1) Definition — Osteoporosis কী?

Osteoporosis হলো systemic skeletal disease যেখানে bone mass কমে যায় এবং bone microarchitecture নষ্ট হয়; ফলে হাড় ভঙ্গুর হয়ে low-trauma/fragility fracture—যেমন hip, vertebra, distal radius fracture—এর ঝুঁকি বাড়ে। Clinically এটি diagnose করা যায় যদি DXA T-score ≤ −2.5 হয় অথবা বয়স ≥50 বছরে fragility hip/vertebral fracture থাকে।

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2) Cause / Etiology & Pathophysiology — কারণগুলো

A. Primary osteoporosis

• Postmenopausal osteoporosis: estrogen কমে গেলে osteoclast activity বেড়ে যায় → bone resorption বেশি → trabecular bone loss → vertebral/wrist fracture বেশি।
• Senile osteoporosis: বয়স বাড়ার সাথে osteoblast activity কমে, vitamin D activation কমে, calcium absorption কমে → cortical ও trabecular দুই ধরনের bone loss → hip fracture ঝুঁকি বাড়ে।
• Genetic/family history: মা-বাবার hip fracture history থাকলে ঝুঁকি বেশি।

B. Secondary osteoporosis

• Drug-induced: long-term glucocorticoid, antiepileptic, heparin, aromatase inhibitor, GnRH analogue, excess thyroxine, PPI দীর্ঘদিন।
• Endocrine: hyperthyroidism, hyperparathyroidism, Cushing syndrome, hypogonadism, diabetes mellitus।
• GI/malabsorption: celiac disease, IBD, chronic liver disease, bariatric surgery।
• Renal: CKD-mineral bone disorder।
• Inflammatory disease: rheumatoid arthritis, chronic inflammatory conditions।
• Malignancy: multiple myeloma, metastatic bone disease।
• Lifestyle: smoking, alcohol, low BMI, physical inactivity, low calcium/vitamin D intake।

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3) Symptoms — লক্ষণগুলো

• অনেক সময় কোনো symptom থাকে না; fracture হওয়ার পর ধরা পড়ে।
• Back pain: vertebral compression fracture হলে acute/chronic back pain।
• Height loss: আগের তুলনায় উচ্চতা কমে যাওয়া।
• Kyphosis / stooped posture: spine compression fracture হলে পিঠ বাঁকা হয়ে যেতে পারে।
• Low-trauma fracture: সামান্য পড়ে hip/wrist/spine fracture।
• Reduced mobility: fracture-এর পর হাঁটাচলা কমে যায়।
• Breathing/abdominal discomfort: severe kyphosis হলে thoracic volume কমে শ্বাসকষ্ট বা abdominal pressure sensation হতে পারে।
• Dental/jaw issue: osteoporosis নয়, কিন্তু bisphosphonate/denosumab therapy-এর rare complication হিসেবে osteonecrosis of jaw হতে পারে।

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4) Clinical Diagnosis — clinically কীভাবে diagnose করবেন

Diagnostic criteria

• Fragility fracture: standing height থেকে পড়ে hip/vertebral fracture হলে osteoporosis ধরে treatment শুরু করা যায়।
• DXA scan: lumbar spine, total hip, femoral neck—T-score:
  • Normal: ≥ −1
  • Osteopenia: −1 to −2.5
  • Osteoporosis: ≤ −2.5
  • Severe osteoporosis: ≤ −2.5 + fragility fracture
• FRAX risk assessment: osteopenia থাকলেও 10-year fracture risk বেশি হলে treatment indicated। BHOF clinician guide fracture risk threshold ও densitometry indication অন্তর্ভুক্ত করে।

Physical examination

• Height measurement, weight/BMI
• Spine tenderness, kyphosis
• Gait/balance assessment
• Fall risk: vision, neuropathy, orthostatic BP, muscle weakness
• Secondary cause signs: thyroid, Cushingoid features, hypogonadism, RA features

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5) Investigations — specific list

A. Confirmatory test

• DXA scan: lumbar spine + hip; follow-up সাধারণত 1–3 বছর পর করা যায় high-risk/treatment monitoring-এ। Endocrine Society treated high-risk women-এ spine/hip DXA every 1–3 years monitoring suggest করে।
• Vertebral fracture assessment / lateral spine X-ray: height loss, back pain, kyphosis, steroid use, elderly patient।

B. Baseline labs before treatment

• CBC
• Serum calcium, phosphate, albumin
• ALP
• Serum creatinine/eGFR
• 25-hydroxy vitamin D
• PTH if hypercalcemia/hypocalcemia or suspected hyperparathyroidism
• TSH if hyperthyroidism suspected
• LFT
• ESR/CRP if inflammatory/malignancy suspicion
• Serum protein electrophoresis ± urine Bence Jones protein if multiple myeloma suspected
• Testosterone in men with hypogonadism suspicion
• Celiac screen if malabsorption suspected
• 24-hour urinary calcium if recurrent stone/hypercalciuria suspicion

C. Before specific drugs

• Bisphosphonate/zoledronic acid: eGFR/CrCl, calcium, vitamin D; dental risk if IV therapy.
• Denosumab: calcium, vitamin D, renal function; hypocalcemia correction before injection.
• Teriparatide: serum calcium, ALP, PTH context; avoid bone malignancy/Paget/radiation history.

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6) Differential Diagnosis

• Osteomalacia / vitamin D deficiency
• Multiple myeloma
• Bone metastasis
• Hyperparathyroidism
• Paget disease of bone
• CKD-mineral bone disorder
• Vertebral infection/malignant compression fracture
• Osteogenesis imperfecta in young/recurrent fracture cases

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7) Complications — রোগের জটিলতা

• Hip fracture: সবচেয়ে serious; surgery, immobility, DVT/PE, pneumonia, pressure sore, mortality risk বাড়ে।
• Vertebral compression fracture: chronic back pain, height loss, kyphosis, recurrent vertebral fracture।
• Wrist fracture: daily activity impairment।
• Loss of independence: elderly patient bed-bound বা caregiver-dependent হয়ে যেতে পারেন।
• Chronic pain & depression: mobility কমে গেলে mental health impact হয়।
• Recurrent falls & fractures: একবার fracture হলে পরের fracture-এর ঝুঁকি বেশি।

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8) Treatment & Management — guideline-based

NOGG 2024 অনুযায়ী অধিকাংশ fragility-fracture risk patient-এ antiresorptive therapy first-line, বিশেষ করে oral alendronate/risedronate অথবা IV zoledronate; alternative হিসেবে denosumab, ibandronate, raloxifene, teriparatide ইত্যাদি বিবেচনা করা যায়। Oral bisphosphonate সাধারণত কমপক্ষে 5 বছর, IV bisphosphonate কমপক্ষে 3 বছর দিয়ে fracture risk reassess করা হয়।

A. Non-pharmacological management

• Weight-bearing exercise: walking, stair climbing
• Muscle strengthening: resistance training
• Balance training: Tai Chi/physiotherapy
• Fall prevention: home lighting, bathroom grab bar, loose carpet remove
• Smoking বন্ধ
• Alcohol কমানো
• Adequate protein
• Dietary calcium: milk, yogurt, small fish with bone, leafy greens
• Sun exposure + vitamin D correction
• Vision/hearing correction
• Sedative/hypnotic review

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9) Pharmacological Drugs — generic, class, dose, duration, side effect, interaction, BD brand

1. Generic name: Alendronic Acid / Alendronate

• Therapeutic category: Anti-osteoporotic drug
• Pharmacological class: Nitrogen-containing bisphosphonate; antiresorptive
• Why used: First-line; osteoclast-mediated bone resorption কমায়, vertebral/hip/non-vertebral fracture risk কমাতে ব্যবহৃত।
• Dose: 70 mg PO once weekly অথবা 10 mg PO daily; সকালে খালি পেটে full glass water দিয়ে, 30 মিনিট শোয়া যাবে না।
• Duration: সাধারণত 5 বছর, তারপর fracture risk reassessment।
• Side effects: dyspepsia, esophagitis, abdominal pain, musculoskeletal pain; rare—osteonecrosis of jaw, atypical femur fracture, hypocalcemia।
• Interactions: calcium/iron/magnesium/antacid absorption কমায়—কমপক্ষে 30–60 min পরে; NSAID GI irritation বাড়ায়।
• Avoid/caution: esophageal stricture/achalasia, inability to sit upright, severe renal impairment.
• Bangladesh available brand name: Alendon 10 mg, Alendon 70 mg — Beximco; MedEx-listed.

2. Generic name: Alendronic Acid + Vitamin D3

• Therapeutic category: Anti-osteoporotic + vitamin supplement
• Pharmacological class: Bisphosphonate + cholecalciferol
• Why used: osteoporosis treatment + vitamin D support in same weekly tablet।
• Dose: 70 mg + 2800 IU PO once weekly.
• Duration: alendronate plan অনুযায়ী; 5 বছর পর reassess.
• Side effects/interactions: alendronate-এর মতো; vitamin D excess হলে hypercalcemia.
• Bangladesh available brands: Bonemass D 70 mg+2800 IU, Ostel-D 70 mg+2800 IU.

3. Generic name: Risedronate Sodium

• Therapeutic category: Anti-osteoporotic drug
• Pharmacological class: Nitrogen-containing bisphosphonate
• Why used: alendronate alternative first-line; osteoclast inhibition করে fracture risk কমায়।
• Dose: 35 mg once weekly অথবা 150 mg once monthly অথবা 5 mg daily.
• Duration: সাধারণত 5 বছর, তারপর reassess.
• Side effects: GI upset, esophagitis, bone/muscle pain; rare—ONJ, atypical femoral fracture.
• Interactions: calcium/iron/antacid/multivitamin absorption কমায়; empty stomach নিয়ম follow করতে হবে।
• Bangladesh available brands: Risonet 35 mg/150 mg, Salost 5 mg/150 mg, Salost DR 35 mg, Sedron 5 mg/35 mg.

4. Generic name: Ibandronic Acid / Ibandronate

• Therapeutic category: Anti-osteoporotic drug
• Pharmacological class: Bisphosphonate; antiresorptive
• Why used: monthly dosing সুবিধাজনক; mainly postmenopausal osteoporosis, especially vertebral fracture risk reduction.
• Dose: 150 mg PO once monthly; IV form 3 mg every 3 months specialist supervision.
• Duration: oral bisphosphonate হিসেবে সাধারণত 5 বছর পর reassess.
• Side effects: dyspepsia, esophagitis, flu-like symptoms with IV, hypocalcemia; rare—ONJ/AFF.
• Interactions: calcium, antacid, iron, magnesium absorption কমায়; oral dose-এর 60 মিনিট পর অন্য medicine/food.
• Bangladesh available brands: Bondrova 3 mg/3 ml IV, Bone-Guard 150 mg, Bonfix 150 mg, Bonmax 150 mg, Bonova 150 mg, Droniva 150 mg, Ibandron 150 mg, Ivana 150 mg, Maxbon 150 mg, Osteonil 150 mg, Ostiban 150 mg, SB-Iban 150 mg.

5. Generic name: Zoledronic Acid 5 mg/100 ml

• Therapeutic category: Anti-osteoporotic IV drug
• Pharmacological class: Bisphosphonate; potent antiresorptive
• Why used: yearly injection; oral bisphosphonate intolerance, adherence problem, GI contraindication, post-hip fracture cases.
• Dose: 5 mg IV infusion once yearly; infusion usually ≥15 minutes.
• Duration: সাধারণত 3 বছর, তারপর fracture risk reassessment.
• Side effects: acute phase reaction—fever, myalgia, flu-like symptoms; hypocalcemia; renal toxicity; rare—ONJ/AFF.
• Interactions/caution: nephrotoxic drugs, dehydration, loop diuretics; calcium/vitamin D deficiency correct করতে হবে; CrCl <35 mL/min হলে avoid.
• Bangladesh available brands: Aclasta 5 mg/100 ml, Bonizol 5 mg/100 ml, Zandra 5 mg/100 ml, Zoldix 5 mg/100 ml, Zoledron 5 mg/100 ml, Zolenic 5 mg/100 ml, Zoltero 5 mg/100 ml.

6. Generic name: Denosumab

• Therapeutic category: Anti-osteoporotic biologic
• Pharmacological class: RANKL monoclonal antibody; antiresorptive
• Why used: high fracture risk, bisphosphonate unsuitable/intolerant, renal impairment contextে specialist decision; 6-monthly injection adherence-friendly.
• Dose: 60 mg SC every 6 months.
• Duration: 5–10 বছর পর্যন্ত reassess; বন্ধ করলে zoledronate/bisphosphonate plan ছাড়া বন্ধ করা যাবে না—rebound vertebral fracture risk থাকে। Endocrine Society ও NOGG denosumab delay/stop না করার কথা বলে যদি subsequent antiresorptive plan না থাকে।
• Side effects: hypocalcemia, eczema/rash, cellulitis, musculoskeletal pain; rare—ONJ/AFF।
• Interactions/caution: severe CKD হলে hypocalcemia risk বেশি; immunosuppressive therapy infection risk বাড়াতে পারে; calcium/vitamin D adequate রাখতে হবে।
• Bangladesh available brands: Denomab 60 mg/ml, Denosis 60 mg/ml. MedEx-এ Denosis 120 mg/1.7 ml-ও আছে, তবে osteoporosis-এর routine dose 60 mg 6-monthly।

7. Generic name: Teriparatide

• Therapeutic category: Bone-forming / anabolic anti-osteoporotic
• Pharmacological class: Recombinant human parathyroid hormone analogue, PTH 1-34
• Why used: very high fracture risk, multiple/severe vertebral fracture, glucocorticoid-induced severe osteoporosis, bisphosphonate failure/intolerance.
• Dose: 20 mcg SC daily.
• Duration: maximum 24 months lifetime; এরপর alendronate/zoledronate/denosumab দিয়ে bone gain maintain করতে হয়। Endocrine Society very high-risk postmenopausal women-এ up to 2 years teriparatide/abaloparatide recommend করে।
• Side effects: nausea, dizziness, leg cramps, orthostatic hypotension, hypercalcemia, hyperuricemia.
• Interactions/caution: digoxin + hypercalcemia arrhythmia risk; avoid Paget disease, bone metastasis, skeletal malignancy, prior skeletal radiation, unexplained high ALP, hypercalcemia.
• Bangladesh available brands: Forteo 20 mcg/80 mcl pen, Teripen 20 mcg/80 mcl pen.

8. Generic name: Calcium Carbonate + Vitamin D3 / Cholecalciferol

• Therapeutic category: Mineral + vitamin supplement
• Pharmacological class: Calcium salt + vitamin D preparation
• Why used: osteoporosis drug-এর adjunct; calcium/vitamin D deficiency correct করে, antiresorptive/anabolic therapy ভালো কাজ করতে সাহায্য করে। Endocrine Society osteoporosis therapy-এর adjunct হিসেবে calcium + vitamin D suggest করে।
• Dose: diet সহ total elemental calcium সাধারণত 1000–1200 mg/day; vitamin D সাধারণত 800–1000 IU/day বা deficiency অনুযায়ী।
• Side effects: constipation, bloating, hypercalcemia, renal stone.
• Interactions: levothyroxine, iron, tetracycline/quinolone antibiotic, bisphosphonate absorption কমায়—2–4 ঘণ্টা gap।
• Bangladesh available examples: Calcin-D 500 mg+200 IU, Calcin-DX 600 mg+400 IU, Calvimax D 500 mg+200 IU, Oscal-D Forte 600 mg+400 IU, Ostoplus-D 500 mg+200 IU, Ostoplus-DX 600 mg+400 IU, Protebon-D 500 mg+200 IU, Calcibo D 500 mg+200 IU, Calfix-Dx 600 mg+400 IU, Calfast DX 600 mg+400 IU. MedEx-এ এই generic-এর বহু brand আছে; prescription-এ সাধারণত available/affordable brand দেওয়া হয়।

9. Generic name: Cholecalciferol / Vitamin D3

• Therapeutic category: Vitamin D preparation
• Pharmacological class: Fat-soluble vitamin
• Why used: vitamin D deficiency থাকলে calcium absorption কমে osteoporosis worsen হয়; deficiency correction জরুরি।
• Dose: deficiency হলে commonly 40,000 IU once weekly × 7 weeks; maintenance 1400–2000 IU/day—MedEx dose section-এ এভাবে দেওয়া আছে।
• Side effects: hypercalcemia, nausea, constipation, polyuria, renal stone if overdose.
• Interactions: thiazide hypercalcemia বাড়াতে পারে; digoxin toxicity risk; cholestyramine/orlistat absorption কমায়; antiepileptic vitamin D metabolism বাড়ায়।
• Bangladesh available brands: Aristo D3 2000 IU/20000 IU/40000 IU/200000 IU/ml, Defrol 2000 IU/50000 IU/200000 IU/ml, D-2000, D-20000, D-40000, Delight 1000 IU/2000 IU/20000 IU/40000 IU/50000 IU/200000 IU/ml, Hi-D 2000 IU/200000 IU/ml.

10. Generic name: Calcitriol

• Therapeutic category: Vitamin-D preparation in bone formation
• Pharmacological class: Active vitamin D analogue
• Why used: postmenopausal osteoporosis-এ কিছু ক্ষেত্রে, বিশেষ করে CKD/renal osteodystrophy/hypoparathyroidism contextে specialist monitoring সহ; routine simple osteoporosis-এ সব রোগীর জন্য নয়।
• Dose: postmenopausal osteoporosis: 0.25 mcg twice daily; serum calcium monitoring দরকার।
• Side effects: hypercalcemia, hypercalciuria, constipation, nausea, polyuria, arrhythmia, nephrocalcinosis.
• Interactions: thiazide → hypercalcemia; digoxin → arrhythmia risk; magnesium antacid → hypermagnesemia; vitamin D derivative একসাথে avoid.
• Bangladesh available brands: Calcitrol 0.25 mcg, Caltrol 0.25 mcg/1 mcg/ml, Colitrol 0.25 mcg/1 mcg/ml, D-Act 0.25 mcg, Dicaltrol 0.25 mcg, Encatrol 0.25 mcg, Improcal 0.25 mcg, Liquical 0.25 mcg, Lucent 0.25 mcg, Ostriol 0.25 mcg, Raditrol 0.25 mcg, Caloren 1 mcg/ml, Promocal 1 mcg/ml.

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Bangladesh doctors commonly prescribe — practical list

• Calcium + Vitamin D3: deficiency correction ও adjunct therapy.
• Vitamin D3 high-dose capsule/injection: low 25(OH)D হলে।
• Alendronate 70 mg weekly: first-line, cheap, effective.
• Risedronate 35 mg weekly / 150 mg monthly: alendronate alternative.
• Ibandronate 150 mg monthly: monthly option; mainly vertebral fracture-risk patient.
• Zoledronic acid 5 mg yearly IV: oral drug intolerance, adherence issue, high-risk, post-hip fracture.
• Denosumab 60 mg 6-monthly SC: high risk/renal issue/bisphosphonate unsuitable, but stopping plan mandatory.
• Teriparatide 20 mcg daily SC: very high-risk, multiple vertebral fracture, severe osteoporosis.
• Calcitriol 0.25 mcg: CKD/hypoparathyroid/postmenopausal selected cases with calcium monitoring.

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Prevention — কীভাবে করবেন

• দৈনিক calcium-rich diet নিশ্চিত করা।
• Vitamin D deficiency screen/correct করা।
• সপ্তাহে কমপক্ষে 150 মিনিট walking/weight-bearing activity।
• সপ্তাহে 2–3 দিন resistance exercise।
• Fall prevention: bathroom non-slip mat, adequate light, walking aid, vision correction।
• Smoking বন্ধ, alcohol কমানো।
• Long-term steroid দিলে শুরুতেই fracture risk assess; NOGG ≥7.5 mg/day prednisolone equivalent for ≥3 months হলে bone-protective treatment দ্রুত বিবেচনা করতে বলে।
• Menopause, age >65, fragility fracture, chronic steroid, RA, low BMI—এই risk থাকলে DXA/FRAX assessment।

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Overview / Summary

Osteoporosis হলো silent disease; fracture হওয়ার আগ পর্যন্ত symptom নাও থাকতে পারে। Diagnosis-এর core হলো fragility fracture + DXA T-score ≤ −2.5 + fracture risk assessment। First-line treatment সাধারণত alendronate/risedronate/zoledronic acid, very high-risk হলে teriparatide, আর selected high-risk/intolerant patient-এ denosumab। Calcium/vitamin D adjunct, কিন্তু একা severe osteoporosis treat করে না।

Actionable Plan / Steps

1. DXA spine + hip করুন।
2. Serum calcium, phosphate, ALP, creatinine/eGFR, 25(OH)D, CBC, TSH ± PTH করুন।
3. Fragility fracture থাকলে X-ray/VFA দিয়ে vertebral fracture খুঁজুন।
4. Vitamin D/calcium deficiency correct করুন।
5. High-risk হলে oral bisphosphonate শুরু; GI intolerance/adherence problem হলে IV zoledronic/denosumab ভাবুন।
6. Very high-risk/multiple vertebral fracture হলে teriparatide → পরে antiresorptive।
7. Follow-up: adherence, side effects, fall risk, calcium/vitamin D; DXA 1–3 বছর পর।

Reference List

Textbooks

• Harrison’s Principles of Internal Medicine, 21st ed., Osteoporosis chapter.
• Davidson’s Principles and Practice of Medicine, 24th ed., Bone disease/Osteoporosis section.
• Robbins & Cotran Pathologic Basis of Disease, 10th ed., Bone pathology/metabolic bone disease section.
• Guyton and Hall Textbook of Medical Physiology, 14th ed., Calcium/phosphate/PTH/vitamin D physiology.

Guidelines

• NOGG Clinical Guideline for the Prevention and Treatment of Osteoporosis, updated 2024.
• Endocrine Society Clinical Practice Guideline: Pharmacological Management of Osteoporosis in Postmenopausal Women.
• Bone Health and Osteoporosis Foundation Clinician’s Guide, 2022.

Peer-reviewed journals with DOI

• Eastell R, Rosen CJ, Black DM, et al. J Clin Endocrinol Metab. 2019;104:1595–1622. DOI: 10.1210/jc.2019-00221.
• LeBoff MS, Greenspan SL, Insogna KL, et al. Osteoporosis International. 2022;33:2049–2102. DOI: 10.1007/s00198-021-05900-y.
• Black DM, Cummings SR, Karpf DB, et al. The Lancet. 1996;348:1535–1541. DOI: 10.1016/S0140-6736(96)07088-2.
• Cummings SR, San Martin J, McClung MR, et al. NEJM. 2009;361:756–765. DOI: 10.1056/NEJMoa0809493.

Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday time:-2-18-28 Pm