At the age of 27, the symptoms of osteoporosis have not been significantly improved after calcium supplementation. What is the reason?

*For medical professionals to read for reference, don’t think that you can relax your vigilance when you are young.
Author of this article: Department of Endocrinology, Southern Theater General Hospital: Zhang Pengxin, Li Jia Diary of a patient with bone pain for 2 years.
.
.
Patient’s diary: Time: Weather in July 2018 : Sunny mood: I don’t know why recently.
I feel my bones are hurting.
The waist and legs are the most obvious.
I feel stiff joints in the morning, obviously weak, and have repeated diarrhea.
Is it because I’m too tired to take care of the baby recently? After physiotherapy for a period of time, the effect seems to be okay, then it doesn't matter.
I'm only 27, so young, it should be fine
.

Time: June 2019 Weather: Sunny Mood: Escape.
Bone pain has worsened in the past few days, and I feel that the lower body is very heavy, walking slowly, and the diarrhea is not getting better.
The physical therapy has no effect at all.
Go to the hospital for examination, the doctor Say I am osteoporosis! Isn't this a disease that old people get? Is it because I dragged it for too long without going to see it? The doctor said that I will take calcium tablets and vitamin D for a long time.
Do I need a jar of medicine in the future? I have to go to the hospital afterwards.
I am so scared that I dare not go.
.
.
Time: June 2020 Weather: Sunny mood: Anxious I went to the Chinese medicine clinic some time ago and prescribed Chinese medicine.
After taking vitamin D for so long, it didn’t have any effect, so I stopped it by myself, but my mouth couldn’t be widened recently, and my left chin was still very painful.
In that case, I’d better go to another hospital for a check.
.
.
● Patient Think.
.
.
Difficulty opening your mouth and jaw pain should be just minor problems, right? Maybe just take some medicine? After taking calcium and vitamin D for so long, there is no effect.
It should be no problem if I stop it by myself, right? Will my bone pain and diarrhea be "eliminated" for a while if I switch to another doctor for treatment this time? ● The doctor thinks.
.
.
what examinations should I perform on the patient next? The patient is only 27 years old.
Why did he suffer from osteoporosis and what is the cause? The patient’s examination and examination results all indicate that the patient has osteoporosis.
Why is the effect of symptomatic treatment with calcium supplementation and vitamin D not good? How should the patient's next treatment be carried out? Stripping the cocoons, layer by layer 1.
Improve related tests: laboratory tests (positive indicators): blood calcium, blood phosphorus, 24-hour urine calcium, 24-hour urine phosphorus, blood albumin, parathyroid hormone (PTH), total I Type collagen N-terminal propeptide (PINP), osteocalcin (BGP), estradiol, testosterone, corticosteroids, and the test results of rhythm, blood sugar, thyroid function, and pancreatic biochemistry showed no obvious abnormalities
.

Thyroid ultrasound: Increased thyroid volume, uneven echo, and abundant blood supply
.

Bone density determination (T value) lumbar spine: -3.
0, femoral neck: -3.
2, total hip: -3.
0; (Z value) lumbar spine: -2.
9, femoral neck: -3.
2, total hip: -3.
0, in line with osteoporosis
.

Gastroscopy: chronic non-atrophic gastritis, mainly gastric antrum, gastric antrum biopsy: chronic inflammation of the gastric mucosa with active inflammation
.

Colonoscopy: Proctitis, rectal biopsy: The large intestine mucosa showed mild acute and chronic inflammation, consistent with erosion
.

The glandular epithelium is slightly atypia, with hyperplastic and dilated vessels in the lamina propria
.

Out-of-hospital inspection results: anti-ENA spectrum (-), rheumatoid factor RF: 12.
2 (reference value: 0-20) IU/ml
.

Hip MRI: bilateral sacroiliitis
.

MRI of the temporomandibular joint: left temporomandibular arthritis
.

Left ankle MRI: left ankle arthritis and a large amount of fluid in the joint cavity
.

2.
Analysis of related indicators and knowledge points: The patient has a history of long-term diarrhea, and the results of colonoscopy suggest proctitis.
Combined with the results of the patient's body mass index (BMI), it indicates that the patient is thin, and the 25(OH)D3 level is reduced.
Consider that the patient may be Lack of fat-soluble vitamin D caused by gastrointestinal diseases leads to calcium malabsorption, coupled with lean body and malnutrition, which leads to secondary osteoporosis
.

Osteoporosis is the most common bone disease.
Due to various reasons, bone quality and bone density decrease, bone tissue microstructure is damaged, and bone fragility increases, which is a systemic bone disease that is prone to fractures
.

Osteoporosis is divided into two categories: primary and secondary: primary osteoporosis is a physiological degeneration that occurs with age; and secondary osteoporosis is caused by Any disease that affects bone metabolism and/or osteoporosis caused by drugs and other definite causes
.

Among them, diseases that affect bone metabolism can involve multiple systems, such as the endocrine system, rheumatic immune system, gastrointestinal system, blood system, neuromuscular system, kidney system, and cardiopulmonary system
.

The patient used calcium and vitamin D regularly for a long time, but the osteoporosis index has not been improved after the admission review, and the patient’s erythrocyte sedimentation rate, C-reactive protein (CRP) increased, and thyroid autoimmune-related antibodies increased.
Review the patient again In the medical history, it was found that the patient's bone pain occurred before osteoporosis and accompanied by morning stiffness.
At this time, it should be considered whether it is a rheumatic immune-related disease
.

Supplementary inspection immediately: HLA-B27 determination (+)
.

The age of onset of the patient was 24 years old, low back pain ≥ 3 months, combined with the above-mentioned related examination results, the final patient can be diagnosed as ankylosing spondylitis
.

3.
Next treatment: Instruct patients to insist on using biological agents, calcium and vitamin D for symptomatic treatment
.

Patient's Diary: Time: September 2020 Weather: Sunny Mood: Pleasant After 2 months of anti-inflammatory treatment, I feel that my bone pain has been relieved a lot, and my mouth opening has completely disappeared, although there is still some diarrhea, and there is no bone density.
It returns to normal completely, but treatment also takes time.
I will listen to the doctor's words carefully in the future.
The future can be expected! At this point, Ms.
Ye finally got effective symptomatic treatment after many times, but why does ankylosing spondylitis secondary to osteoporosis? How to treat it clinically? Analysis of 5 major reasons: Why does osteoporosis secondary to ankylosing spondylitis occur in clinical practice, osteoporosis secondary to ankylosing spondylitis is not uncommon, but because secondary osteoporosis progresses slowly, the symptoms of bone pain are easy It overlaps with ankylosing spondylitis and is easily covered up.
In addition, the disease is mostly young.
Without formal diagnosis and treatment, it is generally impossible to associate with osteoporosis
.

There are five main reasons for osteoporosis secondary to ankylosing spondylitis: 1.
Disuse factor: the maintenance of normal bone mass requires exercise.
Patients with ankylosing spondylitis may reduce activity due to pain and morning stiffness, leading to insufficient exercise and sunlight , Affect the formation and remodeling of normal bone
.

2.
Inflammatory factors: Ankylosing spondylitis is a chronic inflammatory disease.
Excessive activation of a variety of inflammatory factors can lead to active osteoclasts and inhibition of osteogenesis
.

Just like a castle, long-term wind and sun need to be repaired and maintained regularly.
If the rate of damage is greater than the rate of repair, it may cause the wall to leak and the castle to collapse
.

3.
Bone metabolism imbalance: The maintenance of bone metabolism requires the balance of a variety of hormones in the body.
In patients with ankylosing spondylitis, sex hormones, parathyroid hormone, 25-hydroxyvitamin D and other abnormalities interfere with normal bone metabolism
.

4.
Disorders of intestinal metabolic flora: Patients with ankylosing spondylitis complicated with intestinal diseases, resulting in an increase in pathogenic bacteria and a decrease in probiotics, breaking the normal "flora-intestine-skeleton" biological axis, causing calcium absorption barriers and building bone The raw materials of the "castle" are reduced
.

5.
Iatrogenic factors: some patients with ankylosing spondylitis have obvious bone pain, which is unbearable and need to take painkillers.
At the same time, one of the treatment methods for ankylosing spondylitis is the use of hormones.
The adverse reaction of these two drugs is to cause bone quality.
Decalcification, osteoporosis
.

How to treat secondary osteoporosis caused by ankylosing spondylitis? For secondary osteoporosis caused by ankylosing spondylitis, the key to treatment is to control inflammation
.

Anti-inflammatory treatment can choose non-steroidal anti-inflammatory drugs, traditional anti-rheumatic drugs, and biological agents.
Among them, biological agents are the most effective, but they are also relatively expensive
.

At the same time, it is also necessary to actively supplement calcium and vitamin D.
Pay attention to increasing the time of sun exposure daily, and use drugs that inhibit the activity of osteoclasts when necessary
.

In addition, you can’t resist seeking medical advice.
Regular review of bone mineral density, inflammatory factors, and blood calcium, medications and regular follow-up visits are required
.

To summarize clinically, for young patients with osteoporosis, when symptoms such as restricted mouth opening and mandibular joint pain occur, endocrinologists should not only pay attention to endocrine-related metabolic diseases, but also need to consider rheumatic immune diseases, especially ankylosing spondylitis.
Possible
.

Because clinically, patients with ankylosing spondylitis will cause osteoporosis due to disuse factors, inflammatory factors, etc.
, once the treatment is missed, it will have a great impact on the future life of the patient
.

Therefore, multidisciplinary collaboration led by the Department of Endocrinology also plays an important role in the treatment of secondary osteoporosis
.

Expert introduction Li Jia Southern Theater General Hospital, Department of Endocrinology, Chief and Deputy Chief Physician, Doctor of Medicine, Postdoctoral, Master's Supervisor, Member of the Diabetes Branch of the Chinese Society of Gerontology and Geriatrics, Member of the Standing Committee of the Clinical Medication Evaluation Professional Committee of the Chinese Medical Education Association, Guangdong Medical Association Endocrinology The youth committee member of the Guangzhou Medical Association Diabetes Branch Vice Chairman SCI, core journals published more than 40 papers, editor, co-editor, and participated in the translation of 5 monographs References for reviewers of SCI journals: [1] Osteoporosis and Bone Mineral Diseases Branch of Chinese Medical Association.
Guidelines for Diagnosis and Treatment of Primary Osteoporosis (2017) [J].
Chinese Osteoporosis and Bone Mineral Diseases Journal,2017,10(5):413-443.
DOI:10.
3969/j.
issn.
1674-2591.
2017.
05.
002.
[2]Lei Manman,Li Zhuo,Guo Weiying.
Pathogenesis of secondary osteoporosis[J] .
Chinese Journal of Osteoporosis, 2018, 24(11): 1514-1520.
DOI:10.
3969/j.
issn.
1006-7108.
2018.
11.
026.
[3] Xie Ya, Yang Kehu, Lu Qing, etc.
Ankylosing Spondylitis/ A practical guide for patients with spondyloarthritis[J].
Chinese Journal of Internal Medicine,2020,59(7):511-518.
DOI:10.
3760/cma.
j.
cn112138-20200505-00448.
[4] Zhang Liang, Li Hongchao, Song Hui, Etc.
Ankylosing spondylitis and osteoporosis[J].
Chinese Journal of Bone and Joint Surgery,2019,12(11):915-918.
DOI:10.
3969/j.
issn.
2095-9958.
2019.
11.
16.
[5]Song Yongjia, Wang Kai, Song Zhijing, et al.
Molecular mechanism of bone metabolism disorders caused by ankylosing spondylitis[J].
Chinese Journal of Osteoporosis,2020,26(9):1382-1385,1390.
DOI:10.
3969/j.
issn.
1006-7108.
2020.
09.
028.
[6]Meng Yichen, Leng Feng.
Research progress in osteoporosis secondary to ankylosing spondylitis[J].
Chinese Journal of Osteoporosis,2016,22(5):628-631.
DOI :10.
3969/j.
issn.
1006-7108.
2016.
05.
024.
[7] Lin Hai, Zhou Linhua, Huang Chengyu, etc.
Research progress on the relationship between intestinal flora imbalance and osteoporosis, ankylosing spondylitis, rheumatoid arthritis[J].
Shandong Medicine,2018,58(16):107-109.
DOI:10.
3969/j.
issn .
1002-266X.
2018.
16.
034.
[8]Zhong Jiayun,Wu Xin,Xu Huji.
Clinical research progress of ankylosing spondylitis with osteoporosis or osteopenia[J].
Diagnostic Theory and Practice,2019, 18(1):109-112.
DOI:10.
16150/j.
1671-2870.
2019.
01.
023.
-End-"This article is only used to provide scientific information to medical and health professionals and does not represent the platform's position" submission/reprint/business cooperation , Please contact: pengsanmei@yxj.
org.
cn