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, the basic measures
1. adjust lifestyle: maintain a healthy lifestyle, including strengthening nutrition and balanced diet; Exercise regularly to prevent falling; Plenty of 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 supplement of bone health: Supplementing calcium and vitamin D is the basic measure to prevent and treat osteoporosis.
(1) calcium agent: any type of osteoporosis should be supplemented with appropriate calcium agent, so that the total intake of elemental calcium can reach 800 ~1200mg/d. Adequate calcium intake is conducive to obtaining ideal bone peak, slowing down bone loss, improving bone mineralization and maintaining bone health. Calcium supplementation should be avoided for 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 to prevent and treat osteoporosis, the dosage can be 800 ~ 1 200 iu /d. For example, oral vitamin D drops (capsule type), each time1granule, 1~2 times/d, should pay attention to individual differences and safety, and regularly monitor blood calcium and urine calcium concentrations 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 of action.
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) bisphosphonate is the most widely used anti-osteoporosis drug in clinic. Bisphosphonate can specifically bind to the active bone surface of bone remodeling and inhibit osteoclast function, thus inhibiting bone resorption. Bisphosphonate drugs mainly include alendronate sodium, zoledronic acid and risedronate sodium. Alendronate sodium tablets, 70 mg each time, weekly 1 time; Or each time 10 mg, one day 1 time. Take it on an empty stomach, sit or stand 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, 1 time every year, and the drug should be fully hydrated before administration.
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 it cannot be relieved within 3 days, NSAIDs or other antipyretic and analgesic drugs can be used for symptomatic treatment. ③ Nephrotoxicity: creatinine clearance rate
(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 analogue and salmon calcitonin. Such as salmon calcitonin injection 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. Generally speaking, this product does not need a skin test before treatment, but patients who are suspected to be 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 analogue. Intermittent low-dose use can stimulate osteoblast activity, promote bone formation, increase bone density and reduce the risk of vertebral and non-vertebral fractures. Common adverse reactions include nausea, limb pain, headache and dizziness. After drug withdrawal, anti-bone resorption drugs should be used in turn to maintain or increase bone density and continuously reduce the risk of fracture.
4. Other mechanism drugs: active vitamin D and its analogues, vitamin K2, strontium salt, etc. The most commonly used is active vitamin D and its analogues, which are more suitable for the elderly, renal insufficiency 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? Calcium alcohol) and 1, 25? Two kinds of dihydroxy vitamin D3 (calcitriol), α? Calcineol is suitable for patients with normal liver function. α? Calcium Tiaofen capsules, 0.25~ 1.00 μg each time, daily 1 time. Calcitriol capsules, 0.25 μg each time, 1 time /d or 0.50 μg, 1 time/d. In the treatment of osteoporosis, it is generally safe to use the above doses of active vitamin D, and it is advisable to supplement large doses of calcium at the same time. 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. Treatment suggestion: The treatment course of anti-osteoporosis drugs should be individualized, and all treatment courses should last at least 1 year, usually 3-5 years. It is suggested that the medical holiday should be considered after 3~5 years of bisphosphonate treatment. At present, oral bisphosphonate treatment is recommended for 5 years and intravenous bisphosphonate treatment for 3 years. The risk of fracture should be evaluated. If it is low risk, bisphosphonates should be stopped during the drug holiday. If the risk of fracture is still high, you can continue to use bisphosphonates or switch to other anti-osteoporosis drugs. Tripartite therapy should not last more than 2 years. The continuous use of calcitonin generally does not exceed 3 months.
2. Application of anti-osteoporosis drugs after fracture: After osteoporotic fracture, attention should be paid to actively giving anti-osteoporosis drugs, including bone resorption 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 use drugs with the same mechanism in combination. (2) Sequential combination scheme: When some bone resorption inhibitors fail, the course of treatment is too long or there are adverse reactions, and the bone formation promoter reaches the course of treatment, such drugs should be treated sequentially after stopping taking drugs.
Verb (abbreviation of verb) 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.
Effective exercise methods for osteoporosis are: (1) aerobic exercise, such as jogging and swimming. (2) Muscle strength training, gradual resistance exercise with light weight (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 training, such as whole-body vibration training. Pay attention to less torso flexion and rotation during exercise.
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, change bad living habits and improve safety. 4. Rehabilitation project: People with mobility difficulties can choose crutches, walkers 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.