How is primary osteoporosis diagnosed and treated?

*For reference only for medical professionals Osteoporosis is also known as the "silent killer", because most patients have no obvious clinical symptoms at the onset of the disease, which brings difficulties to the early detection and diagnosis of the disease; when patients experience bone pain, body shape changes or even fractures , often too late
.

Osteoporosis includes primary osteoporosis, secondary osteoporosis and idiopathic osteoporosis
.

Compared with secondary osteoporosis and idiopathic osteoporosis, primary osteoporosis has more factors affecting its onset.
Assessment of future fracture risk and appropriate interventions based on the results of diagnosis and differential diagnosis and the magnitude of fracture risk
.

1 Primary Osteoporosis Cases 3 Cases Case 1 Patient Li, female, 69 years old, was admitted to the hospital because of "8 years of osteoporosis discovery and multiple fractures of thoracolumbar spine in 7 months"
.

History of present illness A physical examination in 2010 revealed moderate osteoporosis, but without systematic treatment, only intermittent calcium was taken
.

In August 2017, he suffered from low back pain after carrying heavy objects.
MRI of the lumbar spine showed T12 compression fracture, and the bone mineral density showed that the T value of the lumbar spine was the lowest -5.
2.
He only took calcitriol and other drugs for conservative treatment, and was bedridden for 3 months
.

It's barely possible to move on after exercising
.

In January 2018, he suffered from low back pain after activity, and was admitted to the hospital for lumbar spine MRI and found T12, L3, and L5 compression fractures
.

In February, he suffered from low back pain again, and X-ray of the lumbar spine showed a fresh fracture of L2.
Fang was admitted to the hospital for treatment
.

The patient was mainly vegetarian on weekdays, with less activity and less exposure to the sun.
There was no significant change in weight compared with before, and his height decreased by about 5 cm
.

General Information History of hypertension for 10 years, no medication
.

Menstrual history: menarche at the age of 15, menopause at the age of 45, normal menstruation during this period
.

History of non-smoking, alcohol and special drug use
.

No family history of similar disease
.

On admission, the height was 156 cm, and there was no obvious deformity of the thoracolumbar spine, tenderness and percussion pain in the thoracolumbar back, limited mobility of the thoracic and lumbar spine, and was unable to bend over or turn sideways
.

The muscle strength and sensation of both lower extremities were basically normal, and the pathological signs were negative
.

There were no abnormalities in the three routine examinations of auxiliary examinations, female tumor factors, and five thyroid functions.
Six examinations of sex hormones showed that the level of estrogen was extremely low, and the levels of luteinizing hormone and follicle-stimulating hormone were high, showing typical postmenopausal hormone performance.

.

The blood and urine examinations and bone metabolism indicators are as follows: As can be seen from the figure, the patient's calcium, phosphorus and other element levels are normal, but the vitamin D level is decreased, the type 1 collagen amino-terminal elongation peptide (N1NP) is high, and β collagen degradation products ( β-CTX) level is also high, showing that the patient's bone metabolism is in a state of high transformation, and there is vitamin D deficiency
.

According to the results of past bone mineral density examinations, it can be seen that the bone mineral density of the patient is low and has a downward trend
.

The MRI results of the lumbar spine showed that T12 and L2-3 were very narrow, irregular in shape and had been compressed and deformed
.

The patient was diagnosed with postmenopausal osteoporosis
.

Therapeutic Life>
.

Drug treatment: calcium carbonate D3600mg, 2 times a day; calcitriol 0.
25μg, 2 times a day; menadione 15mg, 3 times a day
.

Anti-osteoporosis treatment: Zoledronic acid 5 mg intravenously
.

Case 2: Yuan Mou, female, 50 years old, was admitted to the hospital because of "body pain and fatigue for 5 years, which worsened for 4 months"
.

The patient with the history of the present illness started to have systemic pain 5 years ago, mainly in the waist and limbs and joint pain, accompanied by general weakness, which was not given special attention at that time
.

Before 4 months, the patient felt that the above symptoms were aggravated, and he used medicine for cold treatment in the local area for many times
.

1 day came to our hospital outpatient clinic, the bone mineral density test showed osteoporosis (lumbar spine TL1-4: -2.
7)
.

The patient usually has less physical activity, less sun exposure, poor diet, average sleep, constipation, normal urination, and no significant changes in height and weight
.

In the past 1 year after childbirth, he took pesticides to commit suicide due to "depression".
After rescue, it improved, and then he gradually developed symptoms such as abdominal distension and anorexia
.

Other information No history of tobacco, alcohol and other special drug use
.

Menarche at the age of 16, 2d/28~30d, menopause at the age of 43, usually sparse menstruation
.

No family genetic disease
.

On physical examination, the height was 160 cm, and there was no deformity of the spine, no obvious limitation of activities, light percussion pain in the waist, no abnormality in muscle strength and sensation of both lower extremities, and pathological signs were negative
.

Due to the premature menopause, the patient was suspected of having bone decalcification, and it was recommended to check the bone density and found osteoporosis
.

There were no abnormalities in the three routine examinations of auxiliary examinations, female tumor factors, and five thyroid function examinations; the six examinations of sex hormones showed that estrogen was quite low, and hormones were high, which was similar to the patient in case 1
.

The blood and urine examinations and bone metabolism indicators are as follows: vitamin D is decreased, N1NP is high, β-CTX is high, and the bone is in a high conversion state
.

Lumbar vertebrae CTL3-4, L4-5 intervertebral disc herniation, lumbar vertebrae osteoporosis, degeneration
.

Bone mineral density L1-4T values ​​were lower than -2.
5
.

Treatment to improve life>
.

Drug treatment: calcium carbonate D3600mg, 2 times a day; calcitriol 0.
25μg, 2 times a day
.

Anti-osteoporosis treatment: Zoledronic acid 5mg, once for 3 years
.

Case 3 Patient Wang, female, 80 years old, was admitted to hospital because of "recurrent low back pain for 10 years"
.

History of present illness 10 years ago, low back pain, progressive aggravation, did not pay attention
.

7 years ago, X-ray in another hospital showed lumbar vertebrae osteoporosis and compression fracture, and was treated with oral calcium carbonate D3 + bisphosphonates
.

2 years ago, the patient suffered from recurrent low back pain and aggravated symptoms.
MRI showed osteoporosis and multiple pathological fractures of the thoracic and lumbar vertebrae.
After maintaining oral calcium carbonate D3, calcitriol, and bisphosphonates twice, the low back pain symptoms were relieved
.

The patient's usual diet and physical activity were normal, his weight did not increase or decrease significantly, and his height decreased by 10 cm
.

General Information Past health, no smoking, alcohol and special drug use history
.

Menarche at the age of 16, menopause at the age of 49, and normal menstruation
.

My sister has a history of repeated fractures
.

Physical examination showed a height of 145 cm, thoracolumbar kyphosis, scoliosis, mild tenderness and percussion pain in the lower back, limited lumbar spine movement, no abnormal muscle strength and sensation of both lower extremities, and negative pathological signs
.

There were no abnormalities in the three routine examinations of auxiliary examinations, female tumor factors, and five thyroid function; the level of estrogen was low
.

The blood, urine and bone metabolism indexes are as follows: low osteocalcin, low vitamin D, N1NP and β-CTX are all low
.

Bone mineral density L1-4 bone mineral density T value has not decreased significantly in the past 3 years, which shows that the treatment is effective
.

Treatment life>
.

Drug treatment: calcium carbonate D3600mg, 2 times a day; calcitriol 0.
25μg, 2 times a day
.

Anti-osteoporosis treatment: Zoledronic acid 5mg, once for 3 years
.

 2 Influencing factors of primary osteoporosis There are many factors affecting primary osteoporosis: inherent factors race (white and yellow are higher than black), old age, early menopause, and maternal family history
.

 Extrinsic factors Low body weight, malnutrition, hypogonadism, smoking, excessive alcohol or coffee, lack of exercise, taking drugs that affect bone metabolism, related diseases
.

Inherent factors are something we cannot change, but we can start with extrinsic factors to improve bone density and bone health
.

Attention should be paid to avoiding underweight, improving nutrition, quitting smoking and limiting alcohol, increasing exercise, improving life>
.

Glucocorticoids, antidepressants, etc.
are typical drugs that affect bone density, which may lead to the occurrence of osteoporosis.
They should be used with caution and the bone condition should be closely observed
.

 Female menopausal women especially need to pay attention to the problem of bone density
.

Bone mass in menopausal women gradually declines.
During this period, the level of estrogen in women decreases significantly, which also causes significant changes in bone density
.

Women begin to lose bone mass at the age of 50, with an average loss of 0.
5% to 1% per year; postmenopausal women even lose 3% to 5% of bone mass per year
.

Therefore, women are more prone to osteoporosis than men
.

Generally speaking, women are prone to osteoporosis 3 years after menopause, and the first fracture may occur 7 years after menopause, which requires vigilance
.

Schematic diagram of decreased bone mass in men and women Falls are an independent risk factor for osteoporotic fractures and require special precautions
.

Risk factors for falls include environmental factors and personal factors
.

Environmental factors Dim light, slippery roads, ground obstacles, loose carpets, no handrails in the bathroom,
etc.

 Self-factors Ageing, sarcopenia, abnormal vision, dysesthesia; neuromuscular disease; lack of exercise, poor balance, abnormal gait, history of previous falls; vitamin D deficiency, malnutrition; heart disease, orthostatic hypotension; depression Symptomatic, psychiatric and cognitive disorders; drugs, such as sleeping pills, anti-epileptic drugs, and psychiatric drugs
.

3.
Principles of treatment of primary osteoporosis The treatment of osteoporosis is mainly divided into 4 aspects
.

Primary disease treatment: Once the cause is identified, the primary disease should be treated in time
.

Anti-osteoporosis drug treatment: active medication
.

General measures: balanced diet, appropriate outdoor activities, sun exposure, prevention of falls, quit smoking and limit alcohol
.

Basic treatment: calcium supplementation, vitamin D or other active metabolites,
etc.

The adjustment method of life measures is shown in the figure below: 4.
Primary osteoporosis treatment drugs include basic supplements for bone health and anti-osteoporosis drugs.
The former contains calcium and vitamin
D.

1.
Calcium supplements can be supplemented at 800mg/d for adults to prevent osteoporosis; people over 50 years old with existing osteoporosis need to supplement with 1000-1200mg/d
.

Calcium carbonate (the highest proportion of elemental calcium) or calcium citrate (suitable for patients with gastric acid deficiency and kidney stones) can be supplemented according to individual circumstances
.

Super-dose calcium supplementation is not recommended, otherwise there is a risk of gastrointestinal damage and hypercalcemia
.

Avoid calcium in hypercalcemia and hypercalciuria
.

It should be noted that the actual calcium content in the traditional Chinese diet is low, so additional calcium supplements are required in addition to the diet
.

2.
Vitamin D Vitamin D can promote intestinal calcium absorption, bone mineralization, improve muscle strength and reduce falls
.

Too much vitamin D may cause secondary hyperparathyroidism, and insufficient vitamin D affects the effect of anti-osteoporosis drugs
.

Daily exposure to the sun promotes the conversion of vitamin D in the body, and the bioavailability of vitamin D formed in this way is highest
.

However, when the sun is not enough to supplement, you still need to take exogenous vitamin
D.

Can be supplemented with meals
.

The intake of vitamin D for ordinary adults should reach 400IU/d, the recommended intake for the elderly over 65 years old is 600IU/d, and the recommended intake for osteoporosis patients is 800-1200IU/d
.

25(OH)D should also be monitored as appropriate, and should be maintained above 75nmol/L (30ng/ml) in elderly patients
.

Pay attention to individual differences and safety, and regularly monitor blood/urine calcium concentration
.

A single high-dose supplement over a year is not recommended
.

In addition to the application of basic supplements, anti-osteoporosis drugs are also required in most cases.
The indications for these drugs are: vertebral body or hip fragility fractures; dual energy X-ray absorptiometry (DXA) (lumbar spine, femoral neck) , total hip or distal 1/3 of occlusal bone) T value ≤ -2.
5; low bone mass (-2.
5 < T value < -1.
0) with fragility fracture (upper humerus, distal forearm or pelvis) and/or FRAX calculated the probability of a hip fracture ≥3% or any major osteoporotic fracture ≥20% over the next 10 years
.

The drugs commonly used in the clinical treatment of primary osteoporosis are further divided into bone nutritional supplements, bone resorption inhibitors, bone formation promoters and other mechanism drugs (see Table 1)
.

These anti-osteoporosis drugs commonly used in clinical practice, what problems should be paid attention to when taking them? An article to sort out the precautions of commonly used anti-osteoporosis drugs! Table 1 Drug treatment of primary osteoporosis Note: People with early menopause also need to use estrogen receptor modulators
.

Bone formation promoters are generally used for about 2 years
.

References: [1] China Health Promotion Foundation Expert Consensus Committee on Osteoporosis Diagnosis and Treatment in Primary Medical Institutions.
Expert Consensus on Osteoporosis Diagnosis and Treatment in Primary Medical Institutions (2021).
Chinese Journal of Osteoporosis.
2021.
27 (7 ): 937-944.