英文_第五节 老年性骨质疏松症课件

DefinitionDefinition Osteoporosis is a systemic skeletal disease characterized by Low bone mass Microarchitectural deterioration of bone tissue, Leading to increased bone fragility And greater susceptibility to fracture 原发性骨疏松是原发性骨疏松是 一种以骨量低下，骨一种以骨量低下，骨 微结构破坏，导致骨微结构破坏，导致骨 脆性增加，易发生骨脆性增加，易发生骨 折为特征的折为特征的全身性全身性骨骨 病病 Epidemiology Epidemiology Incidence /100,000 person yearIncidence /100,000 person year WomenWomen =85=8535-3935-39 II II PathophysiologyPathophysiology RemodelingRemodeling (骨重建过程) Mechanism of bone remodeling. 破骨细胞破骨细胞 成骨细胞成骨细胞 Menopause Menopause AgingAging Other risk Other risk FactorsFactors Hormonal control of bone Hormonal control of bone resorptionresorption. . Clinical Clinical characteriticscharacteritics p Osteoporosis often starts silently and may not be found until a bone fractures. p Fragility fracture is a type of pathologic fracture that occurs as result of normal activities, such as a fall from standing height or less ( the National Osteoporosis Foundation ,NOF) 1.5 million fractures occur each year in US as a 1.5 million fractures occur each year in US as a consequence of osteoporosisconsequence of osteoporosis 700,000700,000 vertebral crush fracutres vertebral crush fracutres 300,000300,000 hip fractures hip fractures 250.000 250.000 wrist fractures wrist fractures 300,000 other fractures300,000 other fractures Pain Only 25-30% of vertebral compression Only 25-30% of vertebral compression fractures present with sudden onset back painfractures present with sudden onset back pain Chronic pain Chronic pain Loss of height Loss of height , Humpback, Humpback n n kyphosiskyphosis（humpbackhumpback） n n KyphosisKyphosis is more severe with is more severe with age age n n 24 Vertebral body 24 Vertebral body Vertebral body height Vertebral body height 2 cm 2 cm Short 2mm Short 2mm，total 3-6cm total 3-6cm FracturesFractures ppFractures are the most dangerous aspect of osteoporosisFractures are the most dangerous aspect of osteoporosis p Multiple vertebral fractures lead to a stooped posture, loss of height, Multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobilityand chronic pain with resultant reduction in mobility ppHip fractureHip fracture, in particular, usually requires prompt surgery, as there , in particular, usually requires prompt surgery, as there are serious risks associated with a hip fracture, such as are serious risks associated with a hip fracture, such as deep vein deep vein thrombosisthrombosis and a and a pulmonary embolismpulmonary embolism, and , and increased mortalityincreased mortality. . A classical case of osteoporosis may start in a woman about 55 years of age with a wrist fracture vv Thoracic fracture are associated with restrictive lung Thoracic fracture are associated with restrictive lung diseases diseases vv Lumbar fracture are associated with abdominal symptom Lumbar fracture are associated with abdominal symptom including distension ,early satiety and constipationincluding distension ,early satiety and constipation Diagnosis and Diagnosis and differential diagnosis differential diagnosis Bone mineral densityBone mineral density（骨密度测定（骨密度测定） Measurement of bone massMeasurement of bone mass Dual-energy x-ray Dual-energy x-ray absorptiometryabsorptiometry ( (DXADXA, , 双能双能X X线吸收法）线吸收法） The gold standard for measuring bone density The gold standard for measuring bone density l l Measurements of any site Measurements of any site l l Clinical determinations are made of theClinical determinations are made of the spine spine andand hip hip l l Bone spursBone spurs ,which are frequently in osteoarthritis ,tend to ,which are frequently in osteoarthritis ,tend to falsely falsely increase bone densityincrease bone density of the spine and are a particular problem in of the spine and are a particular problem in maesuringmaesuring the spine of older individuals the spine of older individuals l l Standard x-rays show changes in bone density after about Standard x-rays show changes in bone density after about 40%40% of of bone lossbone loss l l DEXA scan can detect changes after about a DEXA scan can detect changes after about a 1%1% change change T scoresT scores compare individual results to those in compare individual results to those in yongyong population that is population that is matched for race and gender matched for race and gender Z scoresZ scores compare individual results to those of an age-matched compare individual results to those of an age-matched population population that is matched for race and genderthat is matched for race and gender WHO definitionWHO definition （Based on Bone Density LevelsBased on Bone Density Levels） v Normal Bone density is within 1 SD (+1 or 1) of the young adult mean. v Low bone mass Bone density is between 1 and 2.5 SD below the young adult mean (1 to 2.5 SD). v Osteoporosis Bone density is 2.5 SD or more below the young adult mean (2.5 SD or lower). v Severe (established) osteoporosis Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures. 正常正常 骨密度在年轻成人均值1个SD (+1 或1) 以内 低骨量低骨量 骨密度在年轻成人均值1 到2.5 SD之间 骨质疏松骨质疏松 骨密度等于或低于年轻成人均值 2.5 SD 严重严重( (已确立已确立) )骨质疏松骨质疏松 骨密度等于或低于年轻成人均值 2.5 SD ，而且有一处或多处 骨质疏松性骨折 Treatment Treatment vv A recently developed technique involves A recently developed technique involves percutaneouspercutaneous injection of injection of artificial cement (artificial cement (ploymethymethacrylate)intoploymethymethacrylate)into the vertebral body the vertebral body ( (VertebroplastyVertebroplasty, , kyphoplasty) v This offers significant immediate pain relief in the majority of patients v Long term effects are unknown. VertebroplastyVertebroplasty kyphoplasty Nutritional Recommendation (营养治疗的建议 ) Adequate Adequate Calcium IntakeCalcium Intake Life stage Group Life stage Group EtsimatedEtsimated Adequate Daily Adequate Daily Calcium Intake. mg/d Calcium Intake. mg/d Young children (1-3 years) Young children (1-3 years) 500 500 Older children (4-8 years) 800Older children (4-8 years) 800 Adolescents and young adults (9-18 years)Adolescents and young adults (9-18 years) 1300 1300 Men and women (19-50 years)Men and women (19-50 years) 1000 1000 Men and women (51 and older)Men and women (51 and older) 1200 1200 Note: Pregnancy and lactation needs are the same as for nonpregnant women (e.g., 1300 mg/d for adolescents/young adult and 1000 mg/d for 19 years). Elemental Calcium Content of Various Oral Calcium Preparation 各种口服钙剂的元素钙的含量 Calcium Preparation Elemental CalciumCalcium Preparation Elemental Calcium ( (钙制剂钙制剂 ) () (元素钙含量元素钙含量) ) Calcium citrate Calcium citrate 柠檬酸钙柠檬酸钙 60 mg/300 mg60 mg/300 mg Calcium lactateCalcium lactate乳酸钙乳酸钙 80 mg/600 mg80 mg/600 mg Calcium Calcium gluconategluconate 葡萄糖酸钙葡萄糖酸钙 40 mg/500 mg40 mg/500 mg Calcium carbonate Calcium carbonate 碳酸钙碳酸钙 400 mg/g 400 mg/g Calcium carbonate + 5 Calcium carbonate + 5 ugug vitamin D2 (OsCal250) vitamin D2 (OsCal250) 碳酸钙碳酸钙 250 mg/250 mg/片片 Calcium carbonate Calcium carbonate (Turns 500) (Turns 500)碳酸钙碳酸钙 500 mg/500 mg/片片 Source: Adapted from SM Krane and MF Holick, Chap. 355 in HPIM, 14 ed, 1998. Vitamin DVitamin D vv Vitamin D goal : Serum 25-hydroxyvitaminVitamin D goal : Serum 25-hydroxyvitamin D75 D75 molmol/L /L (30 (30 ng/mLng/mL) ) vv 70 years of age: 600 70 years of age: 600 IUIU/day/day The elderly and chronically ill :The elderly and chronically ill :1000 1000 IUIU/day/day vv Serum 25-hydroxyvitaminSerum 25-hydroxyvitamin D D 75 75 molmol/L (30 /L (30 ng/mLng/mL). ). Inadequate dosageInadequate dosage vv EstrogensEstrogens( (雌激素雌激素) ) vv Selective Estrogen Receptor ModulatorsSelective Estrogen Receptor Modulators ( (SERMsSERMs, ,选择性雌激素受体调节剂选择性雌激素受体调节剂) ) vv BisphosphonateBisphosphonate( (双磷酸盐双磷酸盐) ) vv CalciumCalcium( (降钙素降钙素) ) vv Parathyroid hormoneParathyroid hormone （甲状旁腺激素（甲状旁腺激素PTHPTH） vv FluorideFluoride( (氟化物氟化物) ) Pharmacologic Therapy (Pharmacologic Therapy (药物治疗药物治疗) ) EstrogensEstrogens Results of hormone therapy regimens on bone mineral Results of hormone therapy regimens on bone mineral density (BMD) of the spine (density (BMD) of the spine (A A) and hip () and hip (B B Effects of hormone therapy on event ratesEffects of hormone therapy on event rates SERMsSERMs( (选择性雌激素受体调节剂选择性雌激素受体调节剂) ) vv Two Two SERMsSERMs are currently being used in postmenopausal women are currently being used in postmenopausal women vv RaloxifeneRaloxifene is approved for is approved for prenventionprenvention and treatment of osteoporosis and treatment of osteoporosis vv TamoxifeneTamoxifene is approved for is approved for prenventionprenvention and treatment of breast and treatment of breast cancer cancer vv There is no data confirming that There is no data confirming that raloxifeneraloxifene can reduce the risk of can reduce the risk of nonvertebralnonvertebral fractures fractures vv AlendronateAlendronate , ,risedronaterisedronate ,and ,and ibandronateibandronate are approved for the are approved for the prevention and treatment of prevention and treatment of postmenopausal osteoporosispostmenopausal osteoporosis. . vv RisedronateRisedronate and and AlendronateAlendronate are approved are approved for treatmentfor treatment of steroid of steroid induc