1

3
 Latar belakang/ masalah

• Usia harapan hidup: 58th, 62th,72th (2025)

• Kenaikan lansia : 414 % (2025)
• Lansia meningkat peny.Degeneratif meningkat
Osteoporosis/ Age Related Diseases meningkat
• Osteoporosis Masalah besar Usia lanjut
angka kesakitan dan kematian , pendanaan
• Menopause : 24 juta (2015) Osteoporosis sekitar
352.000
• Osteoporosis fraktur immobilisasi
osteoporosis
• Rontgen kurang sensitif untuk Diagnosis.Penurunan
massa tulang 30 % baru terdeteksi 4
Bone & Teeth Ca ++

98%
2%
-Mekanik
-Protektif
-Metabolik
Extracellular Intracellular
* Excitation – Contraction coupling * Cell division
in heart & others * Muscle contractility
* Nerve system synaptic transmission * Cell motility
* Platelet aggregation, coagulation * Membrane trafficking &
* Hormones secretion secretion
5
 Homeostasis calcium dan pembentukan Tulang

Bone Resorption : Osteoclast Bone formation : osteoblast.

-Paratiroid hormon
Calcium -Estrogen -Estrogen
-Steroid
-I G F I -Calcitriol
-Tiroid Hormon
-Calcitonin
-Insulin,growth hormon

Calcitriol

Catatan :Bone Remodelling Adalah bone formation dan bone Absorption. 6

Bone Turn Over Adalah kecepatan Bone formation dan Bone Absorption
 I

II

CALCITRIOL
CalcItrIol
7
III PTH
 Shifting the Osteoporosis Paradig Bone Strength
NIH Consensus Statement 2000

Bone Bone Bone

Strength Quality + Quantity

Architecture Bone size

Turnover rate Bone density
Damage Accumulation
Degree of Mineralization
Properties of the collagen/
mineral matrix
8
Adapted from NIH Consensus Development Panel on Osteoporosis. JAMA 285:785-95; 2001
Micro architecture and Bone Strength

180 kg
20 kg
Peak bone mass and density changes over
Lifetime in men and women
Umur 0 sampai 34 thn :
Bone Formation >>>>

Umur 34 th --- 44 thn :

B.Formation:B.Resorption

Umur > 44 tahun :

Bone resorption >>>>

10
11
 Osteoporosis

Definisi/ Batasan : Penyakit sistemik tulang

yang disifati oleh berkurangnya MASSA
TULANG dan kelainan MIKROARSITEKTUR
jaringan tulang yang mineralisasinya
NORMAL, sehingga tulang menjadi rapuh
dengan akibat mudah PATAH dengan trauma
MINIMAL.
1Consensus Development Conference. Am J Med. 1991.

12
 Criteria for Osteoporosis

- 2.5 SD - 1.0 SD

Osteoporosis Osteopenia Normal

Quantitatively /density : WHO consensus

Dengan D E X A
Normal : T Score is +/- 1 SD
Osteopenia : T Score is – 1 SD to – 2.5 SD
Osteoporosis : T Score is – 2.5 SD or more
Severe Osteoporosis:
T Score is – 2.5 SD or more plus one or more osteoporosis fracture.

13
Osteoporotic Bone Loss
Normal Bone Osteoporotic Bone

Reproduced from J Bone Miner Res. 1986;1:15-21

14
with permission of the American Society for Bone and Mineral Research
Normal and osteoporotic bone

15
 Osteoporosis- Risk Factors
Factors which
Factors which can
cannot be influenced
be influenced • Sex hormones
• Eating disorders
• Gender • Diet
• Age • Activity level
• Body size • Medication
• Ethnic • Smoking
heritage • Alcohol use
• Obat, Faktor
• Family
16
 KLASIFIKASI & ETIOLOGI
OSTEOPOROSIS
• OSTEOPOROSIS PRIMER :

- Post menopause/ Tipe cepat/ tipe I

- Senilis/ tipe lambat/ Tipe II

• OSTEOPOROSIS SEKUNDER :
- Gagal ginjal kronik
- Cushing sindrome/ tx steroid lama/GIO
- Hipertiroid
- D M tipe I
- imobilisasi
- alkoholisme, obat heparin
- Arthritis rheumatoid 17
- Multiple myeloma
18
 Homeostasis
Patofisiologi Patofisiologi
calcium
osteoporosis post osteoporosis
dan menopause/
pembentukan Post
Tulang
Primer tipe I

Bone Resorption : Osteoclast

-Paratiroid hormon Bone formation : osteoblast.
Calcium -Estrogen : R e ndah -Estrogen :R endah
-Steroid
-I G F I
-Tiroid Hormon
-Calcitriol
-Calcitonin
-Insulin,growth hormon

CALCITRIOL

19
 Normal Osteoporosis

Pada thn awal menopause kehilangan massa tulang

dapat mencapai 15% dari
MASSA PUNCAK TULANG
dan pada
10 thn sampai 15 thn post menopause dapat mencapai
30-40%
20
 Patofisiologi
Homeostasisosteoporosis
calcium dansenilis/ primer
pembentukan tipe II
Tulang

Bone Resorption : Osteoclast

-Paratiroid hormon :Meningkat Bone formation : osteoblast.
-Estrogen: Rendah
Calcium -Steroid
-Estrogen : Rendah

-I G F I : Meningkat -Calcitriol Rendah

-Tiroid Hormon -Calcitonin
-Insulin,growth hormon

Calcium plasma rendah

CALCITRIOL sangat rendah

21
 Osteoporosis Primer tipe II/
Pada Usia lanjut
Usia lanjut

SUV Fg. Ginjal Fg Hati Calcitriol Fungsi Usus ESTROGEN

HOMEOSTASIS CALCIUM TERGANGGU

22
Hipocalcemia, Kejang otot, Osteoporosis
Patofisiologi osteoporosis
Homeostasis oleh
calcium dan karena steroid/GIO
pembentukan Tulang

Bone Resorption : Osteoclast Bone formation :

-Hiperparatiroid sekunder
-Estrogen: Rendah
-Steroid
-I G F I : Meningkat
-Tiroid Hormon
Pembentukan osteoblast
menurun.
-Estrogen : Rendah
-Calcitriol Rendah
-Calcitonin
-Insulin,growth hormon

CALCITRIOL

23
 Corticosteroids

↓ Gastointestinal ↓ Osteoblast ↓ Muscle Effects on:

Calcium absorption bone formation mass GH, IGF-1, TGF-β
↑ Urinary calcium
excretion

Sex hormone effects:

↓ Adrenal androgens
↓ Estrogen
↓ Calcium ↓ Testosterone

↑ Osteoclast
↑ PTH ?
bone resorption

Osteoporosis

Corticosteroids induce bone loss through several mechanisms

(Lane & Lukert, CEM, 1998) 24
25
 GEJALA / Manifestasi klinis
Osteoporosis umumnya
tanpa gejala sampai orang
tsb mengalami patah
tulang.
Gejala yang paling umum:
- Subklinis :
BMD,ALP,PIRIDINOLIN
- Kelainan bentuk tulang
belakang/ Kyphosis.
- Sakit punggung/ nyeri
- Penurunan tinggi
badan
- PATAH TULANG
26
27
The importance of architectural integrity

10% decrease in BMD due to loss 10% decrease in BMD due to

in trabecular thickness equals loss in trabecular number
equals
20% reduction in bone strength
70% reduction in bone strength
Silva MJ, Gibson LJ. Bone 1997:21;191–9
28
Parfitt AM. Am J Med 1991; 91
(Suppl5B):42S-46S.
Increasing age bears consequence of increased fracture.
Rates in men are lower and at a later age than in women.

29
30
 Ax :
- - Nyeri, kesemutan, Tambah bungkuk, Penurunan tinggi badan,
- patah tulang, minum obat corticosteroid yang lama, sakit ginjal
- sakit liver, merokok, alkohol,
 Ph Dx :
- Kyphosis, nyeri tekan, krepitasi
 Penunjang :
- Photo Rontgen Polos :
Penurunan densitas massatulang terutama dinding depan corpus
vertebrae,korteks menipis, trabekulae transversalis menghilang,
Lebar Disc meningkat, cortex bikonkaf

- Quantitative ultrasound Densitometry

- Dual energy X Ray Absorbsiometry
- Bone marker ( Bone remodelling ) : ALP, osteokalsin
Hidroxyproline, Piridinoline
31
- Histomorphometry
32
Bone formation
Bone formation:
Anti Bone resorption
Calcium Anti resorption :

Bisphosphonate
Sodium fluoride Estrogen
Calcitriol
Anabolic steroid Calcitonin
SERM (Tamoxifen )
Calcitriol HRT ( Premarin )

Estrogen

33
• Calcium
• H R T : Premarin
• S E R M : Kompetitif inhibisi pada uterus dan
payudara, Agonis estrogen pada tulang
(Tamoxifen)

• Biphosphonat: Risedronate : ACTONEL

• Kalsitonin

• Kalsitriol: Calcit
• Flouride
• Steroid anabolik : Menurunkan bone turn over
( Nandrolon, Stanozolol )
34
 Approach to management of
osteoporosis post menopause/primer tipe I

Diet
Exercise
Sunlight
Life-style issues

HRT
Pharmacotherapy
35
 cancer ?

HRT
May be contra indicated

ALTERNATIVE TREATMENT

PHYTOESTROGEN
36
Approach to management of
osteoporosis senilis/ primer tipe II

Diet
Exercise
Sunlight
Life-style issues
HRT
Pharmacotherapy
37
Approach to management of
osteoporosis Corticosteroid

Diet
Exercise
Sunlight
Life-style issues
HRT
Pharmacotherapy
38
Bone Formation :
ESTROGEN : bone formation, Anti Resorption

CALCIUM : Material bone formation.

CALCITRIOL : absorption, deposition of Calcium.

Preventif pada Menopause, usia lanjut

Pharmacotherapy ??
39
40
 Ilustrasi Kasus
 Identitas Penderita :
- Nama : Ny.R
- Umur : 76 tnn
- Alamat : Perum Asabri
- Agama : Islam
- Pekerjaan : Ibu Rumah tangga

 Anamnesa + Ph Dx:
- Nyeri punggung, terus menerus, bertambah
saat buat gerak, berlangsung sejak 4 tahun yg
lalu.Ke dokter diberi obat prednison, ponstan.
Nyeri tekan (+), Kiposis (+)

 Penunjang : - Photo thorax :

- Densitas Vertebrae menurun
- Lebar Disc Space Meningkat
- Vertebrae Bikonkaf
41
42
 Terapi
 Calcium : 1500 mg/ Hari

 Calcitriol : 2 x 0,25 micro gram / Hr

 Biphosphonat : 35 mg/minggu selama 5 bln,

istirahat 1 bulan, kmd dilanjutkan

 Calcitonin : 50 IU/ 2 hari sekali

 Phytoestrogen : 2 x 1tablet/ Hr

43
Be a Good Doctor’s with Active Learning and Share Knowledge Each Other
Think Globally but Act Locally (WHO Statement)

44