Osteomalacia - Standard Treatment Guidelines

Osteomalacia is a generalized bone condition in which there is inadequate mineralization of the bone. Many of the effects of the disease overlap with the more common osteoporosis, but the two diseases are significantly different. There are two main causes of osteomalacia: (1) insufficient calcium absorption from the intestine because of lack of dietary calcium or a deficiency of or resistance to the action of vitamin D; and (2) Phosphate deficiency caused by increased renal losses

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines Osteomalacia. Following are the major recommendations :

Case Definition:

Osteomalacia is the softening of the bones due to defective bone mineralization secondary to inadequate amounts of available phosphorus and calcium. It may show signs as diffuse body pains, muscle weakness, and fragility of the bones. The most common cause of the disease is a deficiency in vitamin D, which is normally obtained from the diet and/or sunlight exposure

Incidence of Condition In Our Country

In the US and Europe, more than 40% of the adult population older than age 50 are vitamin D deficient, this being the most prominent cause of osteomalacia. http://bestpractice.bmj.com/bestpractice/monograph/517/resources/references.html - ref-4In developing countries vitamin D deficiency leading to clinical rickets is described in 60% of infants. In the Middle East, a high prevalence of rickets and osteomalacia has been described in Muslim women and their infants, perhaps due to increased clothing coverage of the skin.

Differential Diagnosis

Differential diagnosis of osteomalacia include

Osteoporosis

Pagets disease

Prevention And Counselling

Ensuring adequate sunlight exposure and dietary intake of fortified foods containing vitamin D, calcium, and phosphorus may help avoid osteomalacia It is recommended that maintenance dosing in adults <50 years age should be 400-800 International Units (IU) of vitamin D daily, and that adults ≥50 years age should get 800-1000 IU of vitamin D daily. Adults should also take 1.2 g of elemental calcium in the diet or as a supplement.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

SITUATION 1: At Secondary Hospital / Non Metro situation : Optimal standards of Treatment in situations where technology and resources are limited

Clinical diagnosis:

Osteomalacia in adults starts insidiously as aches and pains in the lumbar (lower back) region and thighs, spreading later to the arms and ribs. The pain is symmetrical, non-radiating and is accompanied by sensitivity in the involved bones. Proximal muscles are weak, and there is difficulty in climbing up stairs and getting up from a squatting position. Physical signs include deformities like triradiate pelvis and lordosis. The patient has a typical "waddling" gait. However, those physical signs may derive from a previous osteomalacial state, since bones do not regain their original shape after they become deformed. May present as pathological fracture.

Investigations:

Serum Calcium

Serum Phosphate

Alkaline Phosphatase

Serum urea creatinine

24 Hr urinary calcium

X rays of the deformed part

Treatment:

Nutritional osteomalacia responds well to administration of 10,000 IU weekly of vitamin D for four to six weeks. Osteomalacia due to malabsorption may require treatment by injection or daily oral dosing of significant amounts of vitamin D

Standard Operating Procedure

In Patient : For corrective surgery

Out Patient : supplementation and bracing

Day Care: Injectable form of Vit D

Referral criteria:

For evaluation and management of cases not responding to conventional therapy.

* SITUATION 2: At Super Specialty facility in Metro Location where higher end technology is available

Clinical diagnosis:

Osteomalacia in adults starts insidiously as aches and pains in the lumbar (lower back) region and thighs, spreading later to the arms and ribs. The pain is symmetrical, non-radiating and is accompanied by sensitivity in the involved bones. Proximal muscles are weak, and there is difficulty in climbing up stairs and getting up from a squatting position. Physical signs include deformities like triradiate pelvis and lordosis. The patient has a typical "waddling" gait. However, those physical signs may derive from a previous osteomalacial state, since bones do not regain their original shape after they become deformed. May present as pathological fracture.

Investigations:

Serum Calcium

Serum Phosphate

Alkaline Phosphatase

Serum urea creatinine

24 Hr urinary calcium

X rays of the deformed part

Others are

1,25 – dihydroxy- Vit D level

Parathormone level

DXA

Bone Biopsy with double tetracycline labelling

Technitium Bone scan

Treatment:

not applicable

Standard Operating Procedure

In Patient : For corrective surgery

UV-B radiation

Tanning beds and other UV-B radiation devices have been used to treat vitamin D deficiency in the elderly and in malabsorptive disorders.

Out Patient : supplementation and bracing

Day Care: Injectable form of Vit D

Referral criteria:

not applicable

WHO DOES WHAT? AND TIMELINES

Doctor

Early diagnosis and appropriate treatment. Counsel the patient for prevention and dietary advice.

Nurse

Counselling the patient

Technician

Appropriate bracing manufacturing and application Physiotherapy

Resources Required For One Patient / Procedure (Patient Weight 60 Kgs)

(Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)

Guidelines by The Ministry of Health and Family Welfare :

Dr. P.K. DAVE, Rockland Hospital, New Delhi, Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. SHARMA Professor Central Instiute of Orthopaedics Safdarjung Hospital New Delhi