Osteoporosis Dr. Luis Jimenez Briceño Endocrinólogo Centro de Especialidades Médicas Pinares

¿Vivirán sus Huesos tanto como Usted? La osteoporosis amenaza a 28 millones de hombres y mujeres norteamericanos, provocando deterioro y debilidad de sus huesos. Esta enfermedad puede desarrollarse silenciosamente durante muchos años. El momento de prevenir Incluya calcio y vitamina D abundantes en su dieta. Evite el tabaco y el abuso del licor. Realice ejercicio físico como caminar, trotar o bailar, todos los días.

El Hueso Tejido Vivo Microarquitectura compleja Múltiples funciones Tejido Dinámico

Remodelamiento Oseo El remodelamiento es el proceso que permite renovar y reparar el tejido óseo

Remodelamiento Oseo

Concepto de Masa Osea Máxima

Los huesos son órganos vivos, que empiezan a crecer desde el nacimiento El primer período de crecimiento rápido ocurre del nacimiento a los 2 años de edad. Un segundo período de crecimiento rápido ocurre durante la adolescencia, momento en que ocurre la maduración sexual

La maduración sexual ocurre entre los 11 a los 14 años de edad en niñas, y entre los 13 y 17 años de edad en niños. Durante la pubertad, la densidad ósea (la calcificación en el hueso) en columna y cadera, aumenta 5 veces

En niñas, la cantidad de hueso que se forma durante los 11 a los 13 años de edad, equivale a la cantidad de hueso que perderán de los 50 a los 80 años de edad

Se estima que un aumento del 10% en el pico de masa ósea reduce el riesgo de fracturas por osteoporosis en la edad adulta, en un 50%

Pérdida de Masa Osea Hueso Normal Osteoporosis Normal trabecular bone, as shown on the left, appears as a dense network of trabeculae with small spaces. Osteoporotic bone, as shown on the right in a micrograph of postmenopausal osteoporosis, reveals lost bone and minimal trabecular connections. The loss of trabecular struts results in weakened bones and leads to fractures. Dempster DW, Shane E, Horbert W, Lindsay R. A simple method for correlative light and scanning electron microscopy of human iliac crest bone biopsies: qualitative observations in normal and osteoporotic subjects. J Bone Miner Res. 1986;1:15-21. Reproduced from J Bone Miner Res. 1986;1:15-21 with permission of the American Society for Bone and Mineral Research

Osteoporosis Enfermedad silenciosa Enfermedad esquelética sistémica1 Baja densidad ósea (DMO) Alteraciones celulares Deterioro microarquitectónico del tejido óseo Fragilidad ósea Riesgo de fractura incrementado Osteoporosis is often referred to as the silent disease because significant bone loss may occur without any symptoms. In fact, individuals may not know they have osteoporosis until their bones become so weak that a strain or fall causes a fracture to occur or vertebrae to collapse. Although collapsed vertebrae can be extremely painful, fractures of the spine can be silent (without symptoms). Osteoporosis is a systemic skeletal disease characterized by low bone mineral density (BMD) and microarchitectural deterioration of bone tissue, leading to bone fragility and increased risk for fracture (Consensus Development Conference, 1991.). People with osteoporosis may also experience silent fractures, which lead to height loss and increased length of hospital stay. A World Health Organization (WHO) panel has defined osteoporosis as a BMD 2.5 standard deviations below the young adult mean (Kanis JA, et al, 1994.). Patients with a BMD between 1 and 2.5 standard deviations below the young adult mean are classified as having low bone mass, or osteopenia. The number of standard deviations below the mean for a young adult healthy population is referred to as a T-score. T-scores are derived from databases of BMD in young healthy patients. These databases vary between manufacturers and the instrument used to obtain the data. Therefore, T-scores for a given patient may vary up to 15% from manufacturer to manufacturer (Faulkner KG, et al, 1999.). Consensus Development Conference: Prophylaxis and treatment of osteoporosis. Am J Med. 1991;90:107-110. Kanis JA, and the WHO Study Group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int. 1994;4:368-381. Faulkner KG, von Stetten E, Miller P. Discordance in patient classification using T-scores. J Clin Densitom. 1999;2:343-350. 1Consensus Development Conference. Am J Med. 1991.

Osteoporosis–Impacto <20% of mujeres europeas osteoporóticas reciben tratamiento1 Afecta 1de cada 3 mujeres postmenopáusicas 1 de cada 5 pacientes con fractura de cadera muere de complicaciones en 6 meses2 Incidencia de fractura de cadera aumentará un 300% para el año 20503 Early detection and prompt treatment are key to the prevention and reduction of fragility fractures. Yet, despite the high and increasing incidence of osteoporosis and the evidence supporting evaluation and treatment, osteoporosis remains largely undertreated. It is estimated that less than 20% of European women with osteoporosis receive treatment (IOF Survey, 1999.). Approximately 1 in 5 osteoporosis patients who sustain hip fractures will die of complications within 6 months (International Osteoporosis Foundation Annual Report, 1999.). As the population continues to age, a worldwide increase in the incidence of osteoporotic fractures is inevitable. The World Health Organization expects the number of osteoporosis-related hip fractures to increase 3-fold by 2050 (World Health Organization, 1999.). Some physicians may believe it is too late to alter the natural course of disease at a late stage; however, even small changes in bone density can substantially reduce the risk of fracture (Riggs, 1992.). Most important, risk of hip fracture and subsequent fracture increases with age. Physicians should not miss the opportunity to diagnose patients at risk and to treat patients, at any age, who have already sustained a fracture. It is never too late to treat. International Osteoporosis Foundation. International Survey. Available at: http://www.osteofound.org/programs_projects/international_survey.html. Accessed September 7, 2000. International Osteoporosis Foundation. Annual Report 1999. Available at: http://www/osteofound.org/who/annual_report.html. Accessed October 6, 2000. World Health Organization. Osteoporosis: both health organizations and individuals must act now to avoid an impending epidemic [press release]. October 11, 1999. Available at: http://www.who.int/inf-pr-1999/en/pr99-58.html. Accessed July 5, 2000. Riggs BL, Melton LJ III. The prevention and treatment of osteoporosis. N Engl J Med. 1992;327:620-627. 1IOF International Survey. Available at: http://www.osteofound. org/programs_projects/international_survey.html.2000. 2IOF. Annual Report. 1999. 3 WHO. [press release]. 1999.

Fracturas Osteoporóticas en Mujeres: Comparación con Otras Enfermedades 2000 1 500 0001 1500 Incidencia Anual USA x 1000 1000 500 0002 500 240 0003 180 0003 The incidence of osteoporotic fracture in women is far greater than the incidence of heart attack, stroke, and breast cancer combined. Yet, osteoporosis remains largely underdiagnosed and undertreated. Although patients are routinely screened for risks factors associated with heart attack, stroke, and breast cancer, prevention and treatment of osteoporosis is often overlooked. In the United States alone, only one third of vertebral deformities are clinically diagnosed, a clear indication that the incidence of vertebral fracture remains underestimated (Cooper C, Melton LJ, 1992.). Cooper C, Melton LJ. Epidemiology of Osteoporosis. Trends Endocrinol Metab. 1992;3:224-229. Osteoporosis Fast Facts. National Osteoporosis Foundation. Available at: http//www.nof.org/osteoporosis/stats.htm. Accessed November 8, 2000. National Institutes of Health, National Heart, Lung and Blood Institute. Healthy Heart Handbook for Women. Available at: http://www.nhlbi.nih.gov/head/public/heart/other/hhw/index.htm. Accessed November 9, 2000. Statistical Information on Women and Women’s Health. The National Women’s Health Information Center, US Department of Health and Human Services Available at: http://www.4woman.gov/media/statistics.htm. Accessed November 9, 2000. Fracturas por Osteoporosis Paro Cardíaco AVC Cáncer de Mama 1Osteoporosis Fast Facts. National Osteoporosis Foundation. 2000. 2 National Institutes of Health. Healthy Heart Handbook for Women. 2000. 3Statistical Information on Women and Women’s Health. US Department of Health and Human Services. 2000.

El estudio LAVOS, realizado en latinoamérica, indica que 15% de las mujeres mayores de 50 años tienen fracturas vertebrales, la mayor parte de ellas asintomáticas En Costa Rica, ocurren alrededor de 4 fracturas de cadera por osteoporosis al día

La pérdida de estatura por osteoporosis se debe a que la columna vertebral se fractura poco a poco.

La cadera es uno de los sitios de mayor peligro de sufrir fractura por osteoporosis. Aproximadamente un 15% de las mujeres blancas mayores de 50 años sufren una fractura de cadera durante su vida

Reconocer la Enfemedad a Tiempo Factores de Riesgo Diagnóstico adecuado Seguimiento adecuado

No Modificables Historia Familiar Raza: Asiático o Caucásico Edad Sexo Femenino Bajo Peso <127 lb (<57.7 kg) Uso crónico de glucocorticoides* Family history, race (Asian or Caucasian), advanced age, being female, and low body weight (<127 lb or <57.7 kg) are all nonmodifiable risk factors. Chronic use of glucocorticoids may or may not be modifiable, depending on the indication for therapy. Therapies are now available to prevent this bone loss. However, the literature has shown that long-term glucocorticoid therapy is a significant risk factor for osteoporosis that should not be overlooked. National Osteoporosis Foundation. Available at: http://www.nof.org/osteoporosis/stats.htm. Accessed November 8, 2000. *Puede ser modificado según la condición tratada National Osteoporosis Foundation. http://www.nof.org/osteoporosis/stats.htm. 2000.

Modificables Tabaquismo Abuso de Licor Ingesta de Ca y Vit D insuficientes Sedentarismo Deficiencia de Estrógenos o Testosterona Uso crónico de glucocorticoides* Potentially modifiable risk factors include cigarette smoking, excessive use of alcohol, lifelong insufficient calcium and vitamin D intake, inadequate physical activity, estrogen deficiency from early menopause or hysterectomy, or amenorrhea of more than 1 year. These risk factors are considered modifiable because one can choose to stop smoking, decrease alcohol intake, increase calcium intake, increase physical activity, and correct hormonal deficiencies. National Osteoporosis Foundation. Available at: http://www.nof.org/osteoporosis/stats.htm. Accessed November 8, 2000. *Puede ser modificable según la condición tratada National Osteoporosis Foundation. Available at: http://www.nof.org/osteoporosis/stats.htm. 2000.

Un caso real Claire Peach, australiana era sana. Tenía 17 años e iba a representar su país en las Olimpiadas de 1996, en remo. Durante una competencia sufrió una fractura pélvica por osteoporosis.

¿Qué pasó? “Estaba entrenando tanto que mis menstruaciones desaparecieron” “Estaba bajo una dieta baja en grasas y baja en calorías, y dejé de consumir lácteos, así que no obtenía suficiente calcio” “No era consciente de que el nivel tan elevado de entrenamiento estaba poniendo mi cuerpo en tanto riesgo” “Estoy bien ahora, pero los tiempos de competir ya se acabaron” “Pero tendré que tener cuidado cuando llegue a la menopausia y educaré a mis hijos sobre la salud de sus huesos”

Condiciones Predisponentes Endocrinas Síndrome de Cushing Hipertiroidismo Deficiencia de Estrógenos o Testosterona Renales Insuficiencia Renal Reumatológicas Espondilitis Anquilosante Artritis Reumatoidea Gastrointestinales Gastrectomía Malabsorción Endocrine disorders associated with the development of osteoporosis include hyperparathyroidism, Cushing’s syndrome, hyperprolactinemia, hypercalciuria, hyperthyroidism, and estrogen or testosterone deficiency (Kohlmeier L, 1999.). In young women, amenorrhea and other menstrual irregularities are associated with decreased bone density (Davies MC, et al, 1990.). Estrogen deficiency interferes with bone formation by enhancing bone resorption or bone loss. Estrogen deficiency also reduces absorption of intestinal calcium. Renal disorders include renal failure or insufficiency, renal tubular acidosis, and renal osteodystrophy. Ankylosing spondylitis and rheumatoid arthritis are rheumatologic disorders associated with osteoporosis. Gastrointestinal disorders include gastrectomy, celiac disease, and malabsorption. Primary biliary or idiopathic cirrhosis is an example of an hepatic disorder associated with osteoporosis. Infiltrative disorders include multiple myeloma, Gaucher’s disease, leukemia, and mastocytosis. Finally, connective tissue disorders associated with osteoporosis include osteogenesis imperfecta, homocystinuria, Ehlers-Danlos syndrome, and Marfan’s syndrome. Several other distinct medical problems are associated with accelerated bone loss and eventual osteoporosis, including renal, rheumatologic, gastrointestinal, hepatic, infiltrative, and connective tissue disorders (Kohlmeier L, 1999.). Davies MC, Hall ML, Jacob HS. Bone mineral loss in young women with amenorrhea. Br Med J. 1990;301:790-793. Kohlmeier L. Osteoporosis update: prevention and treatment. Drug Benefit Trends. 1999;11:43-54. Kohlmeier L. Drug Benefit Trends. 1999.

Medicamentos Asociados con Riesgo Glucocorticoides Heparina (a largo plazo) Anticonvulsantes Litio Inmunosupresores (ej, metrotrexate, ciclosporina) Drogas Citotóxicas Tamoxifeno (uso premenopáusico) Exceso de levotiroxina Agonistas LHRH Rx Lithium Long-term administration of glucocorticoids are well known to predispose to osteoporosis. In addition to glucocorticoids, several other medications also compromise bone density. These drugs fall into a variety of classes, including anticonvulsants, antipsychotics, anticoagulants, immunosuppressants, cytotoxic agents, and hormone agonists (National Osteoporosis Foundation, 1998.). National Osteoporosis Foundation. Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc; 1998:7-8. National Osteoporosis Foundation. Physician’s Guide to Prevention and Treatment of Osteoporosis. 1998.

Densitometría Osea Disciplina médica Requiere de entrenamiento especial Es crucial la interpretación clínica Equipos exactos y precisos Errores de precisión y de interpretación son muy frecuentes, debido a error humano

Pruebas periféricas de Tamizaje

Sistemas DXA Equipos sofisticados Totalmente computarizados Fuente de Rayos X DXA Receptores electrónicos Control Calidad Radiación muy baja

Mediante el estudio densitométrico es posible medir la densidad ósea y diagnosticar osteoporosis Los estudios seriados (usualmente cada año) permiten al médico evaluar le evolución del proceso Siempre deben ser realizados en el mismo equipo y siguiendo un protocolo de seguimiento para evitar errores de precisión

Densitometrías de distintos equipos NO son comparables

Metas del Tx Prevenir Fx Estabilizar o mejorar la masa ósea Minimizar síntomas Mejorar Función Física Mejorar calidad de vida Prevention and treatment of bone loss and osteoporosis can be achieved with agents that stop or decrease bone resorption. These agents decrease the imbalance between bone formation and resorption or reduce the rate of bone turnover. Analgesics and muscle relaxants can help alleviate the acute pain associated with a fracture. Chronic pain can be lessened by stretching and strengthening paraspinal muscles. Patients who engage in daily stretching and strengthening exercises have reported marked decreases in back pain and fatigue (McClung MR, 1994.). Improving physical function involves a comprehensive program of exercise, fall prevention, use of proper body mechanics, and balance enhancement. Learning how to prevent falls is important, since 90% of hip fractures result from falls (Hayes WC, Myers ER, 1995.). Educating patients about osteoporosis, helping them make lifestyle changes (such as stopping smoking or limiting alcohol intake), and supporting them and their families can help them cope with the physical, social, and emotional challenges that osteoporosis presents, including chronic pain, deformity, debility, and social isolation. It is also important to identify sources of support for patients in the community. McClung MR. Nonpharmacologic management of osteoporosis. In: Marcus R, ed. Osteoporosis. Oxford, England: Blackwell; 1994:336-353. Hayes WC, Myers ER. Biomechanics of fractures. In: Marcus, ed. Osteoporosis: Etiology, Diagnosis, and Management. Philadelphia, Pa: Lippincott-Raven; 1995:93-114.

Calcio El calcio y el ejercicio son fundamentales. Fuentes “naturales” : alimentos Evitar suplementos de calcio sin respaldo de calidad Evitar calcio de ostra Evitar uso de vitamina D, salvo por indicación médica

Calcio 1 taza yogurt 300 mg 1 taza de leche 300 mg 1 taza de leche extracalcio 400 mg 1 onza de queso fresco 250 mg 1 onza de queso de soya (tofú) 40 mg 3 onzas de sardinas enlatadas 375 mg 1 taza de bróccoli 90 mg 3 tortillas de maíz 80 mg 1 taza garbanzos 80 mg 2 cucharadas ajonjolí 20 mg

Ejercicio Mejora: Coordinación Motora Equilibrio Fuerza Muscular Reflejos Tono Muscular Otros Beneficios

Ejercicio Baile Natación Caminata Tai Chi Gimnasia Pesas Aeróbicos de bajo impacto Otros

Ejercicio NO hacer flexiones NO hacer ejercicio en condiciones peligrosas Utilizar ropa adecuada NO sobrepasarse

NO hacer Flexiones de Columna

Posturas a Evitar

¿Qué tan Segura es su Casa?

Prevención de Fracturas Para que Ocurra una Fractura deben coexistir varios factores

Prevención de Fracturas Calzado Iluminación Obstáculos Agarraderas Pisos, desniveles, humedad Medicamentos: sedantes, etc Licor Flexiones de columna, etc

Medicamentos Existen muchas opciones de tratamiento Problemas: Cumplimiento Tolerancia Otros medicamentos concomitantes

Bifosfonatos Orales semanales Orales mensuales Intravenosos trimestrales Intravenosos anuales Terapia de reemplazo hormonal Raloxifeno Ranelato de estroncio Teriparatida Calcio y vitamina D como coadyuvantes

Los tratamientos deben ser utilizados por varios años No deben ser cambiados o modificados a menos que sea por indicación médica Los medicamentos para osteoporosis NO son calcio.

Conclusiones La salud esquelética es prioridad a toda edad La osteoporosis es una condición muy frecuente El tratamiento para la osteoporosis consiste en medidas nutricionales, de ejercicio, de prevención de fracturas y medicación Es crucial el cumplimiento del tratamiento

Muchas gracias