Once an osteoporotic fracture occurs, the quality of life decreases and various complications occur, which can be disabling or fatal, so prevention of osteoporosis is more realistic and important than treatment. Moreover, osteoporosis can be prevented.
Primary prevention of osteoporosis is for those who have not had fractures but have risk factors for osteoporosis, or have reduced bone mass.
I. Basic treatment of osteoporosis.
1.Lifestyle adjustment
A balanced diet rich in calcium, low in salt and moderate in protein. Pay attention to appropriate outdoor activities, physical exercise and rehabilitation therapy that help bone health. Avoid smoking, alcohol abuse and the use of drugs that affect bone metabolism, etc. Take various measures to prevent falls: for example, pay attention to the presence of diseases and medications that increase the risk of falls, and strengthen protective measures for yourself and the environment (including various joint protectors), etc.
2.Bone health basic supplements.
(1) Calcium supplements
The recommended daily intake of calcium for adults is 800 mg (elemental calcium), which is a suitable dose to obtain the ideal bone peak and maintain bone health. Calcium intake can slow bone loss and improve bone mineralization. When used for the treatment of osteoporosis, it should be used in combination with other drugs. There is insufficient evidence to suggest that calcium supplementation alone can replace other anti-osteoporosis drug therapy. The choice of calcium should take into account its safety and efficacy.
(2) Vitamin D
It facilitates the absorption of calcium in the gastrointestinal tract. Vitamin D deficiency can lead to secondary hyperparathyroidism, which increases bone resorption, thus causing or aggravating osteoporosis. The recommended dose for adults is 200 units (5ug)/d, while older adults often have vitamin D deficiency due to lack of sunlight and impaired intake and absorption, so the recommended dose is 400-800 IU (10-20ug)/d. Some studies have shown that vitamin D supplementation increases muscle strength and balance in older adults, thus reducing the risk of falls and thus fractures. Vitamin D should be used in combination with other drugs when used for the treatment of osteoporosis. Clinical application should pay attention to individual differences and safety, regularly monitor blood and urine calcium, and adjust the dose as appropriate.
Second, the treatment of osteoporosis drugs.
1.Biphosphonates
Effectively inhibit osteoclast activity and reduce bone turnover. Evidence from a large sample of randomized double-blind controlled clinical trials shows that alendronate (Alendronate) (Fosamax or Gubang) can significantly improve the bone density of the lumbar spine and hip and significantly reduce the risk of fracture of the vertebral body and hip and other parts. Alendronate preparations are available in China. Other bisphosphonates such as hydroxyethyl bisphosphonate (Etidronate) can also be applied exploratively (cyclic dosing). The application should be based on the characteristics of each preparation, and the correct method of administration should be strictly followed (e.g. alendronate should be taken in the morning on an empty stomach with 200ml of water, and not lying down or eating within 30 minutes after taking the drug), and drug reflux or esophageal ulcers occur in very few patients. Therefore, it should be used with caution in patients with esophagitis, active gastric and duodenal ulcers, and reflux esophagitis. The latter is more convenient to take, less irritating to the digestive tract, effective and safe, and thus has better compliance.
2.Calcitonin
It can inhibit the biological activity of osteoclasts and reduce the number of osteoclasts. It can prevent bone loss and increase bone mass. There are two types of calcitonin agents currently used in clinical practice: salmon calcitonin and eel calcitonin analogs. Evidence from randomized double-blind controlled clinical trial studies has shown that 200 IU of synthetic salmon calcitonin nasal spray (migestrol) daily reduces the incidence of vertebral fractures in patients with osteoporosis. Another outstanding feature of calcitonin analogs is their ability to significantly relieve bone pain, which is effective in chronic pain due to osteoporotic fractures or skeletal deformities as well as bone pain caused by diseases such as bone tumors, making them more suitable for osteoporotic patients with painful symptoms. The course of application of calcitonin-based preparations depends on the condition and other conditions of the patient. In general, the application dose is 50 IU/time of salmon calcitonin, subcutaneously or intramuscularly, 2 to 5 times a week depending on the condition, 200 IU/day of salmon calcitonin nasal spray; 20 IU/week of eel calcitonin, intramuscularly. Application of calcitonin, a few patients may have adverse reactions such as facial flushing and nausea, and occasionally allergic phenomena.
3.Selective estrogen receptor modulators (SERMs)
Effectively inhibit osteoclast activity and reduce bone conversion to premenopausal levels in women. Evidence from a large sample of randomized double-blind controlled clinical trial studies shows that one tablet of Raloxifene (60 mg) daily can stop bone loss, increase bone density, and significantly reduce the incidence of vertebral fractures, making it an effective drug for the prevention and treatment of postmenopausal osteoporosis. It is only used for female patients and is characterized by selective action on estrogen target organs, with no adverse effects on the breast and endometrium. It reduces the incidence of estrogen receptor-positive invasive breast cancer and does not increase the risk of endometrial hyperplasia or endometrial cancer. It has a modulating effect on blood lipids. A small number of patients may experience hot flashes and lower extremity cramps while taking the drug. It is temporarily contraindicated in perimenopausal women with severe hot flashes. Foreign studies have shown that this drug mildly increases the risk of venous embolism, so it is prohibited for people with a history of venous embolism and a tendency to thrombosis, such as during long-term bed rest and sedentary periods.
4.Estrogens
These drugs can only be used for female patients. Estrogenic drugs can inhibit bone turnover and prevent bone loss. Clinical studies have fully demonstrated that estrogen or estrogen-progestin supplementation therapy (ERT or HRT) can reduce the risk of osteoporotic fractures and is an effective measure to prevent and treat postmenopausal osteoporosis. Based on a comprehensive assessment of the pros and cons of hormone supplementation therapy, it is recommended that hormone supplementation therapy follow the following principles: Indications: Women with menopausal symptoms (hot flashes, sweating, etc.) and/or osteoporosis and/or risk factors for osteoporosis, especially advocating greater benefit and less risk when started early in menopause. Contraindications: Estrogen-dependent tumors (breast cancer, endometrial cancer), thrombophilia, unexplained vaginal bleeding, and active liver disease and connective tissue disease are absolute contraindications. Use with caution in cases of uterine fibroids, endometriosis, family history of breast cancer, gallbladder disease and pituitary lactinoma. Estrogen should be used in conjunction with appropriate doses of progestin preparations to counteract the stimulation of the endometrium by estrogen in women with a hysterectomy, and only estrogen without progestin should be used in women who have undergone hysterectomy. The regimen, dose, preparation selection and duration of treatment of hormone therapy should be individualized according to the patient’s condition. Apply the lowest effective dose. Adhere to regular follow-up and safety monitoring (especially of the breast and uterus). Whether to continue the medication should be evaluated annually according to the characteristics of each woman for pros and cons.
5. Active vitamin D
An appropriate dose of active vitamin D promotes bone formation and mineralization and inhibits bone resorption. Some studies have shown that active vitamin D is beneficial in increasing bone density, increasing muscle strength and balance in older adults, reducing the risk of falls, and thus reducing the risk of fractures. Active vitamin D is more appropriate for the elderly, and includes both 1α-hydroxyvitamin D (α-osteol) and 1,25-bishydroxyvitamin D (osteotriol), the former being effective when liver function is normal and the latter not affected by liver or kidney function. They should be used under the guidance of a physician and blood and urine calcium levels should be monitored regularly. The dose of osteotriol is 0.25-0.5ug/d; α-osteotriol is 0.25-0.75 ug/d. In the treatment of osteoporosis, it can be used in combination with other anti-osteoporosis drugs.
Third, other assessment (screening) methods of osteoporosis.
1.Quantitative ultrasonography (QUS)
It is also a reference for the diagnosis of osteoporosis, and there is no uniform diagnostic standard. It has similar effect to DXA in predicting the risk of fracture, and it is economical and convenient, more suitable for screening, especially for pregnant women and children. However, monitoring the response to drug therapy is not yet a substitute for direct measurement of bone mass (bone mineral content) in the lumbar spine and hip.
2.X-ray radiography
It is a better method for qualitative and localized diagnosis of various fractures caused by osteoporosis, as well as a method to differentiate osteoporosis from other diseases. Commonly used radiographic sites include vertebrae, hip, wrist, metacarpal, heel and tubular bones. Due to various technical factors, the sensitivity and accuracy of diagnosing osteoporosis by X-ray radiography is low, and only when the bone volume decreases by 30% can it be revealed in the X-ray, so it is not significant for early diagnosis. Since patients with osteoporosis often lack obvious symptoms, many people are only discovered during physical examinations or radiographs for other purposes, such as vertebral fractures. If back pain worsens and height shortens significantly, a vertebral X-ray should be taken.
IV. Laboratory tests.
1.Blood and urine routine, liver and kidney function, blood glucose, calcium, phosphorus, alkaline phosphatase, sex hormones, 25(OH)D and parathyroid hormone can be selected according to the need of differential diagnosis.
2, according to the condition monitoring, drug selection and efficacy observation and differential diagnosis needs, conditional units can choose the following indicators of bone metabolism and bone transformation (including bone formation and bone resorption indicators) respectively. These indicators are useful for the typing of bone transformation, assessment of bone loss rate and risk of fracture in elderly women, and selection and assessment of disease progression and interventions.