Heavy! The "Osteoporosis Novel Coronavirus Infection Clinical Response Guide" is here!

Summary: Osteoporosis is a chronic condition that reflects reduced bone strength and associated increased risk of fractures
.
As a chronic disease, osteoporosis often requires ongoing medical intervention to reduce the risk
of bone loss, impaired bone integrity, and fractures.
The epidemic of the new coronavirus infection (new coronavirus infection) has brought great challenges
to people's health, especially the management of various chronic diseases.
In order to improve the management of osteoporosis and its fractures during the new crown infection, we have made some management recommendations based on the available evidence to guide the treatment
of osteoporosis patients during the pandemic.

The novel coronavirus infection (new coronavirus infection) has brought great challenges
to people's health, especially the management of various chronic diseases.
The emergence of variants with stronger transmission and shorter incubation periods makes disease prevention and control more difficult
.
The study found that patients hospitalized with COVID infection had an 8.
6%
decrease in mean bone mineral density (BMD) from diagnosis to a follow-up of an average of 81 (± 48) days.
BMD decline is significantly greater than age-related bone loss
.

Due to massive bone loss, the rate of osteoporosis tripled
after hospitalization due to COVID infection.
Oxygen therapy through a nasal cannula or cannula, or mechanical ventilation, respiratory failure lasting longer can lead to malnutrition and affect
the musculoskeletal system.
The phase of drastic reduction in physical activity also has an impact on the musculoskeletal system, and reduced sun exposure leads to vitamin D deficiency
.
Animal experiments have shown that new crown infection can lead to inflammatory bone loss
.
In order to further standardize the comprehensive management of osteoporosis patients under the new crown infection epidemic, this guideline
is formulated.

One.
General management of osteoporosis during coronavirus infection

Early screening and evaluation
of osteoporosis was carried out in accordance with the requirements of the guidelines for the diagnosis and treatment of primary osteoporosis (2017) formulated by the Osteoporosis and Bone Mineral Diseases Branch of the Chinese Medical Association.
Initial screening
for disease risk was performed according to the International Osteoporosis Foundation (IOF) Osteoporosis Risk One Minute Test and the Asian Osteoporosis Self-Screening Tool (OSTA) based on age and weight.
In addition, the risk prediction FRAX® tool for osteoporotic fractures assesses the probability
of hip fractures and major osteoporotic fractures (vertebral, forearm, hip, or shoulder) over the next 10 years.
Falls are an independent risk factor for osteoporotic fractures, and it is recommended to assess the risk of falls, educate about falls, and take measures
to prevent falls.
The diagnosis of osteoporosis remains based on dual-energy X-ray bone resorption (DXA) bone density (BMD) measurement and/or fragility fractures
.

The basic measures for the prevention and treatment of osteoporosis are calcium and vitamin D, and 1000-1200mg/day elemental calcium is recommended for osteoporosis patients aged 50 and above, 600IU/day vitamin D for the elderly aged 65 and above, and 800-1200IU/day
for osteoporosis prevention.
Patients with osteoporosis should pay attention to home exercise and nutrition during the epidemic, which is beneficial
to improve the immune prevention mechanism.
People with osteoporosis can move at home by walking in place or trotting in place; You can do simple kicking or squatting activities with the back of the chair; If the physical condition allows, some weight-bearing or resistance activities can be carried out appropriately to enhance muscle strength
.
It is recommended to be active for more than
half an hour a day.
In addition, studies have shown that sleeping longer than 9 hours, or falling asleep later than 22:00, increases the risk of osteoporosis in postmenopausal women, so it is recommended that bad sleep habits
be corrected during the epidemic.

Indications for the use of anti-osteoporotic drugs include: 1.
vertebral fragility fracture (clinical or asymptomatic) or hip fragility fracture; 2.
DXA bone density (lumbar spine, femoral neck, total hip or distal radius 1/3) T value ≤-2.
5, regardless of whether there has been a fracture; 3.
osteopenia (bone density -2.
5< T value <-1.
0), the occurrence of fragility fractures in certain parts (upper humerus, distal forearm or pelvis); 4.
Osteopenia, while the FRAX® tool calculates that the probability of hip fracture in the next 10 years is ≥ 3% or the probability of major osteoporotic fracture is ≥ 20%.

Two.
Prevention and treatment drugs for osteoporosis and their relationship with new crown infection

Patients with vitamin D deficiency have an age-adjusted incidence of COVID infection 5 times higher than those without vitamin D deficiency, and supplementation with active vitamin D analogues in hospitalized patients with COVID improves oxygenation
.
Therefore, patients with osteoporosis with new coronavirus infection should take calcium and vitamin D as the basic treatment
.

Commonly used anti-osteoporotic drugs include: oral or intravenous bisphosphonates, RANKL inhibitors (denosumab), these two classes are broad-spectrum anti-osteorelaxants, oral bisphosphonates are suitable for patients at low or moderate risk of fracture, intravenous bisphosphonates and denosumab are suitable for patients with high fracture risk or oral intolerance/contraindications, and osteogenic drugs recombinant human parathyroid hormone fragment teriparatide are suitable for postmenopausal women at high risk of fracture; Raloxifene is indicated for patients at high risk of vertebral fracture, but both estrogen and raloxifene may increase the risk of thrombosis, and coronavirus infection may also be associated with an increased
risk of hypercoagulable complications.
Therefore, it is not recommended for patients with osteoporosis who have been bedridden or immobilized for a long time with new crown infection
.
Calcitonin
may be considered in patients with new fractures and pain.

To date, there is no evidence that any anti-osteoporosis treatment increases the risk, severity or course of COVID infection
.
Conversely, the incidence of osteoporotic fractures has increased during the pandemic, and disruption of anti-osteoporosis treatment may have a significant impact
on the risk of fragility fractures.
Therefore, as a general rule, anti-osteoporosis treatment regimens should not be interrupted or postponed
indefinitely due to Covid infection.

A side effect of intravenous bisphosphonates is post-infusion inflammation, with a median duration of acute phase reactions of 3 days, and if the patient receives intravenous bisphosphonates and persists for more than 3 days with symptoms consistent with acute phase reactions after intravenous bisphosphonates, consideration should be given to evaluating whether it is related to
fever or other symptoms of illness from COVID-19 infection.
Studies have shown that zoledronate is given longer than once a year and still has a potential protective effect against fractures
.
Therefore, for patients treated with zoledronic acid, subsequent infusions can be delayed for several months
, given the long biological half-life of the drug.

Denosumab is a humanized monoclonal antibody that binds to and inhibits nuclear factor kappa ligand (RANKL) receptor activators
.
Early data show that the use of denosumab is not
associated with an increase in the incidence of coronavirus infection.
Delayed or interrupted treatment with denosumab may result in rapid osteoclast production, a sharp increase in bone resorption, accelerated bone loss, and an increased
risk of multiple vertebral fractures.
Therefore, the timing of denosumab injection should not be postponed more than
7 months after the previous dose.

Patients taking the osteotropic drug teriparatide should not be discontinued for more than 3 months, and if treatment must be discontinued or the course of treatment is about to end, it is recommended to first transition to oral bisphosphonate therapy
.

Remdesivir has been reported to reduce inflammatory factors such as TNF-α, IL-β, IL-6, and IL-18, which increase osteoclast production, and their reduced expression may reduce osteoclastiesis, thus potentially helping to improve bone loss
associated with COVID infection.

3.
Long-term treatment and graded diagnosis and treatment of osteoporosis

Patients with primary osteoporosis combined with novel coronavirus infection are still recommended to grade according to the severity, severity, severity, urgency and difficulty of treatment, and medical institutions at different levels undertake the treatment of different disease conditions, so as to achieve primary primary diagnosis and two-way referral, so as to effectively use health resources, do a good job in the prevention and control of osteoporosis, and at the same time improve the ability
of medical and health institutions to carry out osteoporosis prevention and control.

Members of the expert group that developed this guide

(The following is sorted by last name stroke):

Wang Weiqing Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Ning Guang Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Mu Yiming, Chinese General Hospital of the People's Liberation Army

Cheng Jinluo Changzhou Second People's Hospital affiliated to Nanjing Medical University

Zhu Dalong Drum Tower Hospital Affiliated to Nanjing University School of Medicine

Liu Libin Union Hospital, Fujian Medical University

Liu Jianmin Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

Li Ling Shengjing Hospital Affiliated to China Medical University

Xiao Haipeng The First Affiliated Hospital of Sun Yat-sen University

Zhongyan Shan The First Affiliated Hospital of China Medical University

Zhao Zhigang Zhengzhou Summer Hospital, Henan University

Zhao Jiajun Affiliated Provincial Hospital of Shandong First Medical University

Tao Bei Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Ji Qiuhe Xijing Hospital, Air Force Military Medical University

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