Osteoporosis

From Wikipedia, the free encyclopedia

Osteoporosis

Elderly woman with osteoporosis showing a curved

back from compression fractures of her back bones.
Classification and external resources
Pronunciation /stiopross, -p-/[1][2]
Specialty
Rheumatology
ICD-10
M80-M82
ICD-9-CM
733.0
OMIM
166710
DiseasesDB 9385
MedlinePlus 000360
eMedicine
med/1693 ped/1683 pmr/94 pmr/95
Patient UK
Osteoporosis
MeSH
D010024
[edit on Wikidata]
Osteoporosis is a disease where decreased bone strength increases the risk of a broken bone. It is
the most common reason for a broken bone among the elderly.[3] Bones that commonly break
include the back bones, the bones of the forearm, and the hip.[4] Until a broken bone occurs there

are typically no symptoms. Bones may weaken to such a degree that a break may occur with
minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities
may occur following a broken bone.[3]
Osteoporosis may be due to lower than normal peak bone mass and greater than normal bone
loss. Bone loss increases after menopause due to lower levels of estrogen. Osteoporosis may also
occur due to a number of diseases or treatments including alcoholism, anorexia,
hyperthyroidism, surgical removal of the ovaries, and kidney disease. Certain medications
increase the rate of bone loss including some antiseizure medications, chemotherapy, proton
pump inhibitors, selective serotonin reuptake inhibitors and steroids. Not enough exercise and
smoking are also risk factors.[3] Osteoporosis is defined as a bone density of 2.5 standard
deviations below that of a young adult.[5] This is typically measured by dual-energy X-ray
absorptiometry at the hip.[5]
Prevention of osteoporosis includes a proper diet during childhood and efforts to avoid
medications that cause the condition. Efforts to prevent broken bones in those with osteoporosis
include a good diet, exercise, and fall prevention. Lifestyle changes such as stopping smoking
and not drinking alcohol may help.[3] Medication of the bisphosphonate type are useful in those
with previous broken bones due to osteoporosis.[6][7] In those with osteoporosis but no previous
broken bones they are less effective.[6][7][8] A number of other medications may also be useful.[3][9]
Osteoporosis becomes more common with age.[3] About 15% of white people in their 50s and
70% of those over 80 are affected.[10] It is more common in women than men.[3] In the developed
world, depending on the method of diagnosis, 2% to 8% of males and 9% to 38% of females are
affected.[11] Rates of disease in the developing world are unclear.[12] About 22 million women and
5.5 million men in the European Union had osteoporosis in 2010.[13] In the United States in 2010
about eight million women and one to two million men had osteoporosis.[11][14] White and Asian
people are at greater risk.[3] The word osteoporosis is from the Greek terms for "porous bones".[15]

Signs and symptoms

Osteoporosis is an age-related disorder that causes the gradual loss of bone density
and strength. When the thoracic vertebrae are affected, there can be a gradual
collapse of the vertebrae. This results in kyphosis, an excessive curvature of the
thoracic region.

Illustration depicting normal standing posture and osteoporosis

Osteoporosis locations

Osteoporosis itself has no symptoms; its main consequence is the increased risk of bone
fractures. Osteoporotic fractures occur in situations where healthy people would not normally
break a bone; they are therefore regarded as fragility fractures. Typical fragility fractures occur in
the vertebral column, rib, hip and wrist.
Medication
Certain medications have been associated with an increase in osteoporosis risk; only steroids and
anticonvulsants are classically associated, but evidence is emerging with regard to other drugs.

Steroid-induced osteoporosis (SIOP) arises due to use of glucocorticoids

analogous to Cushing's syndrome and involving mainly the axial skeleton.
The synthetic glucocorticoid prescription drug prednisone is a main candidate
after prolonged intake. Some professional guidelines recommend prophylaxis
in patients who take the equivalent of more than 30 mg hydrocortisone

(7.5 mg of prednisolone), especially when this is in excess of three months. [64]

Alternate day use may not prevent this complication. [65]

Barbiturates, phenytoin and some other enzyme-inducing antiepileptics

these probably accelerate the metabolism of vitamin D. [66]

L-Thyroxine over-replacement may contribute to osteoporosis, in a similar

fashion as thyrotoxicosis does.[54] This can be relevant in subclinical
hypothyroidism.

Several drugs induce hypogonadism, for example aromatase inhibitors used

in breast cancer, methotrexate and other antimetabolite drugs, depot
progesterone and gonadotropin-releasing hormone agonists.

Anticoagulants long-term use of heparin is associated with a decrease in

bone density,[67] and warfarin (and related coumarins) have been linked with
an increased risk in osteoporotic fracture in long-term use. [68]

Proton pump inhibitors these drugs inhibit the production of stomach acid;
this is thought to interfere with calcium absorption. [69] Chronic phosphate
binding may also occur with aluminium-containing antacids.[54]

Thiazolidinediones (used for diabetes) rosiglitazone and possibly

pioglitazone, inhibitors of PPAR, have been linked with an increased risk of
osteoporosis and fracture.[70]

Chronic lithium therapy has been associated with osteoporosis. [54]

Prevention
Lifestyle prevention of osteoporosis is in many aspects the inverse of the potentially modifiable
risk factors.[83] As tobacco smoking and high alcohol intake have been linked with osteoporosis,
smoking cessation and moderation of alcohol intake are commonly recommended as ways to
help prevent it.[84]
In people with coeliac disease adherence to a gluten-free diet decreases risk to develop
osteoporosis[85] and increases bone density.[57] It must ensure optimal calcium intake (of at least
one gram daily) and measure vitamin D levels, and to take specific supplements if necessary.[85]
Nutrition
Studies of the benefits of supplementation with calcium and vitamin D are conflicting, possibly
because most studies did not have people with low dietary intakes.[86] A 2013 review by the
USPSTF found insufficient evidence to determine if supplementation with calcium and vitamin
D results in greater harm or benefit in men and premenopausal women.[87] The USPSTF did not
recommend low dose supplementation (less than 1 g of calcium and 400 IU of vitamin D) in
postmenopausal women as there does not appear to be a difference in fracture risk.[87] It is

unknown what effect higher doses have.[87] A 2015 review found little data that supplementation
of calcium decreases the risk of fractures.[88]
While some meta-analyses have found a benefit of vitamin D supplements combined with
calcium for fractures, they did not find a benefit of vitamin D supplements alone.[89][90]
While supplementation does not appear to affect the risk of death,[90] there is an increased risk of
myocardial infarctions with calcium supplementation,[91][92] kidney stones,[87] and stomach
problems.[90]
Vitamin K deficiency is also a risk factor for osteoporotic fractures. The gene gammaglutamylcarboxylase (GGCX) is dependent on vitamin K. Functional polymorphisms in the gene
could attribute to variation in bone metabolism and BMD. Vitamin K2 is also used as a means of
treatment for osteoporosis and the polymorphisms of GGCX could explain the individual
variation in the response to treatment of vitamin K.[93] Vitamin K supplementation may reduce
the risk of fractures in postmenopausal women;[94] however, there is no evidence for men.[95]
Medications
Bisphosphonates are useful in decreasing the risk of future fractures in those who have already
sustained a fracture due to osteoporosis.[6][7][84] This benefit is present when taken for three to four
years.[99] They have not been compared directly to each other, though, so it is not known if one is
better.[84] Fracture risk reduction is between 25 and 70% depending on the bone involved.[84]
There are concerns of atypical femoral fractures and osteonecrosis of the jaw with long term use,
but these risks are low.[84][100] With evidence of little benefit when used for more than three to five
years and in light of the potential adverse events, it may be appropriate to stop treatment after
this time in some.[99] One medical organization recommends that after five years of medications
by mouth or three years of intravenous medication among those at low risk, bisphosphonate
treatment can be stopped.[101] In those at higher risk they recommend up to ten years of
medication by mouth or six years of intravenous treatment.[101]
For those with osteoporosis but who have not had any fractures evidence does not support a
reduction of in fracture risk with risedronate[7] or etidronate.[8] Alendronate decreases fractures of
the spine but does not have any effect on other types of fractures.[6] Half stop their medications
within a year.[102]
Fluoride supplementation does not appear to be effective in postmenopausal osteoporosis, as
even though it increases bone density, it does not decrease the risk of fractures.[103][104]
Teriparatide ( a recombinant parathyroid hormone ) has been shown to be effective in treatment
of women with postmenopausal osteoporosis.[105] Some evidence also indicates strontium ranelate
is effective in decreasing the risk of vertebral and nonvertebral fractures in postmenopausal
women with osteoporosis.[106] Hormone replacement therapy, while effective for osteoporosis, is
only recommended in women who also have menopausal symptoms.[84] Raloxifene, while

effective in decreasing vertebral fractures, does not affect the risk of nonvertebral fracture.[84]
And while it reduces the risk of breast cancer, it increases the risk of blood clots and strokes.[84]
Denosumab is also effective for preventing osteoporotic fractures.[84] In hypogonadal men,
testosterone has been shown to improve bone quantity and quality, but, as of 2008, no studies
evaluated its effect on fracture risk or in men with a normal testosterone levels.[56] Calcitonin
while once recommended is no longer due to the associated risk of cancer with its use and
questionable effect on fracture risk.[107]
Certain medications like alendronate, etidronate, risedronate, raloxifene and strontium ranelate
can be helpful for the preventing of osteoporotic fragility fractures in postmenopausal women
with osteoporosis.[108]

When should you seek medical attention?

Most cases of kyphosis are caused by postural changes and rarely progress to cause serious
complications. However, any patient that develops signs or symptoms of kyphosis should be
evaluated by a physician to rule out a more serious cause. Additionally, any patient with
worsening of symptoms or who develops any weakness, numbness, or tingling in the legs or
chest pain and shortness of breath should be seen by a physician.
What tests is your physician likely to obtain?

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Your doctor will likely begin by obtaining your medical history, including when you first noticed
your symptoms, any history of family members with similar problems, and other history of back
or neck problems. A physical examination will then be performed. This will assess the curve of
your spine both standing upright and while bending forward. Your strength, sensation, reflexes,
and flexibility in your arms and legs will also be tested.
Based on the results of the history and physical examination, your physician may order X-rays of
your spine. This can help differentiate postural kyphosis (normal shaped vertebrae) from
Scheuermann's kyphosis (wedged-shaped vertebrae). If your doctor finds any evidence of
neurologic injury, you may also obtain an MRI of your spine. This can identify any compression
of the spinal cord or nerves. If you have any chest pain or shortness of breath, your physician
may order additional tests to evaluate your heart and lungs.
How is abnormal kyphosis treated?
Postural kyphosis can usually be treated with physical therapy to help strengthen the muscles of
your back and correct your posture. Mild pain relievers and antiinflammatory medications can
also help with symptoms. These curves do not continue to worsen with time or lead to more
serious complications. Surgery is not needed for postural kyphosis.
Scheuermann's kyphosis is usually initially treated with a combination of physical-therapy
exercises and mild pain and antiinflammatory medications. If the patient is still growing, a brace
can be effective. Braces are often recommended for curves of at least 45 degrees and can be
continued until the patient is no longer growing. Your physician will likely obtain routine X-rays
to monitor the degree of kyphosis over time. Bracing is not typically recommended for adults
who are no longer growing.
In some cases, surgery is recommended for Scheuermann's kyphosis. The goals of surgery are to
partially correct the deformity of the kyphosis, relieve pain, and improve your overall spinal
alignment. Indications for surgery include a curve greater than 75 degrees, uncontrolled pain, and
neurologic, cardiac, or pulmonary complaints.

There are various types of surgical procedures available depending on the specifics of each case.
Surgery can be performed from the front (anterior approach), from the back (posterior approach),
or both (combined anterior and posterior approach). This decision is made by your surgeon based
on the specific characteristics of your curve. You may obtain X-rays bending forward and
backward to determine how flexible your spine is. If it is flexible, a posterior approach may be
adequate. If you are less flexible, you may need an anterior or combined approach. Regardless of
the approach, the surgery involves partially straightening your spine and using rods and screws in
the vertebrae to hold the spine while a bony fusion occurs.
Treatment of congenital kyphosis often involves surgery while the patient is an infant. This is
because the kyphosis is caused by an abnormality in the developing vertebrae. Surgery earlier in
life can help correct the kyphosis before it continues to worsen.
Sometimes kyphosis from painful collapse of vertebrae due to osteoporosis is treated with a
procedure called a kyphoplasty, whereby a balloon is inserted into the affected vertebra and filled
with a liquid (methymethacrylate) that hardens to restore the vertebral height. This procedure is a
last resort after failure of noninvasive treatment.

Psoriasis

What Is Psoriasis?
Psoriasis is a genetically programmed inflammatory disease that affects primarily the skin in
about 3% of individuals in the United States. Psoriasis begins as a small scaling papule. When
multiple papules coalesce, they form scaling plaques. These plaques tend to occur in the scalp,
elbows, and knees.
Symptoms of Psoriasis
Although psoriatic plaques can be limited to only a few small areas, the condition can involve
widespread areas of skin anywhere on the body. These plaques can be itchy, and when the scale
is peeled away, small bleeding points may appear. Psoriasis tends to occur in areas of trauma.
This condition often waxes and wanes spontaneously.

Nail Psoriasis
Many patients with psoriasis have abnormal nails. Psoriatic nails often have a horizontal white or
yellow margin at the tip of the nail called distal onycholysis because the nail is lifted away from
the skin. There can often be small pits in the nail plate, and the nail is often yellow and crumbly.

What Causes Psoriasis?

It is now clear that there is a genetic basis for psoriasis. This hereditary predisposition is
necessary before the disease can be triggered by environmental factors. White blood cells called

T-cells mediate the development of the psoriatic plaques that are present in the skin.

Psoriasis Triggers
The environmental factors that seem to trigger psoriasis include:

streptococcal sore throat,

trauma to the skin,

certain drugs,

alcohol in excess.

Psoriasis Treatment: Topicals

Since psoriasis mainly affects the skin, topical treatments are very useful because they are
relatively safe, quite effective, and can be applied directly to the disease. They take the form of
lotions, foams, creams, ointments, gels, and shampoos. They include topical steroids, tar
preparations, and calcium- modulating drugs. The precise drug used and the form in which it is
delivered depends on the areas involved. In widespread disease in patients with more than 10%
of the body surface involved, it may not be practical to use topical medication alone.

Psoriasis Treatment: Phototherapy

For more extensive disease, a useful option is ultraviolet light exposure. Ultraviolet light (UVL)
can treat large areas of skin with few side effects if performed in the physicians office. It should
be kept in mind that all UVL causes mutational events, which can lead to skin cancer. At this
time, the most popular type of UVL for psoriasis is called narrow-band UVB. Only a small
portion of the UVL spectrum is used, which seems to be particularly beneficial for psoriasis and
may of less carcinogenic potential. This UVB is quite different from the UVA, the wavelength
available in tanning salons.

Psoriasis Treatment: Laser Therapy

There are lasers that produce UVL in wavelengths similar to narrow-band UVB. These can be
quite effective for small plaques of psoriasis, but because the areas of skin that can be treated at
one time are small, they are not practical for extensive disease.

Psoriasis Treatment: Oral Medications

There are a variety of drugs administered systemically that are useful in controlling psoriasis.
The choice of which drug to use depends upon many factors which make this a very individual
choice. Since these drugs are administered either orally or through the skin, they are more risky
for the patient than topical medications. As a generalization, most seem to act by targeting
portions of the immune system. The only exception currently is a drug called acitretin
(Soriatane), which is structurally similar to vitamin A. Since the immune system is necessary in
order to survive, systemic treatments do have a downside. Drugs like methotrexate and
cyclosporine are administered orally and can affect the liver, kidney, and bone marrow. A new
oral medication recently approved for treatment of psoriasis is called Otezla (apremilast). This
drug appears to be considerably safer that most of its predecessors but is also quite expensive.

Psoriasis Treatment: Biologics

A new class of drugs has recently been developed called biologics; they're called biologics
because living cells synthesize them. Since these drugs are proteins, they cannot be administered
orally and must be given by injection through the skin or by an intravenous infusion. These drugs
are very precise in their target and block a single step in the immune process. This seems to have
increased their safety profile as well as their effectiveness when compared to older drugs. On the
other hand, they are quite expensive.

Natural Remedies for Psoriasis

Since the natural solar spectrum contains ultraviolet light, there is no question that heliotherapy
(medicinal sunbathing) can be effective in controlling psoriasis. There is mounting evidence that
increased body mass is associated with psoriasis and that heavier individuals are more difficult to
treat. So a normal body mass is desirable. There is some dispute as to the role of diet in psoriasis,
but a diet low in saturated fats is desirable for many reasons including weight control. So-called
"natural or botanical" treatments have very little evidence to support their use. There is
accumulating evidence that the inflammation present in the skin is also present in other portions
of body which seems to predispose affected patients to diabetes and premature cardiovascular
disease.