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ARTHRITIS  Inflammation of the Joint (over 100 specific diseases) Rheumatoid Arthritis Gout Degenerative Joint Diseases Ankylosing spondylitis JRA Psoriatic Arthritis Bacterial Arthritis Systemic Lupus Erythematosus Scleroderma
ARTHRITIS:   Inflammation of the Joint Pain  Swelling Redness Warmth
IL-8  IL-6  GM-CSF IL-1  TNF-  FGF Fibroblast/ type B synovial cells Metalloproteinases  Prostaglandins  Complement IL-6 IL-1  IL-6 IL-8  GM-CSF  M-CSF Macrophage/ type A synovial cells IL-1 TNF-  Adhesion molecule expression on  blood vessels HLA-DR  Complement metalloptoteinases CYTOKINE NETWORKS IN SYNOVITIS + FEEDBACK
IL-8  IL-6  GM-CSF IL-10 IL-1  TNF-  FGF Fibroblast/ type B synovial cells Metalloproteinases  Prostaglandins  Complement IL-6 TGF-  IL-4 IL-1  IL-6 IL-8  GM-CSF  M-CSF Macrophage/ type A synovial cells IL-1 TNF-  Adhesion molecule expression on  blood vessels HLA-DR  Complement metalloptoteinases CYTOKINE NETWORKS IN SYNOVITIS + FEEDBACK -  FEEDBACK
Points to Remember Cells involved in Inflammation: - macrophage, fibroblast, T-cells  Pro inflammatory cytokines: - IL-1, TNF alpha, IL-6 - IL-8, FGF, GM-CSF Anti inflammatory cytokine: - IL-10, TGF-B, IL-4
Degenerative Joint Disease / Osteoarthritis ,[object Object],Dippe, Paul
Osteoarthritis   ,[object Object],[object Object],[object Object],[object Object],[object Object]
Risk Factors for Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Biochemical markers in Osteoarthritis Major tissue of origin Biochemical markers Synovium Hyaluran, type 2 collagen propeptide, proteases Subchondral bone Type 1 collagen crosslinks, osteocalcin, alk. phosphatase,  Cart. oligomeric protein (COMP)
Management of Degenerative Joint Disease ,[object Object],[object Object],[object Object]
Changes in lifestyle for patients with Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pharmacologic  Agents ,[object Object],[object Object],[object Object],[object Object],Acetaminophen is the first line agent for OA ACR recommendation
Pharmacologic  Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Phospholipids Phospholipase A Arachidonic Acid ( PG, thromboxanes, prostacyclins) Lipooxygenase Cyclooxygenase (-) NSAID’s (leukotrienes, bradykinin)
Mechanism of Action of NSAIDs – New hypothesis Arachidonic Acid Prostaglandins  Prostaglandins  Protection of  gastric mucosa Homeostasis   Mediates pain Inflammation and fever Conventional NSAIDs COX-1 COX-2 Coxibs
COX-1 COX-2 -  produces PG from AA   - produces PG from AA -  constitutively expressed  - inducible -  governs PG production  - governs PG production  that mediate hemostatic  that mediate inflammation function -  essentially important in: gastric, bowel mucosa kidney, platelets
Risks factors for UGI adverse events ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pharmacologic  Agents ,[object Object],[object Object],1. Analgesics 2. NSAIDs 3.Topical Agents
Pharmacologic  Agents ,[object Object],[object Object],1. Analgesics 2. NSAIDs 3.Topical Agents 4. Intraarticular Steroid Injection
Pharmacologic  Agents 1. Analgesics 2. NSAIDs 3.Topical Agents 4. Intraarticular Steroid Injection 5. DMOAD’s ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pharmacologic  Agents 1. Analgesics 2. NSAIDs 3.Topical Agents 4. Intraarticular Steroid Injection 5. DMOAD’s 6. Other Agents ,[object Object],[object Object]
Surgical Treatment for Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Points to Remember - Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rheumatoid Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rheumatoid Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Extra-articular manifestation of RA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Extraarticular Manifestations of RA
Immune Abnormalities ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other causes of (+) RF test: ,[object Object],[object Object],[object Object],[object Object]
Revised criteria for RA diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment of RA Experimental agents Cyclophosphamide, MTX, Azathioprine Gold salts, antimalarials, Penicillamine Salicylates, NSAIDS, analgesics Education, rest, exercise, social service Intraarticular Steroid injection Mechanical devices
DMARDs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Disease Modifying Drugs (DMARD’s) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Biologic Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adverse effects of Biologic Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors Associated with Poorer Prognosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Points to Remember ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Gouty Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Classification of Hyperuricemia and Gout ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Renal  Handling of Urates
Gouty Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
[object Object],[object Object]
[object Object]
Risk Factors for the Development of Gout Alcohol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risk Factors for the Development of Gout  Diet ,[object Object],[object Object],[object Object],[object Object],[object Object],risk gout risk gout risk of gout no association Choi et al. NEJM, 2004;350(11):1093-1103
Risk Factors for the Development of Gout Drugs ,[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PROPHYLACTIC COLCHICINE DOSES ,[object Object],[object Object],[object Object],[object Object],0.6 mg BID 0.6 mg QD 0.6 mg Q2 Days 0.6 mg Q3 Days - COLCHICINE NOT EXTRACTED BY DIALYSIS  - DO NOT USE IN DIALYSIS PATIENTS - REDUCE COLCHICINE BY 50% FOR AGE >= 70 - CAUTION WITH DRUG INTERACTIONS: e.g., CSA, Statins, Macrolides, Gemfibrozil
Points to Remember ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Spondyloarthropathies ,[object Object],[object Object],[object Object],[object Object]
General Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ankylosing Spondylitis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Radiographic Findings ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
AS vs other causes of LBP ,[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Reactive Arthritis / Reiters Disease ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Clinical Forms ,[object Object],[object Object],[object Object],[object Object],[object Object]
Psoriatic Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Major Types of Psoriatic Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Enteropathic Arthritis ( IBD ) ,[object Object],[object Object],[object Object]
Features ,[object Object],[object Object],[object Object],[object Object],[object Object]
Points to Remember ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Systemic Lupus Erythematosus ,[object Object],[object Object],[object Object],[object Object],[object Object]
Theories ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Manifestations ,[object Object],[object Object],[object Object],Cutaneous
Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cutaneous
Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Laboratories ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Laboratories ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Revised Criteria for SLE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Revised Criteria for SLE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Revised Criteria for SLE ,[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pharmacologic Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prognosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cause of Death ,[object Object],[object Object],[object Object],[object Object]
Osteoporosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
Wasnich RD: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999, p 257 Incidence Rates for Vertebral, Wrist and Hip Fractures in Women After Age 50 40 30 20 10 Slide Modified:  Review:  Reviewer Memo:  Source:  Memo:  50 60 70 80 Vertebrae Hip Wrist Age (Years) Annual incidence per 1000 women
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Risk factors taken from Jordan & Cooper  Best Practice and Res Clin Rheumatol,  2002 Categorized by Eli Lilly & Co. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Risk Factors for Osteoporosis and Fracture Slide Modified:  Review:  Reviewer Memo:  Source:  Memo:
Unitary model for postmenopausal  bone loss: role of oestrogen deficiency Indirect effects Directly increases  osteoclast number  and longevity Dietary calcium (decreased  absorption) Secondary hyperparathyroidism Increased bone resorption Bone loss Decreased  bone formation Remodelling imbalance ? Adapted from: Riggs BL, et al. J Bone Miner Res 1998;13:763–73 Oestrogen deficiency
 
Glucocorticoid dose Dependent Effect on Fracture Risk  0.99 1.77 5.18 1.55 2.59 2.27 0 1 2 3 4 5 6 Hip Vertebral Type of Fracture Relative Risk  of Fracture <2.5 mg 2.5 mg-7.5 mg >7.5 mg Dose* Van Staa TP, et al.  J Bone Miner Res.  2000. *Prednisolone equivalent N = 488 470
Most rapid bone loss occurs in the first 6-12 months of Steroid therapy
WHO definition of osteoporosis ,[object Object],[object Object],WHO Study Group. WHO Technical Report Series 843, Geneva Switzerland: WHO;1994:1–129
How should patients be evaluated to determine if they have osteoporosis? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],AACE Osteoporosis Task Force. Endocr Pract 2003;9:545–64 http://www.nof.org/professionals/clinical.htm
Diagnosis and assessment ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Biochemical markers of bone turnover in osteoporosis *CrossLaps TM
Candidates for therapy:  the AACE guidelines ,[object Object],[object Object],[object Object],[object Object],[object Object],AACE Osteoporosis Task Force. Endocr Pract 2003;9:545–64
Therapeutic options for osteoporosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Osteoporosis prevention T-score >–2.5 Osteopenia  treatment with or without  previous fracture Osteoporosis treatment  with multiple fractures and at risk for hip fracture 50 55 60 65 70 75 80 85 Raloxifine Age (years) HRT Therapeutic Management of Postmenopausal Osteoporosis Teriparatide Bisphosphonates Adapted from Seeman & Eisman, MJA Vol 180 15 March 2004, p298-303
Optimal Daily Calcium Requirements 1300 mg 1000 mg 1200 mg Recommended Calcium Intake (Daily) Age 1997 Recommended Dietary Intakes 9-18 years 19-50 years 51 years or older National Academy Press. Available at:  http://books.nap.edu/catalog/5776.html.  1999.
Recommendations for Vitamin D Intake ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Adapted from  European Commission. Report on osteoporosis in the European community: Action on prevention. Luxembourg: Office for Official Publications of the European Communities, 1998;  Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D,  and Fluoride . Washington, DC: Institute of Medicine, National Academy Press, 1997 ; Vieth R et al  Am J Clin Nutr  2001;73:288–294.
Widespread Prevalence of Vitamin D Inadequacy*  Regardless of Geographic Location *Vitamin D inadequacy was defined as serum 25(OH)D <30 ng/ml; **Interim results of ongoing study Study Design: Observational, cross-sectional study of 1285 community-dwelling women with osteoporosis from 18 countries to evaluate serum 25(OH)D distribution. Adapted from Lim S-K et al. Poster presented at ISCD, February 16–19, 2005, New Orleans, Louisiana,USA; Heaney RP  Osteoporos Int  2000;11:553–555. Prevalence (%) 0 10 30 40 60 80 90 Latin America 51% 63% Asia All 59% Australia 59% Europe 52% Regions N=1285 81% Middle East 50 70 20 In a cross-sectional observational international study in 1285 postmenopausal women with osteoporosis**
Probable Reasons for High Prevalence of Vitamin D Inadequacy in Postmenopausal Women  ,[object Object],[object Object],[object Object],[object Object],Adapted from Marcus R  Goodman & Gilman’s The Pharmacological Basis of Therapeutics.  10th ed. New York: McGraw-Hill Medical Publishing Division, 2001:1715–1743;  Bringhurst FR  Harrison’s Principles of Internal Medicine.  16th ed. New York: McGraw-Hill Medical Publishing, 2005:2238–2249; Matsuoka LY  J Clin Endocrinol Metab  1987;64:1165–1168; Parfitt AM  Am J Clin Nutr  1982;36:1014–1031; Lawson RM  Clin Nutr  2000;19:171–175.
Vitamin D Inadequacy* Has Important Consequences Appropriate neuromuscular function *Vitamin D inadequacy is defined as serum 25(OH)D <30 ng/ml. Adapted from Parfitt AM et al  Am J Clin Nutr  1982;36:1014–1031; Allain TJ, Dhesi J  Gerontology  2003;49:273–278; Holick MF  Osteoporos Int  1998;8(suppl 2):S24–S29; DeLuca HF  Metabolism  1990;39(suppl 1):3–9; Pfeifer M et al  Trends Endocrinol Metab  1999;10:417 – 420;  Lips P. In: Draper HH, ed.  Advances in Nutritional Research . New York, Plenum Press, 1994:151–165. Bone mineral density Parathyroid hormone Calcium  absorption Risk of  fracture Artistic rendition
Bisphosphonate mechanism of action Adapted from: Bone H, et al. Clin Ther 2000;22:15–25  RESTING RESORPTION Osteoclast FORMATION Osteoblasts BISPHOSPHONATES  INHIBIT OSTEOCLAST  -MEDIATED BONE RESORPTION
PTH - Mechanism of Action PTH binds to cell surface  G protein-coupled receptor Stimulates differentiation of bone lining cells and preosteoblasts to osteoblasts Decreases apoptosis  of osteoblasts Net increase in number and  action of bone forming osteoblasts
Osteoporosis has been thought of as a silent epidemic….this is not true anymore. At present, there is much noise in the field of research for  its prevention, diagnosis and treatment. Ego Seeman    ARCOS meeting, Feb 2002
One of the Many Faces of Osteoporosis “ You could have floored me when they told me.  It’s very frightening, very frightening… I don’t want to end up in a nursing home incapacitated.”
Thank You ! Please visit: http://crisbertcualteros.page.tl

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Rheumatology

  • 1. ARTHRITIS Inflammation of the Joint (over 100 specific diseases) Rheumatoid Arthritis Gout Degenerative Joint Diseases Ankylosing spondylitis JRA Psoriatic Arthritis Bacterial Arthritis Systemic Lupus Erythematosus Scleroderma
  • 2. ARTHRITIS: Inflammation of the Joint Pain Swelling Redness Warmth
  • 3. IL-8 IL-6 GM-CSF IL-1 TNF-  FGF Fibroblast/ type B synovial cells Metalloproteinases Prostaglandins Complement IL-6 IL-1 IL-6 IL-8 GM-CSF M-CSF Macrophage/ type A synovial cells IL-1 TNF-  Adhesion molecule expression on blood vessels HLA-DR Complement metalloptoteinases CYTOKINE NETWORKS IN SYNOVITIS + FEEDBACK
  • 4. IL-8 IL-6 GM-CSF IL-10 IL-1 TNF-  FGF Fibroblast/ type B synovial cells Metalloproteinases Prostaglandins Complement IL-6 TGF-  IL-4 IL-1 IL-6 IL-8 GM-CSF M-CSF Macrophage/ type A synovial cells IL-1 TNF-  Adhesion molecule expression on blood vessels HLA-DR Complement metalloptoteinases CYTOKINE NETWORKS IN SYNOVITIS + FEEDBACK - FEEDBACK
  • 5. Points to Remember Cells involved in Inflammation: - macrophage, fibroblast, T-cells Pro inflammatory cytokines: - IL-1, TNF alpha, IL-6 - IL-8, FGF, GM-CSF Anti inflammatory cytokine: - IL-10, TGF-B, IL-4
  • 6.
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  • 8.
  • 9.
  • 10.  
  • 11.  
  • 12. Biochemical markers in Osteoarthritis Major tissue of origin Biochemical markers Synovium Hyaluran, type 2 collagen propeptide, proteases Subchondral bone Type 1 collagen crosslinks, osteocalcin, alk. phosphatase, Cart. oligomeric protein (COMP)
  • 13.
  • 14.
  • 15.
  • 16.
  • 17. Phospholipids Phospholipase A Arachidonic Acid ( PG, thromboxanes, prostacyclins) Lipooxygenase Cyclooxygenase (-) NSAID’s (leukotrienes, bradykinin)
  • 18. Mechanism of Action of NSAIDs – New hypothesis Arachidonic Acid Prostaglandins Prostaglandins Protection of gastric mucosa Homeostasis Mediates pain Inflammation and fever Conventional NSAIDs COX-1 COX-2 Coxibs
  • 19. COX-1 COX-2 - produces PG from AA - produces PG from AA - constitutively expressed - inducible - governs PG production - governs PG production that mediate hemostatic that mediate inflammation function - essentially important in: gastric, bowel mucosa kidney, platelets
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  • 35. Treatment of RA Experimental agents Cyclophosphamide, MTX, Azathioprine Gold salts, antimalarials, Penicillamine Salicylates, NSAIDS, analgesics Education, rest, exercise, social service Intraarticular Steroid injection Mechanical devices
  • 36.
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  • 44. Renal Handling of Urates
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  • 100.  
  • 101.  
  • 102. Wasnich RD: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999, p 257 Incidence Rates for Vertebral, Wrist and Hip Fractures in Women After Age 50 40 30 20 10 Slide Modified: Review: Reviewer Memo: Source: Memo: 50 60 70 80 Vertebrae Hip Wrist Age (Years) Annual incidence per 1000 women
  • 103.
  • 104. Unitary model for postmenopausal bone loss: role of oestrogen deficiency Indirect effects Directly increases osteoclast number and longevity Dietary calcium (decreased absorption) Secondary hyperparathyroidism Increased bone resorption Bone loss Decreased bone formation Remodelling imbalance ? Adapted from: Riggs BL, et al. J Bone Miner Res 1998;13:763–73 Oestrogen deficiency
  • 105.  
  • 106. Glucocorticoid dose Dependent Effect on Fracture Risk 0.99 1.77 5.18 1.55 2.59 2.27 0 1 2 3 4 5 6 Hip Vertebral Type of Fracture Relative Risk of Fracture <2.5 mg 2.5 mg-7.5 mg >7.5 mg Dose* Van Staa TP, et al. J Bone Miner Res. 2000. *Prednisolone equivalent N = 488 470
  • 107. Most rapid bone loss occurs in the first 6-12 months of Steroid therapy
  • 108.
  • 109.
  • 110.
  • 111.
  • 112. Biochemical markers of bone turnover in osteoporosis *CrossLaps TM
  • 113.
  • 114.
  • 115. Osteoporosis prevention T-score >–2.5 Osteopenia treatment with or without previous fracture Osteoporosis treatment with multiple fractures and at risk for hip fracture 50 55 60 65 70 75 80 85 Raloxifine Age (years) HRT Therapeutic Management of Postmenopausal Osteoporosis Teriparatide Bisphosphonates Adapted from Seeman & Eisman, MJA Vol 180 15 March 2004, p298-303
  • 116. Optimal Daily Calcium Requirements 1300 mg 1000 mg 1200 mg Recommended Calcium Intake (Daily) Age 1997 Recommended Dietary Intakes 9-18 years 19-50 years 51 years or older National Academy Press. Available at: http://books.nap.edu/catalog/5776.html. 1999.
  • 117.
  • 118. Widespread Prevalence of Vitamin D Inadequacy* Regardless of Geographic Location *Vitamin D inadequacy was defined as serum 25(OH)D <30 ng/ml; **Interim results of ongoing study Study Design: Observational, cross-sectional study of 1285 community-dwelling women with osteoporosis from 18 countries to evaluate serum 25(OH)D distribution. Adapted from Lim S-K et al. Poster presented at ISCD, February 16–19, 2005, New Orleans, Louisiana,USA; Heaney RP Osteoporos Int 2000;11:553–555. Prevalence (%) 0 10 30 40 60 80 90 Latin America 51% 63% Asia All 59% Australia 59% Europe 52% Regions N=1285 81% Middle East 50 70 20 In a cross-sectional observational international study in 1285 postmenopausal women with osteoporosis**
  • 119.
  • 120. Vitamin D Inadequacy* Has Important Consequences Appropriate neuromuscular function *Vitamin D inadequacy is defined as serum 25(OH)D <30 ng/ml. Adapted from Parfitt AM et al Am J Clin Nutr 1982;36:1014–1031; Allain TJ, Dhesi J Gerontology 2003;49:273–278; Holick MF Osteoporos Int 1998;8(suppl 2):S24–S29; DeLuca HF Metabolism 1990;39(suppl 1):3–9; Pfeifer M et al Trends Endocrinol Metab 1999;10:417 – 420; Lips P. In: Draper HH, ed. Advances in Nutritional Research . New York, Plenum Press, 1994:151–165. Bone mineral density Parathyroid hormone Calcium absorption Risk of fracture Artistic rendition
  • 121. Bisphosphonate mechanism of action Adapted from: Bone H, et al. Clin Ther 2000;22:15–25 RESTING RESORPTION Osteoclast FORMATION Osteoblasts BISPHOSPHONATES INHIBIT OSTEOCLAST -MEDIATED BONE RESORPTION
  • 122. PTH - Mechanism of Action PTH binds to cell surface G protein-coupled receptor Stimulates differentiation of bone lining cells and preosteoblasts to osteoblasts Decreases apoptosis of osteoblasts Net increase in number and action of bone forming osteoblasts
  • 123. Osteoporosis has been thought of as a silent epidemic….this is not true anymore. At present, there is much noise in the field of research for its prevention, diagnosis and treatment. Ego Seeman ARCOS meeting, Feb 2002
  • 124. One of the Many Faces of Osteoporosis “ You could have floored me when they told me. It’s very frightening, very frightening… I don’t want to end up in a nursing home incapacitated.”
  • 125. Thank You ! Please visit: http://crisbertcualteros.page.tl