I. Treatment principles
1.Treatment should be started as early as possible
The reason is that completely and partially disappeared bone units (columnar bone units of 0.2mm diameter and trabeculae of cortical bone) cannot be regenerated, but bone units that have become thin can be restored to their original state after treatment. Therefore, reversal of already lost bone units (forming osteoporosis) is not possible, and early intervention can prevent osteoporosis in most people. Treatment should be started at perimenopause (age 45) in women. Men can often be 10 years later.
2. Treatment for the presence of a specific etiology should not be ignored, especially not the overlapping presence of primary and secondary osteoporosis.
3.Therapeutic measures to relieve pain should be chosen rationally.
4.Effectiveness, safety, feasibility and economy of basic treatment should be paid attention to, such as exercise, drinking milk, sunshine and careful prevention of fall.
5.The 3 major classes of drugs, such as calcium, vitamin D and bone resorption inhibitors, have been widely used around the world after being approved by the FDA. For more serious cases, the need and safety of the combined application of these 3 drugs should not be ignored. Calcium provides the raw material for bone formation, vitamin D promotes intestinal calcium absorption and inhibits bone calcium loss, and bone resorption inhibitors can inhibit the excessive rate of bone resorption in postmenopausal and senile osteoporosis. The combined application of the three when the role of mutual coordination, compared to the “land, sea and air joint warfare”.
6, should not be used in combination with two or more bone resorption inhibitors.
Second, drug treatment
Effective pharmacotherapy can stop and treat osteoporosis, including estrogen replacement therapy, calcitonin, selective estrogen receptor modulators, and diphosphonates, which can stop bone resorption but have a particularly small effect on bone formation. Empirical treatment has found that slow-release sodium fluoride, as well as low doses of PTH, increase bone formation and may prevent bone loss in estrogen-deficient women. The former also reduces the incidence of vertebral fractures. Studies have confirmed that these drugs improve BMI and that testosterone therapy given to hypogonadal men with osteoporosis can maintain bone mass. Administration of calcium and vitamin D is an important preventive measure.
The drugs used to treat and halt the progression of osteoporosis fall into two broad categories, the first being drugs that inhibit bone resorption, including calcium, vitamin D and active vitamin D, calcitonin, diphosphonates, estrogens, and isoflavones; the second being drugs that promote osteogenesis, including fluoride, anabolic steroids, parathyroid hormone, and isoflavones. To date, all therapeutic drugs have been experimented in women, and all are assumed to have the same therapeutic effect in men, except for estrogen and selective estrogen receptor modulators.
1. Hormone replacement therapy
Hormone replacement therapy is considered the best option and the most effective treatment for postmenopausal women with osteoporosis. The problem is 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. For these patients, other drugs may be used.
2.Selective estrogen receptor modulators
Selective estrogen receptor modulators have a weak estrogen-like effect in some organs and an estrogen antagonistic effect in others. SERMs can prevent osteoporosis and reduce the incidence of cardiovascular disease, breast cancer and endometrial cancer. Stop using them 3 days before prolonged braking and surgery to avoid thrombosis.
3.Diphosphonates
Diphosphates are synthetic analogues of pyrophosphates combined with hydroxyapatite in bone, which can specifically inhibit osteoclast-mediated bone resorption and increase bone mineral density, the specific mechanism is still not fully understood, and is considered to be related to the regulation of osteoclast function and activity. It is contraindicated in pregnant women and women who are planning to become pregnant.
Among the above-mentioned drugs, alendronate is most commonly used for the treatment and prevention of osteoporosis.
4.Calcitonin
Calcitonin is a 32 amino acid peptide secreted by thyroid C cells, a peptide hormone, which can rapidly inhibit osteoclast activity (osteoclasts have calcitonin receptors, and calcitonin can inhibit bone resorption), and its slow action can reduce the number of osteoclasts, which has the function of pain relief, increasing activity function and improving calcium balance, and has the function of pain relief for patients with fractures, and is suitable for patients with diphosphonates and estrogen. Patients who have contraindications or cannot tolerate it.
5.Vitamin D and calcium
Vitamin D and its metabolites can promote small intestine calcium absorption and bone mineralization. Active vitamin D (such as rogaine, alfa osteoclastic osteolysis) 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 and are more reliable in treatment.
Application of vitamin D
(1) The value of the clinical application of the 2 hydroxylation of vitamin D should not be ignored.
(2) Bone calcium loss due to vitamin D deficiency is common in both the United States, Europe and China.
(3) The recommended daily intake of vitamin D for adults should be followed.
(4) It should be noted that the doses of vitamin D and 1,25-(OH)2D required to increase intestinal calcium absorption are smaller than those required to stimulate bone resorption causing osteoporosis, but not by much. Therefore, long-term application of larger doses of VitD can cause bone loss and aggravate osteoporosis. Long-term daily intake of vitamin D greater than 4000 U, or 1,25 (OH) 2D or lα-D3 long-term daily intake of more than 1.5 to 3.0 μg, is able to cause bone calcium outflow into the blood and excretion through the urine, just like excess PTH, i.e.: excess vitamin D is similar to hyperparathyroidism and can promote bone resorption.
(5) It should be noted that “Calcium VitD’, the most commonly used, basic and quite effective treatment, requires regular monitoring of blood and urine calcium to control blood and urine calcium in the normal range. 24h urine calcium should be controlled to be less than 300mg and more than 100mg.
The application of calcium
(1) Calculation method: National daily elemental calcium intake is 1000mg/d. Most experts recommend a total daily calcium intake of 1000-1500mg/d for postmenopausal women, including calcium in diet, calcium in milk and pharmaceutical supplements. The maximum allowable daily intake of calcium for adolescents and young adults is 1200 mg/d. Most postmenopausal women have a dietary calcium intake of ≤350 to 500 mg/d, approximately 400 mg per day drinking 500 ml of milk per day and being able to obtain 500 mg of elemental calcium. Therefore, in critically ill patients, according to 1500mg per day supplementation, medication calcium supplementation = 1500 recommended amount – 400 diet – 500 milk = 600mg of elemental calcium medication supplementation. If vitamin D supplementation is reasonable and most patients are able to follow 100mg of elemental calcium supplementation per day, the amount of medicated calcium supplementation = 1000-400-500 = 100mg of medicated calcium.
(2) Medicated calcium dosing time: The dosing time of calcium citrate can be when the stomach is emptying, but most calcium supplements are calcium carbonate and should be taken during meals, under the conditions of gastric acid secretion during meals, calcium carbonate is easily dissociated and absorbed. It is difficult to demonstrate the difference in clinical efficacy between different pharmaceutical calcium supplements.
(3) advocate the application of milk for calcium: milk 1ml contains 1mg of calcium, advocate drinking 250-500ml a day. abdominal pain and diarrhea after taking fresh milk, can stimulate the secretion of liver lactase by incremental method, and then gradually increase the amount, can eliminate abdominal pain and diarrhea.
(4) Calcium dose should be divided into doses: so that the amount of calcium lost from the stool is less.
(5) Fluoride: fluoride is an effective stimulant for bone formation, which can increase the bone density of vertebrae and hip and reduce the incidence of vertebral fracture. A small dose of 15-20 mg of fluoride per day is effective in stimulating bone formation with few side effects.
For treated patients with osteopenia and osteoporosis, it is recommended that BMD be reviewed every 1 to 2 years. If the test bone renewal index is high, the drug should be reduced. For long-term prevention of bone loss, it is recommended that women begin estrogen replacement therapy immediately after menopause and maintain it for at least 5 years, with 10 to 15 years being preferable. If the patient has a diagnosed disease known to cause osteoporosis, or is on medications that clearly cause osteoporosis, concomitant treatment with calcium and vitamin D as well as diphosphonates is recommended.
III. Surgical treatment
Surgical treatment is required only after a fracture has occurred due to osteoporosis, with the aim of treating the fracture and restoring normal function as soon as possible.
Treatment of secondary osteoporosis
The main treatment is to actively treat the primary disease, and calcitonin, vitamin D, diphosphonate, estrogen and other drugs can be applied at the same time as appropriate.