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dr Shahrul Rahman, Sp.PD

Departemen Ilmu Penyakit Dalam
Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
Osteoporosis is a major public health problem, and
postmenopausal osteoporosis constitutes as a major part
of the problem.
Claus Christiansen, Am J Med 1993

Hip fractures will increase sharply in the next half
century, especially in Asia, making osteoporosis a truly
global issue.
WHO 1998
A major public threat for more than 28
million Americans. 80 % are women.
One in 2 women and One in 8 men over
50 will have an osteoporosis related
The estimated cost for osteoporotic and
associated fractures is 38 million a day!
What is it?
A disease in which bones become fragile
and more likely to break.
Breaks usually occur in the hip, spine and
What is it?
Hip and spine fractures are a major
Hip fractures almost always require
surgery and hospitalization.
Spine fractures have serious
consequences such as loss of height,
severe back pain, and deformity.
Osteoporosis is a disease characterized
by low bone mass and microarchitectural
deterioration of bone tissue, leading to
enhance bone fragility and a consequent
increase in fracture risk

Osteoporosis is a skeletal disorders

compromised bone strength,

predisposing in an increase risk

of fracture
Rigg and Nelson divided into :
A/. Primary osteoporosis
1. Post menopause osteoporosis
2. Senile osteoporosis

B/. Secondary osteoporosis
Osteoporosis due to other condition
of disease such as metabolic,
endocrine or malignancy
Post menopausal osteoporosis
Most common in woman 15 20 year after menopause
Mostly affects trabecular bone, increasing patient
susceptibility to vertebral compression fractures,
distal radial fractures and intertrochanteric fractures.
Esterogen deficiency plays a primary role
Senile Osteoporosis
Occurs in men and women over the age of 70
years with female to male ratio of 2:1
It affects : cortical and trabecular bone
equally, predisposing patient to multiple
wedges vertebral and femoral neck fractures
Aging and long-term calcium deficiency is
more important.
Primary osteoporosis mostly are old and
elderly people complaining of mild
backache but may also a sudden pain
with only a mild injury due to a
compression fractures of the vertebrae.
Before it reaches the threshold of fractures,
usually the height of patient reduces beside
deformity (kyphotic deformity)
It is a silent disease, meaning there is

no significant signs and symptoms

caused by osteoporosis
Etiology :
General factor predictive of osteoporosis :
1. Peak bone mass at maturity :
General / familial
Physical (activity status, exercise, etc)
Life style (alcohol, cigarettes, caffeine)
Medical (chronic disease, hypogonadal states, etc)
Iatrogenic (corticosteroid, anticonvulsant, etc)
Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889

20 40 80 60


Peak Bone Mass
Bone Loss

Bone Mass Development
Age (year)
2. Post menopausal bone loss

Accelerated trabecular bone loss for 3
to 10 years post menopausal
Due to increased bone resorption
secondary to estrogen loss
Loss of normally 1 to 2% per year to
a maximum of 10%
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
3. Age-related (involutionall) bone loss

Starts at age 35 40 years in both sexes,
continues for 30 to 40 years
Subtle uncoupling of rates of bone formation
and resorption
Both cortical and trabecular bone affected
Loss normally less than 0.5% per year to a
maximum of 20 %
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
4. Risk factors

Genetic, life style, Medical, Iatrogenic
Risk factors for bone loss :
1. Genetic :
- Female sex
- Caucasian / Asian ethnicity
- Family history of osteoporosis
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
2. Life Style :
- Low calcium intake
- Excessive alcohol use
- Cigarette smoking
- Excessive caffeine use
- Extreme or insufficient athlecity
- Excessive acid ash diet (high protein /
soft drink intakes)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
3. Medical :
- Early menopause
- Gonadal hormone deficiency states
- Eating disorders
- Chronic liver / kidney disease
- Malabsorption syndrome
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
4. Iatrogenic :
- Corticosteroids
- Excessive thyroid hormone
- Chronic heparin therapy
- Radiotherapy to skeleton
- Long-term anticonvulsants
- Loop diuretics
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
Bone is the most dynamic tissue.
Metabolism of catabolism and anabolism
as the activity of osteoclast and osteoblast
as a process of bone remodeling or
bone turn over
Degeneration occurs as an aging process

where the activity of osteoclast is not able

to compensate by the activity of osteoblast.

As a result bone mineral density decrease
The main problem of osteoporosis

lies in the effectiveness of intervention-

prevention and treatment
Osteoporosis is preventable if prevention
starts during the childhood and adolescence
when bone reaches maturity at the end
of 3
decade to achieve maximum
Peak Bone Mass
After the 3
decade all organ include skeletal /
bone will degenerate, the speed of
degeneration, differs for different organ.

In general organ will loose function
1% every year (the rule of 1% of Andreas
and Tobin)
Diagnosis should include differential diagnosis of
primary and secondary osteoporosis by :
o Taking a good history
o Physical examination
o Laboratory examination
o Imaging examination

History :
o ras, sex and age
o health status
o life style (alcohol, smoking)
o physical activity (sports)
o history of previous disease including administration of
drugs, previous fracture.
Physical Examination :
Body weight and height (BMI)
Extremities and spine including :
deformity, MMT and ROM
Laboratory findings :
o blood serum
o hormone
o Urine
- Serum :
- Complete blood counts
- Electrolytes, creatinine, blood urea, nitrogen calcium
- Phosphorus, protein, albumin, alkaline phosphatase,
liver enzyme
- Protein electrophoresis
- Thyroid function tests
- Testoterone (men only)
- 24 hours urine :
- calcium
- Pyridinium cross-links
Spesial :
- Serum:
- 25 hydroxyvitamin D3
- 1,25 hydroxyvitamin D3
- intact parathyroid hormone
- osteocalcium (bone Gla protein)
- Urine :
- Immunoelectrophoresis
- Bence-Jones protein
Radiology : plain X-ray
(especially the spine, hip and wirst)
The spine : - the ballooning disc
- deformity of vertebral body
(wedge, fish tail)
The Hip : - Singh Index
The Wirst : - Porotic / thinning cortex
The general diagnostic categories
established in woven : (WHO working group)
Normal : Bone Mass Density (BMD)or
Bone Mineral Content (BMC)
-1 SD from T Score of the young
adult reference mean
Osteopenia : BMD or BMC 1 SD to 2.5 SD
Osteoporosis : BMD or BMC 2.5 SD
(severe osteoporosis when there is followed a fracture)
Prevention and Treatment
T-score Fracture risk Teatment

> +1 very low no treatment
densitometry with indication

-1 s/d 0 low no treatment
densitometry after 5 years

- 1 s/d +1 low no treatment
densitometry after 2 years

-1s/d -2,5 midle prevention
densitometry after 1 years

< - 2,5 high osteoporosis treatment
no fracture continue prevention
densitometry after 1 years

< - 2,5 very high osteoporosis treatment
With fracture continue prevention
surgery with indication
densitometry after within
6 month 1 years
NORA: BMD and Fracture Rate
Aging process is a natural process of a person
getting old

3 steps of osteoporosis prevention :
I. Up to the end of 3
where Peak Bone Mass should be achieved
II. After the 3
decade up to menopause /
III. Senile, prevent from minor injury / accident
Goal of Osteoporosis Prevention
Optimising skeletal development
Physical activity
Life style changes
Minimize medical / iatrogenic factors

Minimize postmenopausal bone loss
Early identification of patients at risk
Reduced risk factors
Hormone replacement therapy (HRT)
Other agents pre-emptively if HRT contraindicated
raloxifene, alendronate

Minimize age-related bone loss
Identification of patients at risk
Reduce risk factors
Full prevention and exercise program (physical therapy)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
Prevention :
Good nutrition

Life style and physical exercise

To achieve maximum Peak Bone Mass
Early diagnose of osteoporosis
The same prevention as 1
In female patient after menopause with HRT
Prevention of the use of medication
consist steroid etc
Prevent from accident
(minor injury could cause fracture)
Care giver especially after fracture
Operative intervention and bracing
Nowadays there is a lot of medication
For osteoporosis such as :
- calcium and vitamin D
- calcitriol
- calcitonin
- bisphosphonate : generation : I III
such as (clorodronate, alendronate, and
risedronate (actonel))
- hormone : - anabolic
- sex hormone
- SEMs (Selective Modulator)
- SERM (Selective Estrogen Reseptor
Modulator : Raloxifene
(analogue of tamosifene)
Calcium : 1500 mg / day
Vitamin D : 500 mg / day
Calcitonin (myacalcic : Nasal spray: 200 mg / daily)

HRT : establish approach for osteoporosis prevention
and treatment.
But what after WHI report ????

SERM : Raloxifene : Evista : 60 mg/daily
- the goal is to increase bone benefits and decrease
deletterious affects on breast and endometrim.
- decrease breast cancer : 76 %
- 60 % women, 2 years : BMD increase 1-2 %

Dr. C. Deeply

Balita 400 700 mg / hari
Remaja 1000 1500 mg / hari
Dewasa 750 1000 mg / hari
Hamil 1500 mg / hari
Menyusui 2000 mg / hari
Sebelum menopause 800 1000 mg / hari
Selama menopause 1000 1200 mg / hari
Setelah menopause 1200 1500 mg / hari

Per Ons Teri nasi mengandung 1000 mg Kalsium
Per Ons Kepiting 210 mg
Per Ons Kerang 133 mg
40 gr Dencis kaleng 200 mg
Per Ons Kuning telur ayam 147 mg
Per Ons Tempe 129 mg
Per Ons Tahu 124 mg
er Ons Emping 100 mg
Per Ons Bayam merah 347 mg
Per Ons Kacang panjang 347 mg
Per Ons Daun singkong 165 mg
1 gelas Susu kental manis 275 mg
1 gelas Susu segar 380 mg
1 gelas susu krim penuh 290 mg
1 gelas Susu non fat 480 mg
1 gelas yurgort 200 mg
20 gr keju 100 mg
No. Jenis Kalsium Nama Dagang Kalsium(mg)
1. Kalsium karbonat Ca-C 100 Sandoz 327
Calsan 1250
Caxon-F 250
Calsium Sandoz 300
Epocaldi 400
2. Kalsium Laktas Ca-C 1000 Sandoz 1000
Calcidin 100
Calsium Sandoz 2940
3. Kalsium fosfat Calcidin 200
Calcalcin 800

Catatan : Kalsium karbonat mengandung 40 % kalsium
Kalsium laktas mengandung 13 % kalsium
Kalsium fosfat mengandung 25 % kalsium
--Fracture risk is still significantly linked to risk of
--Ability to safely transfer is independent risk
--Vitamin D has been shown in numerous
studies to decrease risk of falls independent of
the structural bone benefit