Osteoporosis is the most common skeletal disease in middle-aged and elderly people, and the prevalence of osteoporosis is increasing rapidly with the aging of society. Osteoporosis, or osteopenia, is a group of bone diseases caused by a variety of causes, and is a metabolic bone lesion characterized by a decrease in the amount of bone tissue per unit volume. In most osteoporosis, the decrease in bone tissue is mainly due to increased bone resorption, and is a disease characterized by a decrease in bone strength, leading to an increased risk of fracture. Osteoporotic fractures and the series of complications they cause seriously affect the health of the population, and also bring a heavy burden to families and society.
Definition.
WHO (World Health Organization, 1994) considers osteoporosis as a disease characterized by a general decrease in bone mass and an increase in the brittleness of bone tissue, which is highly susceptible to fracture, and NIH (National Institutes of Health, 2001) considers osteoporosis as a bone disease characterized by a decrease in bone strength, resulting in an increased risk of fracture in patients.
The incidence of osteoporosis in China: 86 million patients suffer from osteoporosis, accounting for 6% of the total population, with a prevalence of up to 50% in women over 50 years of age and greater than 20% in men over 70 years of age.
Etiology.
In addition to primary osteoporosis, which is primarily associated with menopause and old age, osteoporosis may also be caused by a variety of diseases called secondary osteoporosis. The common diseases that may cause osteoporosis are.
1, endocrine diseases: diabetes mellitus (type 1, type 2), hyperparathyroidism, Cushingsyndrome, hypogonadism, hyperthyroidism, pituitary lactinoma, hypopituitarism, etc.
2, connective tissue diseases: systemic lupus erythematosus, rheumatoid arthritis, dry syndrome, dermatomyositis, mixed connective tissue disease, etc.
3, chronic kidney disease: a variety of chronic kidney diseases leading to renal osteodystrophy.
4, gastrointestinal diseases and nutritional diseases: malabsorption syndrome, after major gastrointestinal resection, chronic pancreatic diseases, chronic liver disorders, malnutrition, long-term intravenous nutrition support treatment, etc.
5, hematological system diseases: leukemia, lymphoma, multiple myeloma, Gaucher disease and myelodysplastic syndrome, etc.
6.Neuromuscular system diseases: various causes of hemiplegia, paraplegia, motor dysfunction, myotonic dystrophy, rigid man syndrome and myotonic syndrome, etc.
7, long-term braking: such as long-term bed rest or space travel.
8.After organ transplantation.
9.Constant use of the following drugs: glucocorticoids, immunosuppressants, heparin, anticonvulsants, anticancer drugs, aluminum-containing antacids, thyroid hormones, chronic fluorosis, gonadotropin-releasing hormone analogues (GnRHa) or dialysis solution for renal failure.
Clinical symptoms.
Patients may have low back pain or peripheral aches and pains, which are aggravated by increased load or limited in activity, and in severe cases, difficulty in turning over, getting up and sitting, and walking. Those with severe osteoporosis may have height shortening and hunchback. Vertebral compression fractures can lead to thoracic deformity, abdominal compression, and affect cardiopulmonary function. Fractures that occur with non-trauma or minor trauma are fragility fractures. It is a low-energy or non-violent fracture, such as a fall from a standing height or less than standing height or a fracture that occurs as a result of other daily activities. Common sites where fragility fractures occur are the thoracic and lumbar spine, hip, distal radius and ulna, and proximal humerus.
Hazards.
Pain itself can reduce the patient’s quality of life, crestal deformation and fracture can cause disability, make the patient’s activities limited and unable to take care of themselves, increase the incidence of pulmonary infection and decubitus ulcers, not only the quality of life and mortality of the patient increases also brings a heavy economic burden to the individual, family and society.
Diagnostic methods.
The measured value of dual-energy X-ray absorptiometry (DXA) is currently recognized worldwide as the gold standard for the diagnosis of osteoporosis.
Treatment.
1. Exercise: In adulthood, many types of exercise help maintain bone mass. Menopausal women who adhere to 3 hours of exercise per week have increased overall calcium. But those who exercise excessively to cause amenorrhea, bone loss is accelerated instead. Exercise can also improve sensitivity and balance.
2, nutrition: good nutrition is important for the prevention of osteoporosis, including adequate amounts of calcium, vitamin D, vitamin C and protein. From childhood, the daily diet should have adequate calcium intake, calcium affects the acquisition of peak bone. European and American scholars advocate a calcium intake of 800 to 1,000 mg for adults, 1,000 to 1,500 mg per day for postmenopausal women, and 1,500 mg/day for men after age 65 and other patients with risk factors for osteoporosis. The intake of vitamin D is 400 to 800 U/day.
3.Prevention of falls: The chance of falls in patients with osteoporosis should be minimized to reduce hip fractures as well as Colles fractures.
4.Medication.
Normal adults need to supplement calcium 800mg daily, postmenopausal women and elderly people need to supplement calcium 1000mg daily, elderly people in China take about 400mg of calcium in food daily, and need to supplement elemental calcium 500-600mg extra daily. but only calcium supplement is not enough for osteoporosis treatment, additional medication is needed according to the patient’s condition. Effective medications to stop and treat osteoporosis include estrogen replacement therapy, calcitonin, selective estrogen receptor modulators, and diphosphonates, which can stop bone resorption but have a particularly small effect on bone formation.
(1) Hormone replacement therapy is considered the best option and most effective treatment for postmenopausal women with osteoporosis, with the problem that hormone replacement therapy may bring about other systemic adverse effects. Hormone replacement therapy is avoided in patients with breast disease and in those who cannot tolerate its side effects.
1) Estradiol is recommended to be started right after menopause and taken for life if tolerated. Take it in cycles, i.e. 3 weeks in a row and 1 week off. Contraindicated in allergy, breast cancer, thrombophlebitis and vaginal bleeding with unclear diagnosis. Also ethinylestradiol and norethindrone are progestins and are used to treat moderate to severe vasodilatory symptoms associated with menopause.
(ii) Androgen studies have shown that in male patients with osteoporosis due to severe sex hormone deficiency, administration of testosterone replacement therapy increases BMD in the crest, but does not appear to be effective in the hip, so androgens can be considered an anti-bone resorption agent.
(iii) Intramuscular injection of testosterone once every 2 to 4 weeks may be used to treat patients with decreased BMD in hypogonadism. Testosterone should be used with caution in patients with impaired renal function and in the elderly, as it may increase the risk of prostate enlargement; testosterone can increase the growth of subclinical prostate cancer, so the drug should be monitored for prostate-specific antigen (PSA); liver function, blood count, and cholesterol should also be monitored; the drug should be discontinued in case of edema and jaundice. Calcium and vitamin D supply should be ensured during administration. Topical testosterone is available as an alternative.
Selective estrogen receptor modulators (SERMs) are drugs that have weak estrogen-like effects in some organs and estrogen antagonistic effects in others. Raloxifene, a non-steroidal benzothiophene, is an estrogen agonist that inhibits bone resorption, increases BMD in the crest and hip, and reduces the risk of vertebral fracture by 40% to 50%, but is less effective than estrogen. It is prohibited for premenopausal women.
(2) Diphosphates are synthetic analogues of pyrophosphates bound to hydroxyapatite in bone, which can specifically inhibit osteoclast-mediated bone resorption and increase bone mineral density, the specific mechanism of which is still not fully understood. It is contraindicated in pregnant women and women who are planning to become pregnant. The first generation named hydroxyethyl phosphonate sodium called etidronate sodium, therapeutic doses have adverse effects of inhibiting bone mineralization, therefore, intermittent and cyclic administration is advocated, with 2 weeks of continuous hydroxyethyl phosphonate sodium at the beginning of each cycle and 10 weeks of discontinuation, every 12 weeks as a cycle. The administration of hydroxyethyl phosphonate sodium should be accompanied by calcium.
(3) Vitamin D and calcium and its metabolites can promote calcium absorption and bone mineralization in the small intestine. Active vitamin D can promote bone formation, increase osteocalcin production and alkaline phosphatase activity. The incidence of vertebral and extravertebral fractures in patients with osteoporosis is better reduced with active vitamin D than with calcium alone. Combination preparations of vitamin D and calcium are also available for more reliable treatment.
Prevention.
Osteoporosis brings great inconvenience and pain to the life of patients, and the treatment is very slow, once the fracture and can be life-threatening, therefore, special emphasis should be placed on the implementation of three levels of prevention.
1. Primary prevention should start with children and adolescents, such as paying attention to reasonable dietary nutrition, consuming more foods with high calcium and phosphorus content, such as fish, shrimp, milk, dairy products, bone broth, eggs, beans, mixed grains, green leafy vegetables, etc. Adhere to a scientific lifestyle, such as adhere to physical exercise, more sunbathing, do not smoke, do not drink alcohol, less coffee, strong tea and carbonated beverages, less sugar and salt, animal protein should not be too much, late marriage, less childbirth, breastfeeding period should not be too long, as much as possible to preserve calcium in the body, enrich the calcium pool, increase the peak bone to the maximum is the best measure to prevent osteoporosis later in life. For high-risk groups with genetic predisposition, focus on follow-up and early prevention.
2.Secondary prevention is carried out at an accelerated rate of bone loss when people reach middle age, especially women after menopause. Bone density examination should be conducted annually during this period, and prevention and control measures should be taken early for people with rapid bone loss. In recent years, most scholars in Europe and the United States advocate that long-term estrogen replacement therapy should be started within 3 years after menopause in women, while insisting on long-term preventive calcium supplementation to safely and effectively prevent osteoporosis.
3, tertiary prevention of patients with degenerative osteoporosis should actively carry out drug therapy to inhibit bone resorption and promote bone formation (active VitD), and should also strengthen measures to prevent falls and upsets. For middle-aged and elderly fracture patients should be actively operated, strong internal fixation, early activity, and comprehensive treatment such as physical therapy, physiotherapy psychology, nutrition, calcium supplementation, curbing bone loss, improving immune function and overall quality.
Prognosis.
Factors affecting prognosis are mainly post-fracture related complications. Although osteoporosis cannot be completely prevented, giving certain preventive measures, such as adequate intake of calcium, vitamin D and exercise, can reduce osteoporosis to a great extent and prevent serious complications from appearing.