Back pain will inhibit millions of Americans this year, and an estimated 80% of us will experience back pain sometime in our lives. For some, the pain can be excruciating. Back pain can be caused by a large number of injuries or conditions, thus making a proper diagnosis both difficult and critical. Back pain that occurs with other symptoms like fever and chills, severe abdominal pain or bladder and bowel problems can be an indication of a serious medical condition, and should be evaluated by your doctor immediately.
Musculoskeletal strains are more common among people who live sedentary lifestyles. Those with a higher level of physical fitness generally have stronger muscles in the back, legs and abdomen, all of which help support the back. Perhaps the most significant risk factor is obesity. The strain of carrying excess weight can contribute greatly to back pain. Regular exercise and a balanced diet can help control obesity, and reduce the frequency of back pain episodes.
There are many conditions that can cause back pain other than musculoskeletal strains. They include:
• Arthritis, a disease that causes inflammation of the joints. Three types of arthritis that affect the spine are osteoarthritis, rheumatoid arthritis and ankolyzing spondylitis.
• A herniated disc, or ruptured disc, occurs when the hard outer coating of the discs, the circular pieces of connective tissue that cushion the vertebrae, are damaged. These discs may leak, irritating nearby nerves. A herniated disk can cause severe sciatica, nerve pain that radiates down the leg.
• Spinal stenosis is a condition where the spinal canal narrows, compressing the nerves inside. It is often caused by bone spurs which are a result of osteoarthritis. Compression of the nerves can lead to pain, numbness in the legs and the loss of bladder or bowel control.
• Spondylolisthesis is a condition where a vertebra of the slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged. This can pinch nerves, causing low back pain and severe sciatica leg pain.
• Vertebral fractures can be caused by trauma or by osteoporosis, a disease where the bones become fragile.
• Degenerative disc disease is an aging process where the discs between the vertebrae break down over time.
How To Win Your War Against Back Pain AnkushMamgai
This document provides information and advice about back pain, including:
- Causes of back pain such as strains, arthritis, herniated discs, spinal stenosis, and fractures.
- Ways to prevent back pain such as exercising regularly, maintaining a healthy weight, stretching, and ergonomics.
- Non-surgical and surgical treatment options for back pain relief including rest, medication, physical therapy, injections, and procedures like spinal fusion.
- Alternative therapies like chiropractic care, massage, acupuncture, and exercises that can help manage back pain.
This 510(k) submission is for the WedgeXTM Bone Wedge, a titanium bone wedge intended for internal bone fixation in the ankle and foot. The device is substantially equivalent to the predicate BIOFOAM® Bone Wedge. Testing showed the WedgeXTM Bone Wedge passed biocompatibility testing according to ISO 10993 and performance bench testing including static, fatigue, and flexural testing. The device will be provided sterile for prescription use and is intended as an alternative to bone grafts for procedures such as opening wedge osteotomies and arthrodesis of the foot and ankle.
This document provides information about osteoarthritis from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. It defines osteoarthritis as a type of arthritis that affects cartilage in the joints, causing pain, swelling, and stiffness. The document discusses who is most likely to develop osteoarthritis, how it affects people's lives, and the parts of the joint involved. It also outlines common symptoms, how doctors diagnose the condition, and treatment approaches.
This 510(k) submission from Medstrong Inc. provides information on their Viceroy Aneurysm Clip and Marquis Aneurysm Clip Applier. The devices are intended for occlusion of cerebral aneurysms, temporarily or permanently. Supporting data includes descriptions of the devices, their indications for use, comparison to the predicate Yasargil Aneurysm Clips and Appliers, and summaries of bench, animal, and clinical testing performed. The submission contains documentation of biocompatibility testing, sterilization validation, and other required information to demonstrate substantial equivalence to the predicate device.
This document provides guidance from the European Society of Cardiology (ESC) on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic. It discusses the impact of COVID-19 on patients with pre-existing cardiovascular conditions and the cardiovascular manifestations of COVID-19 infection. The guidance addresses strategies for risk assessment, protective measures, triage systems, diagnosis, categorization of procedures, and treatment pathways for managing various cardiovascular presentations in COVID-19 patients. It aims to optimize cardiovascular care while minimizing risks from the pandemic.
The Effect of an Ageing Population on British DietsAlexander Lewzey
This document analyzes how population aging in the UK will impact British diets through examining household food consumption and nutrient intake over the lifecycle. Using data from the Living Costs and Food Survey from 2008-2013, the author controls for cohort and time effects and estimates age curves showing the nonlinear relationship between age and food/nutrient expenditure and intake. Projections incorporating these age effects and UK population projections forecast the potential impacts of an aging population on food purchases and nutrient consumption, which could significantly affect health outcomes and healthcare costs associated with diet-related diseases.
This document describes a study that investigated the interaction between enamel, porcelain, and a gold alloy through an in vitro wear experiment. The study used a tooth wear machine to simulate wear between enamel specimens and restorative material specimens, including porcelain veneering materials, machinable ceramic, and gold alloy. Wear was assessed quantitatively using 3D scanning and qualitatively using scanning electron microscopy. The study found differences in the wear rates of enamel and restorative materials at pH 6.1 and 1.2, with higher wear occurring under acidic conditions. Surface analysis also showed differences in the wear patterns between materials under the two pH environments.
Back pain will inhibit millions of Americans this year, and an estimated 80% of us will experience back pain sometime in our lives. For some, the pain can be excruciating. Back pain can be caused by a large number of injuries or conditions, thus making a proper diagnosis both difficult and critical. Back pain that occurs with other symptoms like fever and chills, severe abdominal pain or bladder and bowel problems can be an indication of a serious medical condition, and should be evaluated by your doctor immediately.
Musculoskeletal strains are more common among people who live sedentary lifestyles. Those with a higher level of physical fitness generally have stronger muscles in the back, legs and abdomen, all of which help support the back. Perhaps the most significant risk factor is obesity. The strain of carrying excess weight can contribute greatly to back pain. Regular exercise and a balanced diet can help control obesity, and reduce the frequency of back pain episodes.
There are many conditions that can cause back pain other than musculoskeletal strains. They include:
• Arthritis, a disease that causes inflammation of the joints. Three types of arthritis that affect the spine are osteoarthritis, rheumatoid arthritis and ankolyzing spondylitis.
• A herniated disc, or ruptured disc, occurs when the hard outer coating of the discs, the circular pieces of connective tissue that cushion the vertebrae, are damaged. These discs may leak, irritating nearby nerves. A herniated disk can cause severe sciatica, nerve pain that radiates down the leg.
• Spinal stenosis is a condition where the spinal canal narrows, compressing the nerves inside. It is often caused by bone spurs which are a result of osteoarthritis. Compression of the nerves can lead to pain, numbness in the legs and the loss of bladder or bowel control.
• Spondylolisthesis is a condition where a vertebra of the slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged. This can pinch nerves, causing low back pain and severe sciatica leg pain.
• Vertebral fractures can be caused by trauma or by osteoporosis, a disease where the bones become fragile.
• Degenerative disc disease is an aging process where the discs between the vertebrae break down over time.
How To Win Your War Against Back Pain AnkushMamgai
This document provides information and advice about back pain, including:
- Causes of back pain such as strains, arthritis, herniated discs, spinal stenosis, and fractures.
- Ways to prevent back pain such as exercising regularly, maintaining a healthy weight, stretching, and ergonomics.
- Non-surgical and surgical treatment options for back pain relief including rest, medication, physical therapy, injections, and procedures like spinal fusion.
- Alternative therapies like chiropractic care, massage, acupuncture, and exercises that can help manage back pain.
This 510(k) submission is for the WedgeXTM Bone Wedge, a titanium bone wedge intended for internal bone fixation in the ankle and foot. The device is substantially equivalent to the predicate BIOFOAM® Bone Wedge. Testing showed the WedgeXTM Bone Wedge passed biocompatibility testing according to ISO 10993 and performance bench testing including static, fatigue, and flexural testing. The device will be provided sterile for prescription use and is intended as an alternative to bone grafts for procedures such as opening wedge osteotomies and arthrodesis of the foot and ankle.
This document provides information about osteoarthritis from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. It defines osteoarthritis as a type of arthritis that affects cartilage in the joints, causing pain, swelling, and stiffness. The document discusses who is most likely to develop osteoarthritis, how it affects people's lives, and the parts of the joint involved. It also outlines common symptoms, how doctors diagnose the condition, and treatment approaches.
This 510(k) submission from Medstrong Inc. provides information on their Viceroy Aneurysm Clip and Marquis Aneurysm Clip Applier. The devices are intended for occlusion of cerebral aneurysms, temporarily or permanently. Supporting data includes descriptions of the devices, their indications for use, comparison to the predicate Yasargil Aneurysm Clips and Appliers, and summaries of bench, animal, and clinical testing performed. The submission contains documentation of biocompatibility testing, sterilization validation, and other required information to demonstrate substantial equivalence to the predicate device.
This document provides guidance from the European Society of Cardiology (ESC) on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic. It discusses the impact of COVID-19 on patients with pre-existing cardiovascular conditions and the cardiovascular manifestations of COVID-19 infection. The guidance addresses strategies for risk assessment, protective measures, triage systems, diagnosis, categorization of procedures, and treatment pathways for managing various cardiovascular presentations in COVID-19 patients. It aims to optimize cardiovascular care while minimizing risks from the pandemic.
The Effect of an Ageing Population on British DietsAlexander Lewzey
This document analyzes how population aging in the UK will impact British diets through examining household food consumption and nutrient intake over the lifecycle. Using data from the Living Costs and Food Survey from 2008-2013, the author controls for cohort and time effects and estimates age curves showing the nonlinear relationship between age and food/nutrient expenditure and intake. Projections incorporating these age effects and UK population projections forecast the potential impacts of an aging population on food purchases and nutrient consumption, which could significantly affect health outcomes and healthcare costs associated with diet-related diseases.
This document describes a study that investigated the interaction between enamel, porcelain, and a gold alloy through an in vitro wear experiment. The study used a tooth wear machine to simulate wear between enamel specimens and restorative material specimens, including porcelain veneering materials, machinable ceramic, and gold alloy. Wear was assessed quantitatively using 3D scanning and qualitatively using scanning electron microscopy. The study found differences in the wear rates of enamel and restorative materials at pH 6.1 and 1.2, with higher wear occurring under acidic conditions. Surface analysis also showed differences in the wear patterns between materials under the two pH environments.
The document provides an overview of anatomy in ancient Egypt. It discusses possible sources of anatomical knowledge for ancient Egyptian physicians, including observing injuries from battle or accidents. It describes evidence of anatomical knowledge found in medical papyri from the time, such as the Ebers Papyrus noting the heart as the source of blood vessels. The embalmers who performed mummification had extensive knowledge of the body's structures, which laid the foundation for later Greek anatomical study in Alexandria. Overall, the passage outlines how embalmers' practices and observations provided early insights into human anatomy, despite their purpose being religious preservation rather than scientific study.
This document provides a summary of a lecture on reactive oxygen and nitrogen species for medical and graduate students. It gives an overview of these species, including superoxide, hydrogen peroxide, singlet oxygen, and reactive nitrogen species derived from nitric oxide. It discusses both the beneficial and harmful roles of these species in areas like the respiratory burst, reperfusion injury, photodynamic therapy, and disease mechanisms. It also describes the enzymes involved in generating and removing these species, mechanisms of oxidative damage, strategies to mitigate this damage including dietary antioxidants, and implications in disease and drug toxicity. The goal is to teach students the fundamentals of redox biology and its relevance to clinical medicine and health.
This review article defines the skin aging exposome and identifies its key elements based on a literature review by European scientists. The skin aging exposome consists of external and internal factors from birth to death that affect skin aging signs, including solar radiation, air pollution, tobacco, nutrition, stress, sleep, temperature, and cosmetics. The review proposes a definition, discusses each factor, and identifies knowledge gaps regarding their interactions and combined effects on skin aging. It suggests future research is needed to better understand the skin aging exposome and translate this theoretical approach into dermatological practice.
The Center for Advanced Orthopedics represents board certified orthopedic surgeon with combined experience in bone & joint problems of over 45 years. This compassion and competence in problems related to arthritis, joint replacements, and sports related injuries is second to none in this field. We believe and practice in quality with deep care and concern at heart. Although surgery is viewed here as a last resort, if surgery is needed, you'll be glad to know that Dr. Yousaf use the most advanced, least invasive techniques available.
Atlas Of Radiology Of The Traumatized Dog And Cat The Case-Based ApproachLiz Adams
This document appears to be the table of contents for a book titled "Atlas of Radiology of the Traumatized Dog and Cat: The Case-Based Approach" by Joe P. Morgan and Pim Wolvekamp. The book contains chapters on radiology of thoracic trauma, abdominal trauma, musculoskeletal trauma, and soft tissue injuries. Each chapter begins with an introduction and then presents numerous case studies with radiographic images to illustrate different types of trauma seen in dogs and cats.
Review of medical physiology 21 edition william f. ganongRene Andrade
This document is the table of contents for Chapter 1 of the 21st edition of Review of Medical Physiology. It lists 40 figures and 30 tables that are included in the chapter. The chapter introduces topics on the general and cellular basis of medical physiology, including cell structure and function, membrane transport, intracellular signaling, and molecular motors. The tables and figures provide supplemental data on topics like ion concentrations, enzyme functions, protein kinases, G protein-coupled receptors, and illustrations of cell structures and signaling pathways discussed in the text.
This document discusses the use of patient-specific induced pluripotent stem cells (iPSCs) for modeling and developing treatments for inherited retinal degenerative diseases. It describes how iPSCs can be used to model various retinal diseases through disease-specific iPSC lines. Additionally, it explores how iPSCs may be applied to test gene therapies and drug candidates, aid genome editing efforts, and serve as a source of cells for transplantation treatments. Overall, the document outlines the potential of iPSC technology to further our understanding of retinal diseases and develop novel therapeutic strategies.
This document is the copyrighted contents and terms of use for an orthopedics eBook titled "Current Essentials Orthopedics" by Harry B. Skinner and Michael Fitzpatrick. It includes information on the publishers, copyright notice, terms of use, and disclaimer of warranties. The document provides the introductory material and framework for the eBook.
Think of epilepsy as an electrical storm in the brain. This abnormal brain activity causes seizures, unusual behavior or sensations, or a loss of awareness.
Most of the 50 million people who have it can live seizure-free if they take inexpensive, effective medicines. But 80% of people with epilepsy live in low- and middle-income countries, where three-quarters of them lack treatment, according to a new WHO global report on epilepsy.
The report is produced by WHO in collaboration with the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE).
This document is the 2020 edition of the Uganda Clinical Guidelines. It provides national guidelines for the management of common medical conditions in Uganda. The guidelines have been published by the Ministry of Health Uganda and updated periodically since 2003. Any part of the guidelines can be reproduced without permission as long as it is not for profit. Copies are available from the Pharmacy Department of the Ministry of Health in Kampala. The guidelines contain overviews and treatment recommendations for a wide range of emergencies, infectious diseases, trauma, and other medical conditions that are common in Uganda.
This document provides a summary of health indicators in OECD countries. It begins with an introduction that describes the document as the 2013 edition of Health at a Glance, which presents recent comparable data on key health indicators across 34 OECD countries. The data is drawn from contributions of national health agencies and aims to monitor health status, determinants, health workforce, health care activities, and quality of care.
C I O S P C T Strategy To Reduce Inequalities 2001 2916Emma Fowle
This document presents a strategy from 2011-2016 to reduce health inequalities in Cornwall and the Isles of Scilly. It finds that while overall health is good, there are significant differences between areas and groups. The strategy aims to give every child the best start, enable people of all ages to be healthy, create fair employment, ensure financial security, develop communities, and strengthen prevention. It was developed with partners to target support at areas of greatest need.
This document is a chartbook from the New York State Department of Health that examines disability prevalence and health factors in New York using data from the Behavioral Risk Factor Surveillance System. It provides data on the prevalence of disability by gender, age, race, education level and income. It also examines health care access and utilization, chronic health conditions, health risk behaviors, and health-related quality of life for people with and without disabilities. The document is intended to provide information to help address health disparities experienced by people with disabilities.
This document summarizes a literature review on assessing the macroeconomic impact of HIV/AIDS in Uganda. It provides background on Uganda's response to the HIV/AIDS epidemic, including national policies, interventions, and financing of HIV/AIDS activities. It then reviews literature on the economic impact of HIV/AIDS at various levels and in various sectors. The document also examines country studies that have modeled the macroeconomic impact of HIV/AIDS using different approaches. It concludes with recommendations for assessing the macroeconomic impact of HIV/AIDS in Uganda in Phase II of the project.
This document contains a physical education exam paper with multiple choice and short answer questions testing knowledge of physical education concepts. The questions cover topics like cardiovascular fitness, benefits of exercise, healthy active lifestyles, sports injuries, fitness components, and muscle function.
This document provides instructions on making preliminary impressions for complete dentures using an irreversible hydrocolloid (alginate) syringe technique. It emphasizes the importance of custom trays and border molding to accurately capture critical anatomical details like the vestibular tissues. This helps prevent distortion and ensures an effective denture seal for retention. The syringe technique is recommended to ensure alginate captures anatomy sometimes missed using simple tray impressions. Diagnostic casts poured from the preliminary impressions allow for custom tray fabrication.
Huber Final Thesis Write-Up_21 May 2015Aaron Huber
This document is a thesis submitted by Aaron Huber to the University at Buffalo in partial fulfillment of the requirements for a Master of Science degree in Biomaterials. The thesis investigates the influence of hyaluronic acid preparations on ionizing-radiation-treated collagen-based tissues. Specifically, it examines the effects of hyaluronic acid application on irradiated human oral mucosa and bovine pericardium tissue samples through various testing methods, including tensile testing, static friction testing, weight testing, volume testing, hydroxyproline assay testing, histology, and Fourier transform infrared spectroscopy. The goal is to evaluate hyaluronic acid's potential for mitigating radiation damage and its ability to act as a lubric
Atlas of oral disease a guide for daily practice 2016Soe Kyaw
This document provides an overview of an atlas of oral diseases intended to guide daily practice. It contains chapters covering examination of the oral cavity, diseases of the oral mucosa and soft tissues, diseases mainly affecting specific oral sites like the lips and tongue, and diseases of the jaw bones. The atlas aims to be concise, evidence-based, and practical for dentists, dental hygienists, physicians and specialists. It includes over 100 figures to illustrate various oral diseases and disorders.
The document provides an overview of anatomy in ancient Egypt. It discusses possible sources of anatomical knowledge for ancient Egyptian physicians, including observing injuries from battle or accidents. It describes evidence of anatomical knowledge found in medical papyri from the time, such as the Ebers Papyrus noting the heart as the source of blood vessels. The embalmers who performed mummification had extensive knowledge of the body's structures, which laid the foundation for later Greek anatomical study in Alexandria. Overall, the passage outlines how embalmers' practices and observations provided early insights into human anatomy, despite their purpose being religious preservation rather than scientific study.
This document provides a summary of a lecture on reactive oxygen and nitrogen species for medical and graduate students. It gives an overview of these species, including superoxide, hydrogen peroxide, singlet oxygen, and reactive nitrogen species derived from nitric oxide. It discusses both the beneficial and harmful roles of these species in areas like the respiratory burst, reperfusion injury, photodynamic therapy, and disease mechanisms. It also describes the enzymes involved in generating and removing these species, mechanisms of oxidative damage, strategies to mitigate this damage including dietary antioxidants, and implications in disease and drug toxicity. The goal is to teach students the fundamentals of redox biology and its relevance to clinical medicine and health.
This review article defines the skin aging exposome and identifies its key elements based on a literature review by European scientists. The skin aging exposome consists of external and internal factors from birth to death that affect skin aging signs, including solar radiation, air pollution, tobacco, nutrition, stress, sleep, temperature, and cosmetics. The review proposes a definition, discusses each factor, and identifies knowledge gaps regarding their interactions and combined effects on skin aging. It suggests future research is needed to better understand the skin aging exposome and translate this theoretical approach into dermatological practice.
The Center for Advanced Orthopedics represents board certified orthopedic surgeon with combined experience in bone & joint problems of over 45 years. This compassion and competence in problems related to arthritis, joint replacements, and sports related injuries is second to none in this field. We believe and practice in quality with deep care and concern at heart. Although surgery is viewed here as a last resort, if surgery is needed, you'll be glad to know that Dr. Yousaf use the most advanced, least invasive techniques available.
Atlas Of Radiology Of The Traumatized Dog And Cat The Case-Based ApproachLiz Adams
This document appears to be the table of contents for a book titled "Atlas of Radiology of the Traumatized Dog and Cat: The Case-Based Approach" by Joe P. Morgan and Pim Wolvekamp. The book contains chapters on radiology of thoracic trauma, abdominal trauma, musculoskeletal trauma, and soft tissue injuries. Each chapter begins with an introduction and then presents numerous case studies with radiographic images to illustrate different types of trauma seen in dogs and cats.
Review of medical physiology 21 edition william f. ganongRene Andrade
This document is the table of contents for Chapter 1 of the 21st edition of Review of Medical Physiology. It lists 40 figures and 30 tables that are included in the chapter. The chapter introduces topics on the general and cellular basis of medical physiology, including cell structure and function, membrane transport, intracellular signaling, and molecular motors. The tables and figures provide supplemental data on topics like ion concentrations, enzyme functions, protein kinases, G protein-coupled receptors, and illustrations of cell structures and signaling pathways discussed in the text.
This document discusses the use of patient-specific induced pluripotent stem cells (iPSCs) for modeling and developing treatments for inherited retinal degenerative diseases. It describes how iPSCs can be used to model various retinal diseases through disease-specific iPSC lines. Additionally, it explores how iPSCs may be applied to test gene therapies and drug candidates, aid genome editing efforts, and serve as a source of cells for transplantation treatments. Overall, the document outlines the potential of iPSC technology to further our understanding of retinal diseases and develop novel therapeutic strategies.
This document is the copyrighted contents and terms of use for an orthopedics eBook titled "Current Essentials Orthopedics" by Harry B. Skinner and Michael Fitzpatrick. It includes information on the publishers, copyright notice, terms of use, and disclaimer of warranties. The document provides the introductory material and framework for the eBook.
Think of epilepsy as an electrical storm in the brain. This abnormal brain activity causes seizures, unusual behavior or sensations, or a loss of awareness.
Most of the 50 million people who have it can live seizure-free if they take inexpensive, effective medicines. But 80% of people with epilepsy live in low- and middle-income countries, where three-quarters of them lack treatment, according to a new WHO global report on epilepsy.
The report is produced by WHO in collaboration with the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE).
This document is the 2020 edition of the Uganda Clinical Guidelines. It provides national guidelines for the management of common medical conditions in Uganda. The guidelines have been published by the Ministry of Health Uganda and updated periodically since 2003. Any part of the guidelines can be reproduced without permission as long as it is not for profit. Copies are available from the Pharmacy Department of the Ministry of Health in Kampala. The guidelines contain overviews and treatment recommendations for a wide range of emergencies, infectious diseases, trauma, and other medical conditions that are common in Uganda.
This document provides a summary of health indicators in OECD countries. It begins with an introduction that describes the document as the 2013 edition of Health at a Glance, which presents recent comparable data on key health indicators across 34 OECD countries. The data is drawn from contributions of national health agencies and aims to monitor health status, determinants, health workforce, health care activities, and quality of care.
C I O S P C T Strategy To Reduce Inequalities 2001 2916Emma Fowle
This document presents a strategy from 2011-2016 to reduce health inequalities in Cornwall and the Isles of Scilly. It finds that while overall health is good, there are significant differences between areas and groups. The strategy aims to give every child the best start, enable people of all ages to be healthy, create fair employment, ensure financial security, develop communities, and strengthen prevention. It was developed with partners to target support at areas of greatest need.
This document is a chartbook from the New York State Department of Health that examines disability prevalence and health factors in New York using data from the Behavioral Risk Factor Surveillance System. It provides data on the prevalence of disability by gender, age, race, education level and income. It also examines health care access and utilization, chronic health conditions, health risk behaviors, and health-related quality of life for people with and without disabilities. The document is intended to provide information to help address health disparities experienced by people with disabilities.
This document summarizes a literature review on assessing the macroeconomic impact of HIV/AIDS in Uganda. It provides background on Uganda's response to the HIV/AIDS epidemic, including national policies, interventions, and financing of HIV/AIDS activities. It then reviews literature on the economic impact of HIV/AIDS at various levels and in various sectors. The document also examines country studies that have modeled the macroeconomic impact of HIV/AIDS using different approaches. It concludes with recommendations for assessing the macroeconomic impact of HIV/AIDS in Uganda in Phase II of the project.
This document contains a physical education exam paper with multiple choice and short answer questions testing knowledge of physical education concepts. The questions cover topics like cardiovascular fitness, benefits of exercise, healthy active lifestyles, sports injuries, fitness components, and muscle function.
This document provides instructions on making preliminary impressions for complete dentures using an irreversible hydrocolloid (alginate) syringe technique. It emphasizes the importance of custom trays and border molding to accurately capture critical anatomical details like the vestibular tissues. This helps prevent distortion and ensures an effective denture seal for retention. The syringe technique is recommended to ensure alginate captures anatomy sometimes missed using simple tray impressions. Diagnostic casts poured from the preliminary impressions allow for custom tray fabrication.
Huber Final Thesis Write-Up_21 May 2015Aaron Huber
This document is a thesis submitted by Aaron Huber to the University at Buffalo in partial fulfillment of the requirements for a Master of Science degree in Biomaterials. The thesis investigates the influence of hyaluronic acid preparations on ionizing-radiation-treated collagen-based tissues. Specifically, it examines the effects of hyaluronic acid application on irradiated human oral mucosa and bovine pericardium tissue samples through various testing methods, including tensile testing, static friction testing, weight testing, volume testing, hydroxyproline assay testing, histology, and Fourier transform infrared spectroscopy. The goal is to evaluate hyaluronic acid's potential for mitigating radiation damage and its ability to act as a lubric
Atlas of oral disease a guide for daily practice 2016Soe Kyaw
This document provides an overview of an atlas of oral diseases intended to guide daily practice. It contains chapters covering examination of the oral cavity, diseases of the oral mucosa and soft tissues, diseases mainly affecting specific oral sites like the lips and tongue, and diseases of the jaw bones. The atlas aims to be concise, evidence-based, and practical for dentists, dental hygienists, physicians and specialists. It includes over 100 figures to illustrate various oral diseases and disorders.
แนวทางการจัดการความเสี่ยงที่ส่งผลต่อต้นทุนการจัดการสินค้าคงคลัง
ของร้านขายยา CDE ในจังหวัดขอนแก่น
The Approach of Risk Management that Affecting the
Inventory Management Cost of CDE Drugstore in Khonkaen Province
Best Practice in Communication
ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย สมาคมกุมารแพทย์แห่งประเทศไทย
บรรณาธิการ วินัดดา ปิยะศิลป์ วันดี นิงสานนท์
ISBN 978-616-91972-1-8
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoeaUtai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children but not adults. Overall, the results confirm that S. boulardii is effective for preventing antibiotic-associated diarrhea in children and adults.
This document provides information on drugs used to treat acute diarrhea. It begins with definitions of diarrhea from WHO. It then discusses estimates of child mortality due to diarrhea in Thailand from 2010 to 2012. It presents data on the age distribution of diarrhea cases and hospital admissions. It lists common bacterial, viral, and parasitic pathogens that cause childhood diarrhea. It discusses the pathogenesis of acute diarrhea and describes fluid and electrolyte losses and consequences of dehydration and nutritional deficits. It provides details on fluid and electrolyte composition of diarrheal stool from different pathogens. It outlines the objectives of diarrhea treatment and causes of death. It then discusses use of oral rehydration therapy and solutions. It recommends probiotics, continued feeding, and zinc supplementation. It
Systematic review with meta-analysis: Saccharomyces boulardii in the preventi...Utai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children. The quality of evidence was rated as moderate to low based on limitations in the design and reporting of the included studies. This meta-analysis confirms the effectiveness of
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea ...Utai Sukviwatsirikul
Saccharomyces boulardii in the prevention of antibiotic-associated
diarrhoea in children: a randomized double-blind placebo-controlled
trial
M. KOTOWSKA, P. ALBRECHT & H. SZAJEWSKA
Department of Pediatric Gastroenterology and Nutrition, The Medical University of Warsaw, Warsaw, Poland
Accepted for publication 24 November 2004
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptx
Osteoporosis guideline2010
1. Definition, epidemiology, burden and etiology of osteoporosis .....1
I-1
I-2
Definition and concept ............................................................................................................1
Epidemiology of osteoporosis and osteoporotic fractures ....................................................1
2.1
ก (Worldwide epidemiology) ...............................................................1
2.2
(Epidemiology in Asia and Thailand)........2
I-3 Burden and impact of osteoporosis and osteoporotic fractures ...........................................2
3.1
ก
ก กก ก ก ก ก ก ก ก (Osteoporosis related
mortality and morbidity) .................................................................................................3
3.2 ก ก ก ก ก ก
F
(Health economic
aspect of osteoporotic fractures) ...................................................................................3
I-4 Pathogenesis and etiology .....................................................................................................4
4.1
ก
(Pathogenesis) ...........................................................................................4
ก F
......................................................................................................................................5
Diagnosis and bone mass assessment in osteoporosis .................8
II-1
History, physical examination and differential diagnosis .......................................................8
1.1 ก
ก
ก ก (Classification of osteoporosis) .........................8
II-2 Risk factors for osteoporosis and osteoporotic fractures ......................................................9
2.1 ˆ
ก ก
ก ก ก ก ก ก
(Risk factors of
osteoporosis and osteoporotic fracture) ........................................................................9
2.2 ก
ˆ
ก ก ก ก ก ก ก ก
F FRAXTM
Fก
ก (Risk assessment of osteoporotic fracture using WHO-FRAXTM) 9
II-3 Laboratory investigations and bone strength assessments ................................................11
3.1 ก
F
ก (Laboratory investigation) ................................................11
3.2 ก
ก F ก ก (Bone strength assessment) ............................11
II-4 Diagnostic criteria for osteoporosis ......................................................................................12
4.1 ก
F ก ก (Measurement of bone density) ..................................12
4.2
ก
ก F
ก ก (Biochemical markers of bone
turnover) .......................................................................................................................13
4.3 ก
ก (Screening) .......................................................................................14
ก 2.1 ...................................................................................................................................15
OSTA (Osteoporosis Self-Assessment Tool for Asians) ...................................................15
Khon Kaen Osteoporosis study score (KKOS) ..................................................................16
ก 2.2 ...................................................................................................................................18
ก ก
ก ก ก ก
F
ก QUS ...........................................................................................................18
ก F
....................................................................................................................................19
2. Prevention of osteoporosis and prevention of falls .......................21
III-1 Strategies to maximize peak bone mass ............................................................................21
III-2 Strategies to prevent bone loss ...........................................................................................21
ก F F
(Hormone replacement therapy) .....................................................22
III-3 Nutritional aspect in osteoporosis ........................................................................................22
(Calcium) .............................................................................................................22
(Vitamin D) ............................................................................................................26
(Vitamin K) ...........................................................................................................27
III-4 Life style modification and prevention of fall .......................................................................28
4.1 ก
ก
Fก ˈ ก ก
............................................28
4.2 ก ˂ ก ก ก F
F ˁ
ก ก
................................................................29
ก 3.1
Falls Risk Assessment tool ............................................................................32
ก 3.2
ก กก ก
˂ ก ก ก
....................................................33
ก กก ก
F
ก ก
ก ก ก ก
..........................................33
ก ˂ ก ก กF
ก ก ก ก ก ......................................................................34
ก F
....................................................................................................................................34
Treatment of osteoporosis ................................................................38
IV-1 Goal of osteoporosis treatment ............................................................................................38
1.1
ก ˂ ก
ก ก
ก ก
.........................................................38
1.2
F ก ก
ก ก
......................................................................38
1.3
ก
Fก ก
ก ก
F ก
Fก F
F
International Osteoporosis Foundation
National Osteoporosis Foundation 38
1.4
ก
Fก ก
ก ก
F ก
Fก F
F
ก ก
F
....................................................................39
IV-2 Pharmacotherapy for osteoporosis ......................................................................................40
2.1
ก
ก ก (Inhibitors of bone resorption) ..............................................41
2.2 ก F ก F ก ก F (Stimulators of bone formation) ....................................42
2.3
ก
(mixed action agents) ............................................................43
IV-3 Alternative therapy and non-pharmacological treatment .....................................................44
3.1 Hip protector .................................................................................................................44
IV-4 Potential adverse events, prerequisites and contraindications in using anti-osteoporotic
agents ..................................................................................................................................44
4.1
F
F
F F ก F ก
ก ก
..........................44
IV-5 Monitoring treatment and duration of treatment ..................................................................47
5.1 ก
ก ก ...............................................................................47
5.2
ก ก ........................................................................................................48
ก F
....................................................................................................................................54
Glucocorticoid-induced osteoporosis (GIO) ...................................62
3. V-1 Introduction and epidemiology .............................................................................................62
1.1
............................................................................................................................62
1.2
...................................................................................................................62
V-2 Pathophysiology and risk assessment .................................................................................62
2.1 ก กก ก
...........................................................................................................62
2.2 ˆ
.....................................................................................................................63
V-3 Diagnosis ..............................................................................................................................63
V-4 Prevention and treatment .....................................................................................................63
4.1
ก ˂ ก
ก
ก ก
ก กก F ก
F
F ..........63
V-5 Monitoring treatment ............................................................................................................64
5.1 ก
ก ก .................................................................................................64
ก F
....................................................................................................................................65
Osteoporosis in men ..........................................................................68
VI-1 Introduction and epidemiology .............................................................................................68
1.1
ก
..............................................................................................68
1.2
...................................................................................................................68
1.3. ˆ
.....................................................................................................................69
VI-2 Assessment and diagnosis ..................................................................................................69
2.1 ก
....................................................................................................................69
2.2 ก
F ก
ก
..............................................................................69
VI-3 Prevention .............................................................................................................................70
3.1 ก ˂ ก ก ก
F ................................................................................70
VI-4 Treatment and follow-up ......................................................................................................71
4.1
ก ก
ก ก
F .......................................................................71
4.2 ก
ก ก ..................................................................................................71
ก F
....................................................................................................................................72
4. 1
Definition, epidemiology, burden and etiology of
osteoporosis
I-1 Definition and concept
ʾ . . 2543 National Institute of Health F
ก (1) F
ˈ
ก ก
กF
ก ก (bone strength)
F
ก ก ก
กF
ก ก
ก F 2 F
ก
(bone density)
ก ก (bone quality)
ก
ก
F
F
F
ก
ก
I-2 Epidemiology of osteoporosis and osteoporotic fractures
2.1
ก (Worldwide epidemiology)
ʾ . . 2536 F
กก
(2)
ก (WHO)
F
ก
fractures)
1.3 F
F ʾ
25% ˈ ก ก
ก ก (hip fractures)
ก ก
F ก F 30%
F
Consensus Development Conference
ก
F
F ก
ก ก ก ก ก ก
(osteoporotic
50% ˈ ก ก
ก (vertebral fractures)
ก 25% ˈ ก ก ก ก F
ก ก
F 50 ʾ
ˈ ก ก
กก ก National Health and Nutrition Survey (NHANES III)
ก
ʾ . .
2540
F ก
F F
ก
13-18% ˈ ก ก (osteoporosis)
ก 27-50% F
ก ก (osteopenia)
ก ก ก ก
F
F
ก
F ก
FF F
กF F
ก
Fก
กก F 80 ʾ
F ˈ ก ก
70%
(3)
F
ก ก ก
F
ก F (incidence)
F
กF
F
F
F F
F (adolescence)
ก
(middle life)
ก F
ก
ก
(working)
ก
(lifestyle)
F
กก F ก ก ก
ก FF ˈ ก ก ก ก
(high-energy
trauma)
F
F
40-50 ʾ ก ก ก
F ก ก ก
ก
F
ก F ก ก ก
F F ก ก
ก ก F ก ก ก
(4)
ก ก
ก
F ก
F
ก ก ก F ˈ
ก
F
(low-energy trauma)
ก ก ก กก ก
(osteoporotic fractures)
ก
(4)
ก ก
ก F ˁ ก ก
ก ก ʾ
500,000
ก
กก F
10 F
FF
F
ก
กก F 70 ʾ
(4)
ก ก
ก F F
F
ก Fก ก ก ก
ก ก
F
(Caucasian)
F
ʾ 737
F 100,000
F
F F
(5)
ʾ 280
F 100,000
F
ʽ
F
5. 2
2.2
(Epidemiology in Asia and
Thailand)
ก F
F
76.3 ʾ F
F
ก
2541(7)
. . 2544(8)
ก
FF
F
F
F
F 40 ʾ
11-13% ˈ
ก
ʾ . . 2551
(life expectancy)
ก
69.5 ʾ
F ก
ก (prevalence)
ก ก
F
F
กก F
F
ก ก
ʾ . .
F F F ก Fก
ก ก
Fก
ก F
F ก ก Fก
ก F 2.5 F
F
ก
ก ก
F
(T-score ≤ -2.5)
F
19-21%
F
ˈ
ก ก
ก ก
F
(lumbar spine osteoporosis)
ก
ก ก
ก (femoral neck osteoporosis)
(6)
ʾ . . 2540-2541(9)
ก F
ก
F 50 ʾ
ʾ 162
F 100,000
851
F 100,000
ก
ก 75 ʾ
F ก
F 50 ʾ
ก F ก ก
ก ก ʾ 269
ˈ ʾ 1,011
F 100,000
F
กก F 75 ʾ
กF
ก
ก ก F
ก
ก
F ก
ก Fก ก ก ก
ก ก F
Fก ก ก ก
ก ก F
F ก (Hong Kong Chinese)
179
F 100,000
ʾ . . 2508 ˈ ʾ 389
F 100,000
(10)
กF F
กก
ˁ
( . . 2545)
ก ก ก ก ʾ 92,400
5 ʾกF
F
ˈ ʾ 117,900 (11)
ʾ . . 2050
ก
40 ก F ʾ F
F
ก ก ก ก
ก ก
กF 6 F
3 F
ก F
ก
ก
ก
ก ก
ˈ ʾ
ก
F 100,000
ก F ก
ก F
F
F
F ก ก
ก
ก F
ก ʾ
ʾ . . 2528
ก
ก
F ก
ก F FF
ก
ก
(10)
F
F
I-3 Burden and impact of osteoporosis and osteoporotic fractures
F
ก
1. ก
ก ก
กF ก F
2. ก ก ก
ก ˈ
ก
fractures
ก ก
ˈ
ก ก ก ก ก FF
ก
F
ก ก
F
ก
ก ก
F
ก ก F
ก F
ˈ
F ก ก
กก
ˈ กF F ก
(burden)
F
ก
F
clinical consequence
F ก F ˈ 2ก
(low-energy trauma) F ก ก
ก ก กก
กF ก ก F ก F
ˈ F
ก F ก ก
ก กก กF
ก ก
F ก ก ก ก
ก ก
ก
(impact)
ก
กF
ก
ก
osteoporotic
ก ก ก ก ก
6. 3
3.1
ก
ก
กก ก ก ก ก ก
(Osteoporosis related mortality and morbidity)
1. ก ก ก
2.
3.
4.
5.
6.
ก
ก
ก ก
ก
ก
ก
ก
(osteoporotic vertebral fractures) ก ก กก
ก
ก F
F
ˈ
F
40%
F
ก ก
ก F F
F F ˈ
ก ก
ก ก ก ก
ก
F
ก F
ก F
ก F F
F F ก ก
ก ก ก ก
ก
(12)
(13)
ˁ (morbidity)
ก
(mortality)
กก F F
F ก ก ก F
F ˁ
ก
(height loss)
F (kyphosis)
(scoliosis)
F
ก
F F
ก
กก ก
ก
ก ก ก ก
ก
ก ก
(functional disability) ก
F F
ก ก
ก
F
ก F ก
morbidity
mortality ก
F
(12-14)
ก ก ก
ก
F
ก ก ก ก F (14)
ก ก
ก ก (hip fractures) ˈ ก ก ก ก ก ก
ˆ
ก
ก ก
ก
ก
ก ก F
ก
ก
ก
ก
ก F
ก ก F FF
ก
ก
ก ก
ก
กก
กก F ก ก ก
ก F F F ก F
ก F ˁ
F
F
ก
ก F
F ก
F F
(15F ก ก
ก
ก
ˁ
ก ก ก ก
16)
ก
20%
1 ʾ ก ก ก
F
F 30%
ก ก
(permanent disability) F F ก
ก F
F
(nursing home) 40% F
F F ก F F
F
F
F
80% F
ก
F F
F
F กF
ก ก ก ก
ก
ก ก
ก ก กก ก
F(17)
F
2.1%
F
ก
กก ก
ก ก 3
,6
1 ʾ F ก 9%, 12%
17%
ก ก ก ก
(18)
ก ก
ก ก
F
F
F ˁ (22%) F
F 23% F F
wheel chair ก
F
ก ก F ˁ
F
F F ก F
ก
ก
F
F 11% F F
10% F F
F
22% F
F ก
F
5% F F ก
3.2 ก ก ก ก ก ก
F
(Health economic aspect of osteoporotic fractures)
1.
ก
ก
International Osteoporosis Foundation (IOF)
F
ก ก ก ก ก ก ก
(osteoporotic fractures)
FF
ก
ก ก ก ก ก ก ก
ʾ 25
F
(19)
F
FF
(cost)
F
ก F
7. 4
ก
2.
F ก
(20)
ʾ 1.8
F
F ก
ก
ʾ . . 1995(21)
F
ʾ 17
F
F ก
ˆ
ก ก ก ก ก F F ˁ
ก
ก ก ก ก ก ก ก
National Osteoporosis Foundation (NOF)
FF
ก
ก ก ก ก ก ก ก
F F
F
F
F ก
120,000
F ʾ
(22)
F
FF
ก
I-4 Pathogenesis and etiology
4.1
ก
1.
ก
(Pathogenesis)
ก
ก
กก
ก
ก
ก ก
2
ก F
ก ก
F F กF
ˈ
ก
ก ก กก F ก
F
F กก
ก
ก ก กก F ก ก กก F ก
ก ก
F
ก ก
ก
ก ก
ก ก
F
F
F กF
ก ก
(peak bone mass)
ก ก
(8)
ก
F F
30-34 ʾ
ก ก F
ก
ก ก
ก
F ก ก
F
40-45 ʾ ก
ก
ก ก กก F
ก F ก ก
F ก ก
F
F
ก
F
F F
ก
ก ก (rate of bone loss)
F ก
FF ก ก
ก ก F F
F
ก กก
ก F
F
F ก ก ก
ก กF ก ก ก
ก ก
ก
F
ก ก
ก
ก
ก ก F F
Fก
Fก ก ก ก
F
2. ˆ
F
ก ก
F กF
F
ก ก ก
F กF
F
ก
F
F
ก ก
(23-25)
Fก
ก ก
ก กก ก
ก
ก
(26,27)
F
F
ก ก
ก
ก
F
F
(28,29)
(30)
ก ก
ก
ก
F
F ก ก
3. ก
ก ก F
ก
F
F 10 ʾ ก
ก F postmenopausal bone loss
ก
ก ก ʾ 3-5%
ˈ
กก
F
F
F
F
ก ก(osteoclast) ก
F
ก F
ก
ก ก กก F ก F ก ก
ก
ก ก F (cancellous or trabecular bone) กก F ก ก (cortical bone)
ก ก ก
ก ก ก ก
F
ก ก กF
F
ก ก F ก F ก ก
F F
ก ก
F
(31)
ก
ก
ก ก
F ก F
ก ก
ก ก
ก
F
F
ก F
4. ก
ก ก F ก
กF F
ʾ 1-2%
F F F F 40-50 ʾ F
F
F
( F
>70
ʾ)
F ก ก
ก กก
F F ก ก
8. 5
(osteoblast) ก
ก
ก F age-related bone loss
5.
ก F ก ก ก ก ก ก
F
65 ʾ F F
ก ก ก ก ก ก
ˈ
exponential
ก
6. ˆ
Fก
ก ก F กF ก F ก
F F F
F
F
F กก
F ˈ ก ก
F
7.
ก ก ก ก ก ก ก ก
กก ก F ˆ
ก F ก ก F (factors
reflexes F
ก coordination ก F
ก
ก
ก F
F
ก
ก
ก กก ก
F
ก ก ก ก
ก
ก
ก
ก
ก
ก
ก
F
ก
F
70-75
ʾ
ก
ก
F
F
Fก
F ก
F
F ˈ F
ก
ก
ก F
F
(32)
of fall)
F กF ก
postural
fat padding
ก ก
F
F
ก
F ก กก ˂ ก ก F ก
F
F
1. Osteoporosis prevention, diagnosis and therapy. NIH consensus statements 2000; 17: 1-36.
2. Consensus Development Conference: prophylaxis and treatment of osteoporosis. Am J Med
1991;90:107-10.
3. Johnell O. The socioeconomic burden of fracture: today and in the 21st century. Am J Med
1997;103(suppl 2A):S20-5.
4. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. How many women have
osteoporosis? J Bone Miner Res 1992;7(9):1005-10.
5. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in elderly; a crossnational analysis. Osteoporosis Int 1991;1:232-41.
6. Mahidol Population Gazette. Institute of Population and Social Research, Mahidol
University, 2008.
7. Taechakraichana N, Angkawanich P, Panyakhamlerd K, Limpaphayom K. Postmenopausal
osteoporosis: what is the real magnitude of problem? J Med Assoc Thai 1998;81:397-401.
8. Limpaphayom K, Taechakraichana N, Jaisamrarn U, Bunyavejchevin S, Chaikittisilpa S,
Poshyachinda M, et al. Prevalence of osteopenia and osteoporosis in Thai women.
Menopause 2001;8:65-9.
9. Lau EM, Lee JK, Suriyawongpaisal P, Saw SM, Das De S, Khir A, et al. The incidence of
hip fracture in four Asian Countries: the Asian Osteoporosis Study (AOS). Osteoporosis Int
2001;12:239-43.
9. 6
10. Lau EM, The epidemiology of osteoporosis in Asia. In: Lau EM, Ho SC, Leung S, Woo J,
(eds). Osteoporosis in Asia: crossing the frontiers. Singapore World Scientific, 1997:1-20.
11. Orimo H, Nakamura T, Fukunaga M. The Japanese guidelines for prevention and treatment
of osteoporosis. (Translated abridged edition). Life Science Publishing, 2006:5.
12. Nevitt MC, Ettinger B, Black DM, et al. The association of radiographically detected
vertebral fractures with back pain and function: a prospective study. Ann Intern Med 1998;
128:793-800.
13. Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR, for the Study of
Osteoporotic Fractures Research Group. Vertebral fractures and mortality in older women; a
prospective study. Arch Intern Med 1999;159:1215-20.
14. Pongchaiyakul C, Nguyen ND, Jones G, Center JR, Eisman JA, Nguyen TV. Asymptomatic
vertebral deformity as a major risk factor for subsequent fractures and mortality: a long-term
prospective study. J Bone Miner Res 2005;20:1349-55.
15. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major
types of osteoporotic fracture in men and women: an observational study. Lancet
1999;353:878-82.
16. Scaf-Klomp W, van Sonderen E, Sanderman R, Ormel J, Kempen GI. Recovery of physical
function after limb injuries in independent older people living at home. Aging 2001;30:213-9.
17. Chariyalertsak S, Suriyawongpaisal P, Thakkinstain A. Mortality after hip fracture in
Thailand. Int Orthop 2001;25:294-7.
18. Suriwongpaisal P, Chariyalertsak S, Wanvarie S. Quality of life and functional status of
patients with hip fractures in Thailand. Southeast Asian J Trop Med Public Health
2003;34:427-32.
19. European Union Osteoporosis Consultation Panel. Osteoporosis in the European
Community: Action plan, 2003.
20. Burge RT, Worley D, Johansen A, Bhattacharyya S, Bose U. The cost of osteoporotic
fractures in the UK: projections for 2000-2020. J Med Econ 2001;4:51-62.
21. Ray NF, Chan JK, Thamler M, Melton LJ-III. Medical expenditures for the treatment of
osteoporotic fractures in the United States in 1995: report from the National Osteoporosis
Foundation. J Bone Miner Res 1997;12:24-35.
22. Woratanarat P, Wajanavisit W, Lertbusayanukul C, Loahacharoensombat W,
Ongphiphatanakul B. Cost analysis of osteoporotic hip fracture. J Med Assoc Thai 2005;
88(5):S96-104.
23. Krall EA, Dawson-Hughes B. Heritable and life style determinants of bone mineral density. J
Bone Miner Res 1993;8(1):1-9.
24. Brown MA, Haughton MA, Grant SF, Gunnell AS, Henderson NK, Eisman JA. Genetic
control of bone density and turnover: role of the collagen 1alpha1, estrogen receptor, and
vitamin D receptor genes. J Bone Miner Res 2001;16(4):758-64.
25. Ralston SH. Genetics of osteoporosis. Rev Endocr Metab Disord 2001;2(1):13-21.
10. 7
26. Taaffe DR, Robinson TL, Snow CM, Marcus R. High-impact exercise promotes bone gain in
well-trained female athletes. J Bone Miner Res 1997;12(2):255-60.
27. Kemper HC, Twisk JW, van Mechelen W, Post GB, Roos JC, Lips P. A fifteen-year
longitudinal study in young adults on the relation of physical activity and fitness with the
development of the bone mass: The Amsterdam Growth And Health Longitudinal Study.
Bone 2000;27(6):847-53.
28. Matkovic V, Fontana D, Tominac C, Goel P, Chesnut CH, 3rd. Factors that influence peak
bone mass formation: a study of calcium balance and the inheritance of bone mass in
adolescent females. Am J Clin Nutr 1990;52(5):878-88.
29. Johnston CC Jr, Miller JZ, Slemenda CW, Reister TK, Hui S, Christian JC, et al. Calcium
supplementation and increases in bone mineral density in children. N Engl J Med
1992;327(2):82-7.
30. Välimäki MJ, Kärkkäinen M, Lamberg-Allardt C, Laitinen K, Alhava E, Heikkinen J, et al.
Exercise, smoking, and calcium intake during adolescence and early adulthood as
determinants of peak bone mass. Cardiovascular Risk in Young Finns Study Group. BMJ
1994;309:230-5.
31. Garnero P, Sornay-Rendu E, Chapuy MC, Delmas PD. Increased bone turnover in late
postmenopausal women is a major determinant of osteoporosis. J Bone Miner Res 1996;
11(3):337-49.
32. Bouxsein ML, Myers ER, Hayes WC. Biomechanics of age-related fractures. In Marcus R,
Feldmen D, Kelsey J. (eds). Osteoporosis. Academic Press 1996, San Diego, CA.
11. 8
Diagnosis and bone mass assessment in osteoporosis
II-1 History, physical examination and differential diagnosis
1.1 ก
ก
ก ก
(Classification of osteoporosis)
(1)
ก
ก
1.
ก
ก
2.
ก
ก
ก
F
ก ก ก
ก
ˈ ˆ
กก
(Primary osteoporosis)
F F ˈ
(postmenopausal osteoporosis) ก ก
F
ˈ ก
(age-related
senile osteoporosis) ก F
F
F ก ก F F
ก
F F ก ก
ก
(Secondary osteoporosis)
F
ก
ก ก F ˈ
2.1
1.
−
−
−
−
ก
F F F
Cushing s syndrome
hypogonadism
F
F ˈ
F
ก
F
F
2.
3.
− ก
F
F
−
F ก
(heparin, warfarin)
− ก ก F กF phenytoin, phenobarbital
− ก
F ก
ก
ก
−
−
−
ก (malabsorption)
F
− F ก
F
4.
−
−
−
multiple myeloma
osteogenesis imperfecta
ก
2.1
12. 9
II-2 Risk factors for osteoporosis and osteoporotic fractures
2.1 ˆ
ก ก
ก ก ก ก ก ก
(Risk factors of osteoporosis and osteoporotic fracture)
ก
ก
ˆ
ก
ก F
ก
F
F
F
F ก ก (bone densitometer)
ก
(risk assessment)
ˈ
F FF
ก ก ก
ก ก ก F
ˈ
ˆ
ก
ˆ
1.
2.
3.
4.
Fก ก
F
ก
ก ก F ก ก ก ก
F F
ก
ก F
ก Fก
ก
F
(2)
ก
กF
ก
ก
ก
ก ก
ˆ
F
F
F (Non-modifiable risk factors)
(
F 65 ʾ
F
)
F
กF
5.
6.
7.
F
ก
F ก
F F
ก
F กF
ก
ˈ
ก
ก
ˈ
ก F 19 กก./
.
F
(estrogen deficiency) กF
F F
gonadotropin releasing hormone (GnRH) analogue
F
ก
F
F (Modifiable risk factors)
F
(inadequate calcium intake)
ก (sedentary lifestyle)
F F
ˈ
ก
F ก
ก (small body build)
F
ˈ ก ก
ก ก ก ก
ก ก
(fragility fracture)
ก ก ก
ˆ
1.
2.
3.
4.
5.
6.
7.
45 ʾ (early menopause)
F ก
กก
กก
ก
F
ก ˈ
8.
Fก
2.2 ก
ก F (propensity to falls) F ก
ˆ
ก ก ก
ก ก ก
F
ก
(impaired vision)
ก
F FRAXTM
Fก
ก
(Risk assessment of osteoporotic fracture using WHO-FRAXTM)
WHO(3) F ก
ก
ˆ
ก
ก
meta-analysis population-based cohorts
ก
ˆ
ก
ก
ก
ก
13. 10
1. Independent F BMD
2.
ก
ก
3.
adjusts
4.
F
5.
กก ก F
ก
,
F
ก
F ˈ ˆ
ก ก ก F
F F F F
F
F(
ก
F F ˆ
9 ˆ
F
F
F ก ก (bone mass density, BMD) F
femoral neck BMD ˈ ก
F F
F
(BMI)
F
ˆ
F
ˈ F
BMD/BMI F
F F
กก
ˈ ˆ
F
modifiable)
F
2.2
F
F
F
BMD F F F F body mass index
กF
F (yes/no) ก F
2.2 ˆ
WHO
F FRAXTM
Age (yr)
BMD(FN) / BMI (T-score or kg/M2)
A prior fragility fracture (yes/no)
Parental history of hip fracture (yes/no)
Current tobacco smoking (yes/no)
Ever long-term use of oral glucocorticoids (yes/no)
Rheumatoid arthritis (yes/no)
Other causes of secondary osteoporosis (yes/no)
Daily alcohol consumption of three or more units daily (yes/no)
BMD(FN) = femoral neck bone mass density, BMI = bone mass density
WHO task force conference held in Brussels, Belgium in May 2004
F
กก
F
ˈ
ก
ก ˈ
F
ˈ
ก ก ก ก
10 ʾ (10-year probability of fracture)
TM
F
ก FRAX
F
F F internet http://www.shef.ac.uk/FRAX(4)
F
TM
10-year probability
ก
F
F
website ก FRAX
F
ก
ˁ
US-Asian
F
F ˈ 2
10-year probability of hip fracture 10-year probability of other major
osteoporotic fractures
F
F
F ˁ
F ก ก
F
(therapeutic threshold) F
ก ˆ
F F ˁ
F fracture
BMD
F กF
-2.5
Fก
F 10-year probability of fracture ˈ ก
F
F ก
F
F
F ˁ 10-year probability of hip fracture ≥ 3%
10-year probability of other major osteoporotic
(5)
fractures ≥ 20% ก F ก
F
ˆ
ˆ
F ก
F F
F ก ก
F FRAXTM
F
F
ก
ก
ก
ก
FRAX
TM
FRAX
ก F
F
F กF US-Asian
Japan F
ก ก
Asia
F
F
14. 11
ก F
ก
ก
ก
ก F
ก Fก ก F
NOF
10-year probability of hip fracture ≥ 3%
osteoporotic fractures ≥ 20% ก F ก
F
F
ก
ก
F
F F F
10-year probability of other major
II-3 Laboratory investigation and bone strength assessments
3.1 ก
F
F
1.
2.
3.
−
−
−
−
−
3.2 ก
ก
ก
ก
1.
2.
3.
4.
ก
ก (Laboratory investigation)
ก
F
ก ก
ก ก ก
ก ก
ก
ก ก
F
F
ก
Complete blood count (CBC)
Serum calcium, phosphate, albumin
liver transaminases
Serum alkaline phosphatase
Renal function (blood urea nitrogen and creatinine)
Plain x-rays
F ก ก
F ก
F F (lateral thoraco-lumbar spine)
ก ก
ก F
F (antero-posterior hip)
F F
F
ก ก ก
กF
ก
ก (Bone strength assessment)
ก F ก กก ก
ˆ
ก
ก ก (bone mass)
ก ก (bone quality)
ˆ
F
F F ก F
F
F
ก F ก
กF
ก ก
Fก
F ก ก ˈ ก
ก
F plain x-ray F
F กก
ก ก F
ก
x-ray
F ก
ก ก
F F
ก ก F
กก F 30% ก F ก
F
Semi-quantitative method ก
plain film x-ray F
Singh s index ˈ F
F
ก
F F ก
intra-observer
inter-observer
variation ก F
F
F
Bone mass measurements WHO ก
F ˈ
ก
ก ก ก axial dual-energy x-ray absorptiometry (axial DXA) F
Bone mass measurements F
F quantitative ultrasonography (QUS)
peripheral DXA (pDXA) F
F
ก
F axial DXA ก
ก ก
F
F ก
F
ก
F
F ก ก
ก
F axial DXA ก
15. 12
II-4 Diagnostic criteria for osteoporosis
4.1 ก
F ก
F ก
ก (Measurement of bone density)
ก (Bone mass density, BMD)
F
F
F
Dual Energy X-ray Absorptiometry
ก
ก
ก
ก Fก
2.3
ก
Fก F
BMD
กF
F ก -2.5 F
F
ก
ก
ก ก ก ก
1.4 - 2.6 F ก 1 F
F
2.3 ก
ก ก
ก
ก
ก
(normal)
ก
ก
F
F BMD
F
F ก
-1 F
F
ก ก
(osteoporosis)
ก ก
(severe/established
osteoporosis)
F F
Caucasian)
ก
F
Fก
ก
ก
ก
F
F F
ก
ก
F
กก F
ก F
Fก
ก
F กก F
ก ก
ก F
F
ก
ก ก
F
(female reference)
ก
F
F
F
F
F
(fragility fracture)
F
ก ก
F
(lumbar spine
ก F axial DXA F
ˈ F
ก ก
ก
F
axial DXA F
F
ก
F
ก
DXA
F
F F
ก ก
ก F ก (Asian female reference) ก F ก
ก ก
F
Fก
F F
F
F
(8)
F
F
ก
2.3)
F
F ก
F
F
ก
BMD
ก
L-spine) ก ก
ก (hip) F
(peripheral DXA) ก F
F ˁ
F F
ก F ก
F
(T-score ≥ -1)
F ก ก ก F -1 F
F
-2.5 F
F
F
( -2.5 < T-score < -1)
F ก ก กF
F ก -2.5
ก F
ก ก
(T-score ≤ -2.5)
F ก ก กF
F ก -2.5
ก F
ก ก
(T-score ≤ -2.5) F ก ก ก ก ก
(osteopenia)
F F
F F
F ก
ก(6,7)
Fก
ก
FF
F (male reference)
ˈ
Fก
F
ˈ
F
ˁ
F F
ก ก
F
(
(reference young adult mean)
ก
กF ก
ก
F( F
F
F
16. 13
F F
1.
2.
ก
F
F
F 65 ʾ
ก F 65 ʾ
F 1 F
−
กF
−
4.
5.
6.
กF
ˆ
45 ʾ (early menopause)
F
กF 1 ʾ ก F ก
F
ก
F ˈ
กF 3
)
ก ก
F
F ก
(estrogen deficiency) กF
F
F
(
F
F
F F
F
F
7.5
ก.
F
ˈ
ก ก
F
ก F ก F 19 กก./ .
ก ก
ก ก
กก F
ก F (radiographic
osteopenia and / or vertebral deformity by x-ray)
ก ก ก ก
F
F
F กF
กก
ก F OSTA score(10), KKOS score(11)
nomogram กก F 0.3
F
(
ก 2.2)
(
OSTA; Osteoporosis Self Assessment Tool for Asians, KKOS; Khon Kaen
Osteoporosis Study score)
−
−
3.
F
F
−
axial DXA(9)
F 70 ʾ
F
ก F 70 ʾ
BMD F
Quantitative Ultrasound (QUS)
QUS
ก
ก F QUS F
QUS
F F ก OSTA(10)
ก F QUS F ก
F (13) F ก ก
4.2
ก
(sensitivity)
KKOS(11)
ก
F
ก
ก
F
16)
ก F
ก
F F ก ก
F
F ก
ก F
ก ก
3
ก
F
ก
ก
F ก
ˆ
F F ก BMD ก
F
F ก
1 ʾ
F
ก
F
F ก
ก (12)
ก ก
F
ก (nomogram)
F
F ก
ก ก
ก
ก
F
ก
(Biochemical markers of bone turnover)
ก
F
(specificity)
ก
ก ก
ก ก
ก
ก
F
F F ก
ก
ก ก ก
ก
ก
ก (17)
F ก ก F
ก
F
ก ก F(14F
F
F
telopeptide (NTx)
ก
ก ก F กF urinary deoxypyridinoline (DPD), urinary Nserum C-telopeptide (CTx) F
ก F ก ก F กF bone
17. 14
specific alkaline phosphatase (BSAP), osteocalcin, C-terminal propeptide of type 1 procollagen
(P1CP)
N-terminal propeptide of type 1 procollagen (P1NP)(18)
4.3 ก
ก
ก
ก
F F
ก
BMD F
F
F(
(Screening)
ก
ก
F
ก F F FF
ก 2.1)
F
axial DXA
F ˆ
ก
F
F
F
ก
F
ก F
KKOS(11)
(10)
OSTA
ก ก ก
ก
18. 15
ก 2.1
OSTA (Osteoporosis Self-Assessment Tool for Asians)
ก
ก
ก
OSTA index
F F
F ˈ ʾ
OSTA
F ก 0.2 X (
ก F F ˈ ก ก
F ก F -4
F -4 -1
F -1
ก
ก-
)
F
F F
21. 18
ก 2.2
ก
ก
ก ก
ก
ก
F
QUS(15)
ก
ก
1.
2.
3.
4.
5.
ก F
ก F
ก F
กก
ก
(point)
กก
ก
ก
(point)
ก ก QUS
ก
(point)
3
ก (total points)
ก F กก
(total points)
ก
osteoporosis)
6. ก
ก ก ก ก
F 0.3
ก ก
F
BMD F
ก
ก
(risk of
ˈ กF
ก ก
F
F
193 (
F F ก 0.5 (
70 ʾ
ก 50 ก ก
ก F
4)
ก
ก ก
1-3
ก F กก
F
QUS T-score -3 SD
48, 67
193
78
ก
Fก
ก
ก
5)
:
F
ก
ก
70 ʾ
50
ก 50 ก ก
QUS T-score -3 SD
100
22. 19
ก
F
1. Greenspan SL, Luckey MM. Evaluation of postmenopausal osteoporosis. In : Favus MJ,
editor. Primer on the metabolic bone diseases and disorders of mineral metabolism, 6th ed.
Lippincott Raven Press; New York, NY, USA, 2006, pp.268-72.
2. Riggs BL, Melton LJ. Evidence for two distinct syndromes of involutional osteoporosis. Am J
Med 1983;75:899-901.
3. Kanis JA, Black D, Cooper C, et al. on behalf of the IOF and the NOF USA. A new
approach to the development of assessment guidelines for osteoporosis. Osteoporosis Int
2002;13:527-36.
4. FRAX-WHO fracture risk assessment tool, http://www.shef.ac.th/FRAX
5. NOF(National Osteoporosis Foundation). Clinician Guide for Prevention and Treatment of
Osteoporosis 2008.
6. Gallagher JC. The pathogenesis of osteoporosis. Bone Miner 1990;9(3):215-27.
7. National Osteoporosis Foundation. Osteoporosis: review of the evidence for prevention,
diagnosis, and treatment and cost-effectiveness analysis. Osteoporosis Int 1998; 8 (Suppl
4):S1-80.
8. World Health Organization. Assessment of fracture risk and its application to screening for
postmenopausal osteoporosis. No. 843 of Technical Reports Series. Geneva: 1994.
9. Kanis JA, Melton LJ 3rd, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of
osteoporosis. J Bone Miner Res 1994 ;9:1137-41.
10. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral
density predict occurrence of osteoporotic fractures. BMJ 1996; 312(7041):1254-9.
11. WHO.1994. Assessment of fracture risk and its application to screening for postmenopausal
osteoporosis. Technical report series 843. Geneva: WHO
12. Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, et al. A simple tool to
identify asian women at increased risk of osteoporosis. Osteoporosis Int 2001;12:699-705.
13. Pongchaiyakul C, Nguyen ND, Pongchaiyakul C, Nguyen TV. Development and validation
of a new clinical risk index for prediction of osteoporosis in Thai women. J Med Assoc Thai
2004;87:910-6.
14. Pongchaiyakul C, Panichkul S, Songpatanasilp T. Combined clinical risk indices with
quantitative ultrasound calcaneus measurement for identifying osteoporosis in Thai
postmenopausal women. J Med Assoc Thai 2007;90(10):2016-23.
15. Pongchaiyakul C, Panichkul S, Songpatanasilp T, Nguyen TV. A nomogram for predicting
osteoporosis risk based on age, weight and quantitative ultrasound measurement.
Osteoporos Int 2007;18(4):525-31.
16. Gerdhem P, Ivaska KK, Alatalo SL, Halleen JM, Hellman J, Isaksson A, et al. Biochemical
Markers of Bone Metabolism and Prediction of Fracture in Elderly Women. J Bone Miner
Res 2004;19(3):386-93.
23. 20
17. Riis BJ, Hansen MA, Jensen AM, Overgaard K, Christiansen C. Low bone mass and fast
rate of bone loss at menopause: equal risk factors for future fracture: a 15 year follow-up
study. Bone 1996;19(1):9-12.
18. Riggs B, Melton LJ, O Fallon WM. Drug therapy for vertebral fractures in osteoporosis:
evidence that decreases in bone turnover and increases in bone mass both determine
antifracture efficacy. Bone 1996;18:197S-201S.
24. 21
Prevention of osteoporosis and falls
ก
˂ ก ก ก
ก ˂ ก F F ก ก
F ˈ
ก ก
ˆ
ก
F ก ˂ ก
ก ก
F
ก
F F (nonpharmacologic strategy)
F F
F กก F ก ˂ ก F ก F ˈ
F
F ˈ ก F F ก ก
ก
˂ ก ก
ก ก
F
F
กก F 50 ʾ
III-1 Strategies to maximize peak bone mass
ก
F
Fก
1. ก
F
ก
ก
(peak bone mass)
F
F
F
ก (weight bearing exercises) ก
ก
F
กก ก
ก
(resistive exercises)
2. ก
3. ก
4. ก
4.1.
4.2.
4.3.
4.4.
5.
6.
7.
8.
Fก
F
ก
F
F
ก
ก
ก
F ก ก
กก
ก
F
F
F
F กF
F
ก
F
ก
F กก
ก
F
ก
ˈ ˆ
ˈ ˆ
ก
F
ก (physical activities)
F ก ก
F ก ก
ก
F F 20-23 กก./
.
III-2 Strategies to prevent bone loss
กF
ก
F
1.
2.
ก
ก
ก
2.1.
2.2.
ก F ก F
ก ก
F
ก F ก ก (rate of bone formation) F
ก ก (rate of bone resorption)
กF
ก
F
F กF
ก
ก ก F
F F (non-pharmacological management)
ˈ
F III-1
F (pharmacological management) ก F
ก F F กF
F ก ˈ
ก
ก F ก F กF
F
25. 22
ก
F
F
(Hormone replacement therapy)
1. ก ก F
(estrogen therapy, ET)
F
(hormone [replacement]
therapy, H[R]T) ก ก F
F ก
F F
ˈ F ก
ก
F F F
ก F
F
F
˂ ก
ก ก
(1-6)
ก F F
F F
ก F
F
F F
˂ ก
ก
2. ก ก
F Women Health Initiative (WHI) study(7) F
ก F F
ˈ conjugated equine estrogen (CEE) F ก medroxy progesterone acetate (MPA) ˈ
5 ʾ
F
ก F ก ก ก ก
ก ก
ก
ก
ก F 34%
ก ก ก ก
F 23%
3.
ก WHI study F
ก F F
F
F
ก
F
Fก
ก
F ก
F F
WHI
F ก
F ก F F
(CEE F ก MPA) F
F ก F 10 ʾ
ก ก
F
F ˈ ก F
F ก ˈ
7.1 ʾ ก
F
ก ก
F
F กF F F F F F
F ก
F F ก ก
ก CEE
MPA
F
F
F
ก
Fก F F
/
F ก
F
F
ก
Fก ก
F F
F
ˈ (8, 9)
4. ก F F
ˈ
F
ก
F
F ก ก ก ก
F F
F
F
F
(9)
ก F F
F
5. ก
F
Fก ก
ก ก ʾ 3%
6% F
F
ก
F
F
F ก
ก ก ก ก ก
F
(catch-up
phenomenon)
ก F ก ก ก
Fก
F F F F
(10)
ʾ
F F
F
F F
F F
III-3 Nutritional aspect in osteoporosis
Fก
F
ก
F
F
F กF
F
ก
ก F กF
ก
ก
ก
NIH
ก
F
ˈ F
(Calcium)
3.1
(11)
F ก
F
26. 23
3.1
F
a
Health Consensus Panel
ก F
Infant
Birth- 6 months
6 months- 1 year
Children
1-5 years
6-10 years
Adolescents/young adults
11-24 years
Men
25-50 years
Over 65 years
Women
25-50 years
Over 50 years (postmenopausal)
− On estrogen
− Not on estrogen
Over 65 years
Pregnant and nursing
F กF
National Institutes of
Optimal calcium intake (mg/day)
400
600
800
800-1200
1200-1500
1000
1500
1000
1000
1500
1500
1200-1500
ก ก a NIH Consensus Development Panel on Optimal Calcium Intake: Optimal Calcium Intake. JAMA
272:1942-1948; 1994.
ก
F กF
ʾ . . 2545
3.2
F
27. 24
3.2
F
F กF
ก
. . 2545
ก F
F
ก
0-5
6-11
1-3 ʾ
800
9-18 ʾ
1,000
19-50 ʾ
800
กก F 50 ʾ
1,000
F
F
F
F∗
F
∗
ก
∗∗∗
ก
800
F
F
ˈ
F
F F F
1 กF
1 ก F (200
ก
ก
ก 2545:16-23
ก
230
)
ก
.
ˁ
:
F
F
702 ก.
F ก
ˈ
F
F
ก Fก ก
F
balance study(12)
ก
842 ก. F
F
F
F
F
ก .
ก
ก
F
ก.
F
F
กก
788
800
∗
F
∗∗
ก )
210
270
500
4-8 ʾ
ก
(
F
F
F
ก
F
F ก
F
F
ก 20%
946
ˈ
ก.
ก
ˈ F
ˈ
Fก
ก F
ก
ก
ˆ
ก
F
F
F
ก
F
กก
ˈ
ก
FF
F
ก
3.3
ก
ˆ ก
28. 25
3. 3
( ก.)
,
กF
,
กF F
กF
ก ʽ
ก
F
ก
F ˈ
F กF
F กก
,
F F
ก
ก
ˆก
ก
F
ก
.
F
240
150
145
167
156
76
52
106
78
63
30
116
97
240
245
125
469
429
230
49
299
76
17
200 (1 ก F )
150 (1 ก F )
1 F
F ( )
1
2 F
( )
1/2 F
( )
10 ก
1
1
1
1
1
1
1 กF
10
10
1
10 ˆก
1
1
1
1
4
F
F
F
F
.
29. 26
(Vitamin D)
1.
2.
3.
4.
5.
ˈ
F
F F ก
F
ก ก
F ก F
ก
ก
ก F
F ก parathyroid hormone ก
F
ก
ก
ก F F ก
ก ก
ก ก F Fก
ก ก
ก F ก ก ก
ก
F
ก ก (bone formation and
mineralization)
F
F ก
กก
F
กก ก F F
F
(ultraviolet B, UVB)
F
F ก
F กF
ˈ F F
F ก
ก
F
Fก ก F
F
ergocalciferol (
ก )
cholecalciferol (
ก )
F
ˈ
F
F
F ก
OH group
ก OH
F
25 ก
ˈ 25-hydroxyvitamin D (25(OH)D
calcidiol
vitamin D2)ก
ก ก
OH
F 1 ก
ˈ 1,25-dihydroxyvitamin D (1,25(OH)2D
calcitriol
vitamin D3)
ˈ
(active form) ก
ก ก
F F
ก
F F กF
− ก
F 7-dehydrocholesterol
ˈ
F
3
F
F
F F
− ก
ก F
F F
F
( F
F
F
ก F F F )
− ก
Fก F 1,25(OH)2D
− ก
F
F ก
ก
F
F
F
F F
F ก
F
secondary
hyperparathyroidism ก
ก ก ก
ก ก
(13,14)
F F
F
กก ก
F
F ก
400-800 IU ˈ
F ก ˂ ก ก
30. 27
3.4
Food
International Units (IU)
per serving
1,360
360
345
200
250
98
Cod liver oil, 1 Tablespoon
Salmon, cooked, 3 ounces
Mackerel, cooked, 3 ounces
Tuna fish, canned in oil, 3 ounces
Sardines, canned in oil, drained, 1 ounces
Milk, nonfat, reduced fat, and whole, vitamin D fortified, 1
cup
Margarine, fortified, 1 Tablespoon
60
Pudding, prepared from mix and made with vitamin D
50
fortified milk, cup
Ready-to-eat cereals fortified with 10% of the DV for vitamin 40
D, 1 cup servings (servings vary according to the brand)
Egg, 1 whole (vitamin D is found in egg yolk)
20
Liver, beef, cooked, 3 ounces
15
Cheese, Swiss, 1 ounce
12
Percent
DV*
340
90
90
50
70
25
15
10
10
6
4
4
* DV = daily value. DVs are reference numbers developed by the Food and Drug Administration
(FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for
vitamin D is 400 IU (10 µg) for adults. Most food labels do not list vitamin D content unless a food
has been fortified with this nutrient.
ก ก http://www.usda.gov/cnpp/pyramid2.htm.
(Vitamin K)
1.
2.
3.
4.
5.
-1 (phylloquinone) ˈ
ก
-2 (menaquinone) ˈ
F
F F
F
ก
F phylloquinones
phylloquinone ˈ
F ก
chloroplasts
normal flora
F F spore-forming Actinomyces spp.
F menaquinones F
ก
F
F F
ก
F
F F menaquinone F Fก
ˈ
passive diffusion
ก F F
F
ก
F F ก ก (osteoblast) F collagen matrix
osteocalcin
ˈ non-collagen matrix
osteocalcin
F
ก F
F
ˈ osteocalcin
F
ก ˈ
undercarboxylated osteocalcin (ucOC)
ก ucOC ก carboxylated F ˈ mature
osteocalcin
carboxylated osteocalcin (Gla protein)
ก
F F
osteocalcin ก
F
ˈ
F
ก ก ก ก
F
ก ก
31. 28
F
ก
ucOC
ก F
ˈ
F
Fก
F
F ก
F ก F
ก ก
Fก ก
ucOC
Fก ก ก ก
6.
ก ก
ucOC
2.314 ng/mL
ˈ
(15)
F
F F ก ก
ก ก
2.314 ng/mL) 39.1%
F
ucOC ก F 2.314
ultradistal radius
distal 1/3 of radius
25(OH)D
ucOC ก F
(p<0.05)
7.
F
F6 ʾ
ก ก
ก
F
ก
ก
80 µg
F กF
2 ก. F
ก ( ˈ กก.)
8.
F กF ก
ก
ก
ก ก F
F ˈ
ก ก
F กF F ˈ
ก
F
3.5
ก
ก กF
F
ก
(
ng/mL
กF F
(mcg/100 g)
817
400
231
205
147
193
141
775
III-4 Life style modification and prevention of falls
4.1 ก
ก
ก
−
−
−
−
−
−
−
ก
ก
F ก
F
ก
ก
ก
ˈ
ก
ก
F
F
F
ก
ก
F กก
ก
F
ก
ˈ ˆ
ˈ ˆ
ก (physical activities)
F ก ก
F ก ก
ucOC >
F
ก ก
(Thai RDI)
. . 2538
ก
70-140 ก.
ก F ก
F
ก F (Kale)
ก (Spinach)
ก (Endive)
Broccoli
ก
(Cabbage)
Soybean oil
Rapeseed oil
F (Regular natto)
F
F
F
F
F
F
32. 29
4.2 ก
F
ˆ
ˆ
ก
ก F
F ˁ
F
˂ ก ก
ก
ก
F ˁ
ก
ก
ก ก ก ก FF
ก ก ก
F
F ก ก ก ก ก F
F ก
กก
ก Fก ก F
F
F ʾ
F
กก F 65
(16)
F
กก F 80 ʾ ก F
กF F
ก F ก F
3 F ก ก F
กF ก
F
กF
ก
(17)
กก F 40%
F
ก F กก F 1
F ʾ
F
ก กF
F
ก กF ˈ
F F
F
กก F
5 F F ˁ F
F FF
ก กก F
ก กF F
ก ก ก ก
ก ก F F ก
ก
F ˁ
F
F
ก ก
ก ก F
F ก F
F
(18)
F
ก
F
ก
ˈ
F F
กF
ก ˂ ก ก ก F
ˈ
F ก
F
ก F F
ก
F F
ˆ
F ก
ˈ ก F
ก ก
กF
ʾ
กF
2-3
F
F
F
ก F
ˆ
ก ก ก ก F
F ก
F
ก
ก ก
psychotropic
ก F sedative
ˆ
F
F
ˈ F
1.
F ก
ˈ
F F ก ก
ˆ
F
ก กF
F
ก 8-10% F F ˆ
ˈ
20)
ก ก ก
ก ก ˆ
(21)
F ก ก F
F กF
ก F
กก F
Fก 4
F
12% F F ˆ
ก
2.
ˆ
F F
F ˁ
ˆ
ก F
F
F ก
ก
ก
F ก F
ก
F
F
F
Fก ˆ
F
F
ก F
ˆ
ก
ก F
กก F
ˆ
F F ก
F
กF
69-78% F ˆ
กก F
Fก 4 F
multivariate analysis
F
3 ˆ
F
ก F
ก
ก
ก
F
F F ˆ
F
ก กF
F ก กF
ˈ 100%
Fก กF ˂ ก
F
ก ˆ
F
(19,
ˆ
−
−
−
−
−
−
−
ก
กF
(22,23)
(24)
ก
ก
ก
F
ก
ˆ
F ก F (cognitive impairment) (25)
ก F (26)
(27)
F
F
F ก (25)
(27)
F
ก
F ˈ F
ˆ
F
33. 30
− กF
−
ก
ˆ
F
/ก
(28)
(18)
กF
ก
F
−
F
˂ ก ก
(29)
F
F
−
− ก
ก
ก F
F
F
F
ก F
F ก F F
F
/ ʾ ก F
F
ˈ F
F
(30)
F
(22)
ก F
ก ˂ ก
F ก (frail elderly)
F
ก F ก F
F F
ก ก F ก ก ˂ ก ก
ก F
ก F
ก ˈ
F
1.
F
3
=
ก
3
2.
F ˁ กF
กF F ก F
Fก
กF
กF F
(31)
falls risk assessment tool
F
ก
ก(
, 11-20 =
ก , 21-33 =
ก
F ˁ
ก ก กF
ก
กก F F
ก 3.1)
ก) F
F F
F ก
F ˈ
F (0-10
ก
ก ก
F
กF F F F
ก
(32)
F
F F
กF FF
F Berg balance scale, 180 degree
(33)
(34)
turn,
functional reach
ก
F
F
F
F ก
ก
ก F timed up & go test (TUGT)(35)
F F ˁ ก ก กF
ˈ
3
ก
ก
F
(36)
F F ก F
F
ก F
ก F
F ก F ก 10
3.
ก F
F ก
Fก F
กก F
Fก 4
(37)
F ก กF
ก กF F ก ก
F ก F
9 F
FF
F
(38)
ก F psychotropic
F กF
F
F
ก
กF
FF ก
F
ˆ
ก ก
F
F F
(39)
ก
ก F
F F
ˈ
ก F benzodiazepine
ก กF
44%
(40)
ˈ
ก กF
F F F ˁ
4. ก กก ก
ก ˆ
F
กF
F
ก
ก F
ก
กก ก ˈ ก
F ก
F F F
F ก ˂ ก ก ก F (41)
ก ʿกก
(balance training) ก กก ก
กF
(strengthening exercise) ก
กก
ʽ F
(42,43)
(cardiovascular fitness training)
ก
กก ก
ก ก F
F
กF
Fก
F
˂ ก ก กF
ก F ก กก
ก
F F ก F ก F
ก ก
ˈ
F F ˁ
ก ก (
ก 3.2)
5. กF ˆ
F
F ˆ
F
F ก ก กF
ก
F F F
ก
ก ˈ
F ก F
ˈ F
ˆ
F ก กก F
F
F
34. 31
F
counter)
F F
กF
F
F F
F
F
6. ก
F
F
F
F กF
ก
F
ก
F
F
F
ก ˈ
F
7.
F
ก
ก
F
ˆ
F ก
ก
ก ก
F ก
8. F
ก ก ก ˂ ก ก
F กF F ก ก กก
F
F F
ก
F
FFF ก ก กF ก
F
ก
F
ก F
( F ก F 2.5 . .)
F
F
ก F ˂ ก ก
ก
F
F
F
F
F ก
F F
ก
ก ก F
F ก ก
F
FกF
FF
F F
ก
F
F F F
F กF F F ก
F ก ˈ ก
F
ʾ ก
F กF F
ก ˆ ก
F
Fก
F
Fก
ก ก
ก
ก Fก ก F
กF ˆ
กก
F
กF
F กF F ˁ / F
F
ก
F
F FF
ˈ F
F ˁ
F ˁ
F ก
ก F
(firm heel
F กF
1 . . F
F
F
F ˁ
ก F F
ก ก
F
ก
กF F
ก
ก
F ˁ
(44)
FF
ˆ
F
F
F
F
F
กก
กF
ก
35. 32
ก 3.1
Falls Risk Assessment tool
ก
0
F F
1
ก ก
ก
2
8-14
ก
3
กก F 14
F
ก F
0-19 ʾ
F กF
ʾกF
ก
F
F ก
ก F
ก
F
F
F
,
F ก
60-70 ʾ
กF 3
กF
F ก F
F 1
F
กก F 70 ʾ
กF
กF
F F ก F
F F ก
F
F
,
ก
ก
ก
,
20-59 ʾ
กF 6
กF
F ก F
F 2
F
ก
,ก
ก
F F, ก
ก F
ก
ก
,
ก
F F
ก
F
, ก
F
ก
ก
ˆ
ก
ก
F
ก
ก
F / ˆ
ก
ก
ก F
F
ก
F
F
F
F
,
,
ก F psychoactive
β-blocker,
ˆ
,
F
F
ก
กF
1
F ˆ
ˆ
F
0-10=
11-20=
F
>1
ˆ
ก
,
ˆ
(stress
incontinence)
ก
21-33=
ˆ
(urge
incontinence),
ˆ
ก ก Fall prevention: Best Practice Guidelines, Quality improvement and Enhancement Program, version
3, 2003
36. 33
ก 3.2
ก
F
ˈ
−
−
−
−
−
ก
กก ก
F กFก
F
กก
F
กก
F
ก
F ก
ก
ก
ก
ก
ก
ก
ก ก
2 F (weight bearing exercises) F กF
ก
ก
ก
F
กF
กก
กF
F
F กก
ก
ก F
F 3-5
ก
F ก กก ก
F
F
(45-49)
ก ก F 1-3%
ก กก
F
F
F
F ˁ
F
ก F กก
ก
ก
ก
ก
F
F
Rotator cuff
Pectoralis major
Biceps
Triceps
Wrist flexors
wrist extensors
Hip extensors
Hip flexors
Quadriceps
Hamstrings
Back extensors
Abdominal muscles
−
−
−
−
−
−
−
−
−
−
−
ก
ก
กก
ก
กก
F
ก
กF
ก
ˈ
กก
ก
9%
F
ก
F
20 - 60
F
˂ ก
ก
F F
ก
ก
ก
ก
กF
F
F
ก 9%
ก
ก
ก
ก F
ก F
ก
Fก F ก
กก ก ก
F
F
ก
ก ก ก
ก
กก ก
F
ก ก
40
F
F
ก ก กก F 12%
ก
ก ก กก F ก
ก ก
ก ก กก F ก F
ก
กก ก
F กก ก 7%
37. 34
ก
˂ ก ก
ก F
F
ʾ 30%
F F
F 2
กก F
9
F กF
6
ก ก F F 70%
ก
exercises)
F F
ก
ก
ก ก ก
ก ก
F 65 ʾ
ก กF
F F กก ก ˈ
ก ก F
ก ก ก
F
ก ก
F
ก ก ก ก
ก ก กก F 50%
ก
ก ก F
ˈ
กF 6
F
ˆ
กก
ก ก
ก F ก
กก ก
ก ก
ก
กก ก
ก
ก ก
ก
F ก2-3 ʾ F
F
F
F
ก
(vibratory
F ก
ก
F
1. Bush TL, Wells HB, James MK, et al. Effects of hormone therapy on bone mineral density:
2.
3.
4.
5.
6.
7.
8.
results from the postmenopausal estrogen/progestin interventions (PEPI) trial. The Writing
Group for the PEPI. JAMA. 1996;276:1389-96.
Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, et al. Randomized trial of
estrogen plus progestin for secondary prevention of coronary heart disease in
postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS)
Research Group. JAMA. 1998;280(7):605-13.
Lufkin EG, Wahner HW, O'Fallon WM, Hodgson SF, Kotowicz MA, Lane AW, et al.
Treatment of postmenopausal osteoporosis with transdermal estrogen. Ann Intern Med.
1992;117(1):1-9.
Recker RR, Davies KM, Dowd RM, Heaney RP. The effect of low-dose continuous estrogen
and progesterone therapy with calcium and vitamin D on bone in elderly women: a
randomized, controlled trial. Ann Intern Med. 1999;130:897-904.
Weiss NS, Ure CL, Ballard JH, Williams AR, Daling JR. Decreased risk of fractures of the
hip and lower forearm with postmenopausal use of estrogen. N Engl J Med 1980;
303:1195-8.
Wells G, Tugwell P, Shea B, Guyatt G, Peterson J, Zytaruk N, et al.; Osteoporosis
Methodology Group and The Osteoporosis Research Advisory Group. Meta-analysis of the
efficacy of hormone replacement therapy in treating and preventing osteoporosis in
postmenopausal women. Endocr Rev. 2002;23(4):529-39.
Writing Group for the Women s Health Initiative Investigators. Risks and benefits of
estrogen plus progestin in healthy postmenopausal women. JAMA. 2002;288:321-33.
The North American Menopause Society. Management of osteoporosis in postmenopausal
women: 2006 position statement of The North American Menopause Society. Menopause
2006.
38. 35
9. The North American Menopause Society. Estrogen and progestogen use in peri- and
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
postmenopausal women: March 2007 position statement of The North American
Menopause Society. Menopause 2007.
Tremollieres FA, Pouilles JM, Ribot C. Withdrawal of hormone replacement therapy is
associated with significant vertebral bone loss in postmenopausal women. Osteoporosis
Int 2001;12;385-901.
NIH Consensus conference. Optimal calcium intake. NIH Consensus Development Panel on
Optimal Calcium Intake. JAMA 1994;272(24):1942-8.
Uenishi K, Ishida H, Kamei A et al. Calcium requirement estimated by balance study in
elderly Japanese people. Osteoporos Int 2001;12(10):858-63.
Soontrapa Sp, Soontrapa Sk, Chailurkit L. The prevalence and the Calcidiol Levels of
Vitamin D Deficiency in the Elderly Thai Women in municipality of Khon Kaen Province,
Thailand. Srinagarind Med J 2002;17(4):219-26.
Soontrapa Sp, Soontrapa Sk, Pongchaiyakul C, Somboonporn C, Somboonporn W O.
Vitamin D deficiency and the risk of osteoporosis in elderly women. Srinagarind Med J
2002;17(3):154-63.
Soontrapa S, Soontrapa S, Bunyaratavej N. Serum concentration of undercarboxylated
osteocalcin and the risk of osteoporosis in Thai elderly women. J Med Assoc Thai 2005;
88(Suppl 5):S29-32.
Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med
1994;121:442-51.
Krueger PD, Brazil K, Lohfeld LH. Risk factors for falls and injuries in a long-term care
facility in Ontario. Can J Public Health 2001;92:117-20.
Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW. Fear of falling
and activity restriction: the survey of activities and fear of falling in the elderly (SAFE). J
Gerontol B Psychol Sci Soc Sci 1998;53:43-50.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in
the community. N Engl J Med 1988;319:1701-7.
Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent non-syncopal falls: a
prospective study. JAMA 1989;261:2663-8.
Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D, Fine G. Predictors
of falls among elderly people. Results of two population-based studies. Arch Intern Med
1989;149:1628-33.
Kiely DK, Kiel DP, Burrows AB, Lipsitz LA. Identifying nursing home residents at risk for
falling. J Am Geriatr Soc 1998;46:551-5.
Gluck T, Wientjes HJ, Rai GS. An evaluation of risk factors for in-patient falls in acute and
rehabilitation elderly care wards. Gerontology 1996;42:104-7.
Vellas B, Baumgartner RN, Wayne SJ, Conceicao J, Lafont C, Albarede JL, et al.
Relationship between malnutrition and falls in the elderly. Nutrition 1992;8:105-8.
39. 36
25. Salgado R, Lord SR, Packer J, Ehrlich F. Factors associated with falling in elderly hospital
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
patients. Gerontology 1994;40:325-31.
Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of
evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall:
case-control and cohort studies. BMJ 1997;315:1049-53.
Morse JM, Tylko SJ, Dixon HA. Characteristics of the fall-prone patient. Gerontologist
1987;27:516-22.
Lipsitz LA, Nakajima I, Gagnon M, Hirayama T, Connelly CM, Izumo H, et al. Muscle
strength and fall rates among residents of Japanese and American nursing homes: an
International Cross-Cultural Study. J Am Geriatr Soc 1994;42:953-9.
Mitchell A, Jones N. Striving to prevent falls in an acute care setting--action to enhance
quality. J Clin Nurs 1996;5:213-20.
Menz HB, Lord SR. Foot problems, functional impairment, and falls in older people. J Am
Podiatr Med Assoc 1999;89:458-67.
Joanna Briggs Institute: Evidence based practice information sheets for health
professionals. Falls in hospital. Best Practice 1998;2:1-6.
Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly:
preliminary development of an instrument. Physiother Can 1989;41:304 11.
Simpson JM, Worsefield C, Reilly E, Nye N. A standard procedure for using TURN180 to
test dynamic postural stability among elderly people. Physiotherapy 2002;88:342 51.
Weiner DK, Duncan PW, Chandler J, Studenski SA. Functional reach: a marker of physical
frailty. J Am Geriatr Soc 1992;40:203-7.
Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail
elderly persons. J Am Geriatr Soc 1991;39:142-8.
Kuptniratsaikul V, Dejpratham P, Praditsuwan R. The timed Up & Go: the practical basic
mobility skills assessment. Siriraj Hosp Gaz 2006;58:588-91.
Koski K, Luukinen H, Laippala P, Kivela SL. Physiological factors and medications as
predictors of injurious falls by elderly people: a prospective population-based study. Age
Ageing 1996;25:29-38.
Nygaard HA. Falls and psychotropic drug consumption in long-term care residents: is there
an obvious association? Gerontology 1998;44:46-50.
Ray WA, Thapa PB, Gideon P. Benzodiazepines and the risk of falls in nursing home
residents. J Am Geriatr Soc 2000;48:682-5.
Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med
1989;320:1055-9.
Mulrow CD, Gerety MB, Kanten D, Cornell JE, DeNino LA, Chiodo L, et al. A randomized
trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271:519-24.
40. 37
42. Gardner MM, Robertson MC, Campbell AJ. Exercise in preventing falls and fall related
43.
44.
45.
46.
47.
48.
49.
injuries in older people: a review of randomized controlled trials. Br J Sports Med
2000;34:7-17.
Schoenfelder DP. A fall prevention program for elderly individuals. Exercise in long-term
care settings. J Gerontol Nurs 2000;26:43-51.
Lord SR, Dayhew J. Visual risk factors for falls in older people. J Am Geriatr Soc
2001;49:508-15.
Virvidakis K, Georgiou E, Korkotsidis A, Ntalles K, Proukakis C. Bone mineral content of
junior elite competitive weightlifers. Int J Sports Med 1990;11: 244-6.
Hartard M, Haber P, Ilieva D, Preisinger E, Seidl, Huber J. Systematic strength training as a
model of therapeutic intervention: a controlled trial in postmenopausal women with
osteopenia. Am J Phys Med Rehab 1996; 75:21 8.
Kerr D, Morton A, Dick I, Prince R. Exercise effects on bone mass in post menopausal
women are site specific and load dependent. J Bone Miner Res 1996; 11:218 25.
Chow R, Harrison J E, Notarius C. Effect of two randomized exercise programs on bone
mass of healthy post menopausal women. Br Med J 1987; 295:1441 4.
Heinonen A, Oja P, Sievanen H, Pasanen M, Vuori I. Effect of two training regimens on
bone mineral density in healthy perimenopausal women: a randomized controlled trial. J
Bone Miner Res 1998; 13: 483 90
41. 38
Treatment of osteoporosis
IV-1 Goal of osteoporosis treatment
1.1
ก
˂ ก
ก
˂ ก
ก
ก
F
F F F
ก
ก
Fก
กF
ก
ก
ก ก
ก ก
˂ ก F Fก ก ก ก
F
ก
ก
ก
F ก 3
1.
2.
(
ก
ก
F
ก. ก
. ก
. ก
F
F
interventions
F ˁ
F ก
ก
ˈ
ก F ก
ก
F
F F
/
F ก
F
ก
ก
ก
F
ก
ˈ
ก
ก
F
ก
F
ก
ก ก ก
ก
ก
Fก ก ก ก ก
ก ก กก
ก ก
F ˁ
ก
3.
Fก
ก
ก
Fก
1.3
ก ก
ก ก
interventions
กF F ˈ ก ก (
ก Fก
F II-4) F
/
ก ก ก ก ก ก
ก
F
F F F ก ก ก ก ก ก ก
(
ก)
F F F
ก
F
1.2
ก
กF F
F ˈ
F ก ก ก ก
F
F
F
ก
ก
ก
˂ ก
ก ก
F
ก ก ก
ก
ก
ก
ก
ก
ก
interventions
ก F II-4)
ˈ ก ก
Fก
˂ ก
ก
ก
ก
ก
ˈ
F
F
˂
ก
ก
F
Fก ก
ก ก
F ก
International Osteoporosis Foundation
ก
ก ก
interventions
F
ก F anti-fracture efficacy
Fก F
F
National Osteoporosis
Foundation
ก Fก
Fก F
F
case
finding strategy
Fก
F
F
ก ก 2 Fก ˈ F
1. International Osteoporosis Foundation F
F F clinical risk factors (CRFs)(2)
ʾ . . 2007 Fก
ก F
F F
F
ˈ
(1)
ˈ
ˆ
42. 39
ก ก ก ก
10 ʾ
II-2
2. National Osteoporosis Foundation
FRAX tool ก
ก ก ก ก
10 ʾ ก ก
ก
F Fก
ก Fก ก F ˁ F
ก
a. F
F
F 50
ก
b. F
F
F 50
DXA ก ก
ก ก
1.4
ก
Fก
ก
F F
F F
F
ก
neck BMD
ก
ʾ . . 2008(4) F
Fก ก F
ก ≥ 3%
ก
F
F F
ʾ
ก
ʾ
ก F
ก
F
guideline
F
F
F
ˈ
ก
≥ 20% ก Fก
F FRAX
ก ก ก
ก
ก
ก
ก
ก
F ก ก F
F T-score ≤ -2.5 SD
F ก
Fก
> 50 ʾ
F
F
F
F
F
F
ก
F F
ก
F F
ก (Primary indication)
F
1.
2.
ก
ก
F FRAX(3) ก F
F
Fก
ก
F F F
ก ก ก ก ก
ก
F
F
ก ก F
axial DXA lumbar spine BMD
total hip BMD F
F T-score ≤ -2.5
femoral
(Secondary indication)
F ก ก
ก ก ก ก ก
F ก ก F
axial DXA F
F ก Fก ก (T-score < -1.0 F >-2.5 lumbar spine BMD femoral neck
BMD
total hip BMD) ก F ก
ก ก
F
ˆ
F F F F
F F
1 F
1. ก ก ก F F
F ก ก
F
40 ʾ
F ก
F Fก ก
ก ก ก F ก ก F
ก (wrist fracture) ก ก ก
ก (pelvic fracture) ก ก
F ก (distal femur or proximal tibial fracture) ก ก F
(proximal humeral fracture) ก ก F F (ankle fracture)
2. F
glucocorticoid
F prednisolone
7.5 ก. ก F 3
3. ˈ
Fก
secondary osteoporosis F type-1 DM, thyrotoxicosis, rheumatoid
arthritis, SNSA(seronegative spondyloarthropathy)
US-Asian
Japan
F F BMD
F
F 10
4.
F FRAXTM
year probability of hip fracture ≥ 3%
10 year probability of other major osteoporotic
fractures ≥ 20%
5. clinical risk factors(CRFs) F
F2 F
ก. ˈ F
≥ 65 ʾ
F
≥ 70 ʾ
.
ก < 19 กก./ .
43. 40
.
.
.
.
F
กF
ก
ก ก ก
ก
ก
45 ʾ
ˈ
ˈ
ก
ก
Fก
ก
ก
F ก
ก
ก
F F
ก
axial DXA F
F
F
F
F
− CRFs
F
− ก
F ก ก F
F
( ก
ก axial DXA)
ก
F
F
ˆ
ก ก
กก
ˈ
ก
F F F
F
F
ก ก
F ก ก
axial DXA F
F
F F ˁ
F
Fก
ก ก
F F
1. ก ก
ก ก ก ก
2. ก ก ก
F
ก
F
F
F 65 ʾ
F
F 70 ʾ
F ก ก
ก
F
F
ก F
ก ก
ก
ก
F
−
TM
US-Asian
F ก ก ก ก ก กก
F FRAX
−
Japan
F F BMD F10 year probability of hip fracture ≥ 3%
10 year
probability of other major osteoporotic fractures ≥ 20%
F
IV-2 Pharmacological treatment of osteoporosis
ก
ก F ก
ก
ก ก ก ก ก ก F ก ก
(potential adverse events)
F ˁ
F
ก
˂
ก
ก
ก ก
ก
ก
ก
ก กก
ก
F (clinical trial) F
ก
F
F
ก F ˁ ˈ
ก F
ก
ก
ก ˂ ก
(efficacy)
F
ก
F
F
ก
(tailor therapy)
F Fก ก ก ก
F ˈ anti-fracture efficacy(5)
Anti-fracture efficacy
ก ก
F
F ˈ clinical trial phase-III
F
F
F
F ก ก ก ก ก
F
ก placebo (relative risk reduction)
F ก
ก F bisphosphonates
BMD ก bisphosphonate
ก
F
dose F
BMD F F ก
F ˈ
(control) F
F anti-fracture efficacy F
placebo
F ก ก
ก
ก F bridging study
F
ก
F
dose
ก
44. 41
2.1
ก
ก
ก (Inhibitors of bone resorption)
Bisphosphonates
1. Bisphosphonates
ˈ ก F
ก
ก
ก
ก ก
F
ˆ
F ก
F bisphosphonates F
ก ˈ
ก F F
ก F
(5)
simple bisphosphonates
กF
nitrogen-containing bisphosphonates
2.
F
ก F nitrogen-containing bisphosphonates
action ก
osteoclastic
bone resorption
F กF
กก F
ˆ
ก F
bisphosphonates F ก
F
ก ก
F Fก
ก ก
Alendronate (10 ก.)
Risedronate
F8
F ก
(5 ก.) (
ก ) Alendronate Once Weekly (70 ก.)
Risedronate Once Weekly
(35 ก.) (
F
)
Ibandronate Once Monthly (150 ก.) (
) ก
Alendronate plus
ˈ
Alendronate 70 ก.
ก
Cholecalciferol 2800 iu F
F
F
ก
ก2
F
ˈ
F
F F
Ibandronate injection (3 ก.) (IV infusion
F F
ก
)
Zoledronate injection (5 ก.) (IV infusion F F
ʾ
)
/
1.
ก
ก
2.
ก
ก
F
ก
ก
F
ก
ก
F
กF
F
30-40%
ก F Fก
F
ก
(6,7)
F
F ก
ก
ก
Fก
F
ก
ก
ก
ก
ก
F
ˈ
F
ก
ก F
F
F ก
F
3.
ก
ก F 55 ʾ
F
60 ʾ
4.
F
invasive breast cancer(8)
FF ก
ก F
F
ก ก
F F F
ก F
กF ก
(premature menopause)
F ก ˂ ก ก ก ก
F
F
ก
ˈ
Fก F
ˈ
F ก ก cardiovascular diseases, stroke
F
ก F
F
ก F
˂ ก
ก
Selective estrogen receptor modulators (SERMs)
1. SERMs ˈ
F F steroid
ก estrogen receptor
ก
F
(agonist)
ก
F
(antagonist)
ก F ก
raloxifene ˈ SERM
ˆ
ก ก
F F
ก
ก ก
F
2. ก ก ก
F raloxifene
˂ ก ก
ก ก
F
F ก ก ก ก
F 30 50% F
ก
ก
F
ก
ก
45. 42
(9)
F
ก
ก ก ก F
F F
F กF
F cardiovascular diseases
raloxifene
3. Raloxifene
F 60% F F
Nasal spray calcitonin
1. Calcitonin ˈ
F
F
C-cells
receptor
F osteoclast
Fก
ก
(12)
2. กก ก
F salmon calcitonin
F
ก ก ก ก
ก F
ก กF
ก (RR = 0.64)
F ก F ก
ก
F
vertebral fracture
hip fracture F
3. Salmon calcitonin
F ก
(13)
กก ก
ก F
NSAIDs
2.2
ก
1.
2.
3.
4.
F ก
F ก
ก
ก
ก กF
ก กก ก
Fก ก
stroke(10,11)
F
F
กก
ก
F
ก
F
F
invasive
ก calcitonin
ก ก
F ก
100, 200, 400 IU
ก
F 36% ก F
F calcitonin 200 IU
F ก
F ก F 100 IU
400 IU
F calcitonin
F ก
nonFก F
ก
ก
ก ก
F ก F
F (Stimulators of bone formation)
Recombinant human parathyroid hormone 1-34 (Teriparatide, TPTD)
ก ก
prospective, randomized, double-blind, multinational, placebo-controlled
F
ก ก
ก F F
1,637
(14)
TPTD
ก
F ก ก ก ก ก F F
3 ʾ
F ก F ก F TPTD
20 ก. (n = 541) ก F
F TPTD
40 ก.
(n=552) ก F
F placebo (n=544)
F TPTD 20 ก.
F ก
ก ก ก
ก F 65%
F ก ก non-vertebral fracture
F
53%
ก ก
ก
meta-analysis(15)
F ก
ก
F ˁ
ก ก
ก ก
ก F
F TPTD 20 ก.
40 ก.
F ˁ
ก
F กก F
กF
ก
ก ก
F bisphosphonates
hormone therapy
ก
carcinogenicity study
Fischer
344
F TPTD 24
20 F
F
F ก F 20
ก
Fก F
(70-80%
F
)
F
F ก ก osteosarcoma
ก
dose
(16)
dependent
F ก
F F ก osteosarcoma
F TPTD
25
(14)
ก ก
ก
TPTD F F
20
ก.
ก F F
ˈ
กF ก
F
F
F
F
กF
F
F F
ก
ก
กF 2 ʾ
ก TPTD ˈ
ˈ F
F F
potential side effects
กก F ก F ก
ก ก
F F
ก
F
46. 43
F F
F
1.
2.
3.
4.
ก
F
teriparatide
ก
ก
ก
ก
F ก
ก ก
ก F ก ก ก ก ก F
F ˁ
F
F 65 ʾ
F
F F F
F
F F
BMD T-score
axial DXA ก ก
F
( F ก)
F(lumbar spine
BMD)
ก ก
ก(femoral neck or total hip BMD) ≤ -2.5 SD F ก ก ก ก
ก ก ก ก
F2 F
BMD T-score
axial DXA ก ก
F
( F ก)
F(lumbar spine
BMD)
ก ก
ก(femoral neck or total hip BMD) ≤ -2.5 SD F ก ก ก ก
ก ก ก ก ก
BMD T-score
axial DXA ก ก
F
( F ก)
F(lumbar spine
BMD)
ก ก
ก(femoral neck or total hip BMD) ≤ -3.5 SD F ก ก ก ก
ก ก ก ก
1 F
ก
FFก ก
ก F bisphosphonate F
F
(inadequate(17)
response)
ก
F
F
• vertebral fracture ก
F1
F
กก F
vertebral fracture
F ก
ก
ก ก ก กก
F
F F ก ก
กก F 2 ʾ F
• Lumbar spine BMD
ʾ ≥ 3%
ก (total hip
femoral neck BMD)
F
ʾ ≥ 5% (
Fก
ก F least significant change-LSC)(17,18)
ก ก
กก F 2 ʾ F
F 4
F
ก ก ก
2.3
กF
F F ˁ
F
bisphosphonate
F ก F
F F (patient with good compliance and persistence)
F teriparatide
F F
F
F IV-4-7.5 F
ก
(mixed action agents)
Vitamin D and vitamin D analogue
1.
F
ก Fก ก ก ก ก
Fก F
F ก
F
F F
F กF
800 IU
(19)
F ก calcium
F กF
1,000 ก.
2. ก F
FF ก
ก
F ก ก hip
fracture
nonvertebral fracture F ก F (< 20%) F F
vertebral fracture F
(19)
3.
F
F
ก
F ˁ
F
F ก ก
F
F
ก
ก
ก
ˈ
F
F
F
Menatetrenone
1.
ก
F F ˁ high vitamin K intake
ก ก ก ก
ก ก F ก F F low
(20,21)
(22)
vitamin K intake
F low vitamin K intake
BMD ก F
2. Menaquinone-4
menatetrenone
ก ก ก ก
ก F
50% F
(23,24)
Fก
non-vertebral fracture F
47. 44
3.
F
spine F
(25-27)
menatetrenone
45
maintain BMD
BMD
undercarboxylated osteocalcin F F
1,500 ก.
ก. F ก
Lumbar
(25-28)
Strontium ranelate
1. ก ก
strontium ranelate (SR) ก
F ก ก
ก ก
ก ˈ
3 ʾ
F ก ก ก ก
ก F F
(29)
40-50%
2. ก ก
ก
F non-vertebral fractures
F
16%
F
F hip fractures
36% ก F
F
strontium ranelate
(30)
ก
ก
3. ก ก
ˈ integrated analysis(31)
F strontium ranelate
ก
ก ก
ก F F กF
(>80 ʾ) F 32%
nonvertebral fracture F
ก F 31% ก
ก
ก ก
ก F F กF
ˈ
(32)
F osteopenia
30-50%
ก F ก
ก ก
ก F ก F ก ก
F
(
F
ˈ F F
กF
F
F
FF
ก
F III-3) F
/
ก
F F ˁ
ˈ กF
F
ก
F F ˁ
F
F
ก
ก
F
F
IV-3 Alternative therapy and non-pharmacological treatment
3.1 Hip protector
ก
ก F
F ก
F nursing home
ˆ
fracture F
F hip protector
ก compliance ก
F
ก ก hip
(33-35)
IV-4 Potential adverse events, prerequisites and contraindications in
using anti-osteoporotic agents
4.1
F
F
F F
F
F
(36,37)
ก
−
ก
Fก
ก
ก
F
ก
F
F
ก
F
ก
ก
F
ก
−
ก
F
ก
ก
ก
F
ก
F
)
F
ก ˈ
ก
ก
(38)
(36,37,39)
(
F
ก
48. 45
F
F
F
ˆ
F F
active form
(40,41)
−
ก
ก
ก
F
F
ก F
ก
F
ก
(
F ก ก
−
(42,43)
F
−
F
(43)
F
ก
− ก
− ก F
ก ˈ
F
−
F
ก F
F
(43,45)
F
F
F
กก
F
F ก
กF
(43,44)
F
ก
F
F F
F ก
F
กF
ก ก
F
(46)
กF
F
กF
F
F
(cognitive
(48-51)
(dementia)
F ก
F
ก ก
F
กF
ก
ก ก
F ˁ
F
ก
ˈ F F F
mammogram ก
Bisphosphonates
−
F
)
F
F ˁ
−
F
/
ก F
กก F ก F
ก ก
−
F
F F F ก
F calcitriol
F
F
กF
F
F ก F
function)
F
F
(47)
F
ก ก
ก
F F กF
F
F
ʾ
F F F
F alendronate, risedronate
ibandronate
ˈ
ibandronate
zoledronate
F
F ก
F
F non-ulcer dyspepsia
ก
(52)
F
ก ก atrial fibrillation
ก F F ˁ
F
F
ก ก F
F ก
ก
F
F
ˈ F
ECG กF ก F
bisphosphonate กก F ก F
ก ก
Fก
ก F F
F
−
ก ก
ก ก ก ก ก ก
(osteonecrosis of the jaws)
F
ก
F
ก
ก ก F
bisphosphonate
F
ก
ก ก
F ก ก
F
ก ก
ก ก
F ก
(53)
F F กF ˈ F
F
F
ก ก
ก ก
ก F 10
F
ก
F
ก
ก ก
F
ˈ F
ˆ กF ก F
−
ก ก ก ก ก
ก (atypical fracture) ก
ก F
F
bisphosphonate ˈ
(
>5 ʾ) ก
ˈ low-energy
trauma fracture
ˈ transverse configuration
subtrochanteric
shaft of
49. 46
femur
(54,55)
F F
F
ก
ก
F ก
F
ก
ก
F F
กF
ก
˂
F กF
ˈ
กF
−
ก
F
(post-dose
reaction)
F F
(56,57)
bisphosphonate
ก
F ก F
ก F
กF
F F ˈ F
F ก
ก F
ก ก
F
ก
F
F
F ก 2-3
−
ก F bisphosphonates F ˈ
oral form F ก F ก
ก
ก.
F
F F
F F
F ก
ก F
F
ก
1
F ก
ก
. ก
F F
ก
F ก
F ( F ก ก
F
F
ก )
F
ก
ก ก
F
ก
ก
Fก ก ก
F
.
F กก
ก F F
ก ก F F
ˈ
1
F ก
ก bisphosphonates
ก
ก F F
F
Fก
ก
F (esophagitis)
ก F bisphosphonates F ˈ
IV infusion F F
F
−
F
ก
infusion F
F F
F ก F 15
ก
F ก
F ˁ
F ˆ
ก
ก
F ≥ 30 mL/min (
ˈ creatinine clearance ก F)
F
ก
infusion
F
ˈ F F
F
F F
Raloxifene
− ก
ʾ ก
F
F
ก
F ½
F
½
F ก
F
F
F
F GFR
ก
F
(venous thromboembolism)
F
F F
F ก
(59)
hot flushes
ก ˈ
(58,59)
F กF ก
Strontium F
F
F F F ˈ
− F
ก ก
F
−
(61)
thromboembolism)
F
Teriparatide F
−
ก ก
ก
−
5 ʾ
ก
F
F
F F
F
F
ก
F
F
F
(60)
F
(venous
F ก ก
F
ˆ
(62)
F
ก
F
F
ก
(29,30,61)
F
ก
F 2
ก F
F ˁ
ˈ
F
กF F(63,64)
F F
F
50. 47
(16,65)
ก
F
teriparatide ˈ
กก F 20
F
ก ก osteosarcoma
F
ก ˈ ก F
20 F
F
F ก
Fก F
(70-80%
F
)
F
F F
F
ก ก osteosarcoma
ก F teriparatide F 2
ก
− F
(66,67)
ก
F
ก
Fก ก F
F
F
F F ˁ
ก ˈ
กF
F
ก
ก
(67)
osteosarcoma กF
ก ก ก
2
ก F F teriparatide
ก
ก F 500,000
F ก กF
ก F
ก ก osteosarcoma F
(66)
> 60 ʾ
ʾ 1 F 250,000
F
F
F
F F กก F (
F กก F
)
F F ก ก
ก ก
(68)
F
F
F
−
(prerequisite) ก F teriparatide
ก. F
F F F teriparatide
ก 2 ʾ
. F
F F ˁ
F ก ก osteosarcoma F
ˈ
Paget s disease
F
F ก
ก ก
F
alkaline phosphatase
F
F
ก epiphysis
F ʽ
. F
F F F ˁ
ˈ
5 ʾ
.
ก ˈ
F
F F
ก F teriparatide
ˈ F ก
กF
F F
serum creatinine, serum
calcium
intact PTH F ก
−
ก F
ก
Calcitonin
− ก
F
Menatetrenone F
−
F ก
F
(23,70)
F F
ก ก F
F
(12,69)
F
ก
F
F
F
warfarin
ก
F warfarin
IV-5 Monitoring treatment and duration of treatment
5.1 ก
ก
(effectiveness)
ก
ก ก
ก ก
ก ก ก F
ก
1. ก
ก
F ˁ
F
F ก ก ก ก ก
ก
F
2
F (adverse events)
F F ˈ
F
F
(drug response) ก
ก ˂
ก ก
F ก
ˆ
F
ก
F
ก
ก
F
ก
F
ˈ
ก
F F
51. 48
(
Fก ก
F ˁ
F
ก ก
F
1.1. ก
)
ก ก ก
F F
ˆ
ก ก
ก
F ก
F
F
F
F
กF
F
FF
F2
axial DXA
กก
F BMD
F
F F
F
ก กF
F
F
F ก
2
F F F กF 1 ʾ
axial DXA
F ˈ
F
กF
F
ก ก
F ก
กก
BMD F
axial DXA
ก
กก
F F F Lumbar spine BMD
F
ʾ ≥ 3%
(17,18)
total hip BMD
femoral neck BMD
ʾ ≥ 5%
Fก ก
กF 1 ʾ F
F ก
BMD ก
F ˁ
F
F
(probable inadequate response)
Fก
BMD F ก ก F
ก F
F
F
F F ก
F ก ก ก กก
F ก ก
F ก ก
BMD
กก F ก F ก F ก
F F ˁ
F
F (inadequate response)
1.2. ก
F bone turnover markers
กก
F ˈ
ก
ก ก F
bone resorption marker
F
F ˈ ก F ก F
ก ก F
bone formation marker
F
F
F ก
2
กF
F
ˈ F
F F
F F กF 3
ก
F bone turnover markers (BTMs)
F
กก F 30-40%
F
ก
ก
กก
BTMs variation กก F
ก
F กF
ก F NPO F ˁ 12 . . กF
F
F
F
(7.00-9.00 .)
F ˈ F
ก ก
2. ก
ก F
ก
F
ก
F ˁ
F
F ก F
F (compliance)
ก F
(persistence)
ˆ
F
F ก ก
F ก
ก
F ก F
F F
ก
ก ก ก
F F ˁ
F
F
ก F
กF
Fก
F
ก F
F
F F F F
F ก F
F F 80%
ʾ (medication possession ratio: MPR
≥ 80%)
5.2
BMD
ก
F F ก
F
ก
ก
F
ก
F
ก
กF
Fก ˆ
F
F ˆ
F
ˆ
ก F ก F ˁ
ก
F
ˈ clinical trial
กก
ก F F
F ก ก ก ก ก
F ˁ
F
กF F ก ˆ
ก
ˆ
F FF
ก ˈ
F F
F ก ก ก
F ˁ
ˈ
F ก F
F F
ก clinical study
F ก
ก
ก
F
anti-fracture
efficacy F ก F
ก 5 ʾ F(
ก
F)
F F ˁ
F
F ก F
(good compliance and persistence) F new fracture ก
F
F
53. 50
4.1
Alendronate
10 mg
(ALN)
ก
ก
F
Benefit and Indication for use
˂ ก
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
(postmenopausal
osteoporosis, PMO)
- F ก ก
ก ก
ก ก
ก
F
F (Glucocorticoidinduced osteoporosis, GIO)
- F ก ก
ก ก
F
(Male idiopathic osteoporosis, MIO)
˂ ก
ก
ก ก
F F ก F F
ก ALN 10
mg
Alendronate
once weekly
70 mg
(ALN-OW)
Alendronate
˂ ก
plus
F F
ALN 70 mg mg
+
Cholecalcifer
ol 2800 IU
(ALN-plus)
ก
ก
ก
F F
ก
ก ALN 10
ก
ก
ก
F
F ก ก(71-74)
ก
(vertebral fracture),ก ก
ก (hip fracture)
ก กF
ก
กก ก
(nonvertebral fracture)
- F
ก
- F
- F
ก ALN 10 mg(75)
F
- F
ก ALN 10 mg
- F
F
- ก F vitamin D3
2800
IU F
F
= 400 IU/d F
กF ˆ
hypovitaminosis D
vitamin D deficiency(76)
54. 51
Risedronate
5 mg
(RIS)
Risedronate
once weekly
35 mg
(RIS-OW)
Ibandronate
Once
monthly
150 mg
(IBN-OM)
Benefit and Indication for use
˂ ก
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
(postmenopausal
osteoporosis, PMO)
- F ก ก
ก ก
ก
ก ก
F
F
(Glucocorticoid-induced osteoporosis,
GIO)
- F ก ก
ก ก
F
(Male idiopathic osteoporosis, MIO)
˂ ก
ก
ก ก
F F ก F F
ก RIS 5 mg
F
-
Fก ก
ก ก
(vertebral
fracture),ก ก ก (hip fracture)
ก กF
ก
ก
ก ก
(non-vertebral fracture)
- F
(77,78)
- F
- F
ก RIS 5mg(79)
F
F ก ก(80,81)
ก ก
(vertebral fracture),
ก กF
ก
ก
(82)
ก ก
(non-vertebral
fracture)
- F
Zoledronate
˂ ก
ก
ก ก
F ก ก(56,57)
infusion
F F ก F ( US-FDA)
ก ก
(vertebral fracture),
ก ก
ก ก ก (hip fracture)
ก ก
every 1 year - F ก ก
5 mg
(postmenopausal
F
ก
กก ก
(ZOL)
osteoporosis, PMO)
(non-vertebral fracture)
- F ก ก
ก ก
ก ก - F F
ก1 ʾ
ก
F
F(Glucocorticoidinduced osteoporosis, GIO)
*
Ibandronate F ก
F ก ก ก ก
(vertebral fracture) ˈ
ก
ก RCTs F ก
F ก ก ก ก F
ก
กก ก
(non-vertebral fracture) ˈ ก
กก synthesis data ก pooled analysis
RCTs
˂ ก
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
(postmenopausal
osteoporosis, PMO)
-
55. 52
Estrogen
Benefit and Indication for use
˂ ก
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
(postmenopausal osteoporosis,
PMO)
Raloxifene
(RLX) 60 mg
Calcitonin
nasal spray
200 IU/puff
˂ ก
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
(postmenopausal osteoporosis,
PMO)
˂ ก
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
(postmenopausal osteoporosis,
PMO)
Menatetrenone
(MK-4) 15 mg
ก
ก ก
F F ก F ( Japan FDA)
- F ก ก
ก ก
F
ก ก
ก ก
- F
(
preparation
F ก
ก
F ก ก(6,7,8)
(vertebral fracture),
ก (hip fracture)
ก
F
F
efficacy)
F ก ก(9,83)
(vertebral fracture)
- F
F ก ก(12)
ก ก
(vertebral fracture)
- F
ก
กก ก
(13)
( Fก 8
ก ก ก ก
F)
- F
ก
-
ก
- F
ก
F ก ก(23)
(vertebral fracture)
3 (45 mg/d)
(postmenopausal osteoporosis,
PMO)
**
ก
F ก ก
ก WHI
F ก ก ก ก
(vertebral fracture)
ก ก F
ก
กก ก
(non-vertebral fracture) ˈ ก
F conjugate equine estrogen F F extend ก F
preparation
ก
56. 53
Strontium
ranelate
2 g/sachet
Benefit and Indication for use
ก
ก ก
F F ก F ( EMEA)
- F ก ก
ก ก
(postmenopausal osteoporosis,
PMO)
Teriparatide
20 µg/inject
F ก 1,200
mg/d
(Elemental
Calcium)
ก
ก ก
F F ก F ( US-FDA)
- F ก ก
ก ก
F
F ก ก(29,30)
ก ก
(vertebral fracture)
ก กF
ก
ก
ก ก
(non-vertebral fracture)
- F
-
F ก ก(14,15)
ก ก
(vertebral fracture),
ก ก ก (hip fracture)
ก กF
ก
กก ก
(non-vertebral fracture)
- F
F
-
(postmenopausal osteoporosis,
PMO)
- F ก ก
ก ก
ก
ก ก
F
F
(Glucocorticoid-induced
osteoporosis, GIO)
- F ก ก
ก ก
F
(Male idiopathic osteoporosis, MIO)
F ˁ ก
ก
F
F
(84)
F ˁ
F ก
F
ก ก
F
F ˂ ก ก
ก ก ก ก ก
57. 54
Benefit and Indication for use
F ˁ ก
FF ก
400-800
ก F
F
IU / d
F
F
F ก ก
ก ก
ก
ก ก
F
F
-Alphacalcidol (Glucocorticoid-induced
(0.5-1
osteoporosis, GIO) (86,87)
ก F
FF ก
ก
ก ก
ก
F
)
-Calcitriol
ก F
(88,89)
(0.25-0.5
ก ( ≥ 65 ʾ)
ก F
)
ก
F
FF ก
ก ก F
F
ก
FF ก
F
F
(85)
ก ก
ก F
- ก ก
hypercalcemia
(88)
hypercalcicuria
F
1. Kanis JA, Seeman E, Johnell O, Rizzoli R, Delmas P. The perspective of the international
osteoporosis foundation on the official positions of the international society for clinical
densitometry. J Clin Densitom. 2005;8(2):145-7.
2. Kanis JA, Borgstrom F, De Laet C, Johansson H, Johnell O, Jonsson B, et al. Assessment
of fracture risk. Osteoporos Int. 2005;16(6):581-9.
3. FRAX-WHO fracture risk assessment tool, http://www.shef.ac.th/FRAX.
4. NOF Clinician s Guide to Prevention and Treatment of Osteoporosis 2008.
5. Russell G, Xia ZD, Dunford JE, Oppermann U, Kwaasi A, Hulley PA, et al. Bisphosphonate:
an update on mechanisms of action and how these related to clinical efficacy. Ann NY Acad
Sci 2007;1117:209-57.
6. Torgerson DJ, Bell-Syer SE. Hormone replacement therapy and prevention of non-vertebral
fractures: a meta-analysis of randomized trials. JAMA 2001;285:2891-7.
7. Cauley JA, Robbins J, Chen Z, Cummings SR, Jackson RD, LaCroix AZ, et al. Effects of
estrogen plus progestin on risk of fracture and bone mineral density: the Women s Health
Initiative randomized trial. JAMA 2003;290:1729-8.
58. 55
8. Roussow JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML et al. Risks
and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from
the Women s Health Initiative randomized controlled trial. JAMA 2002;288:321-33.
9. Ettinger B, Black DM, Mitlak BH, Knickerbocker RK, Nickelsen T, Genant HK et al.
Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated
with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of
Raloxifene Evaluation (MORE) Investigators. JAMA 1999;282:637-45.
10. Vogel VG, Costantino JP, Wickerham DL, Cronin WM, Cecchini RS, Atkins JN et al. Effect
of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other
disease outcomes: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trail. JAMA
2006;295:2727-41.
11. Mosca L, Barrett-Connor E, Wenger NK, Collins P, Grady D, Kornitzer M et al. Design and
methods of the Raloxifene Use for The Heart (RUTH) study. Am J Cardiol 2001;88:392-5.
12. Chesnut CH III, Silverman S, Andriano K, Genant H, Gimona A, Harris S, et al. A
randomized trial of nasal spray salmon calcitonin in postmenopausal women with
established osteoporosis: the prevent recurrence of osteoporotic fractures study. PROOF
Study Group. Am J Med 2000;109(4): 267-76.
13. Silverman SL, Azria M. The analgesic role of calcitonin following osteoporotic fracture.
Osteoporosis Int 2002;13:858-67.
14. Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, et al. Effect of
parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal
women with osteoporosis. N Engl J Med 2001;344:1434-41.
15. Nevitt MC, Chen P, Dore RK, Reginster JY, Kiel DP, Zanchetta JR, et al. Reduced risk of
back pain following teriparatide treatment: a meta-analysis. Osteoporosis Int
2006;17(2):273-80.
16. Vahle JL, Long GG, Sandusky G, Westmore M, Ma YL, Sato M. Bone neoplasms in F344
rats given teriparatide [rhPTH(1 34)] are dependent on duration of treatment and dose.
Toxicol Pathol 2004;32(34):426 38.
17. Diez-Perez A, Gonzalez-Macias J. Inadequate responders to osteoporosis treatment:
proposal for an operational definition. Osteoporosis Int 2008;19:1511 16.
18. Lewiecki EM, Watts NB. Assessing response to osteoporosis therapy. Osteoporosis Int
2008;19:1363 8.
19. Avenell A, Gillespie WJ, Gillespie LD, O Connell DL. Vitamin D and vitamin D analogues for
preventing fractures associated with involutional and post-menopausal osteoporosis.
Cochrane Database Syst Rev 2005, 20(3). Art. No.: CD000227. DOI:
10.1002/14651858.CD000227.pub2.
20. Feskanich D, Weber P, Willett WC, Rocket H, Booth SL, Colditz GA. Vitamin K intake and
hip fractures in women: a prospective study. Am J Clin Nutr 1999;69:74-9.
59. 56
21. Booth SL, Tucker KL, Chen H, Hannan MT, Gagnon D, Cupples LA, et al. Dietary vitamin K
intakes are associated with hip fracture but not with bone mineral density in elderly men
and women. Am J Clin Nutr 2000;71:1201-8.
22. Booth SL, Broe KE, Gagnon DR, Tucker KL, Hannan MT, McLean RR, et al. Vitamin K
intake and bone mineral density in women and men. Am J Clin Nutr 2003;77:512-6.
23. Shiraki M, Shiraki Y, Aoki C, Miura M. Vitamin K2 (Menatetrenone) Effectively Prevents
Fractures and Sustains Lumbar Bone Mineral Density in Osteoporosis. J Bone Miner Res
2000;15(3):515-21.
24. Cockayne S, Adamson J, Lanham-New S, Shearer MJ, Gilbody S, Torgerson DJ. Vitamin K
and the Prevention of Fractures: systematic review and meta-analysis of randomized
controlled trials. Arch Intern Med 2006;166(12):1256-61 .
25. Purwosunu Y, Muharram , Rachman IA, Reksoprodjo S, Sekizawa A. Vitamin K2 treatment
for postmenopausal osteoporosis in Indonesia. J Obstet Gynaecol Res 2006;32(2):230-4.
26. Ushiroyama T, Ikeda A, Ueki M. Effect of continuous combined therapy with vitamin K2 and
vitamin D3 on bone mineral density and coagulofibrinolysis function in postmenopausal
women. Maturitas 2002;41:211 21.
27. Iwamoto J, Takeda T, Ichimura S. Effect of combined administration of vitamin D3 and
vitamin K2 on bone mineral density of the lumbar spine in postmenopausal women with
osteoporosis. J Orthop Sci 2000;5:546 51.
28. Bunyaratavej N, Penkitti P, Kitimanon N, Boonsangsom P, Bonjongsat P, Yunoi S. Efficacy
and safety of menaquinone-4 in postmenopausal Thai women. J Med Assoc Thai
2001;84(suppl2):S553-9.
29. Meunier PJ, Roux C, Seeman E, Ortolani S, Badurski JE, Spector TD, et al. The effects of
strontium ranelate on the risk of vertebral fracture in women with postmenopausal
osteoporosis. N Engl J Med 2004;350(5):459-68.
30. Reginster JY, Seeman E, De Vernejoul MC, Adami S, Compston J, Phenekos C, et al.
Strontium ranelate reduces the risk of nonvertebral fractures in postmenopausal women
with osteoporosis; Treatment of Peripheral Osteoporosis (TROPOS) Study. J Clin
Endocrinol Metab 2005;90(5):2816 22.
31. Seeman E. Strontium ranelate: vertebral and non-verttenral fractures risk reduction. Curr
Opin Rheumatol 2006;18(suppl1):S17-20.
32. Seeman E, Devogelaer JP, Lorenc R, Spector T, Brixen K, Balogh A, et al. Strontium
Ranelate Reduces the Risk of Vertebral Fractures in Patients With Osteopenia. J Bone
Miner Res 2008;23:433 8.
33. Van Schoor NM, Smit JH, Twisk JW, Bouter LM, Lips P. Prevention of hip fractures by
external hip protectors: a randomized controlled trial. JAMA 2003;289(15):1957-62.
34. Birks YF, Porthouse J, Addie C, Loughney K, Saxon L, Baverstock M, et al. for the Primary
Care Hip Protector Trial Group. Randomized controlled trial of hip protectors among woman
living in the community. Osteoporos Int 2004;15(9):701-6.
60. 57
35. Sawka AM, Boulos P, Beattie K, Thabane L, Papaioannou A, Gafni A, et al. Do hip
protectors decrease the risk of hip fracture in institutional and community-dwelling elderly?
A systematic review and meta-analysis of randomized controlled trials. Osteoporos Int
2005;16(12):1461-74.
36. Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS, McPherson GC, et al.
for RECORD Trial Group. Oral vitamin D3 and calcium for secondary prevention of lowtrauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D,
RECORD): a randomized placebo-controlled trial. Lancet 2005;365(9471):1621-8.
37. Prince RL, Devine A, Dhaliwal SS, Dick IM. Effects of calcium supplementation on clinical
fracture and bone structure: results of a 5-year, double-blind, placebo-controlled trial in
elderly women. Arch Intern Med 2006;166(8):869-75.
38. Bolland MJ, Barber PA, Doughty RN, Mason B, Horne A, Ames R, et al. Vascular events in
healthy older women receiving calcium supplementation: randomized controlled trial. BMJ
2008;336(7638):262-6.
39. Hsia J, Heiss G, Ren H, Allison M, Dolan NC, Greenland P, et al. for Women's Health
Initiative Investigators. Calcium/vitamin D supplementation and cardiovascular events.
Circulation 2007;115(7):846-54.
40. Avenell A, Gillespie WJ, Gillespie LD, O'Connell DL. Vitamin D and vitamin D analogues for
preventing fractures associated with involutional and post-menopausal osteoporosis.
Cochrane Database Syst Rev (Online) 2005(3):CD000227.
41. Cranney A, Horsley T, O'Donnell S, Weiler H, Puil L, Ooi D, et al. Effectiveness and safety
of vitamin D in relation to bone health. Evid Rep Technol Assess; 2007(158):1-235.
42. Chlebowski RT, Hendrix SL, Langer RD, Stefanick ML, Gass M, Lane D, et al. for WHI
Investigators. Influence of estrogen plus progestin on breast cancer and mammography in
healthy postmenopausal women: the Women's Health Initiative Randomized Trial. JAMA
2003;289(24):3243-53.
43. Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, et al. for
Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in
postmenopausal women with hysterectomy: the Women's Health Initiative randomized
controlled trial. JAMA 2004;291(14):1701-12.
44. Cushman M, Kuller LH, Prentice R, Rodabough RJ, Psaty BM, Stafford RS, et al. for
Women's Health Initiative Investigators. Estrogen plus progestin and risk of venous
thrombosis. JAMA 2004;292(13):1573-80.
45. Manson JE, Hsia J, Johnson KC, Rossouw JE, Assaf AR, Lasser NL, et al. for Women's
Health Initiative Investigators. Estrogen plus progestin and the risk of coronary heart
disease. N Engl J Med 2003; 349(6): 523-34.
46. Wassertheil-Smoller S, Hendrix SL, Limacher M, Heiss G, Kooperberg C, Baird A, et al. for
WHI Investigators. Effect of estrogen plus progestin on stroke in postmenopausal women:
the Women's Health Initiative: a randomized trial. JAMA 2003;289(20):2673-84.
61. 58
47. Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, et al.
Postmenopausal hormone therapy and risk of cardiovascular disease by age and years
since menopause. JAMA 2007;297(13):1465-77.
48. Rapp SR, Espeland MA, Shumaker SA, Henderson VW, Brunner RL, Manson JE, et al. for
WHIMS Investigators. Effect of estrogen plus progestin on global cognitive function in
postmenopausal women: the Women's Health Initiative Memory Study: a randomized
controlled trial. JAMA 2003;289(20):2663-72.
49. Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, et al. for WHIMS
Investigators. Estrogen plus progestin and the incidence of dementia and mild cognitive
impairment in postmenopausal women: the Women's Health Initiative Memory Study: a
randomized controlled trial. JAMA 2003;289(20):2651-62.
50. Shumaker SA, Legault C, Kuller L, Rapp SR, Thal L, Lane DS, et al. for Women's Health
Initiative Memory Study. Conjugated equine estrogens and incidence of probable dementia
and mild cognitive impairment in postmenopausal women: Women's Health Initiative
Memory Study. JAMA 2004;291(24):2947-58.
51. Espeland MA, Rapp SR, Shumaker SA, Brunner R, Manson JE, Sherwin BB, et al. for
Women's Health Initiative Memory Study. Conjugated equine estrogens and global cognitive
function in postmenopausal women: Women's Health Initiative Memory Study. JAMA
2004;291(24):2959-68.
52. MacLean C, Newberry S, Maglione M, McMahon M, Ranganath V, Suttorp M, et al.
Systematic review: comparative effectiveness of treatments to prevent fractures in men and
women with low bone density or osteoporosis. Ann Intern Med 2008;148(3):197-213.
53. Khosla S, Burr D, Cauley J, Dempster DW, Ebeling PR, Felsenberg D, et al.; American
Society for Bone and Mineral Research. Bisphosphonate-associated osteonecrosis of the
jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone
Miner Res 2007;22(10):1479-91.
54. Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft
fractures associated with alendronate use. J Orthop Trauma 2008;22(5):346-50.
55. Kweka EBK, Goh SK, Koh JSB, Ping MA, Howe TS. An emerging pattern of
subtrochanteric stress fractures: A long-term complication of alendronate therapy? Injury
2008;39:224-31.
56. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, et al. for the HORIZON
Pivotal Fracture Trial. Once-Yearly Zoledronic Acid for Treatment of Postmenopausal
Osteoporosis. N Engl J Med 2007;356:1809-22.
57. Lyles KW, Colón-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, et al. for
the HORIZON Recurrent Fracture Trial. Zoledronic acid and clinical fractures and mortality
after hip fracture. N Engl J Med 2007;357(18):1799-809.
58. Grady D, Ettinger B, Moscarelli E, Plouffe L Jr, Sarkar S, Ciaccia A, et al. for the Multiple
Outcomes of Raloxifene Evaluation Investigators. Safety and adverse effects associated
62. 59
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
with raloxifene: multiple outcomes of raloxifene evaluation. Obstet Gynecol
2004;104(4):837-44.
Davies GC, Huster WJ, Lu Y, Plouffe L Jr., Lakshmanan M. Adverse events reported by
postmenopausal women in controlled trials with raloxifene. Obstet Gynecol 1999; 93(4):
558-65.
Cranney A, Adachi JD. Benefit-risk assessment of raloxifene in postmenopausal
osteoporosis. Drug Saf 2005;28(8):721-30.
Reginster JY, Sarlet N, Lejeune E, Leonori L. Strontium ranelate: a new treatment for
postmenopausal osteoporosis with a dual mode of action. Curr Osteoporos Rep
2005;3(1):30-4.
Miller PD, Bilezikian JP, Diaz-Curiel M, Chen P, Marin F, Krege JH, et al. Occurrence of
hypercalciuria in patients with osteoporosis treated with teriparatide. J Clin Endocrinol
Metab 2007;92(9):3535-41.
Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, et al. Effect of
parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal
women with osteoporosis. N Engl J Med 2001;344(19):1434-41.
Miller PD. Monitoring osteoporosis therapies. Curr Osteoporos Rep 2007;5(1):38-43.
Jolette J, Wilker CE, Smith SY, Doyle N, Hardisty JF, Metcalfe AJ, et al. Defining a
noncarcinogenic dose of recombinant human parathyroid hormone 1-84 in a 2-year study in
Fischer 344 rats. Toxicol Pathol 2006; 34; 929-40.
Harper KD, Krege JH, Marcus R, Mitlak BH. Letter to the Editor: Osteosarcoma and
Teriparatide? J Bone Miner Res 2007;22(2):334.
Subbiah V, Madsen VS, Raymond AK, Benjamin RS, Ludwig JA. Of mice and men:
divergent risks of teriparatide-induced osteosarcoma. Osteoporos Int 2009 (on line first) DOI
10.1007/s00198-009-1004-0.
Hodsman AB, Bauer DC, Dempster DW, Dian L, Hanley DA, Harris ST, et al. Parathyroid
hormone and teriparatide for the treatment of osteoporosis: a review of the evidence and
suggested guidelines for its use. Endocr Rev 2005;26(5):688-703.
Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C; Osteoporosis Methodology
Group and The Osteoporosis Research Advisory Group. Meta-analyses of therapies for
postmenopausal osteoporosis. IX: Summary of meta-analyses of therapies for
postmenopausal osteoporosis. Endocr Rev 2002;23(4):570-8.
Knapen MH, Schurgers LJ, Vermeer C. Vitamin K2 supplementation improves hip bone
geometry and bone strength indices in postmenopausal women. Osteoporos Int
2007;18(7):963-72.
Black DM, Thompson DE, Bauer DC, Ensrud K, Musliner T, Hochberg MC, et al. Fracture
risk reduction with alendronate in women with osteoporosis: the Fracture Intervention Trial.
J Clin Endocrinol Metab 2000;85:4118-24.
63. 60
72. Cranney A, Wells G, Willan A, Griffith L, Zytarak N, Robinson V, et al. Meta-analysis of
alendronate for the treatment of postmenopausal women. Endocr Rev 2002;23:508-16.
73. Papapoulos SE, Quandt SA, Liberman UA, Hochberg MC, Thompson DE. Meta-analysis of
the efficacy of alendronate for the prevention of hip fractures in postmenopausal women.
Osteoporosis Int 2005;16:468-74.
74. Well GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, et al. Alendronate for
the primary and secondary prevention of osteoporotic fractures in postmenopausal women.
(Review) Cochrane Database of Systematic Rev 2008;1:1-71.
75. Schnitzer T, Bone HG, Crepaldi G, Adami S, McClung M, Keil D, et al. Therapeutic
equivalence of alendronate 70 mg once-weekly and alendronate 10 mg daily in the
treatment of osteoporosis: Alendronate Once-weekly Study Group. Aging Clin Exp Res
2000;12:1-12.
76. Recker R, Lips P, Felsenberg D, Lippuner K, Benhamou L, Hawkins F, et al. Alendronate
with and without cholecalciferol for osteoporosis: result of a 15 week randomized controlled
trial. Curr Med Res Opin 2006;22:1745-55.
77. Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, et al. Effects of
risedronate treatment on vertebral and non-vertebral fractures in women with
postmenopausal osteoporosis: a randomized controlled trial. JAMA 1999;282:1344-52.
78. Cranney A, Tugwell P, Adachi J, Weaver B, Zytarak N, Papaioannou A, et al. Meta-analysis
of risedronate for the treatment of postmenopausal osteoporosis. Endocr Rev 2002;23:51723.
79. Brown JP, Kendler DL, McClung MR, Emkey RD, Adachi JD, Bolognese MA, et al. The
efficacy and tolerability of risedronate once a week for the treatment of postmenopausal
osteoporosis. Calcif Tissue Int 2002;71:103-11.
80. Chesnut-III C, Skag A, Christiansen C, Recker R, Stakkestad JA, Hoiseth A, et al. Effect of
oral Ibandronate administered daily or intermittently on fracture risk in postmenopausal
osteoporosis. J Bone Miner Res 2004;19:1241-49.
81. Reginster JY, Adami S, Lakatos P, Greenwald M, Stepan JJ, Silverman C, et al. Efficacy
and tolerability of once-monthly oral ibandronate in postmenopausal osteoporosis: 2 year
results from the MOBILE study. Ann Rheum Dis 2006;65:654-61.
82. Adachi R, et al. J Bone Miner Res 2007; 22(suppl 1):S210-S211(Abstract).
83. Cranney A, Tugwell P, Zytaruk N, Robinson V, Weaver B, Adachi J, et al. for the
Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group. Metaanalyses of therapies for postmenopausal osteoporosis. IV. Meta-analysis of raloxifene for
the prevention and treatment of postmenopausal osteoporosis. Endocr Rev. 2002;23(4):
524-8.
84. Sanders KM, Nowson CA, Kotowicz MA, Briffa K, Devine A, Reid IR. Calcium and bone
health: position statement for the Australian and New Zealand Bone and Mineral Society,
64. 61
85.
86.
87.
88.
89.
Osteoporosis Australia and the Endocrine Society of Australia. Med J Aust 2009;190:316
20.
Richy F, Schacht E, Bruyere O, Ethgen O, Gourlay M, Reginster JY. Vitamin D analogs
versus native vitamin D in preventing bone loss and osteoporosis-related fractures: a
comparative meta-analysis. Calcif Tissue Int 2005;76(3):176-86.
Richy F, Ethgen O, Bruyere O, Reginster JY. Efficacy of alphacalcidol and calcitriol in
primary and corticosteroid-induced osteoporosis: a meta-analysis of their effects on bone
mineral density and fracture rate. Osteoporos Int 2004;15(4):301-10.
de Nijs RN, Jacobs JW, Algra A, Lems WF, Bijlsma JW. Prevention and treatment of
glucocorticoid-induced osteoporosis with active vitamin D3 analogues: a review with metaanalysis of randomized controlled trials including organ transplantation studies. Osteoporos
Int 2004;15(8):589-602.
Avenell A, Gillespie WJ, Gillespie LD, O'Connell D. Vitamin D and vitamin D analogues for
preventing fractures associated with involutional and post-menopausal osteoporosis.
Cochrane Database Syst Rev 2009;15(2):CD000227.
Ringe JD, Schacht E. Potential of alfacalcidol for reducing increased risk of falls and
fractures. Rheumatol Int 2009;29(10):1177-85.
65. 62
Glucocorticoid-induced osteoporosis (GIO)
V-1 Introduction and epidemiology
1.1
ก
F
F (glucocorticoids)
ˈ
Fก ก
ก
inflammatory
immunosuppressive ก F ก ก
F
F
(rheumatic disease) ˈ F
F F ก
ก
F
F
F F ก F
F
ˈ Fก ก
ก ก
ˈ F
ก
ˈ
F
secondary osteoporosis ก ก
F ก
F
F
F ก ก ก ˈ 1.33 F
non-vertebral fracture 1.61 F
ก ก ก ก
F
ก ก ก ก ก
F
Fก
(1,2)
F
ก
ก
F
F
antiFก
ก
2.6
ก ก
1.2
กก ก
3% ก ก
F 1 70 (
3 ʾ(4)
(3)
ก
F
ก
ก ก
ก
Fก
กก F
F
ก
1.4%)
กก F 50 ʾ
ก
F ˁ
กก F 55 ʾ
F F
ก F F 3
F ก
F
ก กก
F
6-12
ก F ก
ก กก ก
ก ก
ก ก
ก F
F ก
ก ก
5% ʾ ก
1-2%
ก ก
Fก
ก
F
F F (daily dose)
F
ก
F ก
(5)
F ก
1F
F
ก
F
F
F
ก
ก trabecular
ʾ F
ก ก
F (cumulative dose)
(6,7)
V-2 Pathophysiology and risk assessment
2.1 ก กก ก
glucocorticoid-induced osteoporosis (GIO) F F
F
ก
ˆ
F ก F
F
F
F ก ก
(8-9)
GIO
ก ก ก ก ก ก
F ˁ
F
F
F ก ก Fก F F
ก
(10-11)
F
F
F ก ก ก กF F F
Fก ˂ ก
ก
F
ก
F
ก
F
F ก ก
ˈ F F ก
F
(8)
F ก F
Fก ก ก
F F F F
F ก
F
F ก ก
ก
(ankylosing spondylitis) ˆ
ก
F
F กF
ก
F
(12)
ก กกF
F
66. 63
ก ก ก
F
F
Fก ก ก ก ก
Fก F ก ก
ก
(14)
ก ก
F ก secondary hyperparathyroidism
ก
ก F
(15)
(16)
ก
F
ก
ˆ
ก
F F ก ก (osteoblast)
F ก ก
(apoptosis)
osteoblast
F
ก ก (osteoclast)(14,17)
receptor activator
NF-KB ligand (RANKL)
osteoprotegerin (OPG)(18) ก ก
(19)
hypothalamic pituitary gonad axis
ก F
F
testosterone(20)
adrenal androgen(21)
F ก F ก ก
F
ก
F
F ก ก
ก ก
(13)
2.2 ˆ
ˆ
ก
ˆ
ก ก ก
ˆ
F ก ก ก ก ก F
F F
ˆ
F
F กF
ก (≥ 65 ʾ)(22)
body mass index)
F ˈ
Fก ก
(25)
(chronic lung disease) F F ก
ก
กก
F ก ก
F
ก
F
F
ก ก ก ก ก
F ก
F T Score < -1.0 F
F ก ก F F
ก
ʾ ก
guideline
ก
F ˁ
F
ก
F
F
ก ก กก
F
ก
F ก
F
ก ก
F F
ก
ก ก
ก
ก
(23-24)
(low
( F
F ก
F)
(26)
F
(organ transplantation) F
ก
F
กF
F F F F
F ˁ
F
F ก ก กF
F
ก
F
F
ก
10%
1 standard deviation (SD) F 1
F F T-score < -1.0 ˈ
F F ก ก
V-3 Diagnosis
ก
ก ก
score ≤ -2.5 SD
ก
ก
ก
กก
F ก
ก
F
F L-spine, femoral neck
F
F F
F
ก
total hip ˈ ก
ก
F
ก
F F ก BMD T-
V-4 Prevention and treatment
4.1
ก
ก
ก
ก
1. ก
1.1.
˂ ก
F
˂ ก
ก
ก
F ก
F
F F
1.2. กก ก
F
1.3.
ก
1.4. ˂ ก ก ก F
ก
ก
ก
กก
ก ก
ก
ก
F
F
F
F ˁ
F
ก
กก
F
F
F
ก
F
ก
F
ก F F
F ก
F
F
ˈ
67. 64
1.5.
F F
calcium
1.6. F F
2. ก F
F F
F
800 IU
F F F ก
F ก ก
F3
F
F
1,200 ก.
F
Fก
ˆ
F
F ก
elemental
7.5 ก.
ก BMD T-score
ก F -1.0
F
F
ก F F F
ก
4.1(
IV)
(27-29)
2.1.
ก F ˈ
ก
2.1.1. Alendronate
2.1.2. Risedronate
2.1.3. Zoledronate
2.2.
ก F ˈ
( F F
F ก F ก F)(27,28)
2.2.1.
F
F alphacalcidol, calcitriol
2.2.2. F
2.2.2.1. Estrogen replacement therapy premature menopause
2.2.2.2. Testosterone replacement therapy
F
testosterone
(30)
ก ก ก ก ก
2.2.3. Teriparatide
F
F
ก F
ก ก
F
F bisphosphonates
F F F
ก
F IV-2 2.2 (Teriparatide, TPTD)
2.3. SERMs, calcitonin, menatetrenone
strontium ranelate
evidence F
ก Fก
ก ก
ก ก
F
F
F
ก
F F
V-5 Monitoring treatment
5.1 ก
1.
ก
ก
ก
ก
F ก
bisphosphonates
F
ก
ก F
2.
ก
ก
ก
F
ก
F
(31)
กก F ก
F
F
ก ก ก 6-12
F
F
1 ʾ ก
F
ก
ก
ก
ก
F F ก
F
F ˁ
ก
F
ก
F ก
F ก
ก
F
ก
กF
F ก
F
กF