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Osteoporosis – Standard Treatment Guidelines


Osteoporosis – Standard Treatment Guidelines

Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered.

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

Case Definition:

Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density that is 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by DXA; the term “established osteoporosis” includes the presence of a fragility fracture. The disease may be classified as primary type 1, primary type 2, or secondary. The form of osteoporosis most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis. Primary type 2 osteoporosis or senile osteoporosis occurs after age 75 and is seen in both females and males at a ratio of 2:1. Finally, secondary osteoporosis may arise at any age and affects men and women equally. This form of osteoporosis results from chronic predisposing medical problems or disease.

Incidence of Condition In Our Country

The exact incidence of osteoporosis in India is not known .However ,according to one study,approximately 6-7 crores of Indian population is suffering from osteopenia / osteoporosis.

Differential Diagnosis

Differential diagnosis of Osteoporosis include

1.Multiple myeloma

2. Osteomalacia

3. Chronic kidney disease

4. Primary hyperparathyroidism

5. Metastatic bone malignancy

6. Vertebral deformities

Prevention And Counselling

a. Risk factors for Osteoporosis includes following

  1. Prior fragility fracture
  2. Female gender
  3. White ancestry
  4. Old age
  5. Low BMI
  6. Loss of height
  7. Sec amenorrhoea
  8. Primary hypogonadism
  9. Smoking
  10. Excessive alcohol use
  11. Prolonged immobilizatioin
  12. Low calcium intake
  13. Vit D defficiency
  14. Glucocorticoid excess
  15. Corticosteroid use
  16. Hyperthyroidism
  17. Heparin use
  18. Anticonvulsant use
  19. Weight loss

b. Prevention Change in life style, diet, exercise. Amongst the various risk factors for osteoporosis modifiable risk factors can be modified to prevent development of osteoporosis. Medications to prevent development of osteoporosis.

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:

Osteoporosis itself doesn’t have any symptom.

Symptoms develop once the fragility fracture occurs. Symptoms develop according to the site of fracture. Pain may or may not be there due to osteoporotic fracture. Vertebral compression fracture at times may present with neural symptoms.

Investigations:

  1. Plain X-ray of spine
  2. Dual energy X ray absorptiometry (DXA) BMD
  3. Renal function test
  4. Calcium
  5. Albumin
  6. Phosphorus
  7. Urinary calcium level

Standard Operating Procedure

In Patient 

Surgery

  • Vertebroplasty
  • Open surgical spinal stabilization

Out Patient 

supplementation and bracing

1.Pain control

  • Bed rest
  • Analgesics
  • Brace

2. Antiresorptive agents

  • Bisphosphonates
  • Estrogen analogs
  • Raloxifen
  • Calcitonin

3. Bone anabolic agent

  • Teriparatide
  • Calcium salts
  • Sodium fluoride

4. Nutrition

  • Calcium
  • Vitamin D
  • Vitamin K

5. Exercise

  • Aerobics
  • Weight bearing
  • Resistance exercise

6. Orthosis

  • Spinal orthoses

7. Long term Osteoporosis prophylaxis

Day Care:  Injectable medication

Referral criteria:

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

Clinical diagnosis:

Osteoporosis itself doesn’t have any symptom.

Symptoms develop once the fragility fracture occurs. Symptoms develop according to the site of fracture. Pain may or may not be there due to osteoporotic fracture. Vertebral compression fracture at times may present with neural symptoms.

Investigations:

  1. Plain X-ray of spine
  2. Dual energy X ray absorptiometry (DXA) BMD
  3. Renal function test
  4. Calcium
  5. Albumin
  6. Phosphorus
  7. Urinary calcium level
  8. QCT (quantitative computer tomography)
  9. Quantitative Ultrasound
  10. Biochemical markers of bone resorption (increased urinary excretion of C- telopeptides)
  11. Vit D level
  12.  Testosterone level
  13. Urinary free cortisol
  14. Serum protein electrophoresis

Standard Operating Procedure

In Patient 

Surgery

  • Vertebroplasty
  • Open surgical spinal stabilization
  • Vertebroplasty
  • Kyphoplasty

Out Patient 

supplementation and bracing

1.Pain control

  • Bed rest
  • Analgesics
  • Brace

2. Antiresorptive agents

  • Bisphosphonates
  • Estrogen analogs
  • Raloxifen
  • Calcitonin

3. Bone anabolic agent

  • Teriparatide
  • Calcium salts
  • Sodium fluoride

4. Nutrition

  • Calcium
  • Vitamin D
  • Vitamin K

5. Exercise

  • Aerobics
  • Weight bearing
  • Resistance exercise

6. Orthosis

  • Spinal orthoses

7. Long term Osteoporosis prophylaxis

8. Other agents

  • RANKL inhibitors
  • Strontium ranelate

Day Care:  Injectable medication

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 of braces 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)

Situation Human Resources Investigations Drugs & Consumables Equipment
1. Doctor

Nurse

Technician

1. Dual energy X ray absorptiometr y (DXA) BMD

2. Renal function test 3. Calcium 4. Albumin 5. Phosphorus

6. Urinary calcium level

m. Bisphosphonates n. Estrogen analogs o. Raloxifen

p. Calcitonin

q. Teriparatide

r. Calcium salts

s. Sodium fluoride

t. Calcium

u. Vitamin D

v. Vitamin K

w. Spinal braces

x. Consumables for surgery

Lab equipment

Imaging equipment Exercise

equipments Equipments

for Operating

Room

2 (In Addition to Situation 1) 1. QCT (quantitative computer tomography)

2. Quantitative Ultrasound

3. Biochemical markers of bone resorption (increased urinary excretion of Ctelopeptides)

4. Vit D level

5. Testosterone level 6. Urinary free cortisol

7. Serum protein electrophoresi s

RANKL inhibitors Strontium ranelate Equipments

for

vertebroplasty

and kyphoplasty

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

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supriya kashyap

supriya kashyap

Supriya Kashyap Joined Medical Dialogue as Reporter in 2015 . she covers all the medical specialty news in different medical categories. She also covers the Medical guidelines, Medical Journals, rare medical surgeries as well as all the updates in medical filed. She is a graduate from Delhi University. She can be contacted at supriya.kashyap@medicaldialogues.in Contact no. 011-43720751
Source: self

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