Osteoporosis

SEKOLAH TINGGI ILMU KESEHATAN BANI SALEH
OSTEOPOROSIS
Nama Dosen Pengampu :

apt. Fajar Amirulah, S.Si, M.Farm.
Bekasi, Maret 2021
Islami, Unggul dan Profesional dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

DEFINISI OSTEOPOROSIS
Osteoporosis adalah penyakit tulang yang
mempunyai sifat khas yaitu terjadinya penurunan
massa atau kepadatan pada tulang sehingga terjadi
penurunan kualitas jaringan pada tulang yang
menyebabkan timbulnya kerapuhan tulang serta
memiliki nilai T-Score pada BMD -2,5.
Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

OSTEOPOROSIS
Selama ini osteoporosis identik dengan orang tua,
namun faktanya, pengeroposan tulang bisa menyerang
siapa saja termasuk di usia muda. Osteoporosis
merupakan salah satu penyakit degeneratif. Penelitian
https://pusdatin.kemkes.go.id/
terbaru dari International Osteoporosis Foundation
(IOF) mengungkapkan bahwa 1 dari 4 perempuan di
Indonesia dengan rentang usia 50-80 tahun memiliki
risiko terkena osteoporosis. Dan juga risiko osteoporosis
perempuan di Indonesia 4 kali lebih tinggi dibandingkan
laki-laki. Biasanya penyakit keropos tulang ini
menjangkiti sebagian besar wanita paska menopause.
Osteoporosis tidak menampakkan tanda-tanda fisik
2015
yang nyata hingga terjadi keropos atau keretakan pada
usia senja. Hilangnya hormon estrogen setelah
menopause meningkatkan risiko terkena osteoporosis.

JENIS OSTEOPOROSIS
01 HIP
02 VERTEBRAL
03 NON-VERTEBRAL

GEJALA OSTEOPOROSIS
01 Nyeri Punggung
02 Postur tubuh membungkuk
Terjadi penurunan tinggi badan atau keretakan

03 tulang tanpa riwayat adanya
trauma/kecelakaan

Hilangnya arsitektur trabekulasi vertebra
dalam Micro CT-3 Dimensi
Wanita Osteoporosis
Wanita normal (dg. fraktur vertebra)
Borah, et al. Anat. Rec. 2001

FAKTOR OSTEOPOROSIS
1. Merokok
2. Bertambahnya usia
6. Kurang konsumsi vitamin D dan Kalsium

3. Memiliki riwayat fraktur
7. Rendah nya aktivitas fisik
4. Defisiensi Hormon Gonadotropin
8. Minum alkohol 4 gelas per hari untuk laki-laki dan
5. Berat badan kurang dari 58 Kg 2 gelas per hari untuk wanita
9. Minum kafein lebih dari 2 gelas per hari

WHO Osteoporosis Guidelines

( Berdasarkan hasil pemeriksaan kepadatan mineral
tulang dgn alat Bone Densitometer )
T-Score
WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.

Diagnostic Criteria for Osteoporosis and Osteopenia in Postmenopausal Women
and Men Older Than 50 Years
www.aafp.org/afp. Osteoporosis .Volume 92, Number 4 ◆ August 15, 2015

BAHAYA OSTEOPOROSIS
01 Patah tulang (Bone Fractures)
02 Nyeri
03 Terjadi perubahan penampilan
Fraktur kompresi (Compresion

04
fractures)
05 Terjadi kehilangan keseimbangan

HUBUNGAN VITAMIN D
DENGAN
OSTEOPOROSIS

VITAMIN D
Fungsi vitamin D yang paling dikenal adalah dalam regulasi

01
pembentukan & mempertahankan tulang yang kuat.
Vitamin D juga mempunyai peran dalam regulasi proliferasi dan

02 diferensiasi sel, mengatur sistem kekebalan tubuh dan
membantu dalam pencegahan kanker.
Reseptor vitamin D (VDR) dapat ditemukan disaluran

03 pencernaan, tulang, otak, payudara, prostat, selimunitas,
plasenta, pankreas dan beberapa organ lainnya.

FUNGSI VITAMIN D
Islami, Unggul dan Profesional dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

PROSES METABOLISME VITAMIN D DI DALAM TUBUH

KEBUTUHAN HARIAN VITAMIN D DI DALAM TUBUH
"7 Dietary Intake Assessment." Institute of Medicine. 2011. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National
Academies Press. doi: 10.17226/13050

STATUS VITAMIN D DI DALAM TUBUH
PackageInsertLIASON®25-OHVitaminDTotalAssay;Clinchem2015;61(3):462-465

Prevalensi Defisiensi Vitamin D
Defisiensi/insufisiensi
vitamin D juga banyak
ditemukan di negara
tropis termasuk
Indonesia
Asia Pac J Clin Nutr. 2018;27(6):1286-1293. doi: 10.6133/apjcn.201811_27(6).0016; British Journal of Nutrition (2013), 110, S11–S20;Food and
Nutrition Bulletin 2013;34(2):S81-89; Acta Med Indones. 2010 Jul;42(3):123-9

GEJALA KEKURANGAN Vitamin D
Gani LU, et al. Singapore Med J 2015;56(8):433-7; Khan QJ, et al. J Oncol Pract.2010; 6(2):97-101

KAPAN DILAKUKAN
PEMERIKSAAN Vitamin D
https://www.medscape.com/viewarticle/731722_print; https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/?print=1

TERAPI DEFISIENSI VITAMIN D
Gani LU, et al. Singapore Med J 2015;56(8):433-7; QJ, et al. J Oncol Pract2010; 6(2):97-101; Panduan Praktik klinis IDAI 2018
https://www.medscape.com/viewarticle/731722_print;

KEAMANAN VITAMIN D
Institute of Medicine, Food and Nutrition Board; Hathcock JN, et al.Am J Clin Nutr 2007;85:6 -18; Nutrient 2013 Sep; 5(9): 3605-16;
SA Orthopaedic Journal 2011 ;10 (2):36-43

HUBUNGAN KALSIUM DENGAN

OSTEOPOROSIS
Gani LU, et al. Singapore Med J 2015;56(8):433-7; QJ, et al. J Oncol Pract2010; 6(2):97-101; Panduan Praktik klinis IDAI 2018
https://www.medscape.com/viewarticle/731722_print;

KALSIUM
 Calcium is the main mineral constituent of bones, and regulates fundamental cellular
events, such as enzymatic activities and cellular membranes excitability.
 It is essential for many physiologic process, including nerve function, muscle
contraction, and blood clotting.
 Calcium is also a central signaling ion that is crucial for controlling growth, proliferation,
and survival of both normal and malignant cells.
 Serum calcium levels are strictly regulated and, in physiological condition, range from
2.1 to 2.6 mmol/L.
Lumachi, F. et al. Calcium Metabolism & Hypercalcemia in Adults Current Medicinal Chemistry, 2011 Vol. 18, No. 23

KALSIUM
Calcium metabolism mainly depends on the activity of parathyroid hormone (PTH). External
factors, such as diet, medications, and physical activity, can interfere, to a lesser extent, with
calcium metabolism.
A normal adult needs 800-1200 mg/day of calcium for balancing intake and losses. Dairy
products are the principal sources of calcium intake.
The most part of extracellular calcium is present in the form of hydroxyapatite
[Ca10(PO4)6(OH)2] which is the primary component of bones (70%) and teeth (96%), while type I
collagen accounts for more than 90% of the organic matrix of bone.
 In blood, almost half of serum calcium is bound to serum albumin (40-45%) or globulin (2-5%), a
little percentage (5-10%) is bound to small anions (i.e. carbonate, citrate, lactate, phosphate),
and the rest (45-50%) is in ionized form (Ca2+).

Perbedaan Jumlah Konsumsi Kalsium Berdasarkan Usia dan Jenis Kelamin

Perbedaan Jumlah Konsumsi Kalsium Berdasarkan Usia dan Jenis Kelamin

Aksi Hormon Paratiroid pada Kalsium
Catatan : RANKL=receptor activator of nuclear actor-k ligands


Mekanisme Mempertahankan Kadar Kalsium Di Tubuh

ALGORITMA TERAPI OSTEOPOROSIS
Shoback et al Osteoporosis in Postmenopausal Women J Clin Endocrinol Metab, March 2020, 105(3):587–594

TERAPI NON-FARMAKOLOGI UNTUK PENYAKIT OSTEOPOROSIS

TERAPI FARMAKOLOGI UNTUK PENYAKIT OSTEOPOROSIS
01 Bisphosphonates
02
Raloxifene
03
Calcitonin
04 Teriparatide
05
Denosumab

Bisphosphonates
 Oral bisphosphonates inhibit osteoclastic activity and are antiresorptive agents.
 They are considered first-line pharmacologic therapy.
 Randomized clinical trials demonstrate a reduction of vertebral and hip fractures
with alendronate (Fosamax) and risedronate (Actonel).
 Alendronate and risedronate also decrease vertebral fractures in men and in
patients with glucocorticoid-induced osteoporosis.
 Daily and intermittent use of ibandronate (Boniva) have demonstrated
effectiveness in reducing fractures of the spine only.
 Weekly and monthly dosing formulations improve adherence.
 Oral bisphosphonates should be taken only with water and a wait of at least 30
minutes before reclining or ingesting other medication or food.
 This decreases upper gastrointestinal adverse effects and allows for appropriate
absorption.
Bisphosphonates
 The intravenous bisphosphonates approved by the U.S. Food and Drug

Administration for the treatment of postmenopausal osteoporosis are zoledronic acid
(Reclast), 5 mg yearly (shown to decrease vertebral and hip fractures), and
ibandronate, 3 mg every three months.
 Although these medications are expensive, they are useful for high-risk patients who
are unable to tolerate or adhere to oral therapy.

Jenis Obat Bisphosphonates

Raloxifene
 Raloxifene for use vertebral only (Prevention and Treatment)
Raloxifene, a selective estrogen receptor modulator, is approved for treating
postmenopausal osteoporosis, and is effective at reducing vertebral fractures only.
The best candidates for raloxifene are postmenopausal women with osteoporosis
who are unable to tolerate bisphosphonates, have no vasomotor symptoms or history
of venous thromboembolism, and have a high breast cancer risk score.
 Bazedoxifene is a selective estrogen receptor modulator more recently approved for
use in the United States for the prevention of osteoporosis as part of a combination
therapy with conjugated estrogen.

Calcitonin
 Calcitonin nasal spray is an antiresorptive agent approved for the treatment of
postmenopausal osteoporosis.
 It has been shown to decrease the occurrence of vertebral compression fractures
only.
 Although calcitonin has modest analgesic properties in the setting of acute and
chronic vertebral compression fracture, it is not considered first-line treatment for
osteoporosis because more effective medications are available.
 There have also been reports of increased cancer rates associated with use of
calcitonin.

Teriparatide
 Teriparatide is a recombinant human parathyroid hormone with bone anabolic
activity. In a dosage of 20 mcg per day given subcutaneously for up to two years,
teriparatide decreases vertebral and nonvertebral fractures.
 Teriparatide is approved for the treatment of postmenopausal women with severe
bone loss, men with osteoporosis who have high risk of fracture, and individuals whose
condition has not improved with bisphosphonate therapy. One study suggests that it is
advisable to follow teriparatide therapy with bisphosphonate therapy to maintain BMD
gains.

Denosumab
 Denosumab is a human monoclonal antibody that inhibits the formation and activity
of osteoclasts by blocking receptor activator of nuclear factor kappa B ligand. In a dose
of 60 mg given subcutaneously every six months for three years, it significantly
increased BMD in postmenopausal women compared with weekly dosing of
alendronate.
 Denosumab has been shown to decrease hip, vertebral, and nonvertebral fractures
compared with low doses of calcium and vitamin D. It appears to be a reasonable
alternative for persons whose condition does not improve with bisphosphonates. Renal
insufficiency is a listed caution, but denosumab appears to be safe for patients with
chronic kidney disease stages 1 to 3.

Romosozumab (2020)
 Romosozumab is an anabolic agent that increases bone formation and also reduces
bone resorption.
In postmenopausal women with osteoporosis at very high risk of fracture, such as
those with severe osteoporosis (this is supposed to be “i.e.”, low T-score < −2.5 and
fractures) or multiple vertebral fractures, we recommend romosozumab treatment for
up to 1 year for the reduction of vertebral, hip, and nonvertebral fractures.
 The recommended dosage is 210 mg monthly by subcutaneous injection for 12
months.
 Women at high risk of cardiovascular disease or stroke should not be considered for
romosozumab pending further studies on cardiovascular risk associated with this
treatment. High risk includes prior myocardial infarction or stroke.

Romosozumab (2020)
 Romosozumab should be considered as a first-line therapy in patients with multiple

vertebral fractures or hip fracture and BMD in the osteoporotic range (this is supposed
to be “i.e.”, severe osteoporosis). This agent also could be considered in individuals
who have failed antiresorptive treatments.

Rekomendasi klinis untuk Osteoporosis

Terapi tambahan (adjuvan) pada osteoporosis

Calcium and vitamin D
 In postmenopausal women at high risk of fracture with osteoporosis who cannot
tolerate bisphosphonates, estrogen, selective estrogen response modulators,
denosumab, tibolone, teriparatide, and abaloparatide, we recommend daily calcium
and vitamin D supplementation to prevent hip fractures.
In postmenopausal women with low bone mineral density and at high risk of fractures
with osteoporosis, we suggest that calcium and vitamin D be used as an adjunct to
osteoporosis therapies.
Easthel, Ricahard, et.al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice
GuidelineJ Clin Endocrinol Metab, May 2019, 104(5):1595–1622

Monitoring Terapi untuk Osteoporosis
 After initiation of treatment, the need for follow-up bone density testing is
uncertain.
 A decrease in BMD could suggest treatment nonadherence, inadequate
calcium or vitamin D intake, an unidentified secondary cause of osteoporosis,
or treatment failure.
 However, a single-institution study found that although follow-up DEXA
scanning for patients with osteoporosis was performed often, this rarely led to
changes in treatment, even in patients found to have decreased BMD.


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SEKOLAH TINGGI ILMU KESEHATAN BANI SALEH

Nama Dosen Pengampu :

Bekasi, Maret 2021

Islami, Unggul dan Profesional dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Osteoporosis adalah penyakit tulang yang

mempunyai sifat khas yaitu terjadinya penurunan

massa atau kepadatan pada tulang sehingga terjadi

penurunan kualitas jaringan pada tulang yang

menyebabkan timbulnya kerapuhan tulang serta

memiliki nilai T-Score pada BMD -2,5.

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

02 Postur tubuh membungkuk

Terjadi penurunan tinggi badan atau keretakan

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Borah, et al. Anat. Rec. 2001

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

6. Kurang konsumsi vitamin D dan Kalsium

5. Berat badan kurang dari 58 Kg 2 gelas per hari untuk wanita

9. Minum kafein lebih dari 2 gelas per hari

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

WHO Osteoporosis Guidelines

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

www.aafp.org/afp. Osteoporosis .Volume 92, Number 4 ◆ August 15, 2015

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

03 Terjadi perubahan penampilan

Fraktur kompresi (Compresion

05 Terjadi kehilangan keseimbangan

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Fungsi vitamin D yang paling dikenal adalah dalam regulasi

Vitamin D juga mempunyai peran dalam regulasi proliferasi dan

Reseptor vitamin D (VDR) dapat ditemukan disaluran

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Unggul dan Profesional dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

PROSES METABOLISME VITAMIN D DI DALAM TUBUH

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

KEBUTUHAN HARIAN VITAMIN D DI DALAM TUBUH

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

STATUS VITAMIN D DI DALAM TUBUH

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Prevalensi Defisiensi Vitamin D

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

GEJALA KEKURANGAN Vitamin D

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

TERAPI DEFISIENSI VITAMIN D

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

HUBUNGAN KALSIUM DENGAN

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Perbedaan Jumlah Konsumsi Kalsium Berdasarkan Usia dan Jenis Kelamin

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Perbedaan Jumlah Konsumsi Kalsium Berdasarkan Usia dan Jenis Kelamin

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Aksi Hormon Paratiroid pada Kalsium

Catatan : RANKL=receptor activator of nuclear actor-k ligands

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

Mekanisme Mempertahankan Kadar Kalsium Di Tubuh

Islami, Profesional dan Unggul dalam bidang Pelayanan Kefarmasian www.stikesbanisaleh.ac.id

ALGORITMA TERAPI OSTEOPOROSIS