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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 521-524

Osteoporosis in patients with chronic obstructive pulmonary disease


1 Chest Department, Faculty of Medicine, Menoufia University, Menufia
2 Al-Mahalla Chest Hospital, Gharibyia Governorate

Date of Submission11-Aug-2014
Date of Acceptance26-Oct-2014
Date of Web Publication31-Aug-2015

Correspondence Address:
Ahmad M Zanfal
Al-Mahalla Al Kobra, Ayash, Gharibyia Governorate 31951

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163912

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  Abstract 

Objectives
The aim of the study was to determine the incidence and severity of osteoporosis in chronic obstructive pulmonary disease (COPD) patients at different grades of disease.
Background
COPD is a widely prevalent disease with high morbidity and mortality and is associated with important pathologies, among which is osteoporosis. However, osteoporosis is often undiagnosed in these patients.
Participants and methods
This study was conducted on 30 patients with COPD and 10 healthy controls (the control group). They were selected from Al-Mahalla Chest Hospital from April 2012 to March 2013. All participants were subjected to detailed clinical history taking, a thorough clinical examination, plain chest radiography (posteroanterior and lateral views), blood sampling for complete blood picture, erythrocyte sedimentation rate, and serum calcium and phosphates, ventilatory function tests (spirometry), and measurement of bone density using dual-energy X-ray absorptiometry.
Results
The results of this study revealed highly significant reduction in most ventilatory function tests in the COPD group compared with the control group (P ≤ 0.01). Prevalence of osteoporosis was higher in the COPD group compared with the control group (P ≤ 0.05). Prevalence of osteoporosis increased with increasing severity of COPD (P ≤ 0.05).
Conclusion
Osteopenia and osteoporosis are more prevalent in COPD patients than in healthy controls and the severity of osteoporosis increases with increasing severity of COPD.

Keywords: chronic obstructive pulmonary disease, osteopenia, osteoporosis


How to cite this article:
Mansour OF, Bakr RM, Elwahsh RA, Zanfal AM. Osteoporosis in patients with chronic obstructive pulmonary disease. Menoufia Med J 2015;28:521-4

How to cite this URL:
Mansour OF, Bakr RM, Elwahsh RA, Zanfal AM. Osteoporosis in patients with chronic obstructive pulmonary disease. Menoufia Med J [serial online] 2015 [cited 2020 Apr 2];28:521-4. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/521/163912


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases [1] . Osteoporosis has been recognized as one of the systemic effects of COPD, and debate continues on the precise mechanisms involved and on the options for treatment [2] . Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk [3] . Therefore, the aim of the current study was to determine the incidence and severity of osteoporosis in COPD patients of different grades.


  Participants and methods Top


This study was conducted in Al-Mahalla chest hospital during April 2012-March 2013. The study involved 30 male COPD patients ranging in age from 49 to 75 years. The study also included 10 healthy male controls ranging in age from 50 to 63 years. Written consent was obtained from all participants before inclusion and the regional ethical committee of the Menoufia University hospital approved the study.

Study participants were divided into two groups: group A included 30 patients with COPD diagnosed and classified according to GOLD 2011. All patients had FEV 1 /FVC less than 70% after bronchodilator use, and no substantial improvement in FEV 1 after taking 200 μg - that is, two puffs from a standard metered dose inhaler - of salbutmol [4] . They were subdivided into five patients with mild COPD (group I), 10 patients with moderate COPD (group II), 10 patients with severe COPD (group III), and five patients with very severe COPD (group IV). Group B included 10 healthy volunteers who had no symptoms or signs of any chest disease and normal ventilatory function tests; they served as the control group.

All participants were subjected to detailed clinical history, thorough clinical examination, plain chest radiography, blood sampling for complete blood picture, erythrocyte sedimentation rate, serum calcium, and phosphate, spirometry using 'CHEST GRAPH H I - 105' (Hongo Bunkyo-ku, Tokyo 113-0033, Japan) apparatus before and after bronchodilator use, and measurement of bone density with the use of 'Bone Densitometry, Dual Energy apparatus' (Hologic-Delphi, Waltham, Massachusetts, USA) [5] .

Statistical analysis was conducted, with the mean, the Student t-test, the c2 -test, the linear correlation coefficient, and analysis of variance using SPSS, V17 (IBM Corporation, 1 New Orchard Road, Armonk, NY, USA). P values greater than 0.05 were considered statistically nonsignificant, those less than or equal to 0.05 were considered statistically significant, and values less than or equal to 0.01 were considered highly statistically significant.


  Results Top


There was a highly statistically significant difference between patients and controls as regards FEV 1 % of predicted and FEV 1 /FVC (P ≤ 0.01), and no statistically significant difference between patients and controls as regards FVC% of predicted (P 0.05) [Table 1].
Table 1 Statistical comparison between patients and controls as regards ventilatory function tests (spirometry)

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There was a statistically significant difference between patients and controls as regards dual-energy X-ray absorptiometry (DEXA) scan results (P ≤ 0.05). Osteopenia was seen in 50% and osteoporosis in 30% of patients [Table 2].
Table 2 Statistical comparison between patients and controls as regards DEXA scan results

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There was a statistically significant difference between patients and controls as regards T score at the right hip region (P ≤ 0.05) and no statistically significant difference between patients and controls as regards T score at the lumbar spine or the left distal forearm region (P>0.05) [Table 3].
Table 3 Statistical comparison between patients and controls as regards T scores

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There was a highly statistically significant difference between severe COPD patients and controls as regards DEXA scan results (P ≤ 0.01) and a statistically significant difference between moderate COPD patients, very severe COPD patients, and controls as regards DEXA scan results (P ≤ 0.05) [Table 4].
Table 4 Statistical comparison between patients with different COPD grades and controls as regards DEXA scan results

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With regard to the GOLD grades of COPD, of five patients with mild COPD, 4 (80%) showed normal bone mineral density (BMD) and 1 (20%) was osteopenic. Among 10 patients with moderate COPD, 2 (20%) had normal BMD, 4 (40%) were osteopenic, and 4 (40%) were osteoporotic. Among10 patients with severe COPD, no patient had normal BMD, 7 (70%) were osteopenic, and 3 (30%) were osteoporotic. Among five patients with very severe COPD, no patient had normal BMD, 3 (60%) were osteopenic, and 2 (40%) were osteoporotic [Table 4].

There was a highly statistically significant negative correlation between T score at the left distal forearm region and age, and a statistically highly significant positive correlation between T score at the left distal forearm region and FEV 1 /FVC (P ≤ 0.01). Further, there was a statistically significant positive correlation between T score at the left distal forearm region and FEV 1 % of predicted (P ≤ 0.05). There was also a highly statistically significant positive correlation between T score at the right hip region and both FEV 1 /FVC and FEV 1 % of predicted (P ≤ 0.01). Also, there was a statistically significant negative correlation between T score at the right hip region and both age and height (P ≤ 0.05) [Table 5].
Table 5 Correlation between T scores and other parameters

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  Discussion Top


Osteoporosis continues to be a major problem in men with chronic illness. In men with chronic lung disease, osteoporosis may be particularly disabling because vertebral fractures reduce vital capacity, which further compromises ventilation [6] . Evidence suggests that the prevalence of osteoporosis in patients with COPD is high and potentially important [7] .

In the present study, the results of ventilatory function tests showed highly significant reduction in FEV 1 % of predicted and FEV 1 /FVC in the COPD group in comparison with the control group. These results matched with those of Asaad et al. [8] , who found a highly significant reduction in FEV 1 % and FEV 1 /FVC between the COPD group and the control group. This decrease in pulmonary functions in the COPD group may lead to lifestyle changes in these patients, making it more sedentary, with increased effort in breathing and decrease in BMI, which are considered risk factors for osteoporosis.

In the present study, there was an increased prevalence of osteopenia and osteoporosis in COPD patients in comparison with the control group. These results matched those of Shepherd et al. [9] , who reported that the prevalence of osteoporosis and osteopenia in COPD patients varies between 9 and 69% and between 27 and 67%, respectively, depending on the diagnostic methods used, the population studied, and the severity of the underlying respiratory disease. In COPD patients, the prevalence of osteoporosis was assumed to be two- to five-fold higher than that of age-matched individuals without airflow obstruction. In a recently developed screening tool for men at risk for osteoporosis, the presence of COPD was found to be one of the parameters increasing this risk almost four-fold.

In the present study, there was a statistically significant difference between COPD patients and controls as regards the mean of T score at the right hip region. These results were in concordance with the results of the study carried by Lung Health Study Research Group (2004) on 412 COPD patients over 3 years, revealing that BMD was much lower in COPD patients compared with normal individuals of the same sex and age [10] .

In the present study, there was a statistically significant difference between COPD patients and controls as regards DEXA scan results. It was revealed that the risk for osteopenia increases by 40% in patients with moderate COPD and by 70% in those with severe COPD and the risk for osteoporosis increases by 40% in moderate COPD and by 30% in severe COPD, compared with normal individuals. These results were in agreement with those of Sin et al. [11] , who revealed that the risk for osteopenia increases by 30% in patients with moderate COPD and by 70% in those with severe COPD and the risk for osteoporosis increases by 2.1-fold in moderate COPD and by 2.8-fold in severe COPD, compared with normal individuals.

Previous studies demonstrated that the prevalence of osteopenia and osteoporosis increased with increasing COPD severity. These results matched those of EL Gazzar et al. [12] , who reported that the prevalence of osteoporosis was higher in COPD, increasing with increasing COPD severity.

In the present study, there was a statistically significant negative correlation between age and T score at both the left distal forearm region and the right hip region. These results agreed with those of Warming et al. [13] in their study on changes in BMD with age in men and women. They found that in men there was a small longitudinal bone loss in the hip throughout life and a small bone loss in the distal forearm after the age of 50 years.

We also found that there was a statistically significant negative correlation between T score at the right hip region and height. These results agreed with those of Moayyeri et al. [14] in their study on height loss as a predictor of fractures in middle-aged and older men and women. They found that middle-aged and older men and women with annual height loss greater than 0.5 cm are at increased risk for hip and other fractures.

In the present study there was a statistically significant positive correlation between T score at the right hip region and the left distal forearm region and FEV 1 /FVC and FEV 1 % of predicted. These results were in concordance with those of Iqbal et al. [15] who found that in COPD patients who had osteoporosis BMD decreases linearly with the decrease in FEV 1 %.


  Conclusion Top


From the present study we concluded that decreased BMD in the form of osteopenia and osteoporosis was more prevalent in COPD patients than in healthy controls. The prevalence and severity of osteoporosis increased with increasing severity of COPD. The T score of the DEXA scan was positively correlated with FEV 1 % of predicted and FEV 1 /FVC and negatively correlated with age and height.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Global initiative for Chronic Obstructive Lung disease (GOLD). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. A collaborative project of the National Heart, Lung and Blood Institute. NIH and the World Health Organization; 2009.  Back to cited text no. 1
    
2.
Praet JP, Peretz A, Rozenberg S, Famaey JP, Bourdoux P. Risk of osteoporosis in men with chronic bronchitis. Osteoporos Int 1992; 2 : 257-261.  Back to cited text no. 2
    
3.
Peck WA, Burckhardt P, Christiansen C, Fleish HA, Genant HK, Gennari C, et al. Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 1993; 94 :646-650.  Back to cited text no. 3
    
4.
Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD report. A collaborative project of the National Heart, Lung, and Blood Institute. NIH and the World Health Organization; 2006.  Back to cited text no. 4
    
5.
Hangartner TN. A study of the long term precision of dual energy X-ray absorptiometry bone densitometers and implications for the validity of the least-significant-change calculation. Osteoporosis International 2007; 18 :513-523.  Back to cited text no. 5
    
6.
Leech JA, Dulberg C, Kellie S, Pattee L, Gay J. Relationship of lung function to severity of osteoporosis in women. Am Rev Respir Dis 1990; 141 :68-71.  Back to cited text no. 6
    
7.
De Vries F, Van Staa TP, Bracke MS, Cooper C, Leufkens HG, Lammers JW. Severity of obstructive airway disease and risk of osteoporotic fracture, Eur Respir J 2005; 25 :879-884.  Back to cited text no. 7
    
8.
Asaad H, Orabi S, Mohamed S, Sayed E. C3, C4 complement components in serum of patients with emphysema complicating chronic bronchitis, it's correlation with quantity of emphysema [MSc thesis]. Chest Department, Al-Azhar University; 2002.  Back to cited text no. 8
    
9.
Shepherd AJ, Cass AR, Carlson CA, Ray L. Development and internal validation of the male osteoporosis risk estimation score, Ann Fam Med 2007; 5 :540-546.  Back to cited text no. 9
    
10.
Lung Health Study Research Group. Effect of inhaled triamcinolone on the decline in pulmonary function in COPD. N Engl J Med 2004; 343 : 1902-1909.  Back to cited text no. 10
    
11.
Sin DD, Man JP, Man SF. The risk of osteoporosis in Caucasian men and women with obstructive airways disease. Am J Med 2003; 114 : 10-14.  Back to cited text no. 11
    
12.
EL Gazzar AG, Abdullah ME, Al Mahdy MA, El Zoghby YA. Study of osteoporosis in chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc 2013; 62 :91-95.  Back to cited text no. 12
    
13.
Warming L, Hassager C, Christiansen C. Changes in bone mineral density with age in men and women. A longitudinal study. Osteoporos Int 2002; 13 :105-112.  Back to cited text no. 13
    
14.
Moayyeri A, Luben RN, Bingham SA, Welch AA, Wareham NJ, Khaw KT. Measured height loss predicts fractures in middle-aged and older men and women. The EPIC-Norfolk Prospective Population Study. J Bone Miner Res 2008; 23 :425-432.  Back to cited text no. 14
    
15.
Iqbal F, Michaelson J, Thaler L, Rubin J, Roman J, Nanes MS. Declining bone mass in men with chronic pulmonary disease. Chest 2004; 128 :1616-1624.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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[Pubmed] | [DOI]



 

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