Excellencies - Diabetology and Endocrine Diseases

Osteoporosis

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Osteoporosis is a systemic disease of the skeletal system, characterized by low mineral density and deterioration of micro-architecture of bone tissue, resulting in increased bone fragility mainly related to aging. This situation leads, consequently, to an increased risk of fracture (in particular of vertebrae, femur, wrist, humerus, ankle) due to even minimal trauma.
Osteoporosis can be distinguished into primary (typical of senile age) and secondary; the latter is caused by multiple conditions such as chronic steroid therapy, vitamin D and calcium deficiency, hyperparathyroidism, hypercortisolism, hypogonadism, early menopause, DM type 1 or 2, GH deficiency, haematological or gastroenteric diseases such as celiac disease, rheumatological diseases or COPD (1).

In Italy, 23% of women over 40 and 14% of men over 60 are affected by osteoporosis and these numbers are constantly increasing, especially in relation to the increase in life expectancy.
It is estimated that in Italy osteoporosis affects about 5 million people, 80% of whom are post-menopausal women.

Brittle fractures due to osteoporosis have significant consequences, both in terms of mortality and motor disability, with high health and social costs. Mortality from fracture of the femur is 5% in the period immediately following the event and 15-25% at one year. In 20% of cases there is the definitive loss of the ability to walk independently and only 30-40% of the subjects return to the conditions before the fracture (2).

Such data confirm the importance of both primary and secondary prevention of fracture fractures due to fragility, which must begin at an early age, especially in adolescence, when calcium intake through food is absorbed by the body and effectively contributes to the consolidation of bone density, as well as it is essential that young people and children regularly participate in physical activities from nursery school and throughout secondary school.
It is also necessary to follow a varied and balanced diet to prevent overweight and obesity, taking adequate amounts of calcium and vitamin D, reducing salt consumption (which increases the elimination of calcium with urine) and avoiding risk factors predisposing to osteoporosis, such as smoking and alcohol abuse (3).

In our Centre it is possible to carry out a specialist endocrinological examination aimed at carrying out chemical-instrumental examinations that allow us to identify both patients at risk of fracture and those who already have a confirmed osteoporosis.

In addition to a simple blood sample, useful to study the phospho-calcium metabolism of each individual patient, the bone turnover (4) and any endocrinopathies responsible for bone damage, it is possible to undergo a densitometric examination (MOC-DEXA) that allows to measure fairly accurately and precisely the bone mass and in particular its mineral density (Bone Mineral Density or BMD), responsible for the mechanical resistance of bone for 60-80% (5, 6).

For the identification of previous fractures it is possible to perform an X-ray of the cervical-thoracic-lumbosacral column, associating it if necessary to an MRI of the entire column, so as to identify further neo-fractures.
Estimation of fracture risk using algorithms such as FRAX or DEFRA will make it possible to assess the fracture risk at 10 years of femur or other sites, so as to evaluate a possible anti-refractive treatment (7, 8, 9).

At the osteoporosis clinic of IRCCS MultiMedica it is possible to prescribe various anti-reductive drugs, from classic bisphosphonates to the most innovative and effective therapies such as denosumab (Prolia) and teriparathy (10, 11).
The latter drugs are particularly necessary for patients with marked tissue hypoestrogenism induced by adjuvant hormone therapy (with aromatase inhibitors or tamoxifen + LHRH analogues), in women with breast cancer and androgenic deprivation caused by GnRH agonists and/or antiandrogens in males with prostate cancer.
These treatments induce an important acceleration of bone loss, which results in a rapid increase in fracture risk.
At the Istituto di Ricovero e Cura MultiMedica in Sesto, it is possible to book specialist endocrinological examinations thanks to an outpatient space reserved for the treatment of osteoporosis (endocrinological examination for osteoporosis), both in women of senile age and in patients suffering from breast or prostate cancer, in treatment with osteopenizing drugs.
For this reason a constructive collaboration between oncologists and endocrinologists has been established over time.
With the help of a multidisciplinary team (radiologists, nuclear physicians) it is possible to book examinations such as MOC-Dexa, radiography and Rm colonna and, if necessary, bone scans at our facility.

Bibliography:

  1. Guidelines for the diagnosis, prevention and management of osteoporosis M. Rossini, S. Adami, F. Bertoldo, D. Diacinti, D. Gatti, S. Giannini, A. Giusti, N. Malavolta, S. Minisola, G. Osella, M. Pedrazzoni, L. Sinigaglia, O. Viapiana, G.C. Isaia – Reumatismo, 2016; 68 (1): 1-42
  2. www.salute.gov.it
  3. www.epicentro.iss.it
  4. Use of bone turnover markers in postmenopausal osteoporosis – Eastell R1, Szulc P – Lancet Diabetes Endocrinol. 2017 Nov;5(11):908-923.
  5. Sensitivity and specificity assessment of DWI and ADC for the diagnosis of osteoporosis inpostmenopausal patients – Momeni M1, Asadzadeh M2, Mowla K3, Hanafi MG1, Gharibvand MM1, Sahraeizadeh A1 – Radiol Med. 2019 Sep 17. doi: 10.1007/s11547-019-01080-2.
  6. Bioimpedance analysis vs. DEXA as a screening tool for osteosarcopenia in lean, overweight and obese Caucasian postmenopausal females – Peppa M1, Stefanaki C2,3, Papaefstathiou A1, Boschiero D4, Dimitriadis G1, Chrousos GP5,6 – Hormones (Athens). 2017 Apr;16(2):181-193. doi: 10.14310/horm.2002.1732
  7. Novel algorithm generating strategy to identify high fracture risk population using a hybrid intervention threshold. – Hsu CY1, Wu CH2, Yu SF1, Su YJ1, Chiu WC1, Chen YC1, Lai HM1, Chen JF1, Ko CH1, Chen JF3, Cheng TT4 – J Bone Miner Metab. 2019 Oct 3. doi: 10.1007/s00774-019-01046-4.
  8. Recommendations by georgian association of skeletal metabolic diseases on the initiation of treatment with use of age-dependent intervention threshold based on frax in patients with osteoporosis. – Giorgadze E1, Tsagareli M1, Lomidze M1, Sulikashvili T1, Jeiranashvili N1, Uridia N1. – Georgian Association of Skeletal Metabolism Diseases, National Institute of Endocrinology, Tbilisi, Georgia -Georgian Med News. 2019 Jun;(291):89-93.
  9. Hippisley-Cox J, Coupland C. Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study. BMJ. 2012; 344: e3427
  10. Prevention and treatment of postmenopausal osteoporosis – Tella SH, Gallagher JC – J Steroid Biochem Mol Biol. 2014 Jul;142:155-70. doi: 10.1016/j.jsbmb.2013.09.008
  11. Clinical Practice. Postmenopausal Osteoporosis – Black DM, Rosen CJ – N Engl J Med. 2016 Jan 21;374(3):254-62