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sis i s characteri zed by l ow bone m ass, m icroarchitectural
disruption,andincreas edsk eletalfragility .
RiskFactor sfor Osteopor oticFr actures
Personalhi storyoffrac Whiter ace
tureasanadul t Advancedage
Historyoffractureina Lifelongl owcal ciumi n
first-degreerel ative take
Currentci garettesm ok Alcoholism
ing Inadequatephy sicalac
Lowbody w eight(l ess tivity
than58k g[127l b]) Recurrentfa lls
Femalese x Dementia
Estrogendefi ciency Impairedey esightdespi te
(menopausebeforeage adequatecorrecti on
45y earsorbi lateral Poorheal th/frailty
ovariectomy,prol onged
premenopausal
amenorrhea[greaterthan
oney ear])
I. Screeningfor osteopor osisandosteopeni a
A. Normal bone density i s defi ned as a bone m ineral
density (B MD) val ue w ithin one standard devi ation of
the m ean value i n y oung adul ts of the sam e sex and
race.
B. Osteopenia is defi ned as a B MD betw een 1 and 2.5
standarddevi ationsbel owthem ean.
C. Osteoporosis i s defined as a val ue m ore than 2.5
standard de viations bel ow the m ean; thi s l evel i s the
fracture threshol d. T hese val ues are referred to as T
scores (numberofstandarddevi ationsaboveor below
them eanval ue).
D. Dual x-r ay absor ptiometry. In dual x -ray
absorptiometry (DXA),tw ophotonsareem ittedfrom an
x-raytube.D XAi sthem ostcom monlyused method for
measuringbonedensi tybecausei t gives verypreci se
measurements with m inimal radi ation. D XA measure
mentsofthespi neandhi parerecom mended.
E. Biochemical m arkers of bone tur nover. Urinary
deoxypyridinoline (DP D) an d u rinary alp ha-1 to
alpha-2N -telopeptideofcol lagen(N TX)arethem ost
specific and cl inically useful m arkers of bone resorp
tion.B iochemicalm arkersarenotuseful forthescreen
ingordi agnosisof osteoporosisbecausetheval uesi n
normalandosteoporosi sov erlapsubstanti ally.
II. Recommendationsfor screeningfor oseteopor osis of
theN ationalO steoporosisFoundati on
A. Allw omenshoul dbecounsel edabout theri skfactors
for osteoporosi s, esp ecially sm oking cessati on and
limiting al cohol. A ll w omen shoul d be encouraged to
participatei nregul arw eight-bearingandex ercise.
B. MeasurementofB MDi srecom mendedforal l women
65 years and ol der regardl ess of ri sk factors. B MD
should alsobem easuredi nal lw omenunderthe age
of 65 y ears w ho have one or m ore ri sk factors for
osteoporosis (in additiontom enopause).T hehi pi sthe
recommendedsi teofm easurement.
C. Alladul tsshoul dbeadvi sed to consumeatl east1,200
mg of calciumperday and400to800I Uof vitamin D
perday .A dai lym ultivitamin(w hich provides 400 IU) is
recommended.I npati entsw ithdocum ented vitamin D
deficiency, osteoporosi s, or previ ous fracture, tw o
multivitamins may bereasonabl e,parti cularlyi f dietary
intakei si nadequateandaccesstosunl ighti spoor.
D. Treatment i s recom mended for w omen without ri sk
factorsw hohaveaB MDthati s2S D belowthem ean
fory oungw omen,andi nw omenw ith risk factorsw ho
haveaB MDthati s1.5S Dbel owthem ean.
III. Nonpharmacologic th erapy o f o steoporosis in
women
A. Diet. An opt imal di et for treatm ent (or preventi on) of
osteoporosis i ncludes an adequate i ntake of cal ories
(toavoi dm alnutrition),cal cium,andvi taminD .
B. Calcium. Postmenopausalw omenshoul dbeadvi sed
totak e1000 to 1500 mg/day ofel ementalcal cium,i n
divideddoses,w ithm eals.
C. VitaminD total of800I Udai lyshoul dbetak en.
D. Exercise. W omen shoul d ex ercise for at l east 30
minutes three ti mes per w eek. A ny w eight-bearing
exerciseregi men,i ncludingw alking,i sacceptabl e.
E. Cessationof smokingi srecom mendedfor all women
becausesm okingci garettesaccel eratesbonel oss.
IV. Drugther apyofosteopor osisi nw omen
A. Selectedpostm enopausalw omenw ithosteoporosi so r
at hi gh ri sk for the di sease shoul d be considered for
drug therapy . P articular atte ntion shoul d be pai d to
treatingw omenw itha r ecentfr agilityfr acture,in cluding
hipfracture,because they are at highri skforasecond
fracture.
B. Candidates for drug therapy are w omen w ho al ready
have postm enopausal osteoporosi s (l ess than -2.5)
and w omen w ith osteopeni a (T score -1 to -2.5) soon
afterm enopause.
C. Bisphosphonates
1. Alendronate(Fosam ax)(10m g/dayor70 mg once
weekly) or r isedronate (A ctonel) (5 m g/dayor 35
mg once weekly)aregoodchoi cesfor the treatment
ofosteoporosi s.B isphosphonatetherapy i ncreases
bone m ass and reduces the i ncidence of vertebral
andnonvertebral fractures.
2. Alendronate(5 mg/dayor35m goncew eekly)and
risedronate (5 mg/dayof35m goncew eekly)have
beenapprovedforpreventi onofosteoporosi s.
3. Alendronate or ri sedronate shoul d be tak en w ith a
full gl ass of w ater 30 m inutes before the fi rst m eal
or beverageoftheday .P atientsshoul dnot lie down
foratl east30m inutes after taking thedosetoavoi d
theunusual com plicationo fp ill-inducedesophagi tis.
4. Alendronate i s w ell t olerated and effecti ve for at
leastseveny ears.
5. Thebi sphosphonates(al endronate or risedronate)
and ral oxifene are fi rst-line treatm ents for preven
tion of osteoporosis.T hebi sphosphonatesarefi rst
line therapy for treatment of osteoporosi s.
Bisphosphonates are pref erred for preventi on and
treatment of osteoporosi s because they i ncrease
bonem ineraldensi tym orethanral oxifene.
D. Selectiveestr ogenr eceptorm odulators
1. Raloxifene (E vista) (5 m g dai lyor a once-a-w eek
preparation)i sasel ectiveestrogen receptor modu
lator (SERM)forpreventi onandtreatm ent of osteo
porosis. I t i ncreases bone m ineral densi ty and
reduces serum total and l ow-density-lipoprotein
(LDL) cholesterol. I t al so appears to reduce the
incidence of vertebral fractures and i s one of the
first-linedrugsforprev entionofosteoporosi s.
2. Raloxifene i s somewhat l ess effecti ve than the
bisphosphonates for the prevention and treatm ent
ofosteoporosi s.V enousthrom boembolismi sari sk.
TreatmentGuidelinesfor Osteopor osis
Calciumsuppl ementsw ithorw ithoutvi taminD suppl e
mentsorcal cium-richdi et
Weight-bearingex ercise
Avoidanceofal coholtobaccoproducts
Alendronate(Fosam ax)
Risedronate(A ctonel)
Raloxifene(E vista)
Agentsfor Tr eatingOsteopor osis
Medication Dosage Route
Calcium 1,000to1,500 Oral
mgperday
VitaminD 400I Uperday Oral
(800I Uperday
inw interi n
northernl ati
tudes)
Alendronate Prevention:5 Oral
(Fosamax) mgperday or
35m gonce-a
week
Treatment: 10
mgperday or
70m gonce-a
week
Risedronate 5m gdai lyor Oral
(Actonel) 35m gonce
weekly
Raloxifene 60m gperday Oral
(Evista)
Conjugated 0.3m gperday Oral
estrogens
E. Monitoringther esponsetother apy
1. Bonem ineraldensi tyandam arkerofboneturnover
should be m easured at basel ine, fol lowed by a
repeat measurement ofthem arkeri nthree months.
2. If the m arker fal ls appropriately, the drug i s havi ng
thedesi red effect, andtherapy shoul dbeconti nued
for tw o y ears, at which ti me bone m ineral densi ty
can be m easured agai n. T he anti cipated three
month decl ine i n markers i s 50 percent w ith
alendronate.
F. Estrogen/progestinther apy
1. Estrogen-progestin therapy i s no l onger a fi rst-line
approach for the treatm ent of osteoporosi s i n
postmenopausal w omen because of i ncreases i n
the ri sk of breast cancer, strok e, venous throm bo
embolism,andcoronary di sease.
2. Indications for estrogen-progesti n in
postmenopausal w omen i nclude persi stent m eno
pausalsy mptomsandpati entsw ithani ndicationfor
antiresorptivetherapy who cannottol eratetheother
drugs.
References:S eepage166.
Infertility
Infertilityisdefinedas failure ofacoupleofreproductiveage
to conceiveafter12m onthsorm oreofregul arcoi tus without
usingcontraception.I nfertilityis considered prim aryw hen it
occursi naw omanw hohasneverestabl ishedapregnancy
andsecondary w heni t occursi naw omanw hohasahi story [ Pobierz całość w formacie PDF ]
zanotowane.pl doc.pisz.pl pdf.pisz.pl ocenkijessi.opx.pl
sis i s characteri zed by l ow bone m ass, m icroarchitectural
disruption,andincreas edsk eletalfragility .
RiskFactor sfor Osteopor oticFr actures
Personalhi storyoffrac Whiter ace
tureasanadul t Advancedage
Historyoffractureina Lifelongl owcal ciumi n
first-degreerel ative take
Currentci garettesm ok Alcoholism
ing Inadequatephy sicalac
Lowbody w eight(l ess tivity
than58k g[127l b]) Recurrentfa lls
Femalese x Dementia
Estrogendefi ciency Impairedey esightdespi te
(menopausebeforeage adequatecorrecti on
45y earsorbi lateral Poorheal th/frailty
ovariectomy,prol onged
premenopausal
amenorrhea[greaterthan
oney ear])
I. Screeningfor osteopor osisandosteopeni a
A. Normal bone density i s defi ned as a bone m ineral
density (B MD) val ue w ithin one standard devi ation of
the m ean value i n y oung adul ts of the sam e sex and
race.
B. Osteopenia is defi ned as a B MD betw een 1 and 2.5
standarddevi ationsbel owthem ean.
C. Osteoporosis i s defined as a val ue m ore than 2.5
standard de viations bel ow the m ean; thi s l evel i s the
fracture threshol d. T hese val ues are referred to as T
scores (numberofstandarddevi ationsaboveor below
them eanval ue).
D. Dual x-r ay absor ptiometry. In dual x -ray
absorptiometry (DXA),tw ophotonsareem ittedfrom an
x-raytube.D XAi sthem ostcom monlyused method for
measuringbonedensi tybecausei t gives verypreci se
measurements with m inimal radi ation. D XA measure
mentsofthespi neandhi parerecom mended.
E. Biochemical m arkers of bone tur nover. Urinary
deoxypyridinoline (DP D) an d u rinary alp ha-1 to
alpha-2N -telopeptideofcol lagen(N TX)arethem ost
specific and cl inically useful m arkers of bone resorp
tion.B iochemicalm arkersarenotuseful forthescreen
ingordi agnosisof osteoporosisbecausetheval uesi n
normalandosteoporosi sov erlapsubstanti ally.
II. Recommendationsfor screeningfor oseteopor osis of
theN ationalO steoporosisFoundati on
A. Allw omenshoul dbecounsel edabout theri skfactors
for osteoporosi s, esp ecially sm oking cessati on and
limiting al cohol. A ll w omen shoul d be encouraged to
participatei nregul arw eight-bearingandex ercise.
B. MeasurementofB MDi srecom mendedforal l women
65 years and ol der regardl ess of ri sk factors. B MD
should alsobem easuredi nal lw omenunderthe age
of 65 y ears w ho have one or m ore ri sk factors for
osteoporosis (in additiontom enopause).T hehi pi sthe
recommendedsi teofm easurement.
C. Alladul tsshoul dbeadvi sed to consumeatl east1,200
mg of calciumperday and400to800I Uof vitamin D
perday .A dai lym ultivitamin(w hich provides 400 IU) is
recommended.I npati entsw ithdocum ented vitamin D
deficiency, osteoporosi s, or previ ous fracture, tw o
multivitamins may bereasonabl e,parti cularlyi f dietary
intakei si nadequateandaccesstosunl ighti spoor.
D. Treatment i s recom mended for w omen without ri sk
factorsw hohaveaB MDthati s2S D belowthem ean
fory oungw omen,andi nw omenw ith risk factorsw ho
haveaB MDthati s1.5S Dbel owthem ean.
III. Nonpharmacologic th erapy o f o steoporosis in
women
A. Diet. An opt imal di et for treatm ent (or preventi on) of
osteoporosis i ncludes an adequate i ntake of cal ories
(toavoi dm alnutrition),cal cium,andvi taminD .
B. Calcium. Postmenopausalw omenshoul dbeadvi sed
totak e1000 to 1500 mg/day ofel ementalcal cium,i n
divideddoses,w ithm eals.
C. VitaminD total of800I Udai lyshoul dbetak en.
D. Exercise. W omen shoul d ex ercise for at l east 30
minutes three ti mes per w eek. A ny w eight-bearing
exerciseregi men,i ncludingw alking,i sacceptabl e.
E. Cessationof smokingi srecom mendedfor all women
becausesm okingci garettesaccel eratesbonel oss.
IV. Drugther apyofosteopor osisi nw omen
A. Selectedpostm enopausalw omenw ithosteoporosi so r
at hi gh ri sk for the di sease shoul d be considered for
drug therapy . P articular atte ntion shoul d be pai d to
treatingw omenw itha r ecentfr agilityfr acture,in cluding
hipfracture,because they are at highri skforasecond
fracture.
B. Candidates for drug therapy are w omen w ho al ready
have postm enopausal osteoporosi s (l ess than -2.5)
and w omen w ith osteopeni a (T score -1 to -2.5) soon
afterm enopause.
C. Bisphosphonates
1. Alendronate(Fosam ax)(10m g/dayor70 mg once
weekly) or r isedronate (A ctonel) (5 m g/dayor 35
mg once weekly)aregoodchoi cesfor the treatment
ofosteoporosi s.B isphosphonatetherapy i ncreases
bone m ass and reduces the i ncidence of vertebral
andnonvertebral fractures.
2. Alendronate(5 mg/dayor35m goncew eekly)and
risedronate (5 mg/dayof35m goncew eekly)have
beenapprovedforpreventi onofosteoporosi s.
3. Alendronate or ri sedronate shoul d be tak en w ith a
full gl ass of w ater 30 m inutes before the fi rst m eal
or beverageoftheday .P atientsshoul dnot lie down
foratl east30m inutes after taking thedosetoavoi d
theunusual com plicationo fp ill-inducedesophagi tis.
4. Alendronate i s w ell t olerated and effecti ve for at
leastseveny ears.
5. Thebi sphosphonates(al endronate or risedronate)
and ral oxifene are fi rst-line treatm ents for preven
tion of osteoporosis.T hebi sphosphonatesarefi rst
line therapy for treatment of osteoporosi s.
Bisphosphonates are pref erred for preventi on and
treatment of osteoporosi s because they i ncrease
bonem ineraldensi tym orethanral oxifene.
D. Selectiveestr ogenr eceptorm odulators
1. Raloxifene (E vista) (5 m g dai lyor a once-a-w eek
preparation)i sasel ectiveestrogen receptor modu
lator (SERM)forpreventi onandtreatm ent of osteo
porosis. I t i ncreases bone m ineral densi ty and
reduces serum total and l ow-density-lipoprotein
(LDL) cholesterol. I t al so appears to reduce the
incidence of vertebral fractures and i s one of the
first-linedrugsforprev entionofosteoporosi s.
2. Raloxifene i s somewhat l ess effecti ve than the
bisphosphonates for the prevention and treatm ent
ofosteoporosi s.V enousthrom boembolismi sari sk.
TreatmentGuidelinesfor Osteopor osis
Calciumsuppl ementsw ithorw ithoutvi taminD suppl e
mentsorcal cium-richdi et
Weight-bearingex ercise
Avoidanceofal coholtobaccoproducts
Alendronate(Fosam ax)
Risedronate(A ctonel)
Raloxifene(E vista)
Agentsfor Tr eatingOsteopor osis
Medication Dosage Route
Calcium 1,000to1,500 Oral
mgperday
VitaminD 400I Uperday Oral
(800I Uperday
inw interi n
northernl ati
tudes)
Alendronate Prevention:5 Oral
(Fosamax) mgperday or
35m gonce-a
week
Treatment: 10
mgperday or
70m gonce-a
week
Risedronate 5m gdai lyor Oral
(Actonel) 35m gonce
weekly
Raloxifene 60m gperday Oral
(Evista)
Conjugated 0.3m gperday Oral
estrogens
E. Monitoringther esponsetother apy
1. Bonem ineraldensi tyandam arkerofboneturnover
should be m easured at basel ine, fol lowed by a
repeat measurement ofthem arkeri nthree months.
2. If the m arker fal ls appropriately, the drug i s havi ng
thedesi red effect, andtherapy shoul dbeconti nued
for tw o y ears, at which ti me bone m ineral densi ty
can be m easured agai n. T he anti cipated three
month decl ine i n markers i s 50 percent w ith
alendronate.
F. Estrogen/progestinther apy
1. Estrogen-progestin therapy i s no l onger a fi rst-line
approach for the treatm ent of osteoporosi s i n
postmenopausal w omen because of i ncreases i n
the ri sk of breast cancer, strok e, venous throm bo
embolism,andcoronary di sease.
2. Indications for estrogen-progesti n in
postmenopausal w omen i nclude persi stent m eno
pausalsy mptomsandpati entsw ithani ndicationfor
antiresorptivetherapy who cannottol eratetheother
drugs.
References:S eepage166.
Infertility
Infertilityisdefinedas failure ofacoupleofreproductiveage
to conceiveafter12m onthsorm oreofregul arcoi tus without
usingcontraception.I nfertilityis considered prim aryw hen it
occursi naw omanw hohasneverestabl ishedapregnancy
andsecondary w heni t occursi naw omanw hohasahi story [ Pobierz całość w formacie PDF ]