A therapeutic goal
Improve the growth and development of bones and promote the ideal peak bone mass in adulthood; Maintain bone mass and quality, increase bone density and prevent bone loss with age; Avoid falls and fractures. No matter what type of osteoporosis, the principles of treatment and prevention are the same.
Second, basic measures
1. adjust lifestyle: maintain a healthy lifestyle, including strengthening nutrition and balancing diet; Exercise regularly to prevent falling; Adequate sunshine; Quit smoking and limit alcohol; Avoid excessive drinking of coffee and carbonated drinks; Try to avoid or use less drugs that affect bone metabolism.
2. Basic supplements for bone health: supplementing calcium and vitamin D is the basic measure for the prevention and treatment of osteoporosis.
(1) calcium: any type of osteoporosis should be supplemented with a proper amount of calcium, so that the total intake of elemental calcium can reach 800 ~1200mg/d. Adequate calcium intake is beneficial to obtain ideal bone peak, slow down bone loss, improve bone mineralization and maintain bone health. Calcium should be avoided in hypercalcemia and hypercalciuria. Commonly used calcium carbonate D3 tablets, each containing calcium carbonate 1.5 g (equivalent to 600 mg)/ of calcium)/vitamin D3 125 U, taken orally, each time 1 tablet, 1~2 times/d.
(2) Vitamin D: The recommended intake of vitamin D for adults is 400 IU (10 μ g)/d; The recommended intake for the elderly aged 65 and above is 600 iu (15 μ g)/d; When vitamin D is used in the prevention and treatment of osteoporosis, the dose can be 800 ~1200 iu/d.. For example, vitamin D drops (capsule type) are taken orally, each time 1 capsule, 1~2 times/d. Attention should be paid to individual differences and safety, and blood calcium and urine calcium concentrations should be monitored regularly to prevent hypercalcemia and hyperphosphatemia.
Three anti-osteoporosis drugs
Anti-osteoporosis drugs can be divided into bone resorption inhibitors, bone formation promoters and other mechanism drugs according to their mechanism.
1. indications:
(1) Patients diagnosed as osteoporosis by DXA.
(2) Those who have had brittle fracture of vertebral body or hip.
(3) Patients with low bone mass but high fracture risk or brittle fracture in some parts (upper humerus, distal forearm or pelvis).
2. Bone resorption inhibitors: bisphosphonates, calcitonin and estrogen are commonly used.
(1) bisphosphonates are the most widely used anti-osteoporosis drugs in clinic. Bisphosphonate can specifically bind to the active bone surface of bone remodeling, inhibit osteoclast function, and thus inhibit bone resorption. Bisphosphonate drugs mainly include alendronate sodium, zoledronic acid and risedronate sodium. Commonly used oral preparation alendronate sodium tablets, 70 mg each time, weekly 1 time; Or each time 10 mg, daily 1 time. Take it on an empty stomach, keep sitting or standing for 30 minutes after taking the medicine, and avoid eating. Intravenous drugs such as zoledronic acid intravenous injection, 5 mg intravenous drip, at least 15 min or more, once a year 1 time, and the drug should be fully hydrated before use.
The overall safety of bisphosphonates is good, but it should be noted that some adverse reactions may occur, such as: ① gastrointestinal reactions. ② Transient "flu-like" symptoms: Transient "flu-like" adverse reactions may occur after the first oral or intravenous infusion of nitrogen-containing bisphosphonates. If they cannot be relieved within 3 days, NSAIDs or other antipyretic and analgesic drugs can be used for symptomatic treatment. ③ Renal toxicity: creatinine clearance rate <: Patients with 35 ml/min are prohibited. ④ Mandibular necrosis: It is not recommended to use this kind of drugs for patients with severe oral diseases or who need dental surgery. ⑤ Atypical femoral fracture: In case of thigh or groin pain, X-ray examination of both femurs should be performed, and once diagnosed, the use of bisphosphonates and other anti-bone resorption drugs should be stopped immediately.
(2) Calcitonin: Calcitonin can inhibit the biological activity of osteoclasts, reduce the number of osteoclasts, reduce bone loss and increase bone mass. Another prominent feature of calcitonin drugs is that they can obviously relieve bone pain and are effective for bone pain caused by osteoporosis and its fractures. At present, there are two kinds of calcitonin preparations used in clinic: eel calcitonin analogues and salmon calcitonin. For example, salmon calcitonin injection is commonly used in clinic, 50 IU per day or every other day 100 IU, subcutaneous or intramuscular injection. The overall safety is good, and a few patients may have facial flushing, nausea and other adverse reactions, and occasionally allergic phenomena. In general, this product does not need a skin test before treatment, but patients who are suspected of being allergic to calcitonin or have a history of multiple allergies and are too sensitive to any drugs should consider doing a skin test before treatment.
(3) Sex hormone replacement therapy: including estrogen replacement therapy and estrogen and progesterone replacement therapy can reduce bone loss and reduce the risk of osteoporotic vertebral, non-vertebral and hip fractures, which is an effective measure to prevent and treat postmenopausal osteoporosis.
It is suggested that hormone replacement therapy should follow the following principles: (1) to clarify the advantages and disadvantages of treatment; Apply the lowest effective dose; Individualization of treatment plan; Adhere to regular (annual) follow-up and safety testing (especially breast and uterus), and evaluate the advantages and disadvantages every year.
3. Bone formation promoter: Teripartite is a parathyroid hormone analog. Intermittent low-dose use can stimulate osteoblast activity, promote bone formation, increase bone density and reduce the risk of vertebral and non-vertebral fractures. The common adverse reactions are nausea, limb pain, headache and dizziness. After drug withdrawal, anti-bone resorption drugs should be used sequentially to maintain or increase bone mineral density and continuously reduce the risk of fracture.
4. Other mechanism drugs: active vitamin D and its analogues, vitamin K2, strontium salts, etc. The most commonly used is active vitamin D and its analogues, which are more suitable for the elderly, renal dysfunction and 1α? Patients with hydroxylase deficiency or reduction can improve bone mineral density, reduce falls and reduce the risk of fracture. At present, there are 1α? Hydroxyvitamin D3(α? Calcineol) and 1, 25? Two kinds of dihydroxyvitamin D3 (calcitriol), α? Calcineol is suitable for patients with normal liver function. α? Calcineol capsules, 0.25~ 1.00 μg, 1 time /d each time. Calcitriol capsules, 0.25 μg 1 time /d or 0.50 μg 1 time /d orally. In the treatment of osteoporosis, it is generally safe to use the above doses of active vitamin D. It is advisable to supplement a large dose of calcium at the same time, and it is suggested that the blood calcium and urine calcium levels of patients should be tested regularly. In the treatment of osteoporosis, it can be combined with other anti-osteoporosis drugs.
1. Suggestions on the course of treatment: The course of treatment of anti-osteoporosis drugs should be individualized, and all treatments should be at least 1 year, usually 3-5 years. It is suggested that drug holidays should be considered after 3~5 years of bisphosphonate treatment. At present, it is suggested that oral bisphosphonates should be treated for 5 years and intravenous bisphosphonates for 3 years. The risk of fracture should be evaluated. If it is low risk, bisphosphonates should be stopped during drug holidays. If the risk of fracture is still high, you can continue to use bisphosphonates or switch to other anti-osteoporosis drugs. Teripartite treatment should not exceed 2 years. The continuous use time of calcitonin generally does not exceed 3 months.
2. About the application of anti-osteoporosis drugs after fracture: After osteoporotic fracture, attention should be paid to actively giving anti-osteoporosis drugs, including bone absorption inhibitors or bone formation promoters.
3. Combination and sequential treatment of anti-osteoporosis drugs: (1) Concurrent combination scheme: Calcium and vitamin D as basic treatment drugs can be used in combination with bone resorption inhibitors or bone formation promoters. It is not recommended to combine drugs with the same mechanism of action. (2) Sequential combination scheme: When some bone resorption inhibitors fail, the course of treatment is too long or there are adverse reactions, and when bone formation promoters reach the course of treatment, such drugs should be treated sequentially after stopping taking drugs.
V. Rehabilitation treatment
1. Exercise therapy: Exercise therapy is simple and practical, which can not only enhance muscle strength and endurance, improve balance, coordination and walking ability, but also improve bone density, maintain bone structure and reduce the risk of falls and brittle fractures. Exercise therapy should follow the principles of individualization, gradual progress and long-term persistence.
There are: (1) aerobic exercise, such as jogging and swimming, which have therapeutic effects on osteoporosis. (2) Muscle strength training, gradual resistance exercise with light weight bearing (suitable for osteoporosis patients without fracture), such as weight bearing exercise. (3) Impact sports such as gymnastics and skipping rope. (4) Balance and flexibility training, such as Tai Ji Chuan and dancing. (5) Vibration exercise, such as whole-body vibration training. Exercise should pay attention to less trunk flexion and rotation.
2. Physical factor therapy: physical factor therapy such as pulsed electromagnetic field, extracorporeal shock wave, whole body vibration and ultraviolet ray can increase bone mass; Treatment such as ultrashort wave, microwave, transcutaneous electrical nerve stimulation and intermediate frequency pulse can relieve pain; For osteoporotic fracture or delayed fracture healing, low-intensity pulsed ultrasound and extracorporeal shock wave can be selected to promote fracture healing.
3. Occupational therapy: Occupational therapy focuses on rehabilitation education for patients with osteoporosis, including guiding patients to correct posture, changing bad living habits and improving safety. 4. Rehabilitation project: people with mobility difficulties can choose crutches, walking AIDS and other assistive devices to reduce the occurrence of falls. In addition, appropriate environmental transformation can be carried out, such as changing stairs into ramps and adding handrails in bathrooms to increase safety.