2014nof骨質(zhì)疏松指南解讀-江蘇省中西醫(yī)結(jié)合醫(yī)院

1、2014NOF骨質(zhì)疏松指南解讀,江蘇省中西醫(yī)結(jié)合醫(yī)院內(nèi)分泌代謝病院區(qū),epidemiology,Since NOF first published the Guide in 1999, it has become increasingly clear that many patients are not being given appropriate information about prevention and many pati

2、ents are not receiving appropriate testing to diagnose osteoporosis or establish osteoporosis risk. Most importantly, many patients who have osteoporosis-related fractures are not being diagnosed with osteoporosis and a

3、re not receiving any of the FDA-approved, effective therapies.,Medical Impact,Fractures and their complications are the relevant clinical sequelae of osteoporosis. Fractures may be followed by full recovery or by chroni

4、c pain, disability and deathHip fractures are associated with an 8.4 to 36 percent excess mortality within one year, and followed by a 2.5-fold increased risk of future fractures.,Pathogenesis of Osteoporosis-Related Fr

5、actures,Risk Assessment,All postmenopausal women and men age 50 and older should be evaluated for osteoporosis risk in order to determine the need for BMD testing and/or vertebral imaging. In general, the more risk fact

6、ors that are present, the greater the risk of fracture. Osteoporosis is preventable and treatable, but because there are no warning signs prior to a fracture, many people are not being diagnosed in time to receive effec

7、tive therapy during the early phase of the disease.,Others,Gastrointestinal disorders Hematologic disorders Rheumatologic and autoimmune diseaseNeurological and musculoskeletal risk factors Miscellaneous conditio

8、ns and diseases Medications,T-Score,World Health Organization (WHO) 骨質(zhì)疏松診斷標(biāo)準(zhǔn),indication,椎體成像,UNIVERSAL RECOMMENDATIONS FOR ALL PATIENTS,Adequate Intake of Calcium,Men 50-70 1000mg,>71 1200mgwomen >51 1200 mgThe

9、re is no evidence that calcium intake in excess of these amounts confers additional bone strength. Intakes in excess of 1,200 to 1,500 mg per day may increase the risk of developing kidney stones, cardiovascular disease

10、and stroke. The scientific literature is highly controversial in this area,Adequate Intake of Vitamin D,Bring the serum 25(OH)D level to 30 ng/ml (75 nmol/L) and a maintenance dose to maintain this level, particularly f

11、or individuals with osteoporosis. Many patients with osteoporosis will need more than the general recommendation of 800-1,000 IU per day. The safe upper limit for vitamin D intake for the general adult population was in

12、creased to 4,000 IU per day,Treatment of Vitamin D Deficiency,Adults who are vitamin D deficient may be treated with 50,000 IU of vitamin D2 or vitamin D3 once a week or the equivalent daily dose (7,000 IU vitamin D2 or

13、vitamin D3) for 8-12 wks to achieve a 25(OH)D blood level of approximately 30 ng/ml. This regimen should be followed by maintenance therapy of 1,500–2,000 IU/d or whatever dose is needed to maintain the target blood lev

14、el.,Regular Weight-Bearing and Muscle-Strengthening Exercise,Weight-bearing exercise includes walking, jogging, Tai-Chi, stair climbing, dancing and tennis. Muscle-strengthening exercise includes weight training and oth

15、er resistive exercises, such as yoga, Pilates and boot camp programs. Before an individual with osteoporosis initiates a new vigorous exercise program, such as running or heavy weight-lifting, a clinician’s evaluation i

16、s appropriate.,Fall Prevention,maintaining adequate vitamin D levels and physical activity home safety assessment and modification especially when done by an occupational therapist and gradual withdrawal of psychotropic

17、 medication if possible. Appropriate correction of visual impairment may improve mobility and reduce risk of falls. Hip protectors may protect an individual from injuring the hip in the event of a fall,Cessation of Tob

18、acco Use and Avoidance of Excessive Alcohol Intake,Advise patients to stop tobacco smoking Recognize and treat patients with excessive alcohol intake,PHARMACOLOGIC THERAPY,Pharmacologic treatment recommendations,After a

19、ppropriate evaluation: Initiate pharmacologic treatment in those with hip or vertebral (clinical or asymptomatic) fractures. Initiate therapy in those with T-scores 3 percent or a 10-year major osteoporosis-related

20、 fracture probability > 20 percent based on the U.S.-adapted WHO absolute fracture risk model (FRAX®; www.NOF.org and www.shef.ac.uk/FRAX).,U.S. FDA-Approved Drugs for Osteoporosis,bisphosphonates (alendronate, a

21、lendronate plus D, ibandronate, risedronate and zoledronic acid)calcitoninestrogens (estrogen and/or hormone therapy), estrogen agonist/antagonist (raloxifene), tissue-selective estrogen complex (conjugated estrogens/b

22、azedoxifene)parathyroid hormone (PTH[1-34], teriparatide)the RANKL inhibitor denosumab.,Bisphosphonates,雙膦酸鹽,Drug safety,Side effects are similar for all oral bisphosphonate medications and include gastrointestinal pro

23、blems such as difficulty swallowing, inflammation of the esophagus and stomach. All bisphosphonates can affect renal function and are contraindicated in patients with estimated GFR below 30-35 ml/min. Eye inflammation

24、can also occur.,Drug safety,There have been rare reports of osteonecrosis of the jaw (ONJ) with long term use of bisphosphonates for osteoporosis, though ONJ is much more common following high dose intravenous bisphospho

25、nate treatment for patients with cancer. The risk of ONJ appears to increase with duration of treatment beyond five years.,Drug safety,Although rare, low trauma atypical femur fractures may be associated with the long-t

26、erm use of bisphosphonates (e.g. >5 years of use). Pain in the thigh or groin area, which can be bilateral, often precedes these unusual fractures. For patients with thigh and groin pain, a stress fracture in the su

27、btrochanteric region or femoral shaft of the femur may be present. Bilateral x-ray of the femurs should be ordered when an atypical femur fracture is suspected, followed by an MRI or a radionuclide bone scan when clinica

28、l suspicion is high enough. Surgical fixation is required in some cases whereas medical conservative treatment is appropriate in other cases. Bisphosphonates should be stopped if atypical femur fractures have occurred.,

29、Calcitonin,Calcitonin reduces vertebral fracture occurrence by about 30 percent in those with prior vertebral fractures but has not been shown to reduce the risk of nonvertebral fractures.Drug administration: 200 IU de

30、livered as a single daily intranasal spray. Subcutaneous administration by injection also is available.,Drug safety,Intranasal calcitonin can cause rhinitis, epistaxis and allergic reactions, particularly in those with a

31、 history of allergy to salmon. The FDA has reviewed long-term post marketing data concerning calcitonin and the very small increase in the risk of certain cancers.,Estrogen/Hormone Therapy (ET/HT),Estrogen/hormone thera

32、py is approved by the FDA for the prevention of osteoporosis, relief of vasomotor symptoms and vulvovaginal atrophy associated with menopause. Women who have not had a hysterectomy require HT, which also contains proges

33、tin to protect the uterine lining.,Drug efficacy,The Woman’s Health Initiative (WHI) found that five years of HT (Prempro®) reduced the risk of clinical vertebral fractures and hip fractures by 34 percent and other

34、osteoporotic fractures by 23 percent,Drug safety,The Women’s Health Initiative (WHI) reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli and deep vein thrombosis during fiv

35、e years of treatment with conjugated equine estrogen and medroxyprogesterone acetate (Prempro®).,Estrogen Agonist/Antagonist (formerly known as SERMs): Raloxifene,Raloxifene reduces the risk of vertebral fractures b

36、y about 30 percent in patients with a prior vertebral fracture and by about 55 percent in patients without a prior vertebral fracture over three years. Reduction in risk of nonvertebral fracture with raloxifene has not

37、been documented.,Raloxifene,Raloxifene is also indicated for the reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis. Raloxifene does not reduce the risk of coronary heart disease. Dru

38、g administration: Available in a 60 mg tablet form to be taken with or without food. Drug safety: Raloxifene increases the risk of deep vein thrombosis to a degree similar to that observed with estrogen. It can also i

39、ncrease hot flashes and cause leg cramps.,Tissue-Selective Estrogen Complex: Conjugated estrogens/ bazedoxifene (Conjugated estrogens paired with estrogen agonist/antagonist),Drug efficacy,Women who suffer from moderate-

40、to-severe hot flashes (vasomotor symptoms) associated with menopause and to prevent osteoporosis after menopause. Significantly increased mean lumbar spine BMD 1.51 percent, increased total hip BMD. 1.21 percent,Drug Ad

41、ministration,0.45mg / 20mgonce daily without regard to meals.,Drug Safety:,Side effects include muscle spasms, nausea, diarrhea, dyspepsia, upper abdominal pain, oropharyngeal pain, dizziness and neck pain. Because thi

42、s product contains estrogen, it is approved with the same Boxed Warning and other Warnings and Precautions that have been approved with estrogen products.,Parathyroid Hormone: Teriparatide,Teriparatide is approved by the

43、 FDA for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. It is also approved for treatment in men and women at high risk of fracture with osteoporosis associated with sustained s

44、ystemic glucocorticoid therapy.,Drug efficacy,Teriparatide reduces the risk of vertebral fractures by about 65 percent and non-vertebral fragility fractures by about 53 percent in patients with osteoporosis, after an ave

45、rage of 18 months of therapy.,Drug Administration,Teriparatide is an anabolic (bone-building) agent administered by 20 μg daily subcutaneous injection. Treatment duration is recommended not to exceed 18 to 24 months.,Dr

46、ug safety:,Side effects include leg cramps, nausea and dizziness. patients with an increased risk of osteosarcoma (e.g., Paget’s disease of bone and those having prior radiation therapy of the skeleton), bone metastases,

47、 hypercalcemia, or a history of skeletal malignancy should not receive teriparatide therapy. It is common practice to follow teriparatide treatment with an antiresorptive agent, usually a bisphosphonate, to maintain or

48、further increase BMD.,Receptor Activator of Nuclear Factor kappa-B (RANK) Ligand (RANKL)/ RANKL Inhibitor: Denosumab,Denosumab is approved by the FDA for the treatment of osteoporosis in postmenopausal women at high risk

49、 of fracture. Denosumab reduces the incidence of vertebral fractures by about 68 percent, hip fractures by about 40 percent and non-vertebral fractures by about 20 percent over three years. Denosumab is also indicated

50、to increase bone mass in men at high risk of fracture, treat bone loss in women with breast cancer on aromatase inhibitor therapies and to treat bone loss in men receiving gonadatropin-reducing hormone treatment for pros

51、tate cancer who are at high risk for fracture.,Drug administration and safety,Administered by a health professional, 60 mg every six months as a subcutaneous injection. Denosumab may cause hypocalcemia. Denosumab increa

52、sed the risk of serious skin infections (cellulitis) and skin rash. Denosumab has been rarely associated with the development of ONJ and atypical femur fractures,Sequential and Combination Therapy,Sequential treatment w

53、ith anabolic therapy followed by an antiresorptive agent is generally preferred. Combination therapy with teriparatide and an antiresorptive can be considered in a few clinical settings in patients with very severe oste

54、oporosis such as spine and hip fractures. There are few indications for combining two antiresorptive treatments, but such options could be considered in the short-term in women who are experiencing active bone loss whil

55、e on low dose HT for menopausal symptoms or raloxifene for breast cancer prevention.,Duration of Treatment,All non-bisphosphonate medications produce temporary effects that wane upon discontinuation. In contrast, bisphos

56、phonates may allow residual effects even after treatment discontinuation.. Evidence of efficacy beyond five years is limited, whereas rare safety concerns such as ONJ and atypical femur fractures become more common beyo