Osteoporosis (뼈엉성증, 골다공증)
2 장 - Endocrine disease (내분비 질환)
Diabetes Mellitus Type II (당뇨병 제II형)
Goiter - thyroid nodule (갑상샘종 - 갑상샘결절, 갑상선결절)
Hyperthyroidism (갑상샘항진증, 갑상샘과다증, 갑상선기능항진증)
Hypothyroidism (갑상샘저하증, 갑상선기능저하증)
♧ 쉬어가기♧ Antoni van Leeuwenhoek
Obesity (비만, 비만증)
Osteoporosis (뼈엉성증, 골다공증)
1 장 - Cardiovascular diseases (순환기 질환)
3 장 - Ear, Eye, Nose Throat Problems (귀, 눈, 코, 입 질환)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
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