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1、英文第五英文第五节老性骨老性骨质疏松症疏松症第1页，共50页，编辑于2022年，星期二Definition Osteoporosis is a systemic skeletal disease characterized byvLow bone mass vMicroarchitectural deterioration of bone tissue,v Leading to increased bone fragility vAnd greater susceptibility to fracture 原发性骨疏松是一原发性骨疏松是一种以骨量低下，骨微种以骨量低下，骨微结构破坏，导致骨脆结
2、构破坏，导致骨脆性增加，易发生骨折性增加，易发生骨折为特征的为特征的全身性全身性骨病骨病骨病骨病 第2页，共50页，编辑于2022年，星期二Epidemiology 第3页，共50页，编辑于2022年，星期二第4页，共50页，编辑于2022年，星期二第5页，共50页，编辑于2022年，星期二第6页，共50页，编辑于2022年，星期二第7页，共50页，编辑于2022年，星期二Incidence/100,000 person yearIncidence/100,000 person yearIncidence/100,000 person yearIncidence/100,000 person
3、year WomenWomen =85=85=85=8535-3935-3935-3935-39第8页，共50页，编辑于2022年，星期二第9页，共50页，编辑于2022年，星期二第10页，共50页，编辑于2022年，星期二II Pathophysiology第11页，共50页，编辑于2022年，星期二Remodeling(骨重建过程骨重建过程)第12页，共50页，编辑于2022年，星期二Mechanism of bone remodeling.第13页，共50页，编辑于2022年，星期二破骨细胞破骨细胞成骨细胞成骨细胞Menopause AgingOther risk Other risk
4、FactorsFactors 第14页，共50页，编辑于2022年，星期二Hormonal control of bone resorption.第15页，共50页，编辑于2022年，星期二第16页，共50页，编辑于2022年，星期二 Clinical characteritics第17页，共50页，编辑于2022年，星期二 v Osteoporosis often starts silently and may not be found until a bone fractures.v Fragility fracture is a type of pathologic fracture t
5、hat occurs as result of normal activities,such as a fall from standing height or less(the National Osteoporosis Foundation,NOF)第18页，共50页，编辑于2022年，星期二 1.5 million fractures occur each year in US as a consequence of osteoporosis 700,000700,000 vertebral crush fracutres vertebral crush fracutres 300,00
6、0300,000 hip fractures hip fractures 250.000 250.000 wrist fractures wrist fractures 300,000 other fractures300,000 other fractures 第19页，共50页，编辑于2022年，星期二Pain Only 25-30%of vertebral compression fractures present with sudden onset back pain Chronic pain 第20页，共50页，编辑于2022年，星期二Loss of height,Humpback
7、n nkyphosiskyphosis（humpbackhumpback）n nKyphosis is more severe with age Kyphosis is more severe with age n n24 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 第21页，共50页，编辑于2022年，星期二FracturesppFractures are the most d
8、angerous aspect of osteoporosisFractures are the most dangerous aspect of osteoporosisp Multiple vertebral fractures lead to a stooped posture,loss of height,and Multiple vertebral fractures lead to a stooped posture,loss of height,and chronic pain with resultant reduction in mobilitychronic pain wi
9、th resultant reduction in mobilityppHip fracture,in particular,usually requires prompt surgery,as there are Hip fracture,in particular,usually requires prompt surgery,as there are serious risks associated with a hip fracture,such as serious risks associated with a hip fracture,such as deep vein thro
10、mbosisdeep vein thrombosis and a and a pulmonary embolismpulmonary embolism,and,and increased mortalityincreased mortality.第22页，共50页，编辑于2022年，星期二A classical case of osteoporosis may start in a woman about 55 years of age with a wrist fracture第23页，共50页，编辑于2022年，星期二vvThoracic fracture are associated w
11、ith restrictive lung diseases Thoracic fracture are associated with restrictive lung diseases vvLumbar fracture are associated with abdominal symptom including Lumbar fracture are associated with abdominal symptom including distension,early satiety and constipationdistension,early satiety and consti
12、pation第24页，共50页，编辑于2022年，星期二 Diagnosis and differential diagnosis第25页，共50页，编辑于2022年，星期二第26页，共50页，编辑于2022年，星期二Bone mineral density（骨密度测定（骨密度测定）第27页，共50页，编辑于2022年，星期二Measurement of bone mass Dual-energy x-ray absorptiometry(Dual-energy x-ray absorptiometry(DXADXA,双能双能双能双能X X线吸收法）线吸收法）线吸收法）线吸收法）The gol
13、d standard for measuring bone density The gold standard for measuring bone density 第28页，共50页，编辑于2022年，星期二l lMeasurements of any site Measurements of any site l lClinical determinations are made of theClinical determinations are made of the spine spine andand hip hip l lBone spursBone spurs,which are
14、 frequently in osteoarthritis,tend to ,which are frequently in osteoarthritis,tend to falsely increase bone falsely increase bone densitydensity of the spine and are a particular problem in maesuring the spine of the spine and are a particular problem in maesuring the spine of older individuals of o
15、lder individuals l lStandard x-rays show changes in bone density after about Standard x-rays show changes in bone density after about 40%40%of bone loss of bone lossl lDEXA scan can detect changes after about a DEXA scan can detect changes after about a 1%1%change change第29页，共50页，编辑于2022年，星期二T score
16、s compare individual results to those in yong population that is compare individual results to those in yong population that is matched for race and gender matched for race and gender Z scores compare individual results to those of an age-matched compare individual results to those of an age-matched
17、 population population that is matched for race and genderthat is matched for race and gender第30页，共50页，编辑于2022年，星期二WHO definitionWHO definition （Based on Bone Density LevelsBased on Bone Density Levels）vNormal Bone density is within 1 SD(+1 or 1)of the young adult mean.vLow bone mass Bone density is
18、 between 1 and 2.5 SD below the young adult mean(1 to 2.5 SD).vOsteoporosis Bone density is 2.5 SD or more below the young adult mean(2.5 SD or lower).vSevere(established)osteoporosis Bone density is more than 2.5 SD below the young adult mean,and there have been one or more osteoporotic fractures.v
19、v正常正常正常正常 骨密度在年轻成人均值1个SD(+1或1)以内vv低骨量低骨量低骨量低骨量 骨密度在年轻成人均值1 到2.5 SD之间 vv骨质疏松骨质疏松骨质疏松骨质疏松 骨密度等于或低于年轻成人均值 2.5 SD vv严重严重严重严重(已确立已确立已确立已确立)骨质疏松骨质疏松骨质疏松骨质疏松 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第31页，共50页，编辑于2022年，星期二 Treatment第32页，共50页，编辑于2022年，星期二vvA recently developed technique involves percutaneous inj
20、ection of artificial A recently developed technique involves percutaneous injection of artificial cement(ploymethymethacrylate)into the vertebral body(cement(ploymethymethacrylate)into the vertebral body(Vertebroplasty,Vertebroplasty,kyphoplasty)vThis offers significant immediate pain relief in the
21、majority of patientsv Long term effects are unknown.VertebroplastyVertebroplasty kyphoplasty 第33页，共50页，编辑于2022年，星期二Nutritional Recommendation(营养治疗的建议营养治疗的建议)Adequate Adequate Calcium IntakeCalcium Intake Life stage Group Etsimated Adequate Daily Life stage Group Etsimated Adequate Daily Calcium Inta
22、ke.mg/d Calcium Intake.mg/d Young children(1-3 years)Young children(1-3 years)500 500Older children(4-8 years)800Older children(4-8 years)800Adolescents and young adults(9-18 years)Adolescents and young adults(9-18 years)1300 1300Men and women(19-50 years)Men and women(19-50 years)1000 1000Men and w
23、omen(51 and older)Men and women(51 and older)1200 1200Note: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).第34页，共50页，编辑于2022年，星期二 Elemental Calcium Content of Various Oral Calcium Preparation 各种口服钙剂的元素钙的含量各种口服
24、钙剂的元素钙的含量 Calcium Preparation Elemental CalciumCalcium Preparation Elemental Calcium (钙制剂钙制剂钙制剂钙制剂 )()(元素钙含量元素钙含量元素钙含量元素钙含量)Calcium citrate Calcium citrate 柠檬酸钙柠檬酸钙柠檬酸钙柠檬酸钙 60 mg/300 mg60 mg/300 mg Calcium lactate Calcium lactate乳酸钙乳酸钙乳酸钙乳酸钙 80 mg/600 mg80 mg/600 mg Calcium gluconate Calcium glucona
25、te 葡萄糖酸钙葡萄糖酸钙葡萄糖酸钙葡萄糖酸钙 40 mg/500 mg40 mg/500 mg Calcium carbonate Calcium carbonate 碳酸钙碳酸钙碳酸钙碳酸钙 400 mg/g400 mg/g Calcium carbonate+5 ug Calcium carbonate+5 ug vitamin D2(OsCal250)vitamin D2(OsCal250)碳酸钙碳酸钙碳酸钙碳酸钙 250 mg/250 mg/片片片片 Calcium carbonate Calcium carbonate (Turns 500)(Turns 500)碳酸钙碳酸钙碳酸钙
26、碳酸钙 500 mg/500 mg/片片片片Source:Adapted from SM Krane and MF Holick,Chap.355 in HPIM,14 ed,1998.第35页，共50页，编辑于2022年，星期二Vitamin D vvVitamin D goal :Serum 25-hydroxyvitaminVitamin D goal :Serum 25-hydroxyvitamin D75 mol/L(30 D75 mol/L(30 ng/mL)ng/mL)vv 70 years of age:600 70 years of age:600 IUIU/day/day
27、The elderly and chronically ill:The elderly and chronically ill:1000 1000 IUIU/day/dayvvSerum 25-hydroxyvitaminSerum 25-hydroxyvitamin D 75 mol/L(30 ng/mL).75 mol/L(30 ng/mL).Inadequate dosage 第36页，共50页，编辑于2022年，星期二vvEstrogensEstrogens(雌激素雌激素雌激素雌激素)vvSelective Estrogen Receptor ModulatorsSelective E
28、strogen Receptor Modulators (SERMs,(SERMs,选择性雌激素受体调节剂选择性雌激素受体调节剂选择性雌激素受体调节剂选择性雌激素受体调节剂)vvBisphosphonateBisphosphonate(双磷酸盐双磷酸盐双磷酸盐双磷酸盐)vvCalciumCalcium(降钙素降钙素降钙素降钙素)vvParathyroid hormoneParathyroid hormone （甲状旁腺激素（甲状旁腺激素（甲状旁腺激素（甲状旁腺激素PTHPTH）vvFluorideFluoride(氟化物氟化物氟化物氟化物)Pharmacologic Therapy(药物治疗药
29、物治疗)第37页，共50页，编辑于2022年，星期二Estrogens第38页，共50页，编辑于2022年，星期二Results of hormone therapy regimens on bone mineral density Results of hormone therapy regimens on bone mineral density(BMD)of the spine(BMD)of the spine(A A)and hip()and hip(B B第39页，共50页，编辑于2022年，星期二Effects of hormone therapy on event rates第4
30、0页，共50页，编辑于2022年，星期二SERMs(SERMs(选择性雌激素受体调节剂选择性雌激素受体调节剂选择性雌激素受体调节剂选择性雌激素受体调节剂)vvTwo SERMs are currently being used in postmenopausal women Two SERMs are currently being used in postmenopausal women vvRaloxifene is approved for prenvention and treatment of osteoporosisRaloxifene is approved for prenve
31、ntion and treatment of osteoporosisvvTamoxifene is approved for prenvention and treatment of breast cancer Tamoxifene is approved for prenvention and treatment of breast cancer vvThere is no data confirming that raloxifene can reduce the risk of There is no data confirming that raloxifene can reduce
32、 the risk of nonvertebral fractures nonvertebral fractures 第41页，共50页，编辑于2022年，星期二vvAlendronate,risedronate,and ibandronateAlendronate,risedronate,and ibandronate are approved for the prevention are approved for the prevention and treatment of and treatment of postmenopausal osteoporosispostmenopausa
33、l osteoporosis.vvRisedronate and Alendronate are approved Risedronate and Alendronate are approved for treatmentfor treatment of steroid induced of steroid induced osteoporosis.osteoporosis.vvRisedronate is approved for Risedronate is approved for the preventionthe prevention of steroid induced oste
34、oporosis.of steroid induced osteoporosis.vvRisedronate and Alendronate are approved for treatment of Risedronate and Alendronate are approved for treatment of osteoporosis in osteoporosis in menmen Bisphosphonate第42页，共50页，编辑于2022年，星期二 Cumulative Cumulative proportions of women proportions of women w
35、ith osteoporosis who with osteoporosis who suffered clinical suffered clinical fracture(vertebral,fracture(vertebral,hip,or wrist)during hip,or wrist)during 3 years of treatment 3 years of treatment with alendronate or with alendronate or placeboplacebo第43页，共50页，编辑于2022年，星期二第44页，共50页，编辑于2022年，星期二Cal
36、cium(降钙素降钙素)第45页，共50页，编辑于2022年，星期二 Parathyroid hormone （甲状旁腺激素（甲状旁腺激素PTH）Teriparatide(立特帕立特帕 肽肽)第46页，共50页，编辑于2022年，星期二Effect of parathyroid hormone(PTH)treatment on bone microarchitecture第47页，共50页，编辑于2022年，星期二Number of incident vertebral deformities第48页，共50页，编辑于2022年，星期二Summary 第49页，共50页，编辑于2022年，星期二Question What are WHO definitions based on bone density levels？第50页，共50页，编辑于2022年，星期二