Overview
Osteoporosis (OP) is a systemic bone disease characterized by low bone mass, destruction of bone microarchitecture, resulting in increased bone fragility and susceptibility to fracture (WHO). In 2001, the National Institutes of Health (NIH) proposed that osteoporosis is a disease of the skeletal system characterized by decreased bone strength and increased risk of fracture, and that bone strength reflects two major aspects of bone, namely bone mineral density and bone mass. Weng Maojian, Department of Orthopaedics and Traumatology, Panyu District Hospital of Traditional Chinese Medicine, Guangzhou, China
The disease can occur in different genders and at any age, but is mostly seen in postmenopausal women and older men. Osteoporosis is divided into two major categories: primary and secondary. Primary osteoporosis is divided into three types: postmenopausal osteoporosis (type I), senile osteoporosis (type II) and idiopathic osteoporosis (including adolescent type). Postmenopausal osteoporosis generally occurs within 5-10 years after menopause in women; senile osteoporosis generally refers to osteoporosis occurring in the elderly after the age of 70; secondary osteoporosis refers to osteoporosis caused by any disease or drug that affects bone metabolism; and idiopathic osteoporosis mainly occurs in adolescents, the cause of which is unknown.
Clinical manifestations
Pain, spinal deformation and the occurrence of fragility fractures are the most typical clinical manifestations of osteoporosis. However, many patients with osteoporosis often have no obvious symptoms in the early stage and are often found to have osteoporosis only after the fracture occurs by X-ray or bone density examination.
Pain
Patients may have low back pain or circumferential skeletal pain, and the pain worsens or activity is limited when the load increases, and in severe cases, there is difficulty in turning over, getting up and sitting, and walking.
Spinal deformation
In severe cases of osteoporosis, there may be shortening of height and hunchback, spinal deformity and limited extension. Compression fractures of the thoracic spine can lead to thoracic deformity and affect cardiopulmonary function. Fractures of the lumbar spine may alter the abdominal anatomy, causing constipation, abdominal pain, abdominal distention, decreased appetite and a feeling of premature fullness.
Fractures
A fragility fracture is a low-energy or non-violent fracture, such as a fracture that occurs as a result of daily activities. Common sites are the thoracic and lumbar spine, the hip, the distal radius and ulna, and the proximal humerus. Fractures can also occur at other sites. After a fragility fracture has occurred, the risk of a second fracture is significantly increased.
Risk assessment for osteoporosis
There are many clinical methods to assess the risk of osteoporosis, and two simple assessment methods with high sensitivity and easy operation are recommended here as screening tools.
1. International Osteoporosis Foundation (IOM) Osteoporosis 1-minute test questions
(1) Have you ever injured your bones due to a minor bump or fall?
(2) Have your parents ever had a hip fracture after a minor bump or fall?
(3) Do you regularly take hormonal drugs such as cortisone and prednisone for more than 3 months in a row?
(4) Has your height decreased by more than 75px from your youth?
(5) Do you regularly drink a lot of alcohol?
(6) Do you smoke more than 20 cigarettes per day?
(7) Do you often have diarrhea? (caused by digestive tract disease or enteritis)
(8) Ms. answer: Did you become menopausal before the age of 45?
(9) Ms. answer: Have you ever had no menstruation for more than 12 months in a row? (except during pregnancy)
(10) Men: Have you ever experienced impotence or lack of sexual desire?
As long as the answer to one of the questions is “yes”, it is positive.
2.Osteoporosis self-screening tool for Asians
OSTA index = (weight – age) × 0.2
Risk level OSTA index
Low>-1
Medium -1 to -4
High <-4
Diagnosis
The general criteria used clinically to diagnose osteoporosis are the occurrence of fragility fractures and/or low bone mineral density. There is a lack of clinical means to directly measure bone strength; therefore, bone mineral density and bone mineral content measurements are objective quantitative indicators for the clinical diagnosis of osteoporosis and for evaluating the extent of the disease.
1.Brittle fracture
It refers to fractures that occur without trauma or minor trauma, which is a clear manifestation of the decrease in bone strength and the end result and comorbidity of osteoporosis. When a fragility fracture occurs, osteoporosis can be clinically diagnosed.
2. Diagnostic criteria (based on bone densitometry)
The occurrence of osteoporotic fracture is related to the decrease of bone strength, which is determined by bone density and bone mass. Bone density reflects about 70% of bone strength, and if low bone density is accompanied by other risk factors will increase the risk of fracture. Because there is no ideal method for direct measurement or assessment of bone strength, BMD measurement is used clinically as the best quantitative standard for diagnosing osteoporosis, predicting the risk of osteoporotic fracture, monitoring the natural course of disease, and evaluating the efficacy of pharmacological interventions.
[Clinical indications for BMD measurement].
Bone densitometry is recommended when any of the following criteria are met.
-Females over 65 years of age and males over 70 years of age, with or without other risk factors for osteoporosis.
-Females under 65 years of age and males under 70 years of age with one or more osteoporosis risk factors.
-Adults of both sexes with a history of fragility fracture or/and family history of fragility fracture
-Adults of both sexes with low levels of sex hormones from various causes
-Persons with pre-existing osteoporotic changes on radiographs
-People who are receiving osteoporosis treatment and are being monitored for efficacy
-History of diseases affecting bone metabolism or use of drugs affecting bone metabolism.
-Persons with positive answers to the IOF one-minute test questions
-OSTA results ≤ -1
Prevention and treatment
Once osteoporotic fractures occur, the quality of life decreases and various comorbidities occur, which can be disabling and fatal. Therefore, prevention of osteoporosis is more realistic and important than treatment.
(I) Basic measures
The foundation is important and indispensable, but it is not the “all” and “only”. The scope of “basic measures” includes.
–Primary and secondary prevention of osteoporosis
–Osteoporosis drug treatment and rehabilitation
The content of “basic measures” includes
1.Lifestyle adjustment
(1) A balanced diet rich in calcium, low in salt and moderate in protein
(2) Appropriate outdoor activities and sunshine, physical exercise and rehabilitation that contribute to bone health
(3) Avoid smoking and alcohol abuse, and be careful with drugs that affect bone metabolism.
(4) Take various measures to prevent falls and pay attention to the presence of diseases and drugs that increase falls.
(5) Strengthen protective measures for oneself and the environment (various joint protectors), etc.
2.Bone health basic supplements
(1) Calcium: China Nutrition Association has set the recommended daily calcium intake for adults 800mg (elemental calcium) as the appropriate dose to obtain the ideal bone peak to maintain bone health, if the supply of calcium in the diet is insufficient, calcium supplements can be used; the recommended daily calcium intake for postmenopausal women and the elderly is 1000mg; the current dietary nutrition survey shows that the average daily calcium intake for the elderly in China is 400mg from the diet. Calcium intake can slow down the loss of bone and improve bone mineralization. When used for the treatment of osteoporosis, it should be combined with other drugs. There is insufficient evidence that calcium supplementation alone can replace other anti-osteoporosis drug therapy. Calcium selection should take into account its effectiveness and safety.
(2) Vitamin D: promotes calcium absorption, is beneficial for bone health, maintains muscle strength, improves physical stability, and reduces the risk of fracture.
Vitamin D deficiency can cause secondary hyperparathyroidism and increase bone resorption, which can cause and worsen osteoporosis. The recommended dose for adults is 200 IU/d; for the elderly, the recommended dose is 400-800 IU/d due to lack of sunlight and impaired intake and absorption. vitamin D should be used at a dose of 800-1200 IU/d for the treatment of osteoporosis, and can also be used in combination with other drugs. It is recommended that 25OHD blood concentrations be tested in hospitals where available to understand the nutritional status of patients for proper vitamin D. The International Osteoporosis Foundation recommends serum 25OHD levels equal to or higher than 30ng/mL (75nmol/L) in the elderly to reduce the risk of falls and fractures.
(II) Drug intervention
[Anti-osteoporosis drugs].
There are various anti-osteoporosis drugs with different mechanisms of action. They may mainly inhibit bone resorption, or promote bone formation, and there are also some drugs with multiple mechanisms of action. Clinical judgment of the efficacy of anti-osteoporosis drugs includes whether they can improve bone mass and bone quality, and ultimately reduce the risk of fracture. The standardized application of anti-osteoporosis drugs that have been approved for marketing in China is described as follows (in alphabetical order by drug name)
1.Bisphosphonates (Bisphosphonates)
Bisphosphonates are stable analogues of pyrophosphonates, which are characterized by the presence of P-C-P groups. Bisphosphonates have high affinity binding to skeletal hydroxyapatite and specifically bind to the surface of osteoclasts with active bone transformation to inhibit the function of osteoclasts, thus inhibiting bone resorption. The potency of different bisphosphonates to inhibit bone resorption varies greatly, so the dose and usage of different bisphosphonates vary clinically.
2.Calcitonin
Calcitonin is a calcium-regulating hormone that inhibits the activity of osteoclasts and reduces the
Calcitonin is a calcium-regulating hormone that inhibits osteoclast activity and reduces the number of osteoclasts, thereby reducing bone loss and increasing bone mass. Another prominent feature of calcitonins is their ability to provide significant relief from bone pain. They are effective for chronic pain caused by osteoporotic fractures or skeletal deformities and bone pain caused by bone tumors and other diseases. It is more suitable for osteoporosis patients who have bone pain. Two preparations: salmon calcitonin and eel calcitonin analogue. Indications: SFDA approved indication for the treatment of postmenopausal osteoporosis.
Efficacy: Clinical studies have demonstrated increased bone density in the lumbar spine and hip in patients with osteoporosis, and 200 IU daily of synthetic salmon calcitonin nasal spray reduces the risk of vertebral and non-vertebral fractures; it significantly relieves bone pain.
Dosage: Salmon calcitonin nasal spray 200IU/day; injection 50IU/dose, subcutaneous or intramuscular, 2-7 times per week depending on the condition. Eel calcitonin 20IU/week, intramuscular injection.
Precautions: A few patients may have adverse reactions such as facial flushing, nausea, etc. Occasionally, there is allergy, and it can be determined whether to do allergy test according to the requirements of the drug instruction.
3.Estrogens, parathyroid hormone (PTH), selective estrogen receptor modulators (SERMs), strontium salt ranelate and others are not expressed in detail because they are used less frequently.
4.Chinese herbal medicine
Traditional Chinese medicine is treated by tonifying the liver and kidneys and strengthening the muscles and bones.