Diagnosis and Treatment of Osteoporosis. Department of Endocrinology and Metabolism Ajou University School of Medicine.
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1 Diagnosis and Treatment of Osteoporosis Department of Endocrinology and Metabolism Ajou University School of Medicine Yoon-Sok CHUNG WCIM, COEX, Seoul, 27Oct2014
2 Case 1 71-year old woman Back pain Emergency Room Plain X-ray L2 T12 L1
3 What is the most effective method to detect recent fracture in spine? 1) Bone Mineral Density (BMD, DXA spine) 2) Ultrasonography (US, spine) 3) Computed Tomography (CT, spine) 4) Magnetic Resonance Imaging (MRI, spine) 5) Positron Emission Tomography (PET, FDG spine)
4 T12, L1, L2 Fractures T12 L1 L2 Plain X-ray MRI T2WI
5 What is the most effective method to detect recent fracture in spine? 1) Bone Mineral Density (BMD, DXA spine) 2) Ultrasonography (US, spine) 3) Computed Tomography (CT, spine) 4) Magnetic Resonance Imaging (MRI, spine) 5) Positron Emission Tomography (PET, FDG spine)
6 Diagnosis of Osteoporosis and Fracture Simple Method : Plain X-ray (Osteopenia and Fracture) Quantitative Method : Bone Mineral Density (Osteoporosis) Supportive Methods : Bone scan, MRI, CT (Fracture) Biochemical Methods : Bone turnover markers (Osteoporosis) Metabolic Bone Diseases and Rare Bone Diseases : Bone Biopsy (Differential Diagnosis and Confirm)
7 Case 2 52-year old Woman Low Bone Mineral Density Out-patient Clinic Fracture history (-) Menopause : 1 year ago Height 158cm Weight 45kg Blood Pressure 115/75mmHg Pulse Rate 76/min
8 Bone Mineral Density (BMD) Spine L1-4 T-score -1.8, Z-score -1.6 Femur total T-score -1.3, Z-score -1.2 T-L spine X-ray : Fracture (-) Routine Lab. : normal range
9 What is the most appropriate medication? 1) Calcium and Vitamin D (Ca + D) 2) Estrogen and Progesterone (HRT) 3) Selective Estrogen Receptor Modulator (SERM) 4) Bisphosphonate (BP) 5) Parathyroid hormone (PTH)
10 Medical Treatments (in Korea) Anti-resorptives 1. Bisphosphonates 2. SERM 3. Estrogen 4. Vitamin D 5. Calcitonin 6. Ipriflavone 7. Calcium 8. Denosumab (RANKL antibody) 9. Cathepsin K inhibitors Formation Stimulants 1. Androgen 2. Fluoride 3. Vitamin K 4. Parathyroid hormone 5. Strontium 6. Anti-sclerostin antibody
11 What is the most appropriate medication? 1) Calcium and Vitamin D (Ca + D) 2) Estrogen and Progesterone (HRT) 3) Selective Estrogen Receptor Modulator (SERM) 4) Bisphosphonate (BP) 5) Parathyroid hormone (PTH)
12 Case 3 74-year old woman Sustained wound after teeth extraction for 10 weeks Out-patient Clinic Type 2 DM Postmenopausal Osteoporosis
13
14 Patient had been taking 6 years of Osteoporosis Medication. What is the most possible drug for this condition? 1) Estrogen and Progesterone (HRT) 2) Selective Estrogen Receptor Modulator (SERM) 3) Calcitonin (CT) 4) Parathyroid hormone (PTH) 5) Bisphosphonate (BP)
15 Adverse Effects of Bisphosphonates Gastrointestinal disturbance (Erosion, Ulcer) Acute Phase Reaction (Flu-like illness) Hypocalcemia Ocular complication (Conjunctivitis, Uveitis) Osteonecrosis of the Jaw (ONJ) Atypical Femur Fracture
16 Patient had been taking 6 years of Osteoporosis Medication. What is the most possible drug for this condition? 1) Estrogen and Progesterone (HRT) 2) Selective Estrogen Receptor Modulator (SERM) 3) Calcitonin (CT) 4) Parathyroid hormone (PTH) 5) Bisphosphonate (BP)
17 Case 4 43-year old woman Low Bone Mineral Density Out-patient Clinic Fracture history (-) LNMP : 1 month ago Height 162cm Weight 45kg Blood Pressure 115/75mmHg Pulse Rate 68/min
18 Bone Mineral Density (BMD) Spine L1-4 T-score -2.7, Z-score -1.3 Femur total T-score -2.2, Z-score -1.1 T-L spine X-ray : no fracture Routine Lab. : normal range
19 What is the most appropriate medication? 1) Calcium and Vitamin D (Ca + D) 2) Estrogen and Progesterone (HRT) 3) Selective Estrogen Receptor Modulator (SERM) 4) Parathyroid hormone (PTH) 5) Bisphosphonate (BP)
20 Premenopausal Osteoporosis Calcium and Vitamin D : usual risk (not high risk) Estrogen : premature ovarian failure SERM : not a candidate PTH : short-term (no evidence) Bisphosphonate : not a good candidate (fetal risk)
21 Bone Mineral Density (BMD) Spine L1-4 T-score -2.7, Z-score -1.3 Femur total T-score -2.2, Z-score -1.1 T-L spine X-ray : no fracture Routine Lab. : normal range
22 Case 4 43-year old woman Low Bone Mineral Density Out-patient Clinic Fracture history (-) LNMP : 1 month ago Height 162cm Weight 45kg Blood Pressure 115/75mmHg Pulse Rate 68/min
23 Bone Mineral Density (BMD) Spine L1-4 T-score -2.7, Z-score -1.3 Femur total T-score -2.2, Z-score -1.1 T-L spine X-ray : no fracture Routine Lab. : normal range
24 What is the most appropriate medication? 1) Calcium and Vitamin D (Ca + D) 2) Estrogen and Progesterone (HRT) 3) Selective Estrogen Receptor Modulator (SERM) 4) Parathyroid hormone (PTH) 5) Bisphosphonate (BP)
25 Premenopausal Osteoporosis Calcium and Vitamin D : usual risk (not high risk) Estrogen : premature ovarian failure SERM : not a candidate PTH : short-term (no evidence) Bisphosphonate : not a good candidate (fetal risk)
26 Case 5 55-year old man Low Bone Mineral Density Out-patient Clinic Fracture history (-) Medication history (-) Height 173cm Weight 65kg Blood Pressure 125/85mmHg Pulse Rate 78/min
27 Bone Mineral Density (BMD) Spine L1-4 T-score -2.8, Z-score -2.3 Femur total T-score -2.4, Z-score -2.1 T-L spine X-ray : Genant Grade 1 (mild degree) T12 compression fracture
28 What is the most common laboratory abnormality expected in this patient as Korean? 1) Serum Testosterone 2) Serum Cortisol, ACTH 3) Serum TSH and Free T4 4) Serum Prolactin and GH 5) Serum 25OHD and PTH
29 Laboratory Evaluation for Male Osteoporosis as Secondary Causes Additional laboratory tests if indicated Initial laboratory tests Complete chemistry profile (including alkaline phosphatase) Complete blood count Calcium, phosphorus 25 hydroxyvitamin D Testosterone Urinary calcium excretion 24 hour urine for free cortisol FSH, LH Prolactin Magnesium 1,25 dihydroxyvitamin D Intact PTH TSH Celiac screen Serum protein electrophoresis/urine protein electrophoresis Erythrocyte sedimentation rate Rheumatoid factor Ferritin and carotene levels Iron and total iron binding capacity Serum tryptase and histamine levels Homocysteine Skin biopsy for connective tissue disorders COL1A genetic testing for osteogenesis imperfecta Serum and urine markers of bone turnover Late-Onset Hypogonadism. Korean Society for Aging Male Research. Korean Andrological Society 남성골다공증. 정윤석. In 남성갱년기. 대한남성갱년기학회및대한남성과학회. 군자출판사. Pp , 2009
30 Case 5 55-year old man Low Bone Mineral Density Out-patient Clinic Fracture history (-) Medication history (-) Height 173cm Weight 65kg Blood Pressure 125/85mmHg Pulse Rate 78/min
31 What is the most common laboratory abnormality expected in this patient as Korean? 1) Serum Testosterone 2) Serum Cortisol, ACTH 3) Serum TSH and Free T4 4) Serum Prolactin and GH 5) Serum 25OHD and PTH
32 What is the most common laboratory abnormality expected in this patient as Korean? 1) Serum Testosterone, LH 2) Serum Cortisol, ACTH 3) Serum TSH and Free T4 4) Serum Prolactin and GH 5) Serum 25OHD and PTH
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