16 9 Paula TFC BMI PSL hydroxysteroid dehydrogenase (11 -HSD) modulator ( prereceptor mod
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1 Glucocorticoid-Induced Bone Disease (Clinical Practice) NEJM, July 7, 2011 Robert S. Weinstein, M.D. NEJM July Clinical Practice Glucocorticoid-Induced Bone Disease Arcansas Robert S. Weinstein, M.D. Arcansas Iroquois: Paula Underwood %E8%B7%AF%E2%80%95%E3%83%8D%E3%82%A4%E3%83%86%E3%82%A3%E3%83%B 4%E3%83%BB%E3%82%A2%E3%83%A1%E3%83%AA%E3%82%AB%E3%83%B3%E3%81 %AE%E5%8F%A3%E6%89%BF%E5%8F%B2-%E3%83%9D%E3%83%BC%E3%83%A9-%E3 %82%A2%E3%83%B3%E3%83%80%E3%83%BC%E3%82%A6%E3%83%83%E3%83%89/dp/ /14
2 16 9 Paula TFC BMI PSL hydroxysteroid dehydrogenase (11 -HSD) modulator ( prereceptor modulator) 11 -HSD1 11 -HSD2 isoenzymes cortisol prednisolone cortisone prednisone 2/14
3 11 -HSD1 activator 11 -HSD2 inactivator 11 -HSD1 prednisone prednisolone bone strength Medical ID Alert Jewerly Diabetes Asthma Epilepsy Medical ID Alert Jewerly BG,K,Cr,Ca,25-hydroxyvitaminD WHO FRAX FRAX (WHO ) 3/14
4 MRI Ca1200 / VD 800U-2000U/ Ca VD 600 / Ca 130 /g Ca g Ca( Ca 26 / ) 23 Ca 6 / VD800U 20 g g D g 1U 0.5 VD 1 bisphosphonate 2 teriparatide ( ) 3 denosumab PSL5mg 10mg 3 Denosumab humanized monoclonal antibody to the receptor activator of nuclear factor- B ligand (RANKL) FDA Amgen denosumab FDA alendronate ( ) risedronate ( ) zoledronic acid ( ) PSL /14
5 1 2 teriparatide alendronate vertebroplasty kyphoplasty NEJM Aug.6, 2009 A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures NEJM 35 NEJM PSL PSL relative risk BMI HSD HSD bone strength 15. 5/14
6 BG,K,Cr,Ca,25-hydroxyvitaminD 21. WHO FRAX 22. MRI 23. Ca1200 / VD 800U-2000U/ bisphosphonate (alendronate, risedronate, zoledronic acid) teriparatide ( ) denosumab 27. Alendronate,Risedronate relative risk bisphosphonate 29. bisphosphonate 1 1 compliance 30. bisphosphonate bisphosphonate Glucocorticoid-Induced Bone Disease (Clinical Practice) NEJM, July 7, 2011 Robert S. Weinstein, M.D albuterol ( fluticasone salmeterol fluticasone montelukast ( ) 10 / 15 / 45.5kg 157.5cm BMI18 wheezing scattered wheezing 6/14
7 The Clinical Problem cancellous bone 1 6% / relative risk 26 BMI 24 RA Polymyalgia rheumatica Inflammatory bowel disease, 11 -HSD1 bone mass hydroxysteroid dehydrogenase (11 -HSD) 7/14
8 system modulator (prereceptor modulator) 11 -HSD1 11 -HSD2 isoenzymes cortisol predonisolone cortisone prednisone 11 -HSD1 activator 11 -HSD2 inactivator 11 -HSD1 osteoblast osteocyte bone strength bone strength osteoclast osteoblast PTH Strategies and Evidence withdrawal medication identification jewelry 8/14
9 K 25-hydroxyvitamin D X WHO Fracture Prevention Algorithm (FRAX) FRAX FRAX MRI / D 800U 2000U/ 1 bisphosphonate FDA alendronate ( ) risedronate ( ) zoledronic acid ( ) alendronate risedronate relative risk 40 prednisone zoledronic acid ( ) risedronate 9/14
10 Alendronate ( ) osteocyte bisphosphonate bisphophonate glucocorticoid induced osteoporosis alendronate10 / bisphosphonate primary end point not powered bisphosphonate 1 1 compliance poor adherence Zoledronic acid ( ) bisphosphonate Alendronate 0.7 alendronate 1 zoledronic acid 10 Zoledronic acid 5 15 alendronate70 / 90 bisphosphonate bisphosphonate bisphosphonate drug holiday 2 alendronate alendronate alendronate Bisphosphonate bisphosphonate 8 bisphosphonate 10/14
11 bisphosphonate Bisphosphonate bisphosphonate Bisphosphonate 1 2 Bisphosphonate teriparatide (recombinant human parathyroid hormone g) FDA Teriparatide Alendronate teriparatide alendronate 90 Teriparatide bone strength teriparatide Prednisone 5 / 15 / teriparatide 15 Insulin-like growth factor 1 teriparatide Teriparatide denosumab Amgen Denosumab humanized monoclonal antibody to the receptor activator of nuclear factor- B ligand (RANKL) FDA 6 denosumab+prednisone15mg MTX denosumab+mtx Denosumab bisphosphonate teriparatide (vertebropolasty kyphoplasty ) 11/14
12 dose-pack g prednisone 10mg 20 / Prednisone a. American College of Rheumatology Prednisone 7.5 / 3 bisphosphonate teriparatide BMD FRAX algorithm / VD U b. National Osteoporosis Foundation Prednisone 5 / 3 bisphosphonate teriparatide BMD modified FRAX Tscore -2.5 c. Royal College of Physicians of London 65 3 prednisone T-score bisphosphonate 2 teriparatide VD 1g VD BMD d. Belgian Bone Club Prednisone 9.3 mg/ 3 bisphosphonate T-score VD BMD 12/14
13 55 3 albuterol ( fluticasone salmeterol fluticasone montelukast ( ) 10 / 15 / 45.5kg 157.5cm BMI18 wheezing scattered wheezing prednisone 10 3 prednisone prednisone X D 55 BMI prednisone bisphosphonate (alendronate, risedronate, zoledronic acid) teriparatid FDA prednisone bisphosphonate zoledronic acid teriparatide teriparatide PSL /14
14 6. PSL relative risk BMI HSD HSD bone strength BG,K,Cr,Ca,25-hydroxyvitaminD 21. WHO FRAX 22. MRI 23. Ca1200 / VD 800U-2000U/ bisphosphonate (alendronate, risedronate, zoledronic acid) teriparatide ( ) denosumab 27. Alendronate,Risedronate relative risk bisphosphonate 29. bisphosphonate 1 1 compliance bisphosphonate /14
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