さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

骨粗鬆症予防の復習


骨粗鬆症予防にビスホスやカルシウム

ポリファーマシーの側面から減らしたいけど
悩みます。

特に、最近話題のPPI, H2b 使用症例はどのように考えるのか、バランス難しいですね。

昨日、整形外科以外の先生に相談され、
さらに「ミニ丸先生のブログ」から骨粗鬆症を考えてしまいました。勉強させて頂きました。


UpToDate より引用し復習


Osteoporosis is a preventable disease, not an inevitable consequence of aging. The management of skeletal health should be directed toward maximizing peak bone mass and minimizing bone loss that occurs with aging and declining sex hormone levels. In general, healthy lifestyle measures should be encouraged for all individuals to preserve bone mineral density (BMD), bone microarchitecture, and bone strength.

●Healthy lifestyle measures for maximizing peak bone mass during the bone-forming years include adequate calcium and vitamin D intake, physical activity (although not excessive), and avoidance of cigarette smoking and alcohol. Recommended calcium intake for children and adolescents 9 to 18 years old is 1300 mg daily, preferably from calcium-rich or calcium-supplemented foods. Adequate vitamin D (600 international units) is necessary to promote intestinal calcium absorption. Routine supplementation of calcium and vitamin D is not necessary for healthy growing children who consume a varied diet. 

For children and adolescents who have very low intakes of dietary calcium (<600 mg/day) and vitamin D (<400 international units/day), we suggest supplementation (Grade 2C). 

●Similar healthy lifestyle measures for prevention of subsequent bone loss in adults include regular weight-bearing exercise, adequate calcium and vitamin D intake, avoidance of cigarette smoking, and limitation of alcohol to an average of no more than two drinks daily. For postmenopausal women and men over 70 years old, the recommended calcium intake is about 1200 mg daily (total diet plus supplement). The recommended dietary allowance of vitamin D for adults through age 70 years is 600 international units (15 mcg) and 800 international units (20 mcg) after age 71 years. However, older persons confined indoors and other high risk groups may have low serum 25-hydroxyvitamin D concentrations at this intake level and may require higher intakes. 

For older adults with inadequate dietary calcium and vitamin D intake, we suggest calcium and vitamin D supplementation (Grade 2B). 

For the majority of adults, we suggest not using pharmacological therapy for prevention of bone loss (Grade 2B). 

Since pharmacological therapy has significant costs and associated risks, only patients with the highest risk of fracture are candidates for preventive drugs. Thus, patients with low bone mass (T-score between -1.0 and -2.5) should be considered for pharmacological intervention based upon fracture risk, as determined by a combination of BMD and clinical risk factors. Fracture risk can be calculated using the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX). A reasonable cut point that may be cost-effective in some settings is a 10-year probability of hip fracture or major osteoporotic fracture of ≥3.0 or ≥20 percent, respectively. 

For postmenopausal women who are candidates for and desire pharmacological therapy for prevention of osteoporosis, we suggest bisphosphonates or raloxifene as first-line choices (Grade 2B). 

We prefer weekly alendronate or risedronate to other bisphosphonates because of their efficacy, favorable cost, and the availability of long-term safety data. There are nonskeletal considerations with raloxifene that may play an important role in the selection of postmenopausal women for therapy: a reduction in breast cancer risk, but an increase in thromboembolic events and hot flashes, and no apparent effect on heart disease or the endometrium.

For men who are candidates for and desire pharmacological therapy for prevention of osteoporosis, we suggest bisphosphonates (Grade 2B). 

We prefer weekly alendronate or risedronate to other bisphosphonates because of their efficacy, favorable cost, and the availability of long-term safety data.

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Increased intake of dairy products or calcium rich foods should be encouraged if dietary calcium intake is below recommended levels.
 If this is not possible, we suggest calcium and vitamin D supplementation in patients with osteoporosis and inadequate dietary intake (Grade 2B).

calcium carbonate taken with meals is adequate for supplementation and is inexpensive. However, we recommend calcium citrate in patients taking proton pump inhibitors or H2 blockers or who have achlorhydria (Grade 1B)

We suggest cholecalciferol (vitamin D3), when available, rather than ergocalciferol (vitamin D2) for vitamin D supplementation (Grade 2C). 

The total intake of calcium (diet plus supplements) should not routinely exceed 2000 mg/day. The safe upper limit for vitamin D is 4000 international units daily, but this is based on limited data.

There is debate about the cardiovascular risk of calcium supplementation, particularly when the total calcium intake exceeds the recommended amounts or supplements are given in large doses. Until this issue is settled, it would be wise to avoid excess supplementation, to avoid doses over 500 mg at one time, and to encourage dietary intake over tablets. 

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PPIsとH2 blockers

meta-analyses of case-control and cohort studies, the risk of hip, spine, and any-site fractures was modestly but significantly increased in patients taking PPIs (RRs 1.30, 1.56, and 1.16, respectively)
Am J Med. 2011;124(6):519.
Am J Gastroenterol. 2011 Jul;106(7):1209-18; quiz 1219. Epub 2011 Apr 12.
BMJ. 2012;344:e372.

The largest prospective cohort study (the WHI Study) did not find an association between PPI use and hip fracture (HR 1.00, 95% CI 0.71-1.40)
PPI use was associated with an increased risk of clinical vertebral (HR 1.47, 95% CI 1.18-1.82)
Arch Intern Med. 2010;170(9):765.

H2 blockers were associated with an increased risk of hip fracture in some reports (assumption of risk [AOR] 1.23, 95% CI 1.14-1.39)
JAMA. 2006;296(24):2947.
Gastroenterology. 2010;139(1):93.
Osteoporos Int. 2009;20(12):1989.