Osteoporosis Osteoporosis is serious and costly A silent

Osteoporosis (骨質疏鬆症) Osteoporosis is serious and costly 骨質疏鬆在骨折發生前沒有症狀 A silent disease 輕微受傷 (minimal trauma)即可骨折 About 2 M broken bones each year are caused by osteoporosis Cause immobility, pain Placement in a nursing home

Osteoporosis (骨質疏鬆症) Osteoporosis is serious and costly Isolation and other health problems 20% hip fracture的病人在 1年內死於 骨折或手術的相關併發症 對個人健康和醫療是個挑戰 在Medicare給付中，是the 10 th ranked major illness 經濟上對社會或個人極重的負擔

Osteoporosis (骨質疏鬆症) Osteoporosis is serious and costly

Osteoporosis (骨質疏鬆症) 定義: porous bone, Lost bone density or mass

骨骼的代謝 Calcitrophic Hormones Vitamin D 副甲狀腺素 Calcitonin (抑鈣素) Estrogen (雌激素) 甲狀腺素

Normal Bone Mass

Peak Bone Mass的多寡 Largely determined by genes Lifestyle factors – 決定你是否可 以reach full potential of peak bone mass (diet & exercise) Limit time – childhood, adolescence, early adulthood Reach peak bone mass ~ 25 Y/O

Peak Bone Mass的多寡

骨質疏鬆的原因和分類 Postmenopause (停經後) (Primary type 1 osteoporosis) Senile (老化) (Primary type 2 osteoporosis) Disuse (廢用) & Others (Secondary osteoporosis)

哪些人須接受骨質密度檢查? National Osteoporosis Foundation 所有女性 age ≥ 65 Y/O, 男性 ≥ 70 Y/O 年輕 estrogen 缺乏婦女, 男性 < 70 Y/O with ≥ 1 risk factor 有osteoporotic fractures的病史者 Adults with a disease/condition leading to low bone mass or bone loss. Adults taking medications associated with low bone mass or bone loss.

骨質密度檢查 Prefer DEXA for spine & pelvis (Dual-Energy X-ray Absorptiometry) 脊椎和骨盆的雙能量X光吸收儀

骨質疏鬆的治療 預防勝於治療 Begin in childhood But, never too young or too old 何時需要積極治療? Diagnosed osteoporosis History of osteoporotic fracture Consult specialists

骨質疏鬆的預防 - 鈣質補充 Men > 70 Y/O 1200 mg/day Upper limit < 2000 mg/day

骨質疏鬆的預防 –維他命D補充 400 -800 IU/day < 50 years old 800 -1000 IU/day ≧ 50 years old IOM: Tolerable Upper limit 4000 IU/day

Sources of Vitamin D UVB Exposure (90%)- Sunshine Vitamin Sunlight: 10 k-20 k IU, 30 min whole body exposure, summer 10 am-2 pm (or up to 1000 IU/min) Tanning Bed (UVB): 10 k IU per session

Sources of Vitamin D Food (10%) Salmon: fresh, wild, 3. 5 oz, 400 -1000 IU Salmon: farmed, 3. 5 oz: 100 -250 IU Fortified Milk: 8 oz: 100 IU Supplements Vitamin D 3: 400 -10 K IU in tablet/liquid

The New Why High Prevalence of VDD ? 創 2: 25: 當時夫妻兩人赤身 露體，並不羞恥。 Much much less sunlight exposure !!

骨質疏鬆的治療 預防勝於治療 Begin in childhood But, never too young or too old 何時需要積極治療? Diagnosed osteoporosis History of osteoporotic fracture Consult specialists

Caring for bone fractures from osteoporosis costs America $18 billion each year. $18 billion is a stack of dollar bills 1, 119 miles high, or farther than the distance from New York to St. Louis, Missouri.

骨質疏鬆的藥物治療 Antiresorptive (抗骨吸收) Bisphonate*!jaw bone necrosis Hormone-related therapy (SERM or HT) Calcitonin (salmon)*!2013，2. 9%VS 4. 1% Denosumab (2010, RANKL inhibitor) Anabolic drugs (增加骨生成) Teriparatide (~PTH) 2009

骨質疏鬆的藥物治療 Bisphonate Fosamax, Boniva, Actonel, Atelvia, Reclast, Zometa Hormone-related therapy Raloxifene (Evista), testosteron Calcitonin (salmon) Fortical, Miacalcin Denosumab: Prolia, Xgeva Teriparatide: Forteo

追蹤檢查及治療期限 Follow up (追蹤檢� ) Repeat BMD in 2(1) yrs 或 Bone marker No easy way to measure improvement 治療期限: No conclusive research to suggest how long a drug remain safe and effective (雙磷酸鹽藥類停藥 後可能有幾年有benefits) 有些醫生建議 “Drug Holiday” Parathyroid hormone: 不超過2年

常見的老年骨折 Spine compression fracture (脊椎壓迫性骨折)

常見的老年骨折 Intertrochanteric fracture 股骨轉子間骨折 Femoral neck fracture 股骨頸骨折

常見的老年骨折 Wrist fracture (手腕骨折) Shoulder fracture (肩膀骨折)

Treatment of Fracture Traction Brace or casting External fixation Internal fixation Primary arthroplasty

Treatment of Fracture - Brace

Treatment of Fracture – External Fixation

Treatment of Fracture – Internal Fixation

Treatment of Fracture – Primary Arthroplasty

老年骨折的特點 Osteoporosis Minor trauma Fixation difficulties Increased complications 所以，預防骨折比治療骨折重要 !

脊椎壓迫性骨折治療的爭議題 2010, AAOS treatment guideline We recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact. Strength of Recommendation: Strong