osteoporosis

骨粗鬆症 　

WordNet

1. abnormal loss of bony tissue resulting in fragile porous bones attributable to a lack of calcium; most common in postmenopausal women

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/10/12 01:46:22」(JST)

wiki en

[Wiki en表示]

Osteoporosis
Elderly woman with osteoporosis showing a curved back from compression fractures of her back bones.
Classification and external resources
Pronunciation	/ˌɒstioʊpəˈroʊsᵻs, -pɔː-/
Specialty	Rheumatology
ICD-10	M80-M82
ICD-9-CM	733.0
OMIM	166710
DiseasesDB	9385
MedlinePlus	000360
eMedicine	med/1693 ped/1683 pmr/94 pmr/95
Patient UK	Osteoporosis
MeSH	D010024

Osteoporosis is a disease where decreased bone strength increases the risk of a broken bone. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the back bones, the bones of the forearm, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities may occur following a broken bone.

Osteoporosis may be due to lower than normal peak bone mass and greater than normal bone loss. Bone loss increases after menopause due to lower levels of estrogen. Osteoporosis may also occur due to a number of diseases or treatments including alcoholism, anorexia, hyperthyroidism, surgical removal of the ovaries, and kidney disease. Certain medications increase the rate of bone loss including some antiseizure medications, chemotherapy, proton pump inhibitors, selective serotonin reuptake inhibitors, and steroids. Not enough exercise and smoking are also risk factors. Osteoporosis is defined as a bone density of 2.5 standard deviations below that of a young adult. This is typically measured by dual-energy X-ray absorptiometry at the hip.

Prevention of osteoporosis includes a proper diet during childhood and efforts to avoid medications that cause the condition. Efforts to prevent broken bones in those with osteoporosis include a good diet, exercise, and fall prevention. Lifestyle changes such as stopping smoking and not drinking alcohol may help. Medication of the bisphosphonate type are useful in those with previous broken bones due to osteoporosis. In those with osteoporosis but no previous broken bones they are less effective. A number of other medications may also be useful.

Osteoporosis becomes more common with age. About 15% of white people in their 50s and 70% of those over 80 are affected. It is more common in women than men. In the developed world, depending on the method of diagnosis, 2% to 8% of males and 9% to 38% of females are affected. Rates of disease in the developing world are unclear. About 22 million women and 5.5 million men in the European Union had osteoporosis in 2010. In the United States in 2010 about eight million women and one to two million men had osteoporosis. White and Asian people are at greater risk. The word osteoporosis is from the Greek terms for "porous bones".

Signs and symptoms

Osteoporosis is an age-related disorder that causes the gradual loss of bone density and strength. When the thoracic vertebrae are affected, there can be a gradual collapse of the vertebrae. This results in kyphosis, an excessive curvature of the thoracic region.

Illustration depicting normal standing posture and osteoporosis

Osteoporosis itself has no symptoms; its main consequence is the increased risk of bone fractures. Osteoporotic fractures occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist.

Fractures

Fractures are the most dangerous aspect of osteoporosis. Debilitating acute and chronic pain in the elderly is often attributed to fractures from osteoporosis and can lead to further disability and early mortality. These fractures may also be asymptomatic. The most common osteoporotic fractures are of the wrist, spine, shoulder and hip. The symptoms of a vertebral collapse ("compression fracture") are sudden back pain, often with radicular pain (shooting pain due to nerve root compression) and rarely with spinal cord compression or cauda equina syndrome. Multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobility.

Fractures of the long bones acutely impair mobility and may require surgery. Hip fracture, in particular, usually requires prompt surgery, as serious risks are associated with it, such as deep vein thrombosis and pulmonary embolism, and increased mortality.

Fracture risk calculators assess the risk of fracture based upon several criteria, including BMD, age, smoking, alcohol usage, weight, and gender. Recognized calculators include FRAX and Dubbo.

The term "established osteoporosis" is used when a broken bone due to osteoporosis has occurred. Osteoporosis is a part of frailty syndrome.

Falls risk

The increased risk of falling associated with aging leads to fractures of the wrist, spine, and hip. The risk of falling, in turn, is increased by impaired eyesight due to any cause (e.g. glaucoma, macular degeneration), balance disorder, movement disorders (e.g. Parkinson's disease), dementia, and sarcopenia (age-related loss of skeletal muscle). Collapse (transient loss of postural tone with or without loss of consciousness) leads to a significant risk of falls; causes of syncope are manifold, but may include cardiac arrhythmias (irregular heart beat), vasovagal syncope, orthostatic hypotension (abnormal drop in blood pressure on standing up), and seizures. Removal of obstacles and loose carpets in the living environment may substantially reduce falls. Those with previous falls, as well as those with gait or balance disorders, are most at risk.

Risk factors

Risk factors for osteoporotic fracture can be split between nonmodifiable and (potentially) modifiable. In addition, osteoporosis is a recognized complication of specific diseases and disorders. Medication use is theoretically modifiable, although in many cases, the use of medication that increases osteoporosis risk may be unavoidable. Caffeine is not a risk factor for osteoporosis.

It is more likely in females than males.

Nonmodifiable

Bone density peaks at about 30 years of age. Women lose bone mass more rapidly than men.

• The most important risk factors for osteoporosis are advanced age (in both men and women) and female sex; estrogen deficiency following menopause or surgical removal of the ovaries is correlated with a rapid reduction in bone mineral density, while in men, a decrease in testosterone levels has a comparable (but less pronounced) effect.
• Race: While osteoporosis occurs in people from all ethnic groups, European or Asian ancestry predisposes for osteoporosis.
• Heredity: Those with a family history of fracture or osteoporosis are at an increased risk; the heritability of the fracture, as well as low bone mineral density, is relatively high, ranging from 25 to 80%. At least 30 genes are associated with the development of osteoporosis.
• Those who have already had a fracture are at least twice as likely to have another fracture compared to someone of the same age and sex. Early menopause/hysterectomy is another predisposing factor.
• Build: A small stature is also a nonmodifiable risk factor associated with the development of osteoporosis.

Potentially modifiable

• Excess consumption of alcohol: Although small amounts of alcohol are probably beneficial (bone density increases with increasing alcohol intake), chronic heavy drinking (alcohol intake greater than three units/day) probably increases fracture risk despite any beneficial effects on bone density.
• Vitamin D deficiency: Low circulating Vitamin D is common among the elderly worldwide. Mild vitamin D insufficiency is associated with increased parathyroid hormone (PTH) production. PTH increases bone resorption, leading to bone loss. A positive association exists between serum 1,25-dihydroxycholecalciferol levels and bone mineral density, while PTH is negatively associated with bone mineral density.
• Tobacco smoking: Many studies have associated smoking with decreased bone health, but the mechanisms are unclear. Tobacco smoking has been proposed to inhibit the activity of osteoblasts, and is an independent risk factor for osteoporosis. Smoking also results in increased breakdown of exogenous estrogen, lower body weight and earlier menopause, all of which contribute to lower bone mineral density.
• Malnutrition: Nutrition has an important and complex role in maintenance of good bone. Identified risk factors include low dietary calcium and/or phosphorus, magnesium, zinc, boron, iron, fluoride, copper, vitamins A, K, E and C (and D where skin exposure to sunlight provides an inadequate supply). Excess sodium is a risk factor. High blood acidity may be diet-related, and is a known antagonist of bone. Some have identified low protein intake as associated with lower peak bone mass during adolescence and lower bone mineral density in elderly populations. Conversely, some have identified low protein intake as a positive factor, protein is among the causes of dietary acidity. Imbalance of omega-6 to omega-3 polyunsaturated fats is yet another identified risk factor.
• High dietary protein from animal sources: Research has found an association between diets high in animal protein and increased urinary calcium, and have been linked to an increase in fractures. However, the relevance of this observation to bone density is unclear, since higher protein diets tend to increase absorption of calcium from the diet and are associated with higher bone density. Indeed, it has recently been argued that low protein diets cause poor bone health. No interventional trials have been performed on dietary protein in the prevention and treatment of osteoporosis.
• Underweight/inactive: Bone remodeling occurs in response to physical stress, so physical inactivity can lead to significant bone loss. Weight bearing exercise can increase peak bone mass achieved in adolescence, and a highly significant correlation between bone strength and muscle strength has been determined. The incidence of osteoporosis is lower in overweight people.
• Endurance training: In female endurance athletes, large volumes of training can lead to decreased bone density and an increased risk of osteoporosis. This effect might be caused by intense training suppressing menstruation, producing amenorrhea, and it is part of the female athlete triad. However, for male athletes, the situation is less clear, and although some studies have reported low bone density in elite male endurance athletes, others have instead seen increased leg bone density.
• Heavy metals: A strong association between cadmium and lead with bone disease has been established. Low-level exposure to cadmium is associated with an increased loss of bone mineral density readily in both genders, leading to pain and increased risk of fractures, especially in the elderly and in females. Higher cadmium exposure results in osteomalacia (softening of the bone).
• Soft drinks: Some studies indicate soft drinks (many of which contain phosphoric acid) may increase risk of osteoporosis, at least in women. Others suggest soft drinks may displace calcium-containing drinks from the diet rather than directly causing osteoporosis.
• Proton pump inhibitors (such as lansoprazole, esomeprazole, or omeprazole) that decrease stomach acid, are a risk for bone fractures if taken for two or more years, due to decreased absorption of calcium in the stomach.

Medical disorders

The body regulates calcium homeostasis with two pathways; one is signaled to turn on when blood calcium levels drop below normal and one is the pathway that is signaled to turn on when blood calcium levels are elevated.

Many diseases and disorders have been associated with osteoporosis. For some, the underlying mechanism influencing the bone metabolism is straightforward, whereas for others the causes are multiple or unknown.

• In general, immobilization causes bone loss (following the 'use it or lose it' rule). For example, localized osteoporosis can occur after prolonged immobilization of a fractured limb in a cast. This is also more common in active people with a high bone turn-over (for example, athletes). Other examples include bone loss during space flight or in people who are bedridden or use wheelchairs for various reasons.
• Hypogonadal states can cause secondary osteoporosis. These include Turner syndrome, Klinefelter syndrome, Kallmann syndrome, anorexia nervosa, andropause, hypothalamic amenorrhea or hyperprolactinemia. In females, the effect of hypogonadism is mediated by estrogen deficiency. It can appear as early menopause (<45 years) or from prolonged premenopausal amenorrhea (>1 year). Bilateral oophorectomy (surgical removal of the ovaries) and premature ovarian failure cause deficient estrogen production. In males, testosterone deficiency is the cause (for example, andropause or after surgical removal of the testes).
• Endocrine disorders that can induce bone loss include Cushing's syndrome, hyperparathyroidism, hyperthyroidism, hypothyroidism, diabetes mellitus type 1 and 2, acromegaly, and adrenal insufficiency. In pregnancy and lactation can cause reversible bone loss.
• Malnutrition, parenteral nutrition and malabsorption can lead to osteoporosis. Nutritional and gastrointestinal disorders that can predispose to osteoporosis include undiagnosed and untreated coeliac disease (both symptomatic and asymptomatic people), Crohn's disease, ulcerative colitis, cystic fibrosis, surgery (after gastrectomy, intestinal bypass surgery or bowel resection) and severe liver disease (especially primary biliary cirrhosis). People with lactose intolerance or milk allergy may develop osteoporosis due to restrictions of calcium-containing foods. Individuals with bulimia can also develop osteoporosis. Those with an otherwise adequate calcium intake can develop osteoporosis due to the inability to absorb calcium and/or vitamin D. Other micronutrients such as vitamin K or vitamin B₁₂ deficiency may also contribute.
• People with rheumatologic disorders such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus and polyarticular juvenile idiopathic arthritis are at increased risk of osteoporosis, either as part of their disease or because of other risk factors (notably corticosteroid therapy). Systemic diseases such as amyloidosis and sarcoidosis can also lead to osteoporosis.
• Renal insufficiency can lead to renal osteodystrophy.
• Hematologic disorders linked to osteoporosis are multiple myeloma and other monoclonal gammopathies, lymphoma and leukemia, mastocytosis, hemophilia, sickle-cell disease and thalassemia.
• Several inherited disorders have been linked to osteoporosis. These include osteogenesis imperfecta, Marfan syndrome, hemochromatosis, hypophosphatasia (for which it is often misdiagnosed), glycogen storage diseases, homocystinuria, Ehlers–Danlos syndrome, porphyria, Menkes' syndrome, epidermolysis bullosa and Gaucher's disease.
• People with scoliosis of unknown cause also have a higher risk of osteoporosis. Bone loss can be a feature of complex regional pain syndrome. It is also more frequent in people with Parkinson's disease and chronic obstructive pulmonary disease.
• People with Parkinson's disease have a higher risk of broken bones. This is related to poor balance and poor bone density. In Parkinson’s disease there may be a link between the loss of dopaminergic neurons and altered calcium metabolism (and iron metabolism) causing a stiffening of the skeleton and kyphosis.

Medication

Certain medications have been associated with an increase in osteoporosis risk; only steroids and anticonvulsants are classically associated, but evidence is emerging with regard to other drugs.

• Steroid-induced osteoporosis (SIOP) arises due to use of glucocorticoids – analogous to Cushing's syndrome and involving mainly the axial skeleton. The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake. Some professional guidelines recommend prophylaxis in patients who take the equivalent of more than 30 mg hydrocortisone (7.5 mg of prednisolone), especially when this is in excess of three months. Alternate day use may not prevent this complication.
• Barbiturates, phenytoin and some other enzyme-inducing antiepileptics – these probably accelerate the metabolism of vitamin D.
• L-Thyroxine over-replacement may contribute to osteoporosis, in a similar fashion as thyrotoxicosis does. This can be relevant in subclinical hypothyroidism.
• Several drugs induce hypogonadism, for example aromatase inhibitors used in breast cancer, methotrexate and other antimetabolite drugs, depot progesterone and gonadotropin-releasing hormone agonists.
• Anticoagulants – long-term use of heparin is associated with a decrease in bone density, and warfarin (and related coumarins) have been linked with an increased risk in osteoporotic fracture in long-term use.
• Proton pump inhibitors – these drugs inhibit the production of stomach acid; this is thought to interfere with calcium absorption. Chronic phosphate binding may also occur with aluminium-containing antacids.
• Thiazolidinediones (used for diabetes) – rosiglitazone and possibly pioglitazone, inhibitors of PPARγ, have been linked with an increased risk of osteoporosis and fracture.
• Chronic lithium therapy has been associated with osteoporosis.

Evolutionary

Age-related bone loss is common among humans due to exhibiting less dense bones than other primate species. Because of the more porous bones of humans, frequency of severe osteoporosis and osteoporosis related fractures is higher. The human vulnerability to osteoporosis is an obvious cost but it can be justified by the advantage of bipedalism inferring that this vulnerability is the byproduct of such. It has been suggested that porous bones help to absorb the increased stress that we have on two surfaces compared to our primate counterparts who have four surfaces to disperse the force. In addition, the porosity allows for more flexibility and a lighter skeleton that is easier to support. One other consideration may be that diets today have much lower amounts of calcium than the diets of other primates or the tetrapedal ancestors to humans which may lead to higher likelihood to show signs of osteoporosis.

Pathogenesis

Osteoporosis locations

Light micrograph of an osteoclast displaying typical distinguishing characteristics: a large cell with multiple nuclei and a "foamy" cytosol.

Light micrograph of osteoblasts, several displaying a prominent Golgi apparatus, actively synthesizing osteoid containing two osteocytes.

The underlying mechanism in all cases of osteoporosis is an imbalance between bone resorption and bone formation. In normal bone, matrix remodeling of bone is constant; up to 10% of all bone mass may be undergoing remodeling at any point in time. The process takes place in bone multicellular units (BMUs) as first described by Frost & Thomas in 1963. Osteoclasts are assisted by transcription factor PU.1 to degrade the bone matrix, while osteoblasts rebuild the bone matrix. Low bone mass density can then occur when osteoclasts are degrading the bone matrix faster than the osteoblasts are rebuilding the bone.

The three main mechanisms by which osteoporosis develops are an inadequate peak bone mass (the skeleton develops insufficient mass and strength during growth), excessive bone resorption, and inadequate formation of new bone during remodeling. An interplay of these three mechanisms underlies the development of fragile bone tissue. Hormonal factors strongly determine the rate of bone resorption; lack of estrogen (e.g. as a result of menopause) increases bone resorption, as well as decreasing the deposition of new bone that normally takes place in weight-bearing bones. The amount of estrogen needed to suppress this process is lower than that normally needed to stimulate the uterus and breast gland. The α-form of the estrogen receptor appears to be the most important in regulating bone turnover. In addition to estrogen, calcium metabolism plays a significant role in bone turnover, and deficiency of calcium and vitamin D leads to impaired bone deposition; in addition, the parathyroid glands react to low calcium levels by secreting parathyroid hormone (parathormone, PTH), which increases bone resorption to ensure sufficient calcium in the blood. The role of calcitonin, a hormone generated by the thyroid that increases bone deposition, is less clear and probably not as significant as that of PTH.

The activation of osteoclasts is regulated by various molecular signals, of which RANKL (receptor activator of nuclear factor kappa-B ligand) (receptor activator of nuclear factor kappa-B ligand) is one of the best studied. This molecule is produced by osteoblasts and other cells (e.g. lymphocytes), and stimulates RANK (receptor activator of nuclear factor κB). Osteoprotegerin (OPG) binds RANKL before it has an opportunity to bind to RANK, and hence suppresses its ability to increase bone resorption. RANKL, RANK and OPG are closely related to tumor necrosis factor and its receptors. The role of the Wnt signaling pathway is recognized, but less well understood. Local production of eicosanoids and interleukins is thought to participate in the regulation of bone turnover, and excess or reduced production of these mediators may underlie the development of osteoporosis.

Trabecular bone (or cancellous bone) is the sponge-like bone in the ends of long bones and vertebrae. Cortical bone is the hard outer shell of bones and the middle of long bones. Because osteoblasts and osteoclasts inhabit the surface of bones, trabecular bone is more active and is more subject to bone turnover and remodeling. Not only is bone density decreased, but the microarchitecture of bone is also disrupted. The weaker spicules of trabecular bone break ("microcracks"), and are replaced by weaker bone. Common osteoporotic fracture sites, the wrist, the hip and the spine, have a relatively high trabecular bone to cortical bone ratio. These areas rely on the trabecular bone for strength, so the intense remodeling causes these areas to degenerate most when the remodeling is imbalanced. Around the ages of 30–35, cancellous or trabecular bone loss begins. Women may lose as much as 50%, while men lose about 30%.

Diagnosis

Multiple osteoporotic wedge fractures demonstrated on a lateral thoraco-lumbar spine X-ray

The diagnosis of osteoporosis can be made using conventional radiography and by measuring the bone mineral density (BMD). The most popular method of measuring BMD is dual-energy X-ray absorptiometry. In addition to the detection of abnormal BMD, the diagnosis of osteoporosis requires investigations into potentially modifiable underlying causes; this may be done with blood tests. Depending on the likelihood of an underlying problem, investigations for cancer with metastasis to the bone, multiple myeloma, Cushing's disease and other above-mentioned causes may be performed.

Conventional radiography

Conventional radiography is useful, both by itself and in conjunction with CT or MRI, for detecting complications of osteopenia (reduced bone mass; pre-osteoporosis), such as fractures; for differential diagnosis of osteopenia; or for follow-up examinations in specific clinical settings, such as soft tissue calcifications, secondary hyperparathyroidism, or osteomalacia in renal osteodystrophy. However, radiography is relatively insensitive to detection of early disease and requires a substantial amount of bone loss (about 30%) to be apparent on X-ray images.

The main radiographic features of generalized osteoporosis are cortical thinning and increased radiolucency. Frequent complications of osteoporosis are vertebral fractures for which spinal radiography can help considerably in diagnosis and follow-up. Vertebral height measurements can objectively be made using plain-film X-rays by using several methods such as height loss together with area reduction, particularly when looking at vertical deformity in T4-L4, or by determining a spinal fracture index that takes into account the number of vertebrae involved. Involvement of multiple vertebral bodies leads to kyphosis of the thoracic spine, leading to what is known as dowager's hump.

Dual-energy X-ray

Dual-energy X-ray absorptiometry (DXA) is considered the gold standard for the diagnosis of osteoporosis. Osteoporosis is diagnosed when the bone mineral density is less than or equal to 2.5 standard deviations below that of a young (30–40-year-old^:58), healthy adult women reference population. This is translated as a T-score. But because bone density decreases with age, more people become osteoporotic with increasing age.^:58 The World Health Organization has established the following diagnostic guidelines:

Category	T-score range	% young women
Normal	T-score ≥ −1.0	85%
Osteopenia	−2.5 < T-score < −1.0	14%
Osteoporosis	T-score ≤ −2.5	0.6%
Severe osteoporosis	T-score ≤ −2.5 with fragility fracture

The International Society for Clinical Densitometry takes the position that a diagnosis of osteoporosis in men under 50 years of age should not be made on the basis of densitometric criteria alone. It also states, for premenopausal women, Z-scores (comparison with age group rather than peak bone mass) rather than T-scores should be used, and the diagnosis of osteoporosis in such women also should not be made on the basis of densitometric criteria alone.

Biomarkers

Chemical biomarkers are a useful tool in detecting bone degradation. The enzyme cathepsin K breaks down type-I collagen protein, an important constituent in bones. Prepared antibodies can recognize the resulting fragment, called a neoepitope, as a way to diagnose osteoporosis. Increased urinary excretion of C-telopeptides, a type-I collagen breakdown product, also serves as a biomarker for osteoporosis.

Comparison of bone pathology

Condition	Calcium	Phosphate	Alkaline phosphatase	Parathyroid hormone	Comments
Osteopenia	unaffected	unaffected	normal	unaffected	decreased bone mass
Osteopetrosis	unaffected	unaffected	elevated	unaffected	thick dense bones also known as marble bone
Osteomalacia and rickets	decreased	decreased	elevated	elevated	soft bones
Osteitis fibrosa cystica	elevated	decreased	elevated	elevated	brown tumors
Paget's disease of bone	unaffected	unaffected	variable (depending on stage of disease)	unaffected	abnormal bone architecture

Other measuring tools

Quantitative computed tomography differs from DXA in that it gives separate estimates of BMD for trabecular and cortical bone and reports precise volumetric mineral density in mg/cm³ rather than BMD's relative Z score. Among QCT's advantages: it can be performed at axial and peripheral sites, can be calculated from existing CT scans without a separate radiation dose, is sensitive to change over time, can analyze a region of any size or shape, excludes irrelevant tissue such as fat, muscle, and air, and does not require knowledge of the patient's subpopulation in order to create a clinical score (e.g. the Z-score of all females of a certain age). Among QCT's disadvantages: it requires a high radiation dose compared to DXA, CT scanners are large and expensive, and because its practice has been less standardized than BMD, its results are more operator-dependent. Peripheral QCT has been introduced to improve upon the limitations of DXA and QCT.

Quantitative ultrasound has many advantages in assessing osteoporosis. The modality is small, no ionizing radiation is involved, measurements can be made quickly and easily, and the cost of the device is low compared with DXA and QCT devices. The calcaneus is the most common skeletal site for quantitative ultrasound assessment because it has a high percentage of trabecular bone that is replaced more often than cortical bone, providing early evidence of metabolic change. Also, the calcaneus is fairly flat and parallel, reducing repositioning errors. The method can be applied to children, neonates, and preterm infants, just as well as to adults. Some ultrasound devices can be used on the tibia.

Screening

The U.S. Preventive Services Task Force (USPSTF) recommend that all women 65 years of age or older be screened by bone densitometry. Additionally they recommend screening women with increased risk factors that puts them at risk equivalent to a 65‑year‑old. There is insufficient evidence to make recommendations about the intervals for repeated screening and the appropriate age to stop screening. In men the harm versus benefit of screening for osteoporosis is unknown. The International Society for Clinical Densitometry, however, suggest BMD testing for men 70 or older, or those who are indicated for risk equal to that of a 70‑year‑old. A number of tools exist to help determine who is reasonable to test.

Prevention

Lifestyle prevention of osteoporosis is in many aspects the inverse of the potentially modifiable risk factors. As tobacco smoking and high alcohol intake have been linked with osteoporosis, smoking cessation and moderation of alcohol intake are commonly recommended as ways to help prevent it.

In people with coeliac disease adherence to a gluten-free diet decreases the risk of developing osteoporosis and increases bone density. The diet must ensure optimal calcium intake (of at least one gram daily) and measuring vitamin D levels is recommended, and to take specific supplements if necessary.

Nutrition

Studies of the benefits of supplementation with calcium and vitamin D are conflicting, possibly because most studies did not have people with low dietary intakes. A 2013 review by the USPSTF found insufficient evidence to determine if supplementation with calcium and vitamin D results in greater harm or benefit in men and premenopausal women. The USPSTF did not recommend low dose supplementation (less than 1 g of calcium and 400 IU of vitamin D) in postmenopausal women as there does not appear to be a difference in fracture risk. It is unknown what effect higher doses have. A 2015 review found little data that supplementation of calcium decreases the risk of fractures.

While some meta-analyses have found a benefit of vitamin D supplements combined with calcium for fractures, they did not find a benefit of vitamin D supplements alone.

While supplementation does not appear to affect the risk of death, there is an increased risk of myocardial infarctions with calcium supplementation, kidney stones, and stomach problems.

Vitamin K deficiency is also a risk factor for osteoporotic fractures. The gene gamma-glutamylcarboxylase (GGCX) is dependent on vitamin K. Functional polymorphisms in the gene could attribute to variation in bone metabolism and BMD. Vitamin K2 is also used as a means of treatment for osteoporosis and the polymorphisms of GGCX could explain the individual variation in the response to treatment of vitamin K. Vitamin K supplementation may reduce the risk of fractures in postmenopausal women; however, there is no evidence for men.

Management

Lifestyle

Weight-bearing endurance exercise and/or exercises to strengthen muscles improve bone strength in those with osteoporosis. Aerobics, weight bearing, and resistance exercises all maintain or increase BMD in postmenopausal women. Fall prevention can help prevent osteoporosis complications. There is some evidence for hip protectors specifically among those who are in care homes.

Medications

Bisphosphonates are useful in decreasing the risk of future fractures in those who have already sustained a fracture due to osteoporosis. This benefit is present when taken for three to four years. Different bisphosphonates have not been directly compared, therefore it is unknown if one is better than another. Fracture risk reduction is between 25 and 70% depending on the bone involved. There are concerns of atypical femoral fractures and osteonecrosis of the jaw with long term use, but these risks are low. With evidence of little benefit when used for more than three to five years and in light of the potential adverse events, it may be appropriate to stop treatment after this time in some. One medical organization recommends that after five years of medications by mouth or three years of intravenous medication among those at low risk, bisphosphonate treatment can be stopped. In those at higher risk they recommend up to ten years of medication by mouth or six years of intravenous treatment.

For those with osteoporosis but who have not had a fracture evidence does not support a reduction in fracture risk with risedronate or etidronate. Alendronate decreases fractures of the spine but does not have any effect on other types of fractures. Half stop their medications within a year.

Fluoride supplementation does not appear to be effective in postmenopausal osteoporosis, as even though it increases bone density, it does not decrease the risk of fractures.

Teriparatide ( a recombinant parathyroid hormone ) has been shown to be effective in treatment of women with postmenopausal osteoporosis. Some evidence also indicates strontium ranelate is effective in decreasing the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis. Hormone replacement therapy, while effective for osteoporosis, is only recommended in women who also have menopausal symptoms. Raloxifene, while effective in decreasing vertebral fractures, does not affect the risk of nonvertebral fracture. And while it reduces the risk of breast cancer, it increases the risk of blood clots and strokes. Denosumab is also effective for preventing osteoporotic fractures. In hypogonadal men, testosterone has been shown to improve bone quantity and quality, but, as of 2008, no studies evaluated its effect on fracture risk or in men with a normal testosterone levels. Calcitonin while once recommended is no longer due to the associated risk of cancer with its use and questionable effect on fracture risk.

Certain medications like alendronate, etidronate, risedronate, raloxifene and strontium ranelate can be helpful for the preventing of osteoporotic fragility fractures in postmenopausal women with osteoporosis.

Prognosis

Hip fractures per 1000 person-years

WHO category	Age 50–64	Age > 64	Overall
Normal	5.3	9.4	6.6
Osteopenia	11.4	19.6	15.7
Osteoporosis	22.4	46.6	40.6

Although osteoporosis patients have an increased mortality rate due to the complications of fracture, it is rarely lethal.

Hip fractures can lead to decreased mobility and additional risks of numerous complications (such as deep venous thrombosis and/or pulmonary embolism, and pneumonia). The six-month mortality rate following hip fracture is around 13.5%, and a substantial proportion (almost 13%) of people who have suffered a hip fracture need total assistance to mobilize after a hip fracture.

Vertebral fractures, while having a smaller impact on mortality, can lead to a severe chronic pain of neurogenic origin, which can be hard to control, as well as deformity. Though rare, multiple vertebral fractures can lead to such severe hunch back (kyphosis), the resulting pressure on internal organs can impair one's ability to breathe.

Apart from risk of death and other complications, osteoporotic fractures are associated with a reduced health-related quality of life.

The condition is responsible for millions of fractures annually, mostly involving the lumbar vertebrae, hip, and wrist. Fragility fractures of ribs are also common in men.

Hip fractures

Hip fractures are responsible for the most serious consequences of osteoporosis. In the United States, more than 250,000 hip fractures annually are attributable to osteoporosis. A 50-year-old white woman is estimated to have a 17.5% lifetime risk of fracture of the proximal femur. The incidence of hip fractures increases each decade from the sixth through the ninth for both women and men for all populations. The highest incidence is found among men and women ages 80 or older.

Vertebral fractures

Between 35 and 50% of all women over 50 had at least one vertebral fracture. In the United States, 700,000 vertebral fractures occur annually, but only about a third are recognized. In a series of 9704 women aged 68.8 on average studied for 15 years, 324 had already suffered a vertebral fracture at entry into the study and 18.2% developed a vertebral fracture, but that risk rose to 41.4% in women who had a previous vertebral fracture.

Wrist fractures

In the United States, 250,000 wrist fractures annually are attributable to osteoporosis. Wrist fractures are the third most common type of osteoporotic fractures. The lifetime risk of sustaining a Colles' fracture is about 16% for white women. By the time women reach age 70, about 20% have had at least one wrist fracture.

Rib fractures

Fragility fractures of the ribs are common in men as young as age 35. These are often overlooked as signs of osteoporosis, as these men are often physically active and suffer the fracture in the course of physical activity. An example would be as a result of falling while water skiing or jet skiing. However, a quick test of the individual's testosterone level following the diagnosis of the fracture will readily reveal whether that individual might be at risk.

Epidemiology

It is estimated that 200 million people have osteoporosis. Osteoporosis becomes more common with age. About 15% of White people in their 50s and 70% of those over 80 are affected. It is more common in women than men. In the developed world, depending on the method of diagnosis, 2% to 8% of males and 9% to 38% of females are affected. Rates of disease in the developing world are unclear.

There are 8.9 million fractures worldwide per year due to osteoporosis. Globally, 1 in 3 women and 1 in 5 men over the age of 50 will have an osteoporotic fracture. Data from the United States shows a decrease in osteoporosis within the general population and in white women, from 18% in 1994 to 10% in 2006. White and Asian people are at greater risk. People of African descent are at a decreased risk of fractures due to osteoporosis, although they have the highest risk of death following an osteoporotic fracture.

It has been shown that latitude affects risk of osteoporotic fracture. Areas of higher latitude such as Northern Europe receive less Vitamin D through sunlight compared to regions closer to the equator, and consequently have higher fracture rates in comparison to lower latitudes. For example, Swedish men and women have a 13.% and 28.5% risk of hip fracture by age 50, respectively, whereas this risk is only 1.9% and 2.4% in Chinese men and women. Diet may also be a factor that is responsible for this difference, as vitamin D, calcium, magnesium, and folate are all linked to bone mineral density.

About 22 million women and 5.5 million men in the European Union had osteoporosis in 2010. In the United States in 2010 about 8 million women and one to 2 million men had osteoporosis. This places a large economic burden on the healthcare system due to costs of treatment, long-term disability, and loss of productivity in the working population. The EU spends 37 billion euros per year in healthcare costs related to osteoporosis, and the USA spends an estimated 19 billion USD annually for related healthcare costs.

History

The link between age-related reductions in bone density and fracture risk goes back at least to Astley Cooper, and the term "osteoporosis" and recognition of its pathological appearance is generally attributed to the French pathologist Jean Lobstein. The American endocrinologist Fuller Albright linked osteoporosis with the postmenopausal state. Bisphosphonates were discovered in the 1960s.

Anthropologists have studied skeletal remains that showed loss of bone density and associated structural changes that were linked to a chronic malnutrition in the agricultural area in which these individuals lived. "It follows that the skeletal deformation may be attributed to their heavy labor in agriculture as well as to their chronic malnutrition", causing the osteoporosis seen when radiographs of the remains were made.

Osteoporosis means "porous bones", from Greek: οστούν/ostoun meaning "bone" and πόρος/poros meaning "pore".

References

External links

• Osteoporosis at DMOZ
• Handout on Health: Osteoporosis - US National Institute of Arthritis and Musculoskeletal and Skin Diseases
• Osteoporosis - NIH Osteoporosis and Related Bone Diseases ~ National Resource Center
• Office of the Surgeon General (2004). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services. PMID 20945569. Retrieved 18 July 2016. 

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 閉経後の女性における骨粗鬆症のマネージメントの概要 overview of the management of osteoporosis in postmenopausal women
• 2. 骨粗鬆症のスクリーニング screening for osteoporosis
• 3. 閉経前の骨粗鬆症の疫学および病因 epidemiology and etiology of premenopausal osteoporosis
• 4. 男性における骨粗鬆症の治療 treatment of osteoporosis in men
• 5. 男性における骨粗鬆症の臨床症状、診断、および評価 clinical manifestations diagnosis and evaluation of osteoporosis in men

English Journal

• Secondary prevention of osteoporosis following fragility fractures of the distal radius in a large health maintenance organization.

• Benzvi L1, Gershon A1,2, Lavi I3, Wollstein R4,5,6.
• Archives of osteoporosis.Arch Osteoporos.2016 Dec;11(1):20. doi: 10.1007/s11657-016-0275-2. Epub 2016 May 3.
• A retrospective study evaluated a large health maintenance organization for secondary prevention of osteoporosis following fragility fractures of the distal radius. Our population remained undiagnosed and untreated despite the ability of the system to provide adequate care. These patients specifical
• PMID 27142832

• Patient-reported barriers to osteoporosis therapy.

• Lindsay BR1, Olufade T2, Bauer J3, Babrowicz J3, Hahn R3.
• Archives of osteoporosis.Arch Osteoporos.2016 Dec;11(1):19. doi: 10.1007/s11657-016-0272-5. Epub 2016 Apr 29.
• We investigated reasons for non-treatment of osteoporosis and discontinuation of osteoporosis therapy. Barriers to treatment include patients' preference for alternative treatments and a fear of possible side effects. Side effects are a common reason for treatment discontinuation, and they may be as
• PMID 27129487

• A new implementation of digital X-ray radiogrammetry and reference curves of four indices of cortical bone for healthy European adults.

• Thodberg HH1, Böttcher J2, Lomholt J3, Kreiborg S3, Wolf G2, Pfeil A2.
• Archives of osteoporosis.Arch Osteoporos.2016 Dec;11(1):17. doi: 10.1007/s11657-016-0267-2. Epub 2016 Apr 26.
• Digital X-ray radiogrammetry performs measurements on a hand radiograph in digital form. We present an improved implementation of the method and provide reference curves for four indices for the amount of bone. We collected 1662 hand radiographs of healthy subjects of age 9-100 years.PURPOSE: The d
• PMID 27116027

Japanese Journal

• Renin Inhibition Improves Ovariectomy-Induced Osteoporosis of Lumbar Vertebra in Mice

• Zhang Fang-Yi,Yang Feng-Jian,Yang Jiu-Lin [他]
• Biological & pharmaceutical bulletin 37(12), 1994-1997, 2014-12
• NAID 40020277895

• Puerarin Enhances Bone Mass by Promoting Osteoblastogenesis and Slightly Lowering Bone Marrow Adiposity in Ovariectomized Rats

• Li Binbin,Liu Hao,Jia Shengnan
• Biological & pharmaceutical bulletin 37(12), 1919-1925, 2014-12
• NAID 40020277805

• 卒後研修講座 骨粗鬆症を伴った橈骨遠位端骨折の治療と予防

• 酒井 昭典
• 整形外科 = Orthopedic surgery 65(13), 1373-1378, 2014-12
• NAID 40020271690

Related Links

• Osteoporosis Center: Symptoms, Treatments, Causes ...

From symptoms to treatment options, find in-depth news and information to help cope with osteoporosis. ... Osteoporosis Overview Osteoporosis, or thinning bones, can result in painful fractures. Risk factors for osteoporosis include ...

• Osteoporosis - Mayo Clinic

Osteoporosis — Comprehensive overview covers risk factors, treatment, prevention of this condition of weakened bones. ... Osteoporosis causes bones to become weak and brittle — so brittle that a fall or even mild stresses like ...

Related Pictures

---

★リンクテーブル★

リンク元	「骨粗鬆症」「100Cases 27」「age-related bone loss」「age-related osteoporosis」「osteoporotic」
拡張検索	「low turnover osteoporosis」

「骨粗鬆症」

　　[★]

英

osteoporosis

同

骨多孔症、オステオポローシス

関

骨軟化症、くる病、老人性骨粗鬆症、若年性特発性骨粗鬆症、糖質コルチコイド誘発骨粗鬆症。骨粗鬆症治療薬

• 骨の絶対量の減少を生じているが骨の質的な変化を伴わない状態をいう。
• 骨はたえず吸収、形成されているものであり、したがって吸収率と形成率に差を生じ骨形成が負の平衡となれば骨粗鬆が起こる。

概念

• 骨量の減少(≒骨密度の減少)と骨組織の微細構造の破錠(骨質の劣化)により骨強度が低下して、骨折をきたしやすくなった疾患

• 骨強度は骨密度(7割)と骨質(3割)に規定される。

定義

• WHO(1994)、骨量測定法,女性の骨粗鬆症：若年健常女性の平均骨量値から2.5SD以上減少したもの　⇔　骨量減少：2.5<T-score<-1
• 日本：骨量が30%以上減少したもの

リスクファクター

YN.D-156

• 1. 局所性：廃用性、関節リウマチ、Sudeck骨萎縮
• 2. 全身性：閉経後、高齢者、るいそう

• 全身性：閉経、無月経、加齢、やせ、偏食、運動不足、ステロイド投与、日光照射不足、タバコ、糖尿病、胃切除、遺伝的素因
• Ca欠乏：Ca摂取不足
• ビタミンD欠乏：腎障害、肝障害、胃・小腸切除、日照不足
• マグネシウム欠乏状態
• 内分泌：糖尿病、医原性、Cushing症候群、甲状腺機能亢進症、副甲状腺機能亢進症、エストロゲン分泌能低下

ガイドライン2

• 高齢、既存骨折(リスク1.9-4倍)、喫煙(リスク1.3-1.8倍)、飲酒(1日2単位以上でリスク1.2-1.7倍)、ステロイド使用(1日5mg以上の経口摂取でリスク2-4倍)、骨折家族歴(親の骨折でリスク1.2-2.3倍)、運動不足(大腿頚部骨折リスク1.3-1.7倍)、易転倒性

以下のリスクファクターを有する65歳未満か、65歳以上の女性は骨量測定によるスクリーニングの対象となる。

• 高齢、低体重、骨折既往、骨粗鬆症による骨折の家族歴、白人・アジア人、アルコール(1日２杯以上)、カフェイン、喫煙、運動不足、カルシウム不足、ビタミンD不足、骨粗鬆症を起こす薬剤

原因による分類

• 原発性骨粗鬆症
• 続発性骨粗鬆症

原発性骨粗鬆症

• 閉経後骨粗鬆症：女性ホルモンの低下→破骨細胞の過活動。高代謝回転型骨粗鬆症
• 老人性骨粗鬆症：低代謝回転型骨粗鬆症
• 若年性、特発性

続発性骨粗鬆症

内分泌性

• 甲状腺機能亢進症
• 副甲状腺機能亢進症：正常より骨吸収が促進される。高代謝回転型骨粗鬆症
• クッシング症候群：
• 性腺機能低下症、運動しすぎの無月経
• 1型糖尿病]
• 末端肥大症

栄養性

• 壊血病
• その他(蛋白質欠乏、ビタミンA過剰、ビタミンD過剰)

別ソース

• アルコール、摂食障害、ビタミンD欠乏、胃切除

遺伝性

• 骨形成不全症、
• ホモシスチン尿症

薬物性

• コルチコステロイド(ステロイド)　→　ステロイド性骨粗鬆症
• ヘパリン(長期)
• メトトレキセート methotrexate MTX

別ソース

• 抗痙攣薬(フェノバルビタール、フェニトイン)
• 性腺機能低下症を来す薬物
• リチウム
• PPI

不動性

• 全身性：長期臥床、宇宙飛行、対麻痺
• 局所性：骨折後

先天性

• 先天性骨形成不全症
• Marfan症候群

その他

• 関節リウマチ
• 糖尿病
• 肝疾患

別ソース

• COPD, RA, HIV, IBD, 吸収不良症候群, 多発性骨髄腫, リウマチ熱, 心不全, アミロイドーシス, 長期臥床

小児の骨粗鬆症

Dent CE：Osteoporosis in childhood．Postgrad Med J 53：450－456，1977

遺伝性症候群	骨形成不全症
特発性若年性骨粗鬆症
慢性後天性症候群	胆道閉鎖症、チアノーゼ性心疾患
急性後天性症候群	身体の固定、体動制限
後天性代謝異常	甲状腺中毒、クッシング症候群、カルシウム欠乏、壊血病
新生物による	白血病、原発/転移性悪性腫瘍

男性の骨粗鬆症

原因

• 多：クッシング症候群、アルコール多飲、ステロイド使用(5mg, 3ヶ月以上)、性腺機能低下、カルシウム摂取量減少、ビタミンD欠乏、喫煙、家族の中で骨折しやすい人がいる、男性ホルモン異常
• 希：BMI<20, 運動不足、抗てんかん薬、甲状腺中毒症、副甲状腺機能亢進、慢性肝障害、慢性腎障害、吸収不良症候群、高カルシウム血症、リウマチ、脊椎関節炎、糖尿病、多発性骨髄腫、HIV、臓器移植、免疫抑制剤

病理

• 皮質骨が薄くなる。海綿骨は骨梁が減少。

検査

• 骨評価：骨量測定　＋　胸椎/腰椎の単純X線撮影

• 骨量測定

• 躯幹骨DXA、末梢骨DXA、RA/MD、QUSなどで測定可能
• 椎体DXAと大腿近位部DXAの両方を評価することが望ましい。できなければ橈骨DXAで代替する。

• 胸椎/腰椎の単純X線撮影

• 椎体の骨折/変形、退行性変化、骨粗鬆症に類維持した疾患(腰背部痛、円背や低骨量を呈する疾患)の鑑別に必要

治療

薬物治療

• 女性ホルモン製剤
• 活性化ビタミンD3製剤
• ビタミンK2製剤
• エチドロネート
• アレンドロネート
• リセドロネート
• SERM:塩酸ラロキシフェン
• カルシトニン製剤
• イプリフラボン

薬物治療開始基準

ガイドライン2

• 以下のいずれかを満たす場合。

• 1. 脆弱性既存骨折有り
• 2. 脆弱性既存骨折無し

• 1) 骨密度が若年成人平均値の70%未満
• 2) 骨密度が若年成人平均値の70-80%で、かつ閉経後女性/50歳以上男性であって、次のいずれかを有する。

• a) 過度のアルコール摂取：1日2単位以上
• b) 現在の喫煙
• c) 大腿骨頚部骨折の家族歴

治療開始のトリガー

別ソース

• 骨粗鬆症による大腿骨骨折、椎骨骨折の既往
• Tスコアが-2.5以下
• Tスコアが-1～-2.5 FRAX

• FRAXにて10年後の大腿骨折リスクが3%、主要な骨粗鬆症性骨折リスクが15-20%を超えるなら治療。

腎機能障害がある場合の治療の選択肢

https://www.kyorin-pharm.co.jp/prodinfo/useful/doctorsalon/upload_docs/150359-1-15.pdf

慎重投与となっており、禁忌ではないから

• アレンドロン酸 フォサマック
• ミノドロン酸 ボノテオ

肝臓や腎臓で代謝されないから

• プラリア

検診

スクリーニング

USPSTF

• 65歳以上の女性、64歳以下で骨折リスクが高い女性(脆弱骨折の既往、ステロイド内服など)
• 男性ではエビデンスがない

スクリーニング間隔

• DEXA:1.0～-1.5→15年
• DEXA:-1.5～-2.0→5年
• DEXA:-2.0～-2.5→1年

ガイドライン

• 1. 骨粗鬆症 - ガイドライン

http://minds.jcqhc.or.jp/stc/0046/1/0046_G0000129_GL.html

• 2. <amazon mode="text" text="骨粗鬆症の予防と治療ガイドライン(2006年版) ダイジェスト版">4897752329</amazon>

<amazon mode="script" ></amazon>

参考

• 1. 糖尿病と骨粗鬆症

http://www.richbone.com/kotsusoshosho/basic_shindan/tonyo.htm

「100Cases 27」

　　[★]

☆case27　関節痛

■症例

37歳　女性

主訴：関節痛

現病歴：数ヶ月、膝の痛みがだんだん強くなっていると感じていた。痛みは手や足の小関節に多く、朝歩くときに最もこわばる。痛みはジクロフェナクを飲むと和らぐ。そのほかの症状として疲労感を感じ、最近、体重が３ヶ月で４ｋｇ減っている。

喫煙歴：なし。

飲酒歴：機会飲酒

既往歴：なし

家族歴：既婚、子供は２人

服薬歴：ジクロフェナク

職業歴：legal sevretary

身体所見 examination

　顔貌　青白、臨床的な貧血を認める。近位指節間関節・中手指節関節　腫脹・effusionを伴う疼痛。中足趾節関節　圧痛。それ以外は正常。

検査　investigation

　血液検査

　　Hb低下

　　ESR上昇

　　尿素軽度上昇

　　クレアチニン軽度上昇

　　正常：白血球、MCV、血小板、ナトリウム、カリウム、グルコース、アルブミン

　尿検査

　　蛋白(-)、尿糖(-)、潜血(-)、

■問題

　本症例では診断とその根拠を考えるのは簡単なので、鑑別疾患をあげてその疾患に特徴的な症候を列挙しましょう。

■関節痛 DIF.283

　V Vascular

　　血友病 hemophilia　血友病性関節症(急性：疼痛、腫脹、熱感(SOR.241)

慢性：可動域の低下、変形、関節周囲筋萎縮(SOR.241))。家族歴

　　壊血病 scurvy　。生活環境。食事歴

　　無菌性骨壊死 aseptic bone necrosis (Osgood-Schlatter diseaseとか)

　I Inflammatory

　　感染性関節炎(細菌性関節炎(化膿性関節炎・淋菌性関節炎・結核性関節炎・嫌気性菌関節炎 )、真菌性関節炎、スピロヘータ関節炎(梅毒性関節炎・ライム関節炎)、マイコプラズマ関節炎、ウイルス性関節炎)

　N Neoplastic disorders

　　骨原性肉腫 osteogenic sarcoma

　　巨細胞腫 giant cell tumors

　D Degenerative disorders

　　degenerative joint disease

　　変形性関節症 osteoarthritis

　I Intoxication

　　痛風 gout (uric acid)

　　偽痛風 pseudogout (calcium pyrophosphate)

　　ループス症候群 lupus syndrome of hydralazine (Apresoline) and procainamide

　　gout syndrome of diuretics

　C Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.

　A Autoimmune indicates

　　関節リウマチ RA

　　血清病 serum sickness

　　全身性エリテマトーデス lupus erythematosus

　　リウマチ熱 rheumatic fever

　　ライター症候群 Reiter syndrome

　　潰瘍性大腸炎 ulcerative colitis

　　クローン病=限局性回腸炎 regional ileitis

　　乾癬性関節炎 psoriatic arthritis

　　リウマチ性多発筋痛症 polymyalgia rheumatica

　T Trauma

　E Endcrine

　　先端肥大症 acromegaly

　　閉経 menopause

　　糖尿病 diabetes mellitus

■関節炎の分類

・炎症部位の数

　単関節炎：痛風、偽痛風、離断性骨軟骨炎、血行性の化膿性関節炎のほとんど

　多関節炎：リウマチ性疾患、ウイルス性疾患、白血病での関節症状、易感染性宿主における血行性の化膿性関節炎

■関節リウマチ

　診断基準

　関節症状

　　朝のこわばり、疼痛、腫脹、関節の動揺、関節可動域制限、変形(手指、足趾、膝関節)。(SOR.211)

　　手指の近位指節間関節(PIP関節)、中手指節関節(MP関節)。遠位指節間関節(DIP関節)に初発することは稀。(SOR.211)

　　左右対称性に生じることが多い。手関節、足趾、膝関節に初発する。(SOR.211)

　関節外症状

　　全身症状：発熱

　　皮膚症状：リウマトイド結節(肘の伸側、後頭部、手指)

　　眼症状：上胸膜炎(10日の経過で治癒)、強膜炎(予後不良)。稀に角膜穿孔

　　血液障害：(高頻度)貧血、白血球減少(Felty病。DMARDs投与中の場合は薬剤性の骨髄抑制を考慮)

　　アミロイドーシス：ネフローゼや下痢を来した症例で疑う。アミロイド蛋白はAA

　　腎障害：稀。アミロイドーシスの続発症か薬剤性を考慮。

　　呼吸器症状：間質性肺炎の合併多い。下肺野に好発。通常無症状。メトトレキセートなどの使用により薬剤性の急性間質性肺炎を生じることがある。

　　心・血管障害：リンパ管炎による難治性の浮腫。

　　神経症状：環軸関節亜脱臼により項部痛や脊髄症上が出現しうる。

　　骨粗鬆症

　　腱鞘滑膜炎：手指、手関節、足関節

■両側性多関節炎の鑑別疾患

　OA：遠位指節間関節を冒すのが特徴的で、近位指節間関節、中手指節関節を冒しうる。

　RA：

　SLE：軽度、症状の程度が変動する非びらん性の関節炎

　gout：単関節炎からはじまる。

　血清陰性関節炎：強直性脊椎炎、感染、ライター病：中～大関節に非対称性の関節炎。仙腸関節と遠位指節間関節にも関節炎

　急性ウイルス性関節炎：風疹。

■KEY POINTS

・RAでは遠位指節間関節は冒されない傾向がある。

・RAの全身症状は関節症状に先行することがある。

・RAの活動性と貧血及びESRは相関している。

・NSAIDsは腎機能に悪影響を与えることがある。

■initial plan

　Dx 1. 単純X線写真

　　　　・亜脱臼、関節周囲の骨萎縮(傍関節性骨骨粗鬆症,juxta-articular osteoporosis)、関節裂隙の狭小化、関節辺縁のびらん(bony erosion)

　　　　　・初期のRAで第5趾に骨びらんが一般的に見られる。

　　　　・血液検査

　　　　　・RF、抗DNA抗体

　Tx 1. 鎮痛薬

　　　　・NSAIDs：鎮痛とこわばりの軽減

　　 2. DMARDs(メトトレキセート、レフルノミド、金製剤、ペニシラミン)

　　　　・NSAIDsで症状が治まらない場合に考慮

　　 3. 抗TNF抗体

　　　　・重症のRAで効果がある場合がある。

■参考文献

SOR　標準整形外科学 第10版 医学書院

DIF　Differential Diagnosis in Primary Care Fourth Edition版 Lippincott Williams & Wilkins

「age-related bone loss」

　　[★]

• 加齢性骨喪失、加齢性骨減少

関

age-related osteoporosis、osteoporosis、senile osteoporosis

「age-related osteoporosis」

　　[★]

加齢性骨粗鬆症

関

age-related bone loss、osteoporosis、senile osteoporosis

「osteoporotic」

　　[★]

• adj.

• 骨粗鬆症の、骨多孔症の

関

osteoporosis

「low turnover osteoporosis」

　　[★] 低代謝回転型骨粗鬆症