Stikes Akbid Osteoporosis

7/30/2019 Stikes Akbid Osteoporosis

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Usia harapan hidup: 58th, 62th,72th (2025)

Kenaikan lansia : 414 % (2025)

Lansia meningkat peny.Degeneratif meningkatOsteoporosis/ Age Related Diseases meningkat

Osteoporosis Masalah besar Usia lanjut

angka kesakitan dan kematian , pendanaan

Menopause : 24 juta (2015) Osteoporosis sekitar352.000

Osteoporosis fraktur immobilisasiosteoporosis

Rontgen kurang sensitif untuk Diagnosis.Penurunan

massa tulang 30 % baru terdeteksi

Latar belakang/ masalah


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Bone & Teeth Ca ++

98%

Extracellular Intracellular* Excitation Contraction coupling

in heart & others* Nerve system synaptic transmission* Platelet aggregation, coagulation* Hormones secretion

* Cell division* Muscle contractility* Cell motility* Membrane trafficking &

secretion

2%

-Mekanik-Protektif

-Metabolik


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Homeostasis calcium dan pembentukan Tulang

Bone formation : osteoblast.

-Estrogen-Calcitriol

-Calcitonin

-Insulin,growth hormon

Bone Resorption : Osteoclast-Paratiroid hormon

-Estrogen-Steroid-I G F I-Tiroid Hormon

Catatan :Bone Remodelling Adalah bone formation dan bone Absorption.Bone Turn Over Adalah kecepatan Bone formation dan Bone Absorption

Calcium

Calcitriol


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C a l c I t r I o lCALCITRIOL

I

III PTH

II


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Bone

QualityBone

Strength +

Architecture

Turnover rate

Damage AccumulationDegree of Mineralization

Properties of the collagen/

mineral matrix

Shifting the Osteoporosis Paradig Bone Strength

NIH Consensus Statement 2000

Adapted from NIH Consensus Development Panel on Osteoporosis. JAMA 285:785-95; 2001

Bone

Quantity

Bone size

Bone density


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180 kg

20 kg

Micro architecture and Bone Strength


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Umur 0 sampai 34 thn :

Bone Formation >>>>

Umur 34 th --- 44 thn :

B.Formation:B.Resorption

Umur > 44 tahun :

Bone resorption >>>>

Peak bone mass and density changes overLifetime in men and women


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Osteoporosis

Definisi/ Batasan : Penyakit sistemik tulang

yang disifati oleh berkurangnya MASSA

TULANG dan kelainan MIKROARSITEKTUR

jaringan tulang yang mineralisasinya

NORMAL, sehingga tulang menjadi rapuh

dengan akibat mudahPATAHdengan trauma

MINIMAL.1Consensus Development Conference.Am J Med. 1991.


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Criteria for Osteoporosis

- 2.5 SD - 1.0 SD

Osteoporosis Osteopenia Normal

Quantitatively /density : WHO consensus

Dengan D E X A

Normal : T Score is +/- 1 SD

Osteopenia : T Score is 1 SD to 2.5 SD

Osteoporosis :T Score is 2.5 SD or more

Severe Osteoporosis:

T Score is 2.5 SD or more plus one or more osteoporosis fracture.


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Normal Bone Osteoporotic Bone

Reproduced from J Bone Miner Res. 1986;1:15-21

with permission of the American Society for Bone and Mineral Research

Osteoporotic Bone Loss


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Normal and osteoporotic bone


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Osteoporosis- Risk Factors

Factors which can be influenced Sex hormones

Eating disorders Diet

Activity level

Medication Smoking

Alcohol use

Obat, Faktor mobilisasi

Factors which cannotbe influenced

Gender

Age

Body size

Ethnic heritage

Family history


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KLASIFIKASI & ETIOLOGIOSTEOPOROSIS

OSTEOPOROSIS PRIMER :

-Post menopause/ Tipe cepat/ tipe I- Senilis/ tipe lambat/ Tipe II

OSTEOPOROSIS SEKUNDER :-Gagal ginjal kronik- Cushing sindrome/ tx steroid lama/GIO

- Hipertiroid- D M tipe I- imobilisasi- alkoholisme, obat heparin- Arthritis rheumatoid- Multiple myeloma


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CALCITRIOL



-Estrogen :R e n d a h

-Calcitriol

-Calcitonin


Bone Resorption : Osteoclast-Paratiroid hormon

-Estrogen : R e n d a h

-Steroid-I G F I-Tiroid Hormon

Patofisiologi osteoporosis PostPatofisiologi osteoporosis post menopause/ Primer tipe I

Calcium


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Pada thn awal menopause kehilangan massa tulangdapat mencapai15%dari

MASSA PUNCAK TULANGdan pada

10 thn sampai 15 thn post menopause dapat mencapai30-40%

Normal Osteoporosis


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CALCITRIOL sangat rendah

Calcium plasma rendah



-Estrogen : Rendah

-Calcitriol Rendah

-Calcitonin


Bone Resorption : Osteoclast-Paratiroid hormon :Meningkat-Estrogen: Rendah-Steroid-I G F I : Meningkat-Tiroid Hormon

Patofisiologi osteoporosis senilis/ primer tipe II

Calcium


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Osteoporosis Primer tipe II/Pada Usia lanjut

Usia lanjut

HOMEOSTASIS CALCIUM TERGANGGU

Hipocalcemia, Kejang otot,Osteoporosis

Fg. Ginjal Fg Hati Fungsi UsusS U V ESTROGENCalcitriol


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CALCITRIOL


Bone formation :Pembentukan osteoblastmenurun.

-Estrogen : Rendah

-Calcitriol Rendah

-Calcitonin


Bone Resorption : Osteoclast-Hiperparatiroid sekunder-Estrogen: Rendah

-Steroid-I G F I : Meningkat-Tiroid Hormon

Patofisiologi osteoporosis oleh karena steroid/GIO


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Corticosteroids

Gastointestinal

Calcium absorptionUrinary calcium

excretion

Sex hormone effects:

Adrenal androgens

EstrogenTestosteroneCalcium

PTH ?Osteoclast

bone resorption

Osteoporosis

Osteoblast

bone formation

Muscle

mass

Effects on:

GH, IGF-1, TGF-

Corticosteroids induce bone loss through several mechanisms

(Lane & Lukert, CEM, 1998)


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GEJALA / Manifestasi klinis

Osteoporosis umumnya

tanpa gejala sampai orang

tsb mengalami patah

tulang.

Gejala yang paling umum:

- Subklinis :BMD,ALP,PIRIDINOLIN

- Kelainan bentuk tulangbelakang/ Kyphosis.

- Sakit punggung/ nyeri- Penurunan tinggi

badan

- PATAH TULANG


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Th i t f h i t t l i t i t


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Silva MJ, Gibson LJ. Bone1997:21;1919

Parfitt AM. Am J Med 1991; 91(Suppl5B):42S-46S.

The impo rtance of archi tectu ral integr i ty

10% decrease in BMD due toloss in trabecular number

equals

70% reduction in bone strength

10% decrease in BMD due to lossin trabecular thickness equals

20% reduction in bone strength


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Increasing age bears consequence of increased fracture.Rates in men are lower and at a later age than in women.


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Ax :- - Nyeri, kesemutan, Tambah bungkuk, Penurunan tinggi badan,

- patah tulang, minum obat corticosteroid yang lama, sakit ginjal

- sakit liver, merokok, alkohol,

Ph Dx :

-Kyphosis, nyeri tekan, krepitasi

Penunjang :

- Photo Rontgen Polos :Penurunan densitas massatulang terutama dinding depan corpusvertebrae,korteks menipis, trabekulae transversalis menghilang,Lebar Disc meningkat, cortex bikonkaf

- Quantitative ultrasound Densitometry

- Dual energy X Ray Absorbsiometry

- Bone marker ( Bone remodelling ): ALP, osteokalsinHidroxyproline, Piridinoline

- Histomorphometry


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Bone formation:

Calcium

Sodium fluoride

Anabolic steroid

Calcitriol

Estrogen

Anti resorption :

Bisphosphonate

Estrogen

Calcitriol

Calcitonin

SERM (Tamoxifen )

HRT ( Premarin )

Bone formation Anti Bone resorption


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Calcium H R T : Premarin S E R M : Kompetitif inhibisi pada uterus danpayudara, Agonis estrogen pada tulang

(Tamoxifen)

Biphosphonat: Risedronate : ACTONEL Kalsitonin

Kalsitriol: Calcit Flouride Steroid anabolik : Menurunkan bone turn over( Nandrolon, Stanozolol )


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Approach to management ofosteoporosis post menopause/primer tipe I

DietExerciseSunlight

Life-style issues

HRTPharmacotherapy


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cancer ?

May be contra indicatedH R T

ALTERNATIVE TREATMENT

PHYTOESTROGEN


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Approach to management ofosteoporosis senilis/ primer tipe II

Diet

ExerciseSunlightLife-style issues

HRTPharmacotherapy


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Approach to management ofosteoporosis Corticosteroid

DietExerciseSunlight

Life-style issues

HRTPharmacotherapy


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ESTROGEN : bone formation, Anti Resorption

CALCIUM : Material bone formation.

CALCITRIOL : absorption, deposition of Calcium.

Bone Formation :

Pharmacotherapy ??

Preventif pada Menopause, usia lanjut


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Ilustrasi Kasus

Identitas Penderita :- Nama : Ny.R- Umur : 76 tnn- Alamat : Perum Asabri- Agama : Islam- Pekerjaan : Ibu Rumah tangga

Anamnesa + Ph Dx:- Nyeri punggung, terus menerus, bertambahsaat buat gerak, berlangsung sejak 4 tahun yglalu.Ke dokter diberi obat prednison, ponstan.Nyeri tekan (+), Kiposis (+)

Penunjang : - Photo thorax :- Densitas Vertebrae menurun- Lebar Disc Space Meningkat- Vertebrae Bikonkaf


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T e r a p i

Calcium : 1500 mg/ Hari

Calcitriol : 2 x 0,25 micro gram / Hr

Biphosphonat : 35 mg/minggu selama 5 bln,

istirahat 1 bulan, kmd dilanjutkan

Calcitonin : 50 IU/ 2 hari sekali

Phytoestrogen : 2 x 1tablet/ Hr


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Be a Good Doctors with Active Learning and Share Knowledge Each OtherThink Globally but Act Locally (WHO Statement)

Stikes Akbid Osteoporosis

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