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1、Definition Osteoporosis is a systemic skeletal disease characterized byLow 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，导致骨微结构破坏，导致骨微
2、结构破坏，导致骨脆性增加，易发生骨脆性增加，易发生骨脆性增加，易发生骨脆性增加，易发生骨折为特征的折为特征的折为特征的折为特征的全身性全身性全身性全身性骨骨骨骨病病病病 Epidemiology Incidence/100,000 person yearIncidence/100,000 person yearIncidence/100,000 person yearIncidence/100,000 person year WomenWomen =85=85=85=8535-3935-3935-3935-39II PathophysiologyRemodeling(骨重建过程骨重建过程)Me
3、chanism of bone remodeling.破骨细胞破骨细胞成骨细胞成骨细胞Menopause Menopause AgingAgingOther risk Other risk FactorsFactors Hormonal control of bone resorption.Clinical characteritics p Osteoporosis often starts silently and may not be found until a bone fractures.p Fragility fracture is a type of pathologic frac
4、ture 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
5、 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 on
6、set back painfractures present with sudden onset back pain Chronic pain Chronic pain Loss of height,Humpback n nkyphosiskyphosis（humpbackhumpback）n nKyphosisKyphosis is more severe with is more severe with age age n n24 Vertebral body 24 Vertebral body Vertebral body height Vertebral body height 2 c
7、m 2 cm Short 2mm Short 2mm，total 3-6cm total 3-6cm FracturesppFractures are the most dangerous aspect of osteoporosisFractures are the most dangerous aspect of osteoporosisp Multiple vertebral fractures lead to a stooped posture,loss of height,Multiple vertebral fractures lead to a stooped posture,l
8、oss of height,and chronic pain with resultant reduction in mobilityand chronic pain with resultant reduction in mobilityppHip 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 fra
9、cture,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 fra
10、cturevvThoracic fracture are associated with restrictive lung Thoracic fracture are associated with restrictive lung diseases diseases vvLumbar fracture are associated with abdominal symptom Lumbar fracture are associated with abdominal symptom including distension,early satiety and constipationincl
11、uding distension,early satiety and constipation Diagnosis and differential diagnosisBone mineral density（骨密度测定（骨密度测定）Measurement of bone mass Dual-energy x-ray Dual-energy x-ray absorptiometryabsorptiometry(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 gold standard for measuring bone density The gold s
12、tandard for measuring bone density 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 frequently in osteoarthritis,tend to ,which are frequently in osteoar
13、thritis,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 lStandard x-rays show changes in bone density after
14、about Standard x-rays show changes in bone density after about 40%40%of of bone lossbone lossl lDEXA scan can detect changes after about a DEXA scan can detect changes after about a 1%1%change changeT scores compare individual results to those in yong population that is compare individual results to
15、 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 population population that is matched for race and genderthat is matched for race and genderW
16、HO 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 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
17、 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.vv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
18、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 TreatmentvvA recently developed technique involves percutaneous injection of A recently developed technique involves percutaneous injection of artificial cement(ploymethymethacrylate)into the vertebral body artificial cement(pl
19、oymethymethacrylate)into the vertebral body(Vertebroplasty,Vertebroplasty,kyphoplasty)vThis offers significant immediate pain relief in the majority of patientsv Long term effects are unknown.VertebroplastyVertebroplasty kyphoplasty Nutritional Recommendation(营养治疗的建议营养治疗的建议)Adequate Adequate Calcium
20、 IntakeCalcium Intake Life stage Group Etsimated Adequate Daily Life stage Group Etsimated Adequate Daily Calcium Intake.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)A
21、dolescents and young adults(9-18 years)1300 1300Men and women(19-50 years)Men and women(19-50 years)1000 1000Men and women(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/
22、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
23、 lactateCalcium lactate乳酸钙乳酸钙乳酸钙乳酸钙 80 mg/600 mg80 mg/600 mg Calcium gluconate Calcium gluconate 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/g 400 mg/g Calcium carbonate+5 ug Calcium carbonate+5 ug vitamin D2(OsCal250)vitamin D2(OsCal250)碳酸钙碳
24、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.Vitamin D vvVitamin D goal :Serum 25-hydroxyvitaminVitamin D goal :Serum 25-hydroxyvitamin D75 mol/L D75 mol/L(3
25、0 ng/mL)(30 ng/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/dayvvSerum 25-hydroxyvitaminSerum 25-hydroxyvitamin D D 75 mol/L(30 75 mol/L(30 75 mol/L(30 75 mol/L(30 ng/mL).ng/mL).ng/mL).ng/mL).Inadequate
26、dosageInadequate dosage vvEstrogensEstrogens(雌激素雌激素雌激素雌激素)vvSelective Estrogen Receptor ModulatorsSelective Estrogen 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 hormoneParat
27、hyroid 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(药物治疗药物治疗)EstrogensResults 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
28、Effects of hormone therapy on event ratesSERMs(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 i
29、s approved for prenvention and treatment of osteoporosisvvTamoxifene is approved for prenvention and treatment of breast Tamoxifene is approved for prenvention and treatment of breast cancer cancer vvThere is no data confirming that raloxifene can reduce the risk of There is no data confirming that
30、raloxifene can reduce the risk of nonvertebral fractures nonvertebral fractures vvAlendronate,risedronate,and ibandronateAlendronate,risedronate,and ibandronate are approved for the are approved for the prevention and treatment of prevention and treatment of postmenopausal osteoporosispostmenopausal
31、 osteoporosis.vvRisedronate and Alendronate are approved Risedronate and Alendronate are approved for treatmentfor treatment of steroid of steroid induced osteoporosis.induced osteoporosis.vvRisedronate is approved for Risedronate is approved for the preventionthe prevention of steroid induced of st
32、eroid induced osteoporosis.osteoporosis.vvRisedronate and Alendronate are approved for treatment of Risedronate and Alendronate are approved for treatment of osteoporosis in menosteoporosis in men Bisphosphonate Cumulative Cumulative proportions of proportions of women with women with osteoporosis w
33、ho osteoporosis who suffered clinical suffered clinical fracture(vertebral,fracture(vertebral,hip,or wrist)hip,or wrist)during 3 years of during 3 years of treatment with treatment with alendronate or alendronate or placeboplaceboCalcium(降钙素降钙素)Parathyroid hormone （甲状旁腺激素（甲状旁腺激素PTH）Teriparatide(立特帕立特帕 肽肽)Effect of parathyroid hormone(PTH)treatment on bone microarchitectureNumber of incident vertebral deformitiesSummary Question What are WHO definitions based on bone density levels？