OSTEOPOROSIS

ANITA SRIWATY PARDEDE SKM

OSTEOPOROSIS

KEROPOS TULANGMASALAH KESEHATAN (KURANG DISADARI)

Osteoporosis

• The most common metabolic bone disorder• A large, silent epidemic, afflicting the whole world• Insidious & progressive :

frequently diagnosed only after a fracture• Cause enormous socio – economic impact

( Ang, K.C 2005)

• The exact pathogenesis remains unclear• Impairement of calcium absorption is one of its

primary cause( Dechant, K.L et al 1994 )

Osteoporosis

• Ditandai dengan:– Massa tulang yang berkurang

– Deteriorasi struktur tulang (mikroskopis)

• Tulang jadi rapuh - risiko fraktur

MASSA TULANG

TULANG DEWASA

• PUNCAK KEPADATAN MASSA TULANG MAKSIMAL + USIA 30 TAHUN

• KONSEP MASSA TULANG RENDAH,FAKTOR RISIKO PATAH TULANGTULANG

USIA LANJUT

TULANG :

- KEHILANGAN MASSA TULANG

WANITA : 45 – 50 %

PRIA : 20 – 30 %

PUNCAK MASSA TULANG

PEMBENTUKAN MASSA TULANG

REMODELLING TULANG

Faktor Genetik

Bentuk tubuh, gaya hidup Status nutrisi

Menopause

Penyakit

Perubahan hormonalAkibat usia

Trauma ringan

Puncak Massa Tulang

Penurunan MassaTulang

Sangat RentanTerhadap Fraktur

Usia ( tahun )

M A S S ATULANG

Takao Suzuki, 2001

0 504020 10060 70 80

FAKTOR RISIKO PADA OSTEOPOROSIS

TIDAK DAPAT DIMODIFIKASI• JENIS KELAMIN• USIA LANJUT (WANITA)• RAS KAUKASIA (KULIT PUTIH)• RIWAYAT PATAH TULANG

DAPAT DIMODIFIKASI• POSTUR TUBUH KURUS• JATUH BERULANG• AKTIFITAS FISIK KURANG• KEKURANGAN

ESTROGEN• KEKURANGAN KALSIUM• PEROKOK• PEMINUM ALKOHOL• TINGKAT KESEHATAN

BURUK

Osteoporosis

KriteriaNormal Nilai BMD < 1 SD di bawah nilai rata-rata dewasa

muda

Osteopenia Nilai BMD 1 – 2.5 SD d bawah nilai rata-rata

Osteoporosis Nilai BMD > 2.5 SD di bawah nilai rata-rata

Osterporosis berat

Nilai BMD > 2.5 SD di bawah nilai rata-rata

+ ada 1 fraktur osteoporosis

Osteoporosis in Men

A public health concern :• Age – spesific incidence of fractures is

increasing in men• Prevalence of spinal fractures are similar in

women• Over the next 15 yrs, 30 % of all hip fractures

will occur in men• Mortality after spinal & hip fractures is higher

than in women( Ebeling, P.R at al

2001 )

Osteoporosis in Men cont’d

• As devastating as in women• Detection & treatment in men are dismal

– Not as extensively as in woman

• International Society for Clinical Densitometry, 2003 : 70 yrs : regular BMD– T score < - 2 : treatment of OP & other risk factors

The Osteoporosis Continuum

75+ KyphoticAt risk for hip fracture

55+ PostmenopausalAt greater risk for vertebral

fracture than any other type of fracture

Healthy spine

Kyphotic spine

50 MenopausalExperiencing

vasomotor symptoms

Fraktur Vertebra

• Fraktur vertebra terjadinya lebih awal dari fraktur lain.

Fraktur Vertebra

PatahTulang

Kelainan BentukNyeri KecacatanMasa TulangRendah

Kualitas Hidup

PENCEGAHAN1. PRIMER

2. SEKUNDER

PRIMER :• NUTRISI YANG BAIK• POLA HIDUP AKTIF• HINDARI FAKTOR RISIKO• TES UNTUK DETEKSI DINI• UPAYA-2 KHUSUS :

(OBAT-OBAT TERTENTU)

FAKTOR NUTRISI :1. CUKUP KALSIUM

2. CUKUP VIT.D

3. KURANGI FOSFAT

4. CUKUP PROTEIN

5. BATASI KAFEIN

6. HINDARI ALKOHOL

7. KURANGI GARAM, GULA

8. HENTIKAN ROKOK

POLA HIDUP AKTIF :

KURANG GERAK PROGRAM LATIHAN FISIK

Osteoporosis Exercise Program, 1998 :

• Improve gait, balance, coordination, propioception, reaction time, and key – muscles strength prevent falls

• Increase bone – mass / preserve bone – mass prevent osteoporosis

“keep both young & older person moving”

( Oliver, D. et al. 2005 )

PENCEGAHAN SEKUNDER :

• SUDAH ADA OP SEBELUM ADA PATAH TULANG

• PENCEGAHAN PRIMER + OBAT-2AN (ESTROGEN, BISFOSFONAT, DLL)

JATUH PADA USIA LANJUTFAKTOR INSTRINSIK

KONDISI FISIK DAN KEJIWAAN

PENURUNAN PENGLIHATAN & PENDENGARAN

PERUBAHAN PERSYARAFAN, GAYA BERJALAN, REFLEK BERDIRI

FAKTOR EKSTRINSIK

OBAT-2AN YANG DIMINUM

ALAT-2 BANTU BERJALAN

LINGKUNGAN YANG TIDAK

MENDUKUNG

JATUH

Falls In The Elderly

• A common problem• 30 % - 50 % 65 in the community, female > male• 70 % occurs at home, 50 % from environmental

hazard• Majority occur with mild to moderate activity• Compared with children, 10x to be hospitalized, 8x

more likely to die 10 % result in fracture, especially hip fracture• May be a non spesific presenting sign of acute

illness / acute exacerbation of a chronic disease

Fall cont’d

• The true geriatric giant : an indication for a more detailed assessment

( Davidson, C. 2000 )

• Psychologic impact of a fall : post-fall anxiety– Fear of falling activity restriction, dependance &

increasing immobility further risk factor : muscle atrophy, poorer balance, deconditioning greater risk of falling

Cycle of Osteoporosis

• Strong association : Osteoporosis, Fall, Fracture

must be managed together– Preventing both : osteoporosis & fall

FractureOld Age

Fall

Osteoporosis

Immobility

KOMPLIKASI PATAH TULANGSIKLUS OSTEOPOROSIS

USIA LANJUT OSTEOPOROSIS PATAH TULANG

• ASESMEN PENYEBAB JATUH• ASESMEN PATAH TULANG YANG TERJADI

RUDA PAKSA

MOBILITAS BERKURANG

Indonesian Rheumatic Association’s Recommendation :

Drug Treatment in Osteoporosis

Kelompok risiko tinggiAtau faktor risiko

Patah tulang denganrudapaksa minimal atau

kekurangan massa tulang

Merubah gaya hidupdiet, latihan fisik, merokok

Pengukuran kepadatan tulang(Bone Densitometri)

Diatas + 1 SD + 1 SD sp –1 SD -1 SD sp –2,5 SD Dibawah –2,5 SD

Ulang 5 th lagi Ulang 1 th lagi Estrogen

Estrogen Bisfosfonat Kalsitriol Kalsitonin

Source : Harry Isbagio et al 2002

Calcitriol

• Photosynthesis of vitamin D :– Occurred on earth, over 750 millions years– Vertebrates, including human, obtain most of their vit. D,

from exposure to sunlight– Sunlight :

• High energy ultraviolet B radiation : photolysis 7 dehydro calciferol pre vit D3, leaves the epidermal cell membrane circulation

• Requires two hydroxylations processes in the liver & kidney biologically active metabolite :

1.25 (OH)2 D3

“CALCITRIOL”

The Primary Role of Calcitriol

• The main regulator of intestinal calcium absorption active absorption

• Responsible for calcium homeostasis & mineralisation of the bone

• Stimulate bone spesific protein’s production : osteocalcin

Charaterizes of Type II OP

• Decreased calcium absorption, particularly 70 yrs :Age – related decline in serum levels of calcitriol :– Decreased capacity of the ageing skin to synthezise

vit. D3

– Decreased renal hydroxylase activity with ageing– Decreased osteoblast function

calcitriol is the logical course of treatment in the elderly

UPAYA PENCEGAHAN

& PENGOBATAN

Never too late to Prevent a Fracture