KEYWORDS: ..Characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture incidence. BMD (by WHO) Category BMD : T-score Normal > -1 Osteopenia -1~-2.5 Osteoporosis ≤ -2.5 Severe osteoporosis ≤ -2.5 + fragility fracture 1. Asymptomatic during its early and intermediate stages 2. Sudden compression fractures of the spine with minimal trauma (bending, lifting, coughing ) 3. Fractures of the forearm (Colles' fracture) or hip fractures associated with falls ..Only about half of vertebral compression fractures present to the clinician with acute pain, therefore a high index of suspicion is indicated in examining patients with back pain and disability. Risk factors for osteoporosis fracture Non-modifiable Fracture history (in adult or first degree relative) Advanced age Osteoporosis Key symptoms Female Dementia Caucassian race (Asians) Modifiable Current smoking Low body weight (<58kg) Estrogen deficiency : early menopause (<45 yr) Bilateral oophorectomy, Prolonged premenopausal amenorrhea ( > 1yr) Low Calcium intake (<400mg/day) Alcoholism Impaired eyesight Recurrent falls Inadequate physical activity Poor health/frailty ..Risk factors are often not very accurate in predicting osteoporosis because genetic factors play a large role (up to 80%) in the incidence. 1. Sudden onset of acute back pain 2. Kyphoscoliosis (dowager’s hump) 3. Rapid loss of height 4. Incidental finding on radiograph BMD : 보통 두곳에서 측정-DEXA < 65yr (spine) / > 65yr (hip) ; 한곳에서라도 기준 만족시 진단 To establish the etiology 1. CBC 2. U/A 3. Serum calcium,phosphorus 4. Alkaline phosphatase 5. LFT 75 The Root of ambulatory care Key signs Key tests Osteoporosis 6. TFT 7. BUN/Cr 8. Testosterone (men only) 9. 25-Hydroxyvitamin D (If suspected malnutrition) ..T-score : SD of the mean value in young adults, same sex/race Indication for BMD measurement - FDA approved - Estrogen-deficient women at clinical risk of osteoporosis - Vertebral abnormalities on X-ray suggestive of osteoporosis (osteopenia, vertebral fracture) - Glucocorticoid treatment equivalent ≥ 7.5mg of prednisone, or duration of therapy > 3months - Primary hyperparathyroidism - Monitoring response to an FDA-approved medication for osteoporosis - Repeat BMD evaluation at > 23-month intervals, or more frequently, if medically justified Classification of primary & secondary osteoporosis Primary osteoporosis (almost all) Involutional - Type I : postmenopausal - Type II : age-related (occurs in both men and women over 70yrs of age. The female to male ratio is 2:1 to 3:1) Idiopathic (juvenile and adult) Secondary osteoporosis (uncommon in women,but almost half of the cases in men) Drugs : alcoholism, anticonvulsants, glucocorticoids, Heparin, methotrexate, excess thyroid hormone 77 The Root of ambulatory care Endocrine : cushing’s syndrome, hyperparathyroidism, hyperthyroidism, hypogonadism Gastrointestinal : chronic liver disease, gastrectomy, inflammatory bowel disease, malnutrition Renal : renal failure 치료기준 (by NOF) - Women with no risk factor : ≤ 2.0 - Women with risk factor : < 1.5 - Nonpharmacologic 1. Encourage calcium intake : premenopause, men : 1000mg, postmenopause : 1500mg ..Calcium supplement 2. Vitamin D : 200IU < 50yr, 400IU for 50~70yr, 600IU > 70yr ..Multivitamin 1T = 400IU 3. Exercise : more than 30minutes and 3 times/week, regular weightbearing, musclestrengthening ..Exposure of 10~15minutes for the hands, arms, and face three times per week is enough to supply vitamin D. But vitamin D is traditionally recommended in supplemental form since intake or endogenous production is frequently suboptimal. Key treatments Key treatments Osteoporosis - pharmacologic : FDA apporved Treatment 1. Bisphosphonate ..Actonel.. 5mg, 35mg 1T, 5mg 1T qd/35mg 1T qwk ..Fosamax.. 10mg, 70mg 1T, 10mg 1T qd / 70mg 1T qwk (아침 공복시 한 컵 이상의 물 과 함께 복용하며, pill induced esophagitis를 예방하기 위해 30분간 눕지 않아야 하며, 식사도 약물복용 30분 후에 하도록 교육) 2. Raloxifen ..Evista.. 60mg 1T, 1T qd Prevention - postmenopausal bone loss and steroid induced bone loss 1. Bisphosphonate ..Actonel.. 5mg 1T, 1T qd ..Fosamax.. 10mg 1T, 1/2T(5mg) qd Monitoring : BMD after 2year at 2 sites ..Actonel.. - risedronate ..Fosamax.. - alendronate ..Evista.. - raloxifen : SERM(Selective Estrogen Receptor Modulator) ..SERM : 자궁내막과 유방조직에 대한 영향이 없으며, 폐경기 증상과 질위축을 완화시키지 못 하고 홍조 유발 가능성이 있다. 하지만 총 콜레스테롤과 저밀도 지단백 콜레스테롤을 감소시 키는 효과가 있다. ..The addition of bisphosphonates to estrogen therapy provides little additional improvement in BMD and no data are available on fracture outcomes. 79 The Root of ambulatory care 참고 문헌 Kenneth K. Steinweg : Osteoporosis,in Saunders Manual of Medical Practice, 2nd ed,Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 928-931 조경환 : 골다공증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 327-333 가톨릭의과대학 내과학교실 : 골다공증. in Current Principles and Clinical Practice of Internal Medicine. 서 울, 군자출판사, 2005, P 837-843 Richard O. Schamp, M.D. : Osteoporosis, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 539-548 오창석(ed) : 골다공증, in Complete Guide To Practical Based Prescription Medicine. 서울, 한우리, 2005, P 184-187 성균관대학교의과대학 삼성서울병원내과 : Osteoporosis.in Handbook of Internal Medicine, 2nd ed. 서울, 군자출판사, 2004, P 447-449 Stanley J. Brige, H,D. : Osteoporosis, in Conn’s Current Therapy 2004, Robert E, Rakel(ed). philadelphia, Saunders, 2004. P638~642 Jae-Hyoung Cho, Ji-Hyeon Ju, Jeoung-Won Jang : Osteoporosis, in Clinical Road Map of Internal Medicine. Seoul, Panmun Book, 2005, P 170 Drug Mechanism of Action FDA-Approved Relative Efficacy Prevention Treatment Spine fracture Hip fracture Hormone Antiresorptive Yes No ＋＋＋ ＋＋＋ replacement Raloxifene Antiresorptive Yes Yes ＋＋＋ 0 Alendronare/ Antiresorptive Yes Yes ＋＋＋ ＋＋＋ Risedronate Calcitonin Antiresorptive No Yes ＋ 0 Parathyroid Anabolic No Yes ＋＋＋＋ ＋＋＋ hormone