类固醇诱发的骨质疏松优质PPT.ppt

1、Corticosteroid-Induced OsteoporosisCorticosteroid-Induced Osteoporosis20122012OsteoporosisSystemic skeletal diseaseLow bone massMicroarchitectural deterioration of bone tissueIncrease in bone fragility and fracture susceptibilityClinical Burden of CIOMost common form of drug-related osteoporosis in

2、men and womenOccurs at any age,in both genders,across racesUp to 50%of patients on chronic steroid therapy sustain osteoporotic fractures and/or develop osteonecrosisCorticosteroid-Induced OsteoporosisCommon,iatrogenic form of secondary osteoporosisAssociated with corticosteroid use in chronic,nonin

3、fectious medical conditionsAsthma-Nephrotic syndromeChronic lung disease-TransplantationRheumatologic disorders-etcInflammatory bowel diseaseClinical significant-Increase bone loss and fracture:#6 Mo.-Trabecular cortical bone-7.5 mg of prednisolone（equivalent）-Incidence of osteoporosis 30-50%-Verteb

4、ral fracture 30-35%,hip fracture 50%-Rate of bone loss 2-4%per year-Alternate day regimen,inhale steroidsFracture Risk and Dose of CorticosteroidsRelative risk of fracture by dosages of corticosteroids of prednisolone.van Staa TP,et al,1998.01234562.5 mg/d2.5-7.5 mg/d7.5 mg/dRelative risk of fractur

5、e compared with controlHip fractureVertebral fractureCIO in Patients With AsthmaRelationship of percentage predicted bone density to duration of corticosteroid use in 44 corticosteroid-treated asthmatic patients.Schatz M,Dudl J,Zeiger RS,et al.Allergy Proc.1993;#14:#341-345.Reprinted with permission

6、.Percent predicted bone densityr=-0.39（P=0.009）Duration of corticosteroid use（years）1201008060402 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36CIO in Patients With Rheumatoid ArthritisCS=corticosteroid;#therapy=7 mg prednisone equivalent per day.Density change measured as change in absolute or Z s

7、core（difference in standard deviation compared with healthy age-matched controls of the same race and sex）compared to baseline.Verhoeven AC,et al,1997.*P0.001;#*P=0.002.Percentage of SLE patients（N=97）with low BMD,as measured by DXA.Kipen Y,et al,1997.CIO and Systemic Lupus Erythematosus*Potential F

8、actors Causing Bone Loss in Inflammatory Bowel DiseaseCorticosteroidsVitamin D/Calcium deficiencyPoor nutritional statusInflammationPhysical inactivityConcurrent medications（immunosuppressive agents）CIO and Chronic Obstructive Pulmonary Disease*P0.05 vs.ISU or NSU;#*P0.005 vs ISU.McEvoy CE,et al,199

9、8.*Pathophysiology of CIO:#OverviewBone remodeling occurs throughout adulthoodOsteoporosis results from an imbalance between osteoclast and osteoblast activityTwo metabolic abnormalities contribute to increased bone resorptionSecondary hyperparathyroidism due to decreased GI absorption and urinary e

10、xcretion of calciumAltered gonadal function and decreased adrenal production of androgensPathophysiology of CIO Calcium homeostasis Gonadal hormone Inhibit bone formation Increase bone resorption other Calcium homeostasis Decrease calcium and phosphate from GI tractsunknown mechanism Increase urinar

11、y calcium excretiondecrease calcium reabsorption at distal tubules Stimulatiom PTH secretionGonadal hormone effects Decrease sex hormone:#direct&#indirectDecrease LH from pituitary gland:#estrogen and testosteroneDecrease synthesis from adrenal glandsDecrease sex hormone binding globulinBone formati

12、on and bone resorptionOsteoblast-inh.Osteoblast proliferation-decrease matrix synthesis-increase apoptosis-decrease protein synthesis（type 1 collagen and noncollagenous protein-decrease osteocalcin,IGF1,IGFBP3,5,insulin-like growth factors,transforming growth factor B,prostaglandin EOsteoclastincrea

13、se osteoclast activityincrease apoptosis of mature osteoclastBone formation and bone resorptionOsteoblast proliferationApoptosis OB numberProtein synthesis Bone formationDifferentiation Bone mass Fracture RiskAndrogenOsteoclast apoptosisBone resorptionOsteoclast formationPTHCalcium and phosphate abs

14、orption（gut and kidney）GlucocorticoidDiagnosis of CIO:#Initial Clinical Work-UpMedical historyRisk factors for bone lossPhysical examClinical signs and symptomsPatient Evaluation History Documentation of height,weight,muscle strength,balance,vision Documentation of medical historyDocumentation of me

15、nstrual history,infertility in menFracture history and Family history of fracturesOther risk factors for osteoporosis:#-Lifestyles influences:#calcium and vitamin D intake,smoking,alcohol intake,medications,prevention of falling -Patient education:#prevention of falling,exercise General health and p

16、rognosisPatient EvaluationPhysical examinationEvidence of osteoporosis:#evidence of fracture,kyphosis,loss of height,muscle strength and sizeGeneral physical findings:#assessment of underlying disorder,other medical conditionsPatient Evaluation Complete blood count and erythrocyte sedimentation rate（ESR）Serum calcium,phosphate,creatinine,electrolyte,alkaline phosphatase,25-hydroxyvitamin D,estradiol,testosterone（male）24 hr-Urinary calcium and creatinine BMD of spine and hip X-rays of appropriate areaslaboratory