Quando avaliar e como manejar Osteopenia e Osteoporose na DPOC

Apresentação em tema: "Quando avaliar e como manejar Osteopenia e Osteoporose na DPOC"— Transcrição da apresentação:

1 Quando avaliar e como manejar Osteopenia e Osteoporose na DPOC
Fernando Lundgren

2 Osteopenia e Osteoporose na DPOC doença concomitante ?
Pontos para pensar Ocorre em todo paciente com DPOC? Se relaciona com a gravidade da DPOC? Se relaciona com o tratamento da DPOC? Osteopenia e Osteoporose na DPOC doença concomitante ? indicar afecções que coexistem ou sucedem uma outra. Expresso ao mesmo tempo; simultâneo:

3 Mecanismo RANKL 5 (receptor activator of nuclear factor- k B ligand)
DPOC = aumento do RANK-L redução do OPG RANKL 5 (receptor activator of nuclear factor- k B ligand) OPG 5 (osteoprotegerin) Bone is generally classifi ed into two types. Cortical bone is a dense and strong bone found primarily in the shaft of long bones. Trabecular bone is more porous or weak and typically occurs at the ends of long bones and within the interior of vertebrae and fl at bones. Bone tissue is continuously renewed through- out life and it is estimated that in adults, approxi- mately 25% of trabecular bone and 3% of cortical bone is replaced every year. After reaching peak bone mass at the age of 25 to 30 years, remodeling is associated with an imbalance between formation and resorption, resulting in a mean annual bone loss of 0.5% to 1%, which differs by sex, skeletal site, and age. Key deter- minants of the rate of bone remodeling and bone loss are parathyroid hormone (PTH), vitamin D, and sex hormones At the cellular level, bone remodeling is a complex interplay in which osteoblasts, osteo- clasts, and osteocytes work together ( Fig 1 ). Basically, osteoclasts resorb bone and osteoblasts replace bone by forming an osteoid protein matrix that subsequently mineralizes, whereas osteocytes and their canicular network serve as sensors to adjust bone response to mechanical stimuli. On their surface, osteoblasts constitutively express the receptor activator of nuclear factor- k B ligand (RANKL). When binding to its recep- tor (receptor activator of nuclear factor- k B [RANK]) on the surface of preosteoclast cells, the latter differ- entiate into mature and activated osteoclasts. Addi- tionally, osteoblasts but also stromal cells secrete a soluble decoy receptor, osteoprotegerin (OPG), which blocks the RANK/RANKL interaction, thereby acting as a physiologic regulator of bone turnover. 30Imbal-ance between RANKL and OPG results in excessive activity of osteoclasts and is considered a major cause of osteoporosis. 31Another pathway that is less wellunderstood is the Wnt/ b -catenin signaling cascade downstream of a number of osteoblast-activating pro- teins and receptors. Wnt signaling activates osteo- blasts and bone formation, whereas reduced Wnt signaling may lead to osteoporosis. 32Several factorsthat have often been described in COPD patients (ie, systemic infl ammation, use of corticosteroids, and vitamin D defi ciency) clearly interact with these pathways and are discussed in the following sections. Lehouck A, Chest 2011 Mar;139(3):648–5

4 Osteopenia e Osteoporose na DPOC
Tópicos a seres Abordados Osteopenia e Osteoporose na DPOC Quais fatores levam ao aparecimento? Idade; Tabagismo ; Redução atividades; Medicamentos Como diagnosticar Historia clinica TAC; Densitomeria, US calcâneo Como tratar Reposição cálcio ; Atividades físicas; Vitamina D

5 Coeficiente de Incidência em 6 anos:
Incidência Geral Presente em 10% da população mundial e em 30% das mulheres após menopausa Intenational Osteoporosis Foundation : Coeficiente de Incidência em 6 anos: Mulher = 22,95/1000 pessoas-ano IC95% (19, ) [2,29 %] Homem = 3,34/1000 pessoas-ano IC95% (1,85-7,73) [0,34%] Tese Mestrado USP - Nutrição 2011 Lujan; Marianella ACTA INFORM MED Dec; 21(4): doi: /aim Received: 15 September 2013 • Accepted: 12 November 2013 Introduction: Osteoporosis is a disease characterized by a decrease in bone mineral density, making bones become less rigid, and therefore susceptible to fractures, either spontaneously or with force, which is lower than otherwise needed for healthy bones fractured. Nearly 10% of the world population and 30% of women after menopause, suffer from osteoporosis. Clinical assessment of osteoporosis in family medicine is key to prevention, early detection and treatment of osteoporosis. Objective: To investigate the possibility of early detection and diagnosis of osteoporosis by analyzing the risk factors for osteoporosis and to compare the results with the parameters obtained by ultrasound densitometry of calcaneus, and determine the relationship of calcaneus densitometry with DXA findings, as the gold standard for the diagnosis of osteoporosis. Patients and methods: The study included all patients of Family Medicine Kalesija Team 1, aged 50 years and over, a total of 711 patients, of whom 425 were women and 286 men. In all patients we assessed the existence of the following risk factors for osteoporosis: Constitutional: gender, age, weight, constitution, menarche and menopause, loss of height and stooped posture; Living habits: smoking, alcohol consumption, coffee, physical activity, and medications: long-term use corticosteroids, anticonvulsants, antacids, thyroid hormones. Comorbidity: history of fractures, hyperthyroidism, COPD, Chussing’s disease, diabetes. In the group of high-risk patients determined by the clinical assessment, quantitative ultrasound densitometry screening was carried out. Monitoring parameters derived with densitometry: the value of T-score, BUA (Broadband Ultrasound Attenuation), SOS (Speed of Sound), QUI (Quantitative Ultrasound Index). To confirm the diagnosis of osteoporosis, in all patients with positive findings using ultrasound densitometry (T score lower than 2.5), another densitometry was performed by standard DXA method. Results: The incidence of osteoporosis was 96% in women and 4% in men. Differences in prevalence between men and women are statistically significant. People with and without osteoporosis significantly differ in gender, age, weight, constitution (BMI-Body Mass Index). The parameters that distinguish those with and without osteoporosis: age, weight, height, BMI, gender. Out of the total of 711 patients, in 11% of patients the clinical evaluation showed the existence of high risk of osteoporosis. In 9.8% patients, the values were determined by ultrasound densitometry, where T score was lower than 2.5 what induces a high risk of fractures, and for 8.8% patients the DXA confirmed the diagnosis of osteoporosis. Conclusion: Clinical assessment of osteoporosis in the family medicine clinic performed in timely and focused history of risk factors for osteoporosis, with additional findings from quantitative densitometry of calcaneus, was sufficient for the early detection and screening of patients with high risk for osteoporosis. With good clinical assessment of osteoporosis it will be necessary to send all patients who enter the high-risk group to undergo ultrasound densitometry of calcaneus, to make it possible to determine the risk of bone fractures and osteoporosis in time, and then refer patients for further processing and DXA measurements according to the guidelines by the WHO.

6 Cazzola M et al. Respiration 2010 Feb ;112–9
Incidência em DPOC 35,1% osteoporose e 38,4% osteopenia [Revisão literatura] Graat-Verboom et al. ERJ.2009 Jul;34(1):209–18. 14,8 % (4,6% homens 30,5% mulheres DPOC) e 10,8% (1,7% homens 18,4,% mulheres Não DPOC) [Banco de dados Italiano] Cazzola M et al. Respiration 2010 Feb ;112–9 Deficiência de alfa 1 [Redução da densidade óssea / osteopenia] Duckers JM, et al. Respir Res.; 2010 Jan;11(1):173. N=95 40% osteoporose 40% osteopenia 20% normal [DPOC] Knost, MM. Respir Care 2011 Jul;56(7):961–8. 18% homens , 30% mulheres [TORCH] Fergunson G et al Chest 2009

7 Fatores de Risco Causas Osteoporose em Mulheres OR Idade > 60 anos
2,67 Idade > 70 anos 5,17 Tempo de menopausa > 6 anos > 10 anos 1,75 4,06 ACTA ORTOP BRAS 15 (3: , 2007) Após atingir o pico de massa óssea, os indivíduos iniciam uma perda que varia de 0,3% a 0,5% de sua massa óssea a cada ano. Mulheres na pós-menopausa apresentam uma diminuição acelerada da massa óssea após a última menstruação, a qual pode ser até 10 vezes maior do que a observada no período de pré-menopausa. Rev Bras Ortop. 2010;45(5):392-6

8 Gravidade da Obstrução Extensão do enfisema
Fatores de Risco Gravidade da Obstrução Extensão do enfisema Mecanismo infamatório sistêmico Gravidade da DPOC Idade IMC Oral Inalatório – dose dependente Corticóide Deficiência de Vitamina D Redução da atividade física Tabagismo Oral and inhaled corticosteroids are widely used in patients with COPD despite their adverse effects, such as oropharyngeal candidiasis, hoarseness and pneumonia [47]. In addition, the use of oral corticos- teroids has been associated with decreased bone mass and increased risk of fracture. Indeed, the total cumulative dose of oral corticoster- oids was inversely correlated with bone mineral density [48], and prior or current exposure to oral corticosteroids was associated with increased risk of fracture [49]. With respect to COPD patients, patients receiving oral corticosteroids were more likely to have one or more vertebral fractures [50, 51] The effects of inhaled corticosteroids on bone health are less clear. A randomised controlled trial in 658 patients with moderate-to-severe COPD demonstrated that inhaled corticosteroids had no effect on bone mineral density at the hip and lumbar spine over 3 years [10]. However, a case– control study including 1,708 cases with non-vertebral fractures and 6,817 matched controls showed that the use of high-dose corticosteroids (o700 mg per day) was associated with increased risk of fracture compared with patients who did not use inhaled corticosteroids [52]. More recently, a systematic review concluded that long-term use of inhaled fluticasone or budesonide was associated with a dose-dependent increased risk of fracture [53]. Although accumulating evidence shows that the use of inhaled corticosteroids is correlated with increased risk of fracture, there is a need for more prospective studies that correct for confounders such as COPD severity. Romme E et al. Osteoporosis in COPD. Eur Respir Monogr ;(59):93–104

9 Fatores de Risco Gravidade da DPOC
The use of inhaled corticosteroids has been associated with a dose-related increased risk of fracture. This may be related to systemic absorption. However, several studies have found that patients with more severe reductions in pulmonary function had reduced bone mineral density, independent of inhaled corticosteroids. The objective of this study was to evaluate the relationship between disease severity and fracture risk. A large case-control study (108,754 cases) was conducted using data from the UK General Practice Research Database. It was found that higher doses of inhaled corticosteroids were associated with greater risks of fracture. The crude odds ratio of fracture among patients exposed to >1,600 microg de Vries F et al. Eur Respir J May;25(5):879–84.

10 Obstrução Vias Aéreas Classificação OR (IC)
Fatores de Risco VEF1 Obstrução Vias Aéreas Classificação OR (IC) Presente Ausente 1,9 (1,4-2,5) Grave 2,4 (1,3-4,4) Moderada > 1 Leve 1 Jorgenson Estudo comparativo de disturbios obstrutivos e presenca de osteoporose Jørgensen NR et alRespir Med [Internet] Jan;101(1):177–85.

11 Fatores de Risco VEF1 62%  Homens Espirometria (n)
Marly Knost Osteoporosis is one of the systemic features of COPD. OBJECTIVE: To deter- mine the prevalence of osteoporosis in a sample of COPD out-patients, and investigate the corre- lation between T-score (a comparison of the patient’s bone mineral density to that of a healthy 30-year-old of the same sex and ethnicity) and several factors suggested to be associated with osteoporosis. METHODS: In a cross-sectional study, we conducted dual-energy X-ray absorptiom- etry bone mineral density scans of the hips and lumbar spine, and collected data on smoking and alcohol habits, menopausal status, comorbidities, inhaled and oral corticosteroid dose and duration of treatment, previous bone fractures, pulmonary function tests, calcium intake (via questionnaire on food frequency), vitamin D intake (via questionnaire on sunlight exposure), and physical activity (via the International Physical Activity Questionnaire). RESULTS: We evaluated 95 patients. Forty (42%) were osteoporotic, 40 (42%) were osteopenic, and 15 (16%) had normal bone mass. We found significant bivariate correlations between femoral-neck T-score and body mass index (r ? 0.551, P<.001), and femoral-neck T-score and International Physical Activity Questionnaire total activity score (r ? 0.378, P < .001). There was a significant inverse relationship between femoral-neck T-score and BODE (body mass index, air-flow obstruction, dyspnea, and exercise capacity) index (r??0.246, P ? .02). We also found significant correlations between T-score and FEV1 (r ? 0.251, P?.01), forced vital capacity (r?0.229, P?.03), percent-of-predicted functional residual capacity (r ??0.415, P < .001), inspiratory capacity (r ? 0.252, P ? .01), ratio of inspiratory capacity to total lung capacity (r ? 0.241, P ? .02), and absolute and percent-of-predicted diffusing capacity of the lung for carbon monoxide (r ? 0.366, P < .001, and r ? 0.338, P ? .003, respectively). CONCLUSIONS: We identified a high prevalence of osteoporosis and osteopenia in out-patients with COPD. Patients with osteoporosis had more severe COPD than patients with normal bone mass. Key Espirometria (n) N (osteopenia/osteoporose) % Normal (n / %) VEF1>50% (22) 18 ( 82%) 4 (18%) VEF % (46) 39 (85%) 7 (15%) VEF1< 30% (27) 23 (85%) 4 (15%) Silva DR, Respir Care Jul;56(7):961–8.

12 Fatores de Risco Inatividade
3.262 homens saudáveis (idade média=44 anos) Atividade física regular e intensa Acompanhados por 21 anos Redução de incidência de fratura do quadril com OR 0,38 (IC=0,16-0,91) doi: /cmaj CMAJ March 14, 2006 vol. 174 no

13 Fatores de Risco Corticóide
(N=1235 Controles=4598), Uso de Corticoide inalatório OR IC1,74 Não usou 1 < 100 1,06 0,88-1,28 0,99 0,78-1,27 1,17 0,95-1,44 1,21 0,97-1,51 1,13 0,87-1,4 1600 1,74 1,00-3,01 Uso de Corticoide oral /anual – Quintiles de uso OR IC Não usou 1 1 x 1,12 0,91-1,39 2 x 1,28 1,03-1,59 3 x 1,21 0,99 -1,59 4 x 1,05 0,83 – 1,65 5 x 1,31 1,04-1,63 Background: Inhaled corticosteroids are used increasingly to treat people with COPD, but the extent to which these drugs increase the risk of fracture is unclear. Aim: To quantify the dose–response relationship between fracture risk and inhaled corticosteroids in people with COPD, independent of the effects of percent predicted FEV 1 and oral corticosteroids. Design : Nested case-control study. Methods: Cases and controls were COPD patients aged 5 40 years or more at diagnosis, with a FEV measurement recorded in The Health Improvement Network database, up to 5 July Cases (people with a fracture event after 1 January 1998, n 1235) were assigned up to four controls ( 4598), matched by gender and general practice. Results: Mean FEV was 57.5% in cases, and 58.5% in controls. Inhaled corticosteroids had been prescribed in 69% of cases (median dose 269mcg/day) and 66% (226mcg/day) of controls. Oral corticosteroids had been prescribed in 60% of cases (median annual prescription rate 0.6) and 56% of controls (also 0.6 per year). Risk of fracture increased with increasing mean daily doses of inhaled corticosteroid ( p for trend 0.007), and was most marked in those whose daily dose was 1600mcg (OR 1.80, 95% CI 1.04–3.11). This effect was virtually unchanged by adjust- ment for mean percent predicted FEV and annual prescription rate for oral corticosteroids (OR for highest dose exposure 1.74, 95% CI 1.00–3.01). Discussion: Our findings add to the evidence that the use of inhaled corticosteroids is associated with a small increase in fracture risk, particularly at higher doses Pujades-Rodríguez M et al. QJM Aug;100(8):509–17.

14 Fatores de Risco Doenças Obstrutivas
Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of osteoporosis. However, the prevalence, correlates and effectiveness of treatment of osteoporosis in COPD patients remain unclear. We performed a systematic review of the literature to answer three questions. 1) What is the prevalence of osteoporosis in COPD? 2) What are identified correlates of osteoporosis in COPD? 3) What are the effects of treatment of osteoporosis in COPD? A computerised literature search in MEDLINE/PubMed and the Cochrane database was carried out. In addition, reference lists were searched by hand and authors were contacted if necessary. The prevalence of osteoporosis and osteopenia varied 9–69% and 27–67%, respectively.Prevalence of osteoporosis was generally higher than in healthy subjects and some other chronic lung diseases. Correlates of osteoporosis in COPD are mainly measures of body composition, disease severity and the use of corticosteroids, although causality has not been proven. Effects of treatment of osteoporosis have not been investigated in samples consisting ofCOPD patients only. Longitudinal follow-up to assess determinants of osteoporosis in COPD and randomised placebo-controlled trials on the effects of treatment of osteoporosis in patients with COPD only are warranted.KEYWORDS: Graat-Verboom L et al. Eur Respir J Jul;34(1):209–18.

15 Fatores de Risco Vitamina D
Níveis séricos normal: 40 e 50 nmol/l (16-20 ng/ml). Exposição ao Sol diária de 15 a 30 minutos Raça branca – menor exposição Alimentação Vitamina D Níveis séricos abaixo do normal – População adulta com doenças crônicas Vitamina D na dieta: Ingesta zona rural > zona Urbana Maior na infância A ocorrência de fraturas osteoporóticas em idosos está relacionada às concentrações reduzidas de vitamina D e conseqüente hiperparatiroidismo secundário, sendo os institucionalizados de maior risco. No Brasil, por seu alto grau de insolação, infere-se que a quantidade de vitamina D da população seja adequada. Neste estudo, objetivamos avaliar as concentrações plasmáticas de 25-hidroxivitamina D (25OHD), paratormônio (PTH) e cálcio ionizado (Cai), assim como analisar a prevalência de hipovitaminose D e de hiperpa- ratiroidismo secundário em idosos moradores da cidade de São Paulo. Estudamos 177 pacientes institucionalizados (125 mulheres e 52 homens) com idade média (DP) de 76,6 (9,0) anos, e 243 idosos ambulatoriais (168 mulheres e 75 homens) com 79,1 (5,9) anos. Nesta avaliação, 71,2% do grupo institucionalizado e 43,8% do ambulatorial possuíam valores de 25OHD menores do que o mínimo recomendado (50 nmol/l), sendo que as mulheres apresentaram valores consideravelmente mais baixos que os homens. O hiperparatiroidismo secundário ocorreu em 61,7% dos pacientes institu- cionalizados e em 54% dos ambulatoriais. Considerando os resultados obtidos, recomendamos a suplementação com doses eficientes de vitamina D para a população idosa brasileira, alem de sugerir uma discussão para a implementação de políticas de fortificação alimentar com vitamina D, espe- cialmente direcionada àqueles com maior risco. (Arq Média do consumo de minerais e vitaminas, por sexo, grupos de idade e situação do domicílio, segundo os nutrientes - Brasil - período Arq Bras Endocrinol Metab vol 50 nº 1 Fevereiro 2006

16 Redução das atividades
Diagnóstico Historia Clinica Tabagismo Redução das atividades Perda de peso Corticóide sistêmico Dor localizada lombar Cifose Perda de altura

17 Radiografia de coluna em perfil Fraturas ósseas
Diagnóstico Radiografia de coluna em perfil Fraturas ósseas DXA (Dual X –ray absorptiometry) Quadril e coluna lombar Densitometria do calcâneo por US Tomografia quantitativa de coluna Medidas de Densidade óssea Osteoporosis International 1997, Volume 7, Issue 1, pp 7-22

18 Diagnóstico

19 Não Farmacológico Farmacológico Manejo Atividade física
Nutrição balanceada Tabagismo, Alcoolismo Farmacológico Reposição Vit D Cálcio Analgésicos

20 Manejo Vitamina D N= 9820 / > 60 anos Context The role and dose of oral vitamin D supplementation in nonvertebral fracture prevention have not been well established. Objective To estimate the effectiveness of vitamin D supplementation in preventing hip and nonvertebral fractures in older persons. Data Sources Asystematic review of English and non-English articles using MEDLINE and the Cochrane Controlled Trials Register ( ), and EMBASE ( ). Additional studies were identified by contacting clinical experts and searching bibliog- raphies and abstracts presented at the American Society for Bone and Mineral Research ( ). Search terms included randomized controlled trial (RCT), controlled clini- cal trial, random allocation, double-blind method, cholecalciferol, ergocalciferol, 25- hydroxyvitamin D, fractures, humans, elderly, falls, and bone density.Study Selection Only double-blind RCTs of oral vitamin D supplementation (cholecalciferol, ergocalciferol) with or without calcium supplementation vs calcium supple- mentation or placebo in older persons (?60 years) that examined hip or nonvertebral fractures were included.Data Extraction Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators.Data Synthesis All pooled analyses were based on random-effects models. Five RCTs for hip fracture (n=9294) and 7 RCTs for nonvertebral fracture risk (n=9820) met our inclusion criteria. All trials used cholecalciferol. Heterogeneity among studies for both hip and nonvertebral fracture prevention was observed, which disappeared after pooling RCTs with low-dose (400 IU/d) and higher-dose vitamin D ( IU/d), separately. A vi- taminDdose of 700 to 800 IU/d reduced the relative risk (RR) of hip fracture by26%(3 RCTs with 5572 persons; pooled RR, 0.74;95%confidence interval [CI], ) and any nonvertebral fracture by 23% (5 RCTs with 6098 persons; pooled RR, 0.77; 95% CI, ) vs calcium or placebo. No significant benefit was observed for RCTs with 400 IU/d vitamin D (2 RCTs with 3722 persons; pooled RR for hip fracture, 1.15; 95% CI, ; and pooled RR for any nonvertebral fracture, 1.03; 95% CI, ).Conclusions Oral vitamin D supplementation between 700 to 800 IU/d appears to reduce the risk of hip and any nonvertebral fractures in ambulatory or institutional- ized elderly persons. An oral vitamin D dose of 400 IU/d is not sufficient for fracture prevention. JAMA. Bischoff-Ferrari H et al. Jama. 2005;293(18):2257–64.

21 Manejo Vitamina D e Cálcio
Pacientes portadores de DPOC que usaram ou estão em uso de Corticóide Evento Pacientes (n) Redução OR IC Fratura 52.625 12% 0,88 0,83-0,95 Densidade Óssea(Quadril) 41.419 46% 0,54 0,35-0,73 Dose usada/diária Cálcio = mg Vit. D = 800 ui Nowadays, calcium and vitamin D supplementation are recommended in the treatment of osteoporosis since they have positive effects on bone health and muscle function, resulting in reduced risk of fracture. A meta-analysis stated that calcium supplementation alone or in combination with vitamin D was effective in the preventive treatment of osteoporotic fracture [73]. In addition, another meta-analysis stated that vitamin D supplementation with doses of 700– 800 IU per day reduced the relative risk of hip fracture by 26% and of any non-vertebral fracture by 23% compared with calcium supplementation or placebo in individuals aged 60 years or older [74]. In contrast, a Cochrane review stated that vitamin D without calcium supplementation appeared unlikely to be effective in preventing hip fracture, vertebral fracture or any new fracture [75]. These data suggest that both calcium and vitamin D are important in the prevention of osteoporotic fracture. In addition to its effect on fracture risk, vitamin D supplementation had beneficial effects on fall prevention among ambulatory or institutionalised older individuals with stable health [76]. Vitamin D supplementation with doses of 700–1,000 IU per day reduced falls by 19–26%, whereas vitamin D doses ,700 IU did not prevent falls Romme E a et al. Eur Respir Monogr Mar 1;(59):93–104 The Lancet, Volume 370, Issue 9588, Pages , 25 August 2007

22 Tratamento Particularizado
Bifosfonatos Aledronato Rosumab (anticorpo monoclonal RANK-L) Reposição hormonal The role of bisphosphonates in the prevention and treatment of osteoporosis is well established. Bisphosphonates are chemically stable derivatives of inorganic pyrophosphate and inhibit calcification by binding to hydroxyapatite crystals. In addition, bisphosphonates inhibit hydroxyapatite breakdown, thereby effectively suppressing bone resorption. It has been suggested that bisphosphonates also function to limit both osteoblast and osteocytes apoptosis. In post- menopausal females with osteoporosis, alendronate was associated with significant and clinically important reductions in the incidence of hip fracture [80]. In patients treated with corticosteroids, bisphosphonates were shown to increase bone mineral density and prevent the development ofnew fractures [81]. In patients with airway disorders (asthma or chronic obstructive airway disease), daily intake of alendronate for 12 months was shown to significantly improve bone mineral density at the lumbar spine [82]. Romme E a et al. Eur Respir Monogr Mar 1;(59):93–104

23 Conclusão Alterações ósseas devem ser pensadas em todo paciente com DPOC Fatores de risco devem ser avaliados Avaliação de fratura deve ser rotina em DPOC de alto risco Densitometria deve ser realizada para diagnóstico precoce