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Osteoporosis

2009.12.21

Osteoporosis

 

nincs pontos módszer a csont szilárdságának mérésére.

 

WHO szerint csontritkulásról beszélünk, ha a csont denzitás legalább a szórás 2,5-szeresével elmarad a fiatal felnőtt fehér nők átlag értékétől.

 

Annak valószínűsége, hogy egy 50 éves fehér nő élete során csípőtáji törést szenved 14 %-a, férfiak esetében 5-6 %-a. Jelentős életminőség romlást okoz. 75 évnél idősebb nők 80 %-a inkább a halált részesíti előnyben az ápolási otthonban való elhelyezésüket szükségessé tevő súlyos csípőtáji törésekkel szemben.

 

Hogyan változik a kockázat a népesség különböző csoportjaiban?

  • Nem etnikum

  • Kockázati tényezők

  • Másodlagos osteoporosis: genetikai rendellenesség, hypogonadizmus, endokrin, gastrointestinalis, haematológiai, kötőszöveti betegségek, hiányos táplálkozás, gyógyszer (5 vagy ennél magasabb dózisú Prednisolon két hónapot meghaladó alkalmazása esetén számolni kell a nagyfokú csontvesztéssel

 

Mely faktorok játszanak szerepet a csontváz egészségének kialakításában, megőrzésében?

Táplálkozás – Calcium bevitel

3-8 év között napi 800 mg, 9-17 év között 1300 mg calcium

fiúknak 25 %-a, lányoknak 10 %-a felel meg ennek az elvárásnak

Időseknek calcium szükséglete 1100 mg (50-60 %-a felel meg az elvárásoknak)

 

D vitamin bevitel

Testmozgás

Nemi hormonok

Növekedési hormonok

 

Az osteoporosis diagnózisa

  1. Denzitometria

  2. Sarok quantitatív UH vizsgálat

  3. Biokémiai markerek (alkalikus foszfatáz, osteocalcin, vizelet piridinolin, dezoxipiridinolin szint, valamint szérum és vizelet I-es típusú kollagén, és telopeptid szint)

 

Az osteoporosis therápiája

    • D vitamin optimális dózisa 400-1000 NE

    • 25-hidroxi-D3 vitamin

    • ciklikus aleondronát, risendronát

    • hormonpótló kezelés

    • szelektív ösztrogén receptor modulátor (SERM)

    • tamoxifen

    • természetes ösztrogének, növényi erdetű fitoösztrogén (a törési kockázat csökkenését emberben még nem tudták kimutatni)

    • calcitonin (200 NE/die)

 

A terápia nyomon követése

 

Az osteoporosisos törések ortopédiai ellátása (5 %-a kerül szakirányú kivizsgálásra és kezelésre)

 

A jövő kutatásának irányai

  • alapvető jelentőségű fiúk és lányok csúcstömegének maximalizálása

  • milyen következménye van a gyerekeket érintő krónikus megbetegedésekhez társuló töréseknek

  • milyen következménye van a gyermekkori Calcium és D vitamin hiányának és ezek visszafordíthatók-e

  • gonadális steroid elégtelenség, későn induló pubertás

  • genetikai tényezők

  • glucocorticoid kezelés az osteoporosis gyakori oka

  • hogyan lehetne azonosítani az osteoporosis irányában vizsgálandó és kezelendő betegeket

  • bifoszfonátok vagy egyéb szerek alkalmazása szekunder osteoporosisban szenvedő fiatal felnőttek esetében

  • prospektív tanulmányok

  • életminőség vizsgálata osteoporosisban

  • tünetmentes betegeknél szűrővizsgálat

  • neuro-psychiátriai rendellenességek okai és következményei lehetnek az osteoporosisnak

  • farmakológiai, diétás, életmódbeli változások meghatározása

  • optimális szemlélet törések kivizsgálása, kezelése kapcsán

  • új therápiás lehetőségek kipróbálása (fluorid hatástalan)

 

 

 

Osteoporosis

 

Olyan csontanyagcsere betegség, amelynek lényege a csontszövet mennyiségének megfogyása, anélkül, hogy a csont alkotóeleme arányosan megkisebbedik.

 

Az osteoporosis rizikófaktorai:

  1. Családi halmozottság

  2. Genetikai faji különbségek

  3. Késői menses jelentkezés, korai vagy művi menopausa

  4. Alkohol fogyaszás

  5. Dohányzás, koffein

  6. Mozgásszegény életmód, ülő foglalkozás

  7. Nullipara lét

  8. Elégtelen Ca és D vitamin ellátottság

  9. Tartós fekvés, külső rögzítés trauma után

Az osteoporosis formái

 

Primer, involuciós osteoporosis

  1. típusú – postmenopausalis

  2. típusú – senilis

 

Szekunder osteoporosis

    • Endokrin betegségek

    • Hyperthyreosis

    • Hyperparathyreosis

    • Hypogonadismus

    • Cushing kór

    • Diabetes mellitus

 

    • Krónikus májbetegségek

    • Krónikus vesebetegségek

    • Haematológiai betegségek

    • Táplálkozási, felszívódási zavarok

    • Tartós immobilizáció

 

Tartós gyógyszerszedés

    • Steroiok

    • Heparin, kumarin

    • Teofillin

    • Antiepileptikumok

    • Diuretikumok

 

A primer, involutios osteoporosis formái:

 

I. típus II. típus

postmenopausalis senilis

Jellemző életkor 55-75 év 70 év felett

 

Nemi arány

Nő/férfi 6/1 2/1

 

Csontvesztés

típusa főleg trabecularis trabecularis

és corticalis

 

Etiológiai faktor postmenopausalis életkor

ösztrogén hiány

 

Jellemző törés rádiusz disztális vég, femur, humerus

csigolya proximalis vég, csigolya

 

 

Klinikai tünetek:

  • Testforma megváltozik

  • Háti kypohosis fokozódása

  • Testmagasság csökkenése

  • Terhelésre jelentkező deréktáji, háti fájdalom

  • néma járvány”

 

Dg.: rtg vizsgálat – hagyományos rtg vizsgálat – korai dg.-ra nem használható (30-50 %-os csontvesztés esetén kórjelző)

 

Röntgen morfometria: úgynevezett rtg morfometriás indexekkel, melyek a csont corticalisának és teljes vastagságának végzett arányát adják meg (metacarpus, femur, csigolya)

 

Osteodensitometria: csont, ásványi anyag tartalmának csökkenését mutatja

  1. Photon absorptimetria

  2. Quantitativ computertomographia

  3. UH csontvizsgálat

 

Photon absorptimetriás vizsgálat lényege: adott testtájékon átbocsátott izotóp vagy rtg sugárnyaláb elnyelődése döntően a csonttól, annak ásványi anyag tartalmától függ.

 

Perifériás csontok esetén /radius/SPA/single foton/ ill. SXA ( single X-ray) absorptiméterek

 

Mélyebben fekvő csontok esetén /combnyak tájék, csigolya /kettős/ fotonabsorrptimetriával (DEXA – dual energy x-ray) absorptimetriával végezzük a vizsgálatokat.

 

A csont ásványi anyag tartalmát a sugár irányába eső csontfelszínen g/cm2-ben adják meg, melyek csontsűrűségnek (Bone mineral density – BMD) az ebből számított grammban kifejezett ásványi csonttömeget BMC-nek nevezzük.

Az osteodensitometriás leletként arányszámot kapunk. Z-score, T-score.

 

Z-score: a csontok ásványi anyag tartalmának eltérése a beteg korának, nemének megfelelő normális átlagáról. Standard deviációban (SD) kifejezve.

 

T-score: a fiatalkori csúcs csonttömegtől való eltérést jelenti, SD-ben kifejezve.

 

Z-score 1-2-SD közöt csökkent ásványi anyag tartalomról, T-score 1,5-2,5 SD között csökkent ásványi anyag tartalomról beszélünk.

 

Z-score 2 ill. T-score 2,5 érték alatt manifeszt kalciumhiányos osteopathiáról beszélünk.

 

Az osteoporosis therápiája

1. Preventio

 

Primer preventio: a csonttömeg 70 %-ban genetikus tényezőktől fögg. A csúcs csonttömeget a III-IV. évtizedben érjük el. Gyermek és fiatal korban Ca és D vitamin adása. Rendszeres testedzés. Rizikófaktorok kerülése

 

Secunder prevenció: veszélyeztetett betegek szűrővizsgálata. Nők esetében post- menopausalis hormonpótlás

 

Tertier preventio: típusos osteoporoticus törések esetén további fracturák elkerülése végett komplex antiporoticus kezelés

 

2. Gyógyszeres kezelés

 

Csontlebontást gátló szerek

  • hormonpótlás (ösztrogén, gesztagén) Egyértelműen kimutatott veszélyek pl. emlő cc, kardiovaszkuláris eltérések

  • calcitonin

  • biszfoszfonátok

  • kalcium

  • ipriflovon

  • D-vitamin és aktív metabolitjai (alfa-calcidol)

  • tiazid diureticumok

 

 

Csontképzést serkentő szerek

  • fluorid

  • anabolicumok

  • parathormon

 

3. Kiegészítő kezelés

  • elesések kerülése

  • gyógytorna

  • úszás

 

 

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