deprivation therapy∗ Treat with bisphosphonates ( oral, iv)∗ Denosumab licensed USA
Iatrogenic
Case 4
∗ 45 year old man presented with acute mid thoracic back pain.
∗ Keen runner up to marathon level.∗ Fatigue recently, not running and weight gain.∗ No past medical history.
∗ X-rays showed 3 thoracic vertebral fractures
Case 4
∗ FBP∗ Admission profile, bone profile, PSA∗ ESR / CRP∗ PPE, Bence Jones∗ Testosterone∗ TFTs, 24hr urinary cortisol and calcium∗ Coeliac screen∗ Urine Cortisol 4020 (<210) and subsequent CT
showed adrenal carcinoma
Case 4 Investigations
∗ Endogenous is very rare compared with exogenous corticosteroids.
∗ Complex effect on bone metabolism.∗ Direct bone cell effects with initial rapid
increase in bone resorption followed by long term decrease in bone formation.
∗ Indirect effects through Vit D and calcium, growth hormones, IGF and hypogonadism.
Glucocorticoid Induced Osteoporosis (GIO)
∗ Standard relationship between BMD and fracture risk does not apply.
∗ In GIO apply higher threshold for treatment ( T score -1.5).
∗ Bone microstructure is important.∗ Trabecular bone is affected most.∗ Vertebral fractures are often asymptomatic.
GIO and Fracture
∗ Lifestyle, weight bearing exercise.∗ Calcium (1000mg) and Vit D (800iu).∗ Depending on fracture risk
∗ Bisphosphonates oral (IV)∗ Denosumab if C/I to bisphosphonates.
∗ New ACR guidelines∗ Pred dose 2.5mg for > 3 months or 5 gm total∗ Based on fracture risk and age < or > 40yrs.
Management of GIO