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- Disease review -
Approach to the patients with
secondary osteoporosis
R3 강 경 환
Bone
resorption
Bone
formation
Primary osteoporosis
(more common)
Secondary osteoporosis
(less common)
: occurring as a result of menopause or the
aging process
: accounting for approximately 80% of
cases of osteoporosis in women
: is becoming more frequently recognized
(especially in men and premenopausal
women)
: accounts for 40% to 60% of all cases of
osteoporosis
: due to underlying disease or concurrent
medication
: require specific diagnostic tests
: response to osteoporosis therapy may be
limited if the underlying disorder goes
unrecognized
N Engl J Med 2008;358:1474-82
소아, 청소년, 폐경기전 여성, 50세 이하 남성
Z score <-2.0 (below the expected range for age)
→ secondary cause?
N Engl J Med 2008;358:1474-82
Harrison’s principle of internal medicine, 17th edition
Harrison’s principle of internal medicine, 17th edition
N Engl J Med 2005;353:164-71.
.
N Engl J Med 2008;358:1474-82
Harrison’s principle of internal medicine, 17th edition
N Engl J Med 2008;358:1474-82
European Journal of Endocrinology (2010) 162 1009–1020
이차성 골다공증을 의심해야 하는 경우
1.
이차적 원인이 이미 있는 환자에서 골다공증 병발 확인
2.
골량의 감소 정도가 기대치보다 현저한 경우
- Z-점수 < –2 (연령 기대치 이하)
- 골다공증성 골절의 병력 (폐경 전 여성, 남성)
3.
치료에 대한 반응이 적절하지 않은 경우
4.
골다공증 발생 위험 인자가 적은데도 불구하고 현저하게
골밀도가 감소되어 있는 경우
5.
기타 의심되는 경우
골다공증 진단 및 치료 지침 2008
European Journal of Endocrinology (2010) 162 1009–1020
European Journal of Endocrinology (2010) 162 1009–1020
Mechanism
Glucocorticoid excess
- serum estrogen & testosterone↓ ,Ca absorption↓
urine Ca↑ serum Ca↓
→ bone resorption↑, bone formation↓
- an increased risk of falls due to muscular atrophy and
altered neuromuscular function
Hyperthyroidism
- activation of thyroid hormone receptor α on osteoblasts
and osteoclasts
→ enhanced bone resorption and bone loss
(TSH level <0.1 mU/l was associated with a four- and
fivefold risk of hip and vertebral fractures respectively)
Primary hyperparathyroidism
- chronic effects of PTH are to increase the number both
osteoblasts and osteoclasts
- continuous exposure to elevated PTH leads to increased
osteoclast-mediated bone resorption
→ affects cortical rather than cancellous bone
European Journal of Endocrinology (2010) 162 1009–1020
Pregnancy-associated
osteoporosis
- preexisting vitamin D deficiency
- low intake of calcium and protein
- low bone mass, increased PTH-related protein, high bone
turnover
- unfractionated heparins for thromboembolic disorders
Hypogonadisim
- through disruption of HPA or through gonadal function
- androgens are crucial for the accrual of peak bone mass
- use of androgen ablation Tx or GnRH agonist for prostate
ca., tamoxifen for breast ca.
Diabetes mellitus type 1
- lack of the bone anabolic actions of insulin &
β-cell-derived proteins (amylin)
→ contribute to low BMD
- diabetic complications
(retinopathy, polyneuropathy, and nephropathy)
: major determinants of low bone mass and
increased fracture risk
- type 2 diabetes mellitus with TZD
→ associated with fractures of the hip, humerus
GH deficiency
- GH→stimulation of hepatic receptor→production of IGF-1
and IGF-binding protein
: a potent stimulator of osteoblastic functions and bone
formation
European Journal of Endocrinology (2010) 162 1009–1020
GI disease
Disease
Celiac disease
Pancreatic insufficiency
Inflammatory bowel disease
Treatment
gluten-free diet
exocrine pancreatic enzymes
modify the immunosuppressive regimen to control
inflammatory activity and to reduce the glucocorticoid
dose
Endocrinologic disorder
Disease
Treatment
Cushing’s syndrome
- surgically treated if osteoporosis is present
Primary hyperparathyroidism
- surgically treated if osteoporosis is present
Hyperthyroidism
- endogenous
: anti-thyroid drugs, radioiodine therapy, or
surgery
- exogenous
: adjustment of the L-T4 dosage with a
target serum thyrotropin level within the
normal range
Sex hormone deficiency
(premenopausal women and men)
- should be replaced, if signs and symptoms of
hormone deficiency are present
(decreased libido, sarcopenia, visceral obesity)
GH deficiency
- GH replacement therapy increases BMD
Diabetes mellitus
- intensive insulin therapy
- aggressive prevention of diabetic vascular
complications
Anorexia nervosa
- estrogen replacement therapy
: resulted in variable increase in BMD
N Engl J Med 2008;358:1474-82
N Engl J Med 2005;353:595-603