osteoporosis guideline2010

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Definition, epidemiology, burden and etiology of osteoporosis ..... 1 I-1 Definition and concept ............................................................................................................ 1 I-2 Epidemiology of osteoporosis and osteoporotic fractures .................................................... 1 2.1 ก (Worldwide epidemiology) ............................................................... 1 2.2 (Epidemiology in Asia and Thailand)........ 2 I-3 Burden and impact of osteoporosis and osteoporotic fractures ........................................... 2 3.1 กกกกกกกกกกก (Osteoporosis related mortality and morbidity) ................................................................................................. 3 3.2 กกกกกก (Health economic aspect of osteoporotic fractures) ................................................................................... 3 I-4 Pathogenesis and etiology ..................................................................................................... 4 4.1 ก (Pathogenesis) ........................................................................................... 4 ...................................................................................................................................... 5 Diagnosis and bone mass assessment in osteoporosis ................. 8 II-1 History, physical examination and differential diagnosis ....................................................... 8 1.1 กกกก (Classification of osteoporosis) ......................... 8 II-2 Risk factors for osteoporosis and osteoporotic fractures ...................................................... 9 2.1 กกกกกกกก (Risk factors of osteoporosis and osteoporotic fracture) ........................................................................ 9 2.2 กกกกกกกก FRAX TM กก (Risk assessment of osteoporotic fracture using WHO-FRAX TM ) 9 II-3 Laboratory investigations and bone strength assessments ................................................ 11 3.1 กก (Laboratory investigation) ................................................ 11 3.2 กกกก (Bone strength assessment) ............................ 11 II-4 Diagnostic criteria for osteoporosis ...................................................................................... 12 4.1 กกก (Measurement of bone density) .................................. 12 4.2 กกกก (Biochemical markers of bone turnover) ....................................................................................................................... 13 4.3 กก (Screening) ....................................................................................... 14 ก 2.1 ................................................................................................................................... 15 OSTA (Osteoporosis Self-Assessment Tool for Asians) ................................................... 15 Khon Kaen Osteoporosis study score (KKOS) .................................................................. 16 ก 2.2 ................................................................................................................................... 18 กกกกกก ก QUS ........................................................................................................... 18 .................................................................................................................................... 19

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แนวทางเวชปฏิบัติเรื่องโรคกระดูกพรุน http://www.tmsociety.or.th/ckfinder/userfiles/files/guideline2010.pdf

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Page 1: Osteoporosis guideline2010

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Definition, epidemiology, burden and etiology of osteoporosis .....1

I-1 Definition and concept ............................................................................................................1

I-2 Epidemiology of osteoporosis and osteoporotic fractures ....................................................1

2.1 ������ !"�!#$�%&ก (Worldwide epidemiology) ...............................................................1

2.2 ������ !"�,-./0 .�123245"6&�7��2!89!" (Epidemiology in Asia and Thailand)........2

I-3 Burden and impact of osteoporosis and osteoporotic fractures ...........................................2

3.1 3#?��ก��?�"6&�@ ก��A�กก��2ก �ก���/กB#กA�ก%�1ก���/ก@�C- (Osteoporosis related mortality and morbidity) .................................................................................................3

3.2 ก���/กB#กA�ก%�1ก���/ก@�C-,-24 F28�GH8�I?�J!�FI�K��LICM (Health economic aspect of osteoporotic fractures) ...................................................................................3

I-4 Pathogenesis and etiology .....................................................................................................4

4.1 @"�K กQ�2- � (Pathogenesis) ...........................................................................................4

23กI��3R�F3 F ......................................................................................................................................5

Diagnosis and bone mass assessment in osteoporosis .................8 II-1 History, physical examination and differential diagnosis .......................................................8

1.1 ก��AQ�6-ก7��2.!M3F%�1ก���/ก@�C- (Classification of osteoporosis) .........................8

II-2 Risk factors for osteoporosis and osteoporotic fractures ......................................................9

2.1 7[AA#"2I5$"FM3F%�1ก���/ก@�C-6&�ก���/กB#กA�ก%�1ก���/ก@�C- (Risk factors of osteoporosis and osteoporotic fracture) ........................................................................9

2.2 ก��7��20 -7[AA#"2I5$"FM3Fก��2ก �ก���/กB#กA�ก%�1ก���/ก@�C- %�",4R FRAXTM M3F3F1Jก��3-�0#"%&ก (Risk assessment of osteoporotic fracture using WHO-FRAXTM) 9

II-3 Laboratory investigations and bone strength assessments ................................................11

3.1 ก��?��A!�FBR3F7a �#? ก�� (Laboratory investigation) ................................................11

3.2 ก��7��20 -1��06MbF6ก�cFM3Fก���/ก (Bone strength assessment) ............................11

II-4 Diagnostic criteria for osteoporosis ......................................................................................12

4.1 ก��?��A1��0B-�6-c-ก���/ก (Measurement of bone density) ..................................12

4.2 �#4-545�2105M3Fก����-ก��I�R�F6&�I&�"ก���/ก (Biochemical markers of bone turnover) .......................................................................................................................13

4.3 ก��?��A1#�ก�3F (Screening) .......................................................................................14

.�1e-�ก 2.1 ...................................................................................................................................15

OSTA (Osteoporosis Self-Assessment Tool for Asians) ...................................................15

Khon Kaen Osteoporosis study score (KKOS) ..................................................................16 .�1e-�ก 2.2 ...................................................................................................................................18

%-%06ก�0,-ก��!Q�-�"ก��2ก �%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3-%�",4R3�"C -iQ�B-#ก6&� QUS ...........................................................................................................18

23กI��3R�F3 F ....................................................................................................................................19

Page 2: Osteoporosis guideline2010

Prevention of osteoporosis and prevention of falls .......................21

III-1 Strategies to maximize peak bone mass ............................................................................21

III-2 Strategies to prevent bone loss ...........................................................................................21

ก��,BRm3�J%0-!�6!- (Hormone replacement therapy) .....................................................22

III-3 Nutritional aspect in osteoporosis ........................................................................................22

61&2o5"0 (Calcium) .............................................................................................................22

� ?�0 -�5 (Vitamin D) ............................................................................................................26

� ?�0 -21 (Vitamin K) ...........................................................................................................27

III-4 Life style modification and prevention of fall .......................................................................28

4.1 ก��7�#�27&5$"-@r? ก��0!5$2I5$"F?c3ก��27s-%�1ก���/ก@�C- ............................................28

4.2 ก��7t3Fก#-ก��Bก&R0,-e/R7u�"%�1ก���/ก@�C- ................................................................29

.�1e-�ก 3.1 Falls Risk Assessment tool ............................................................................32

.�1e-�ก 3.2 ก��33กกQ�&#Fก�"2@h$37t3Fก#-%�1ก���/ก@�C- ....................................................33

ก��33กกQ�&#Fก�"2@h$3I�R�F0�&ก���/ก6&�&�ก��2ก �ก���/ก@�C- ..........................................33

ก��7t3Fก#-ก��Bก&R06&�&�ก��2ก �ก���/กB#ก ......................................................................34

23กI��3R�F3 F ....................................................................................................................................34

Treatment of osteoporosis ................................................................38

IV-1 Goal of osteoporosis treatment ............................................................................................38

1.1 - "�0M3Fก��7t3Fก#-6&�ก���#กG�%�1ก���/ก@�C- .........................................................38

1.2 �#?wC7��IF1JM3Fก���#กG�%�1ก���/ก@�C- ......................................................................38

1.3 6-�!�Fก��?#�I -,A,BRก���#กG�%�1ก���/ก@�C-�R�"ก&"C!KJก��1R-B�e/R!5$051��02I5$"FI/F %�" International Osteoporosis Foundation 6&� National Osteoporosis Foundation 38

1.4 6-�!�Fก��?#�I -,A,BRก���#กG�%�1ก���/ก@�C-�R�"ก&"C!KJก��1R-B�e/R!5$051��02I5$"FI/F %�"0/&- K %�1ก���/ก@�C-6BcF7��2!89!"x ....................................................................39

IV-2 Pharmacotherapy for osteoporosis ......................................................................................40

2.1 "�"#�"#iFก��I&�"ก���/ก (Inhibitors of bone resorption) ..............................................41

2.2 "�ก��?CR-ก��I�R�Fก���/ก,B0c (Stimulators of bone formation) ....................................42

2.3 "�!5$33กr!K z!#iFI3F!�F (mixed action agents) ............................................................43

IV-3 Alternative therapy and non-pharmacological treatment .....................................................44

3.1 Hip protector .................................................................................................................44

IV-4 Potential adverse events, prerequisites and contraindications in using anti-osteoporotic agents ..................................................................................................................................44

4.1 e&MR�F215"F MR31�����#F 6&�MR3BR�0,-ก��,4R"��#กG�%�1ก���/ก@�C- ..........................44

IV-5 Monitoring treatment and duration of treatment ..................................................................47

5.1 ก��? �?�06&�7��20 -e&ก���#กG� ...............................................................................47

5.2 ��"�2�&�ก���#กG� ........................................................................................................48

23กI��3R�F3 F ....................................................................................................................................54

Glucocorticoid-induced osteoporosis (GIO) ...................................62

Page 3: Osteoporosis guideline2010

V-1 Introduction and epidemiology .............................................................................................62

1.1 �!-Q� ............................................................................................................................62

1.2 ������ !"� ...................................................................................................................62

V-2 Pathophysiology and risk assessment .................................................................................62

2.1 ก&9กก��2ก �%�1 ...........................................................................................................62

2.2 7[AA#"2I5$"F .....................................................................................................................63

V-3 Diagnosis ..............................................................................................................................63

V-4 Prevention and treatment .....................................................................................................63

4.1 6-�!�Fก��7t3Fก#-6&��#กG�%�1ก���/ก@�C-!5$2ก �A�กก��,4R"�ก&/%113�J? 13"�J ..........63

V-5 Monitoring treatment ............................................................................................................64

5.1 ก��? �?�0e&ก���#กG� .................................................................................................64

23กI��3R�F3 F ....................................................................................................................................65

Osteoporosis in men ..........................................................................68

VI-1 Introduction and epidemiology .............................................................................................68

1.1 �!-Q� 6&� 1Q�AQ�ก#�1��0 ..............................................................................................68

1.2 ������ !"� ...................................................................................................................68

1.3. 7[AA#"2I5$"F .....................................................................................................................69

VI-2 Assessment and diagnosis ..................................................................................................69

2.1 ก��� - A|#" ....................................................................................................................69

2.2 ก��?��A�c�Fก�"6&�ก��?��A@ 28G ..............................................................................69

VI-3 Prevention .............................................................................................................................70

3.1 ก��7t3Fก#-%�1ก���/ก@�C-,-e/R4�" ................................................................................70

VI-4 Treatment and follow-up ......................................................................................................71

4.1 6-�!�Fก���#กG�%�1ก���/ก@�C-,-e/R4�" .......................................................................71

4.2 ก��? �?�0e&ก���#กG� ..................................................................................................71

23กI��3R�F3 F ....................................................................................................................................72

Page 4: Osteoporosis guideline2010

1

Definition, epidemiology, burden and etiology of osteoporosis

I-1 Definition and concept

,-7} @.8. 2543 National Institute of Health 6BcFIB�#H320� ก�(1) 9�R- "�0%�1ก���/ก@�C-�#F-5i1h3 27s-%�1M3Fก���/ก!5$051��06MbF6ก�cFM3Fก���/ก (bone strength) &�&F IcFe&,BR2@ $01��02I5$"F?c3ก���/กB#ก 1��06MbF6ก�cFM3Fก���/ก,-- "�0-5i7��ก3��R�" 2 Ic�-B&#ก1h3 1��0B-�6-c-M3Fก���/ก (bone density) 6&�1CL.�@M3Fก���/ก (bone quality)

I-2 Epidemiology of osteoporosis and osteoporotic fractures

2.1 �,��-./01�0�2.34ก (Worldwide epidemiology)

,-7} @.8. 2536 9�R05��"F�-A�กก��7��4C0 Consensus Development Conference M3F 3F1Jก��3-�0#"%&ก (WHO)(2) @��c� ,-IB�#H320� ก� 05e/R!5$2ก �.���ก���/กB#กA�ก%�1ก���/ก@�C- (osteoporotic fractures) I/Fw~F 1.3 &R�"��",-6?c&�7} %�"!5$,-AQ�-�--5i 50% 27s-ก���/กI#-B&#FB#ก (vertebral fractures) 25% 27s-ก���/กI�%@กB#ก (hip fractures) 6&�!5$2B&h335ก 25% 27s-ก��B#ก!5$ก���/กMR30h36&�ก���/ก3h$-� -3กA�ก-#i-"#F05��"F�-�c� ก�c� 30% M3Fe/RB� F,-!�57"C%�7!5$053�"C?#iF6?c 50 7}M~i-9727s-%�1ก���/ก@�C-

A�กก��8~กG� National Health and Nutrition Survey (NHANES III) ,-IB�#H320� ก�20h$37} @.8. 2540(3) 9�R05ก��7��20 -�c� 05e/RB� F4��320� ก#-e �M��w~F 13-18% 27s-%�1ก���/ก@�C- (osteoporosis) 6&�35ก 27-50% 3"/c,-.���ก���/ก��F (osteopenia) 3#?��ก��2ก �%�1ก���/ก@�C-,-e/RB� F2B&c�-5i2@ $0M~i-20h$33�"C0�กM~i- 9�R05ก��7��20 -9�R�c�wR��/2|@��,-ก&Cc0e/RB� F320� ก#-e �M��!5$053�"C2!c�ก#�B�h30�กก�c� 80 7}M~i-97 A�@��c�27s-%�1ก���/ก@�C-w~F 70%

%�"!#$�97wR�1Q�-~Fw~F.���ก���/กB#ก%�"��06&R� 3C�#? ก��LJ (incidence) ,-e/R4�"A�I/Fก�c�,-e/RB� F3"c�F4#�2A- ?#iF6?c4c�F�#"�Cc- (adolescence) A-w~F�#"ก&�F1- (middle life) I�2B?CB&#ก,-4c�F-5i1��A�0�A�ก�/76��ก��!Q�F�- (working) 6&��/76��ก���Q�2- -45� ? (lifestyle) M3Fe/R4�"o~$Fe��%e-6&�2I5$"F3#-?��"0�กก�c� ก���/กB#ก6��-5i3�A2�5"ก9�R�c�27s-ก���/กB#กA�ก."#-?��"6���C-6�F (high-energy trauma) 6?c.�"B&#F4c�F3�"C 40-50 7} ก&#�2ก �ก��27&5$"-67&FM3F6-�%-R0ก���/กB#ก97,-!�F?�Fก#-MR�0 3C�#? ก��LJM3Fก���/กB#ก,-B&�"� ?Q�6B-cF 24c- ก���/กI#-B&#F ก���/กMR30h3 ก���/ก24 Fก��- 6&�ก���/กI�%@ก x&x ,-e/RB� Fก&#�2@ $0I/FM~i-3"c�F���2�b�(4) ก���/กB#ก2B&c�-5i27s-e&A�ก."#-?��"6��90c�C-6�F (low-energy trauma) B�h3ก���/กB#กA�กก���/ก@�C- (osteoporotic fractures) -#$-23F A�กก��8~กG�,-IB�#H320� ก� e/R7u�"ก���/กI#-B&#FB#ก050�กw~F7}&�7��0�L 500,000 ��"(4) %�"@�0�ก,-2@8B� F0�กก�c�2@84�" w~F 10 2!c� @/�9�R�c�,-e/RB� F4��320� ก#-e �M��!5$053�"C0�กก�c� 70 7} A�05w~F1�~$FB-~$F!5$05B�h321"05ก���/กI#-B&#FB#ก3"c�F-R3"B-~$FMR3(4) IQ�B�#�3C�#? ก��LJก��2ก �ก���/กI�%@กB#ก,-e/RB� Fe �M�� (Caucasian) @�9�RI/FIC� w~F7}&� 737 1�#iF?c3 100,000 ��" ,-e/RB� F4��-3�J2�"J 6&�?$Q�IC�7��0�L7}&� 280 1�#iF?c3 100,000 ��" ,-e/RB� F4����-6&-�J(5)

Page 5: Osteoporosis guideline2010

2

2.2 �,��-./01�89:;</:�=>?>@A1B4,C�,>0DE01 (Epidemiology in Asia and Thailand)

A�กMR30/&&c�IC�,-7} @.8. 2551 3�"CM#"2|&5$" (life expectancy) M3F7��4�ก�9!" 1h3 69.5 7},-e/R4�" 6&� 76.3 7},-e/RB� F(6) 9�R05ก��IQ���A1��04Cก (prevalence) M3F%�1ก���/ก@�C-,-e/RB� F!5$0��#��� ก��,-%�F@"���&M3F�#H��F6BcF 6&�A�กก��ICc0?��Ae/RB� F,-4C04-A�ก!Cก.�1M3F9!" ,-7}@.8. 2541(7) 6&� @.8. 2544(8) ?�0&Q��#�@��c� wR�,4R2กL�Jก��� - A|#"%�1ก���/ก@�C- o~$F3F1Jก��3-�0#"%&ก9�RกQ�B-�9�R�c�B0�"w~F1c�1��0B-�6-c-ก���/ก!5$2!c�ก#�B�h3?$Q�ก�c� 2.5 2!c�M3F1c�2�5$"F2�-0�?�H�-A�ก1c�2|&5$"M3F1��0B-�6-c-ก���/ก,-1-B-Cc0I�� (T-score ≤ -2.5) A�@��c�7��0�L 19-21% J?KL;MN�/K0A2<A?�1OP�QKBPR 40 CUJVQ9EC >CW93�=ก�,-;กX�O90A2ก�,-;ก��9N4�K�R.9>?. (lumbar spine osteoporosis) B4, 11-13% >CW93�=ก�,-;กX�O90A2ก�,-;ก=?�,3Xก (femoral neck osteoporosis)

,-7��2!89!" 05��"F�-ก��IQ���A!5$A#FB�#�245"F,B0c��B�c�F7} @.8. 2540-2541(9) @�3C�#? ก��LJM3Fก���/กI�%@กB#ก,-7��4�ก�!#iFB� F6&�4�" !5$053�"C?#iF6?c 50 7}M~i-97 w~F7}&� 162 1�#iF?c3 100,000 ��" 6&�A�2@ $0M~i-27s-7}&� 851 1�#iF?c3 100,000 ��" ,-7��4�ก�!5$053�"C2ก - 75 7}M~i-97 wR�6"ก@ A��L�2|@��,-7��4�ก�2@8B� F!5$3�"C?#iF6?c 50 7}M~i-97 A�@�3C�#? ก��LJM3Fก���/กI�%@กB#กw~F7}&� 269 1�#iF?c3 100,000 ��" 6&�A�2@ $027s-7}&� 1,011 1�#iF?c3 100,000 ��" wR�3�"C0�กก�c� 75 7}M~i-97 3#?���#Fก&c��,ก&R215"Fก#�3C�#? ก��LJM3Fก���/I�%@กB#ก,-e/RB� F,-7��2!86w�23245"B&�"7��2!8 o~$Fก��IQ���A,-7��2!82B&c�-#i-!5$2�&�?c�Fก#-@�6-�%-R0ก��2@ $0M~i-M3F3C�#? ก��LJก��2ก �ก���/กI�%@กB#ก3"c�F4#�2A-24c- ก��8~กG�3C�#? ก��LJก��2ก �ก���/กI�%@กB#ก,-e/RB� F4��A5-mc3FกF (Hong Kong Chinese) @�3C�#? ก��LJ2@ $0M~i-A�ก7}&� 179 1�#iF?c3 100,000 ��" ,-7} @.8. 2508 27s-7}&� 389 1�#iF?c3 100,000 ��" ,-7} @.8. 2528 o~$F2@ $0M~i-ก�c�2!c�?#�(10) 6&�A�กก��IQ���A,-7��2!8�5$7Cu-20h$32�b�� -5i (@.8. 2545) @�ก��2@ $0M~i-M3FAQ�-�-ก���/กI�%@กB#ก A�ก7}&� 92,400 ��" ,- 5 7}กc3-B-R�-#i- 27s-7}&� 117,900 ��"(11) 9�R05ก��1��ก��LJ9�R�c�,-7} 1.8. 2050 B�h335ก7��0�L 40 ก�c�7}MR�FB-R�-5i A�05ก��2ก �ก���/กI�%@กB#ก2ก �M~i-!#$�%&กw~F7��0�Lก�c� 6 &R�-��" 6&�1�~$FB-~$FB�h37��0�L 3 &R�-��"M3F!#iFB0�-5i A�2ก �3"/c,-7��2!86w�23245"(10)

I-3 Burden and impact of osteoporosis and osteoporotic fractures

%�"!#$�976&R�%�1ก���/ก@�C-27s-%�1!5$90c053�ก��,�� 6?ce&!5$?�00�B�h3 clinical consequence !5$IQ�1#�M3F%�1-5iกb1h3 ก��2ก �ก���/กB#ก9�RFc�" o~$F6�cF33ก9�R27s- 2 ก�L5 1h3 1. ก�,-;กN�ก[�ก:1�9P��1B��E<R�O9B�K (low-energy trauma) 24c- ก���/กI�%@กB#กA�กก��

Bก&R0A�ก!c�"h- B�h3?กA�ก!5$I/F,-���#�,ก&R215"Fก#�ก��&R0A�ก!c�"h- 27s-?R- 2. ก�,-;กN�ก3-1E<R<AB�Kก�,B0ก[�ก:�19?ก 24c- ก���/กI#-B&#FB#กA�กก��กR0?#� B�h3ก��"ก

M3FB-#ก 27s-?R-

ก���/กB#ก2B&c�-5i2��A�2�5"ก�c���0� �c� ก���/กB#กA�ก%�1ก���/ก@�C- B�h3 osteoporotic fractures o~$F27s-e&&#@KJB&#ก!5$2ก �M~i-A�กก��!5$ก���/กI/�2I5"1��06MbF6ก�cF97 ก���/กB#กA�ก%�1ก���/ก@�C--5i23F!5$27s-?#�กc3,BR2ก �.��� (burden) 6&�e&ก��!� (impact) ?�00�

Page 6: Osteoporosis guideline2010

3

3.1 ?�P��ก��P�1B4,X/ก��[�กก��>ก/-ก�,-;กN�ก[�ก3�=ก�,-;กX�O9 (Osteoporosis related mortality and morbidity) 1. ก��2ก �ก���/กI#-B&#FB#กA�ก%�1ก���/ก@�C- (osteoporotic vertebral fractures) 0#กA�2ก �A�กก��

!Q�F�-?�07ก? B�h3ก A�#?�7��AQ��#- %�"!5$0#กA�90c057���#? 9�R�#�3C�#? 2B?C,�� A~F27s-2B?Ce&�c�052@5"F 40% M3Fe/RB� F!5$05ก���/กI#-B&#FB#ก2B&c�-5i2!c�-#i-!5$�/R?#��c�27s-

2. ก���/กI#-B&#FB#กA�ก%�1ก���/ก@�C- 3�AA�053�ก��2@5"F61c7��2&bก-R3"97A-w~F7��0�กA-?R3F-3-%�F@"���&กb9�R 6?c%�"!#$�976&R�e/R!5$05ก���/กI#-B&#FB#กA�ก%�1ก���/ก@�C-A�053#?��ก��2Ab�7u�" (morbidity)(12) 6&�3#?��ก��?�" (mortality)(13) 0�กก�c�e/R!5$"#F90c05ก���/กB#ก3"c�F4#�2A-e/R7u�"A�053�ก��7��B&#F2�hi3�#F ?#�2?5i"&F (height loss) B&#F1c30 (kyphosis) B&#F1� (scoliosis) !R3F3h� 2�h$33�B�� 2-h$3FA�ก1��0AC4c3F!R3F&�&F 6&�3�AA�053�ก��7��23�2-h$3FA�กก���/ก4�"%1�F&F0�ก��!�ก#�ก���/ก24 Fก��-

3. ก��I/�2I5"1��0I�0��w,-ก��!Q�ก A�#?�7��AQ��#- (functional disability) ก��05AQ�-�-7&R3FMR3ก���/กI#-B&#F!5$B#กB&�"7&R3F " $F0�ก2!c�9�กbA�" $F2@ $0 morbidity 6&� mortality 0�กM~i-2!c�-#i-(12-14) 6&�"#F2@ $01��02I5$"F!5$A�2ก �ก���/กI#-B&#FB#ก,-7&R3F!5$2B&h3 6&�ก���/กI�%@กB#ก�R�"(14)

4. ก���/กI�%@กB#ก (hip fractures) 27s-ก���/กB#กA�ก%�1ก���/ก@�C-!5$057[�B�0�ก!5$IC� -3กA�กก��!5$053#?��?�"!5$I/F0�ก?�0B&#Fก��B#ก6&R� "#F051��0@ ก��6&�ก��I/�2I5"1��0I�0��w,-ก��!Q�ก A�#?�7��AQ��#-,-3#?��!5$I/F35ก�R�" -3กA�ก-#i-1c�,4RAc�",-ก���/6&�#กG�B&#Fก���/กI�%@กB#กกb"#FI/F0�กก�c�ก���/กB#ก!5$3h$-� 2-h$3FA�กwR�90c9�R�#�ก��ec�?#��#กG�e/R7u�"A�90cI�0��w2� -9�R 35ก!#iF%�16&�.���6!�กoR3-B&#Fec�?#�กb@�9�R�c3"6&��C-6�F

5. 9�R05ก��8~กG�3#?��ก��?�"6&� 3#?��ก��2Ab�7u�".�"B&#Fก���/กI�%@กB#ก,-1-e �M��I/F3�"C(15-16) @�3#?��ก��?�"I/Fw~F7��0�L 20% .�",- 1 7}B&#Fก���/กB#ก IQ�B�#�e/R!5$�3�45� ?@��c� 30% A�051��0@ ก��2ก �M~i-6��w��� (permanent disability) ?R3F9�R�#�ก���/6&A�กe/R3h$- B�h3 3"/c,-Iw�-@"���& (nursing home) 40% 90cI�0��w2� -9�R3"c�F7ก? ?R3F,4R21�h$3F4c�"2� -3"c�F,�3"c�FB-~$F 6&� 80% 90cI�0��w7a �#? ก A�#?�7��AQ��#-3"c�F-R3"B-~$F3"c�F !5$21"!Q�9�R23Fกc3-ก���/กI�%@กB#ก

6. ,-7��2!89!" 3#?��ก��?�".�"B&#Fก���/กI�%@กB#กA�กก��8~กG�!5$A#FB�#�245"F,B0c(17) @��c� 2.1% ?�"��B�c�F"#F�#กG�?#�,-%�F@"���& 6&� 3#?��?�"B&#FA�กก���/กI�%@กB#ก!5$ 3 2�h3-, 6 2�h3- 6&� 1 7} 2!c�ก#� 9%, 12% 6&� 17% ?�0&Q��#� IQ�B�#�ก��8~กG�2ก5$"�ก#�1CL.�@45� ?B&#Fก���/กI�%@กB#ก,-1-9!"(18) @��c�B-~$F,-BR�M3Fe/R7u�" (22%) 90cI�0��w2� -9�R 23% ?R3F,4R wheel chair ,-ก��21&h$3-"R�" -3กA�ก-#i-e/R7u�"2B&c�-5i"#F?R3F9�R�#�ก��4c�"2B&h3,-ก��7a �#? ก A�#?�7��AQ��#-?c�F� ,-3#?��!5$I/F 24c- 11% ?R3F4c�"3��-iQ� 10% ?R3F4c�"6?cF?#� 22% ?R3F4c�",-ก��M#�wc�" 6&� 5% ?R3F4c�",-ก���#�7��!�-3�B��

3.2 ก�,-;กN�ก[�ก3�=ก�,-;กX�O989>@/K>D�\]D��P�0�K��_��`�OJ (Health economic aspect of osteoporotic fractures) 1. A�ก��"F�-M3F International Osteoporosis Foundation (IOF) !5$9�RIQ���A1c�,4RAc�" (cost) ,-

ก���/6&�#กG�ก���/กB#กA�ก%�1ก���/ก@�C- (osteoporotic fractures) ,-"C%�7(19) @��c�IB.�@"C%�7,4RAc�"2F -,-ก���/6&�#กG�ก���/กB#กA�ก%�1ก���/ก@�C-I/Fw~F7}&� 25 @#-&R�-"/%� A�กMR30/&

Page 7: Osteoporosis guideline2010

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M3F7��2!83#FกrG7��2!82�5"�@��c�05ก��,4R2F -,-ก���/6&�#กG�ก���/กB#กA�ก%�1ก���/ก@�C-w~F7}&� 1.8 @#-&R�-73-�J(20) ก��7��0�L%�" National Osteoporosis Foundation (NOF) M3FIB�#H320� ก�,-7} 1.8. 1995(21) @��c�1c�,4RAc�",-ก���/6&�#กG�ก���/กB#กA�ก%�1ก���/ก@�C--c�A�I/Fw~F7}&� 17 @#-&R�-2B�5"�IB�#H

2. ,-7��2!89!""#F90c05ก��7��20 -7[�B�-5i,-���#�7��2!8 6?c05ก��7��0�L1c�,4RAc�",-ก���/6&�#กG�ก���/กI�%@กB#ก?c3e/R7u�"B-~$F��"3"/c!5$7��0�L 120,000 ��!?c37}(22)

I-4 Pathogenesis and etiology

4.1 X1�_/กb�>9/- (Pathogenesis) 1. %�1ก���/ก@�C-2ก �A�กก��!5$0�&ก���/ก6&�1CL.�@M3Fก���/ก&�&F %�" 2 I�2B?CB&#ก,B�c� 1h3

7� 0�L0�&ก���/ก!5$I�I09�R05-R3"ก�c�!5$1��A�27s- B�h3 05ก��I&�"ก���/ก0�กก�c�7ก? ,-4c�F?#iF6?c6�ก2ก �A�05ก��2@ $0M~i-M3F0�&ก���/กA�กก��I�R�Fก���/ก!5$0�กก�c�ก��I&�"ก���/ก !Q�,BR052-hi3ก���/ก2@ $0M~i-2�h$3"� A-w~FAC�B-~$Fก��2@ $0M~i-M3F0�&ก���/กA�B"C�&F 7� 0�L0�&ก���/กA�051c�I/FIC�2!c�!5$�C11&-#i-�A�059�R2�5"ก�c� 0�&ก���/กI/FIC� (peak bone mass) o~$F0�&ก���/กI/FIC�,-7��4�ก�9!"3"/c!5$4c�F3�"C7��0�L 30-34 7}(8) B&#FA�ก-#i-ก��I�R�F6&�ก��I&�"ก���/กA�I0�C&ก#-!Q�,BR0�&ก���/ก1F!5$ ?c30�!5$3�"C7��0�L 40-45 7} กbA�2� $005ก��I&�"ก���/ก0�กก�c�ก��I�R�Fก���/ก!Q�,BR0�&ก���/ก2� $0&�&F,-3#?��4R�� 6?cB&#FA�ก-#i-20h$3e/RB� F2MR�I/c�#"B0�7��AQ�2�h3- 3#?��ก��I&�"ก���/ก (rate of bone loss) A�I/FM~i-3"c�F0�ก !Q�,BR�c�Fก�"05ก��I/�2I5"0�&ก���/ก3"c�F?c32-h$3F 6&R�,-!5$IC�0�&ก���/กกbA�&�&F?$Q�A-w~F2กL�J!5$!Q�,BR1��02I5$"F?c3ก���/กB#ก2@ $0M~i-0�ก 2�5"ก�c�2ก �%�1ก���/ก@�C--#$-23F �#F-#i-ก��ก��!Q�,��กb?�0!5$!Q�,BR0�&ก���/กI/FIC�2@ $0M~i- B�h3ก��4�&33#?��ก��I&�"ก���/ก,BR&�-R3"&F9�R กbA�I�0��w&�1��02I5$"F?c3ก��2ก �%�1ก���/ก@�C-&�&F9�R

2. 7[AA#"!5$05e&?c30�&ก���/กI/FIC� 9�R6กc 24hi34�? @��c�4�? !5$050�&ก���/ก0�ก!5$IC�9�R6กc 4��e ��Q� ?�0�R�"4��e �M�� 6&�e �2B&h3F?�0&Q��#� @#-KCก��0 @��c�1��0B-�6-c-M3F0�&ก���/ก,-0����051��0I#0@#-KJก#�0�&ก���/กI/FIC�M3F�C?�(23-25) ก��33กกQ�&#Fก�"6��&F-iQ�B-#ก,-�#"2�bก6&��#"�Cc-!Q�,BR050�&ก���/กI/FIC�2@ $0M~i-(26,27) ก���#�7��!�-61&2o5"0,-�#"2�bก6&��#"�Cc-A�4c�"2@ $00�&ก���/กI/FIC�(28,29) ก��I/��CB�5$6&��h$063&ก3m3&J!Q�,BR0�&ก���/กI/FIC�&�&F(30)

3. ก��I&�"M3Fก���/ก,-e/RB� F2ก �M~i-3"c�F���2�b�6&��C-6�F,-4c�F 10 7}6�กB&#FB0�7��AQ�2�h3- 2�5"ก�c� postmenopausal bone loss %�"A�053#?��ก��&�&FM3F0�&ก���/กw~F7}&� 3-5% 3#-27s-e&A�กก��&�&FM3Fm3�J%0-23I%?�2A- IcFe&,BR2o&&JI&�"ก���/ก(osteoclast) 05ก��!Q�F�-2@ $0M~i-3"c�F0�ก,-4c�F-5i A~F05ก��I&�"M3Fก���/ก0�กก�c�ก��I�R�Fก���/ก %�"A�2ก �M~i-!5$ก���/ก%7�cF(cancellous or trabecular bone) 0�กก�c�ก���/ก!~� (cortical bone) �#F-#i-ก���/กB#ก!5$2ก �A�ก%�1ก���/ก@�C-,-e/RB� F�#"B0�7��AQ�2�h3-A~F0#กA�2ก �M~i-กc3-,-?Q�6B-cF!5$057� 0�Lก���/ก%7�cF0�ก 24c- ก���/กI#-B&#F 20h$3ec�-4c�F-5i970�&ก���/กA�I/�2I5",-3#?��!5$4R�&F 2B&h3@3� ก#�3#?��ก��I/�2I5"0�&ก���/ก,-2@84�"(31) 3"c�F9�กb�5 e/RB� F��F1-กb"#F05ก��I/�2I5"ก���/ก,-3#?��ก��!5$I/F3"/c?&3�4c�F3�"Cกb9�R

4. ก��I/�2I5"0�&ก���/ก,-e/R4�"2ก �M~i-,-3#?��!5$?$Q�ก�c�e/RB� F 1h3 053#?��7}&� 1-2% %�"2� $0M~i-?#iF6?c"c�F2MR�I/c3�"C 40-50 7} ,-e/R4�"!#iFB0� 6&� ,-e/RB� F��F1-!5$B0�7��AQ�2�h3-0�-�-6&R� (24c- 3�"C>70 7}) I�2B?CIQ�1#�!5$!Q�,BR0�&ก���/ก&�&F2ก �A�กก��!5$2o&&JI�R�Fก���/ก

Page 8: Osteoporosis guideline2010

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(osteoblast) 05ก��!Q�F�-!5$2Ih$30w3"&FA�ก3�"C!5$2@ $00�กM~i- B�h3 ก��I/�2I5"0�&ก���/ก6��-5i2�5"ก�c� age-related bone loss

5. !#iFI3F2@8A�053C�#? ก��LJM3Fก��2ก �ก���/กB#กA�ก%�1ก���/ก@�C-2@ $0M~i- %�",-e/RB� FA�2@ $0I/FM~i-?#iF6?c3�"C7��0�L 65 7} 6?c,-e/R4�"A�2@ $0M~i-?#iF6?c3�"C 70-75 7} 3#?��ก��2@ $0M~i-M3Fก���/กB#กA�ก%�1ก���/ก@�C-A�27s-6�� exponential B�h33-Cก�02�M�1L ? -#$-1h3A�2@ $0M~i-3"c�F���2�b�20h$33�"C0�กM~i-

6. 7[AA#"3h$-� !5$2�cFก��I&�"ก���/ก9�R6กc ก��,4R"�ก&/%113�J? 13"�J ก��M��� ?�0 -�5 %�1!�F?c309�R!c324c- m3�J%0-9!�3"�J6&�@���9!�3"�J0�ก2ก -97 6&�%�1MR33#ก2I��/0�?3"�J 27s-?R- A�!Q�,BR27s-%�1ก���/ก@�C-9�R2�b�M~i-

7. I�2B?CIQ�1#�M3Fก��2ก �ก���/กB#กA�ก%�1ก���/ก@�C-1h3 ก��056�Fก��!Q�.�"-3ก o~$FIc�-,B�c0�A�กก��Bก&R0 7[AA#"!5$2ก5$"�MR3Fก#�ก��&R0 (factors of fall)(32) 9�R6กc ก��1��1C0 postural reflexes ?c�F� ก�� coordination M3Fก&R�02-hi3 ก��03F2Bb- ��0!#iF fat padding �3�� ก���/ก!5$A�I�0��w&�6�Fก��6!ก9�R A�2Bb-�c�?�F-5i3�"CA�2MR�0�05�!��!3"c�F0�ก!52�5"� !#iF-5i2-h$3FA�ก20h$31-2��20h$3053�"C0�กM~i--3กA�กก���/กA�@�C-6&R� ก&9กก��7t3Fก#-ก��&R0กbA�6"c&F?�097�R�" 1��02I5$"F!5$A�2ก �ก���/กB#กA~F050�กM~i-

>?ก���?M�K?/K 1. Osteoporosis prevention, diagnosis and therapy. NIH consensus statements 2000; 17: 1-36. 2. Consensus Development Conference: prophylaxis and treatment of osteoporosis. Am J Med

1991;90:107-10. 3. Johnell O. The socioeconomic burden of fracture: today and in the 21st century. Am J Med

1997;103(suppl 2A):S20-5. 4. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. How many women have

osteoporosis? J Bone Miner Res 1992;7(9):1005-10. 5. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in elderly; a cross-

national analysis. Osteoporosis Int 1991;1:232-41. 6. Mahidol Population Gazette. Institute of Population and Social Research, Mahidol

University, 2008. 7. Taechakraichana N, Angkawanich P, Panyakhamlerd K, Limpaphayom K. Postmenopausal

osteoporosis: what is the real magnitude of problem? J Med Assoc Thai 1998;81:397-401. 8. Limpaphayom K, Taechakraichana N, Jaisamrarn U, Bunyavejchevin S, Chaikittisilpa S,

Poshyachinda M, et al. Prevalence of osteopenia and osteoporosis in Thai women. Menopause 2001;8:65-9.

9. Lau EM, Lee JK, Suriyawongpaisal P, Saw SM, Das De S, Khir A, et al. The incidence of hip fracture in four Asian Countries: the Asian Osteoporosis Study (AOS). Osteoporosis Int 2001;12:239-43.

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10. Lau EM, The epidemiology of osteoporosis in Asia. In: Lau EM, Ho SC, Leung S, Woo J, (eds). Osteoporosis in Asia: crossing the frontiers. Singapore World Scientific, 1997:1-20.

11. Orimo H, Nakamura T, Fukunaga M. The Japanese guidelines for prevention and treatment of osteoporosis. (Translated abridged edition). Life Science Publishing, 2006:5.

12. Nevitt MC, Ettinger B, Black DM, et al. The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 1998; 128:793-800.

13. Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR, for the Study of Osteoporotic Fractures Research Group. Vertebral fractures and mortality in older women; a prospective study. Arch Intern Med 1999;159:1215-20.

14. Pongchaiyakul C, Nguyen ND, Jones G, Center JR, Eisman JA, Nguyen TV. Asymptomatic vertebral deformity as a major risk factor for subsequent fractures and mortality: a long-term prospective study. J Bone Miner Res 2005;20:1349-55.

15. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 1999;353:878-82.

16. Scaf-Klomp W, van Sonderen E, Sanderman R, Ormel J, Kempen GI. Recovery of physical function after limb injuries in independent older people living at home. Aging 2001;30:213-9.

17. Chariyalertsak S, Suriyawongpaisal P, Thakkinstain A. Mortality after hip fracture in Thailand. Int Orthop 2001;25:294-7.

18. Suriwongpaisal P, Chariyalertsak S, Wanvarie S. Quality of life and functional status of patients with hip fractures in Thailand. Southeast Asian J Trop Med Public Health 2003;34:427-32.

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20. Burge RT, Worley D, Johansen A, Bhattacharyya S, Bose U. The cost of osteoporotic fractures in the UK: projections for 2000-2020. J Med Econ 2001;4:51-62.

21. Ray NF, Chan JK, Thamler M, Melton LJ-III. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 1997;12:24-35.

22. Woratanarat P, Wajanavisit W, Lertbusayanukul C, Loahacharoensombat W, Ongphiphatanakul B. Cost analysis of osteoporotic hip fracture. J Med Assoc Thai 2005; 88(5):S96-104.

23. Krall EA, Dawson-Hughes B. Heritable and life style determinants of bone mineral density. J Bone Miner Res 1993;8(1):1-9.

24. Brown MA, Haughton MA, Grant SF, Gunnell AS, Henderson NK, Eisman JA. Genetic control of bone density and turnover: role of the collagen 1alpha1, estrogen receptor, and vitamin D receptor genes. J Bone Miner Res 2001;16(4):758-64.

25. Ralston SH. Genetics of osteoporosis. Rev Endocr Metab Disord 2001;2(1):13-21.

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26. Taaffe DR, Robinson TL, Snow CM, Marcus R. High-impact exercise promotes bone gain in well-trained female athletes. J Bone Miner Res 1997;12(2):255-60.

27. Kemper HC, Twisk JW, van Mechelen W, Post GB, Roos JC, Lips P. A fifteen-year longitudinal study in young adults on the relation of physical activity and fitness with the development of the bone mass: The Amsterdam Growth And Health Longitudinal Study. Bone 2000;27(6):847-53.

28. Matkovic V, Fontana D, Tominac C, Goel P, Chesnut CH, 3rd. Factors that influence peak bone mass formation: a study of calcium balance and the inheritance of bone mass in adolescent females. Am J Clin Nutr 1990;52(5):878-88.

29. Johnston CC Jr, Miller JZ, Slemenda CW, Reister TK, Hui S, Christian JC, et al. Calcium supplementation and increases in bone mineral density in children. N Engl J Med 1992;327(2):82-7.

30. Välimäki MJ, Kärkkäinen M, Lamberg-Allardt C, Laitinen K, Alhava E, Heikkinen J, et al. Exercise, smoking, and calcium intake during adolescence and early adulthood as determinants of peak bone mass. Cardiovascular Risk in Young Finns Study Group. BMJ 1994;309:230-5.

31. Garnero P, Sornay-Rendu E, Chapuy MC, Delmas PD. Increased bone turnover in late postmenopausal women is a major determinant of osteoporosis. J Bone Miner Res 1996; 11(3):337-49.

32. Bouxsein ML, Myers ER, Hayes WC. Biomechanics of age-related fractures. In Marcus R, Feldmen D, Kelsey J. (eds). Osteoporosis. Academic Press 1996, San Diego, CA.

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Diagnosis and bone mass assessment in osteoporosis

II-1 History, physical examination and differential diagnosis

1.1 ก��[b�B9กC�,>:0J?K3�=ก�,-;กX�O9(1) (Classification of osteoporosis)

%�1ก���/ก@�C-AQ�6-ก33ก9�R27s-

���ก����ก����� ������ (Primary osteoporosis) o~$F6�cF"c3"27s- 1. 3�=ก�,-;กX�O989L;MN�/K.�1N<-C�,[b�>-e?9 (postmenopausal osteoporosis) 2ก �ก��

I/�2I5"0�&ก���/กA�ก.���M��m3�J%0-23I%?�2A-27s-B&#ก 2. 3�=ก�,-;กX�O989.�1�;K?�1O (age-related N�e? senile osteoporosis) 2ก �9�R!#iF,-e/R4�"6&�

e/RB� F o~$F27s-7[�B�A�กก��I�R�Fก���/ก9�R-R3"&FA�ก1��02Ih$30M3F2o&&JI�R�Fก���/ก

���ก����ก������ �!���� (Secondary osteoporosis) ?�0?���F!5$ 2.1 P���K0A2 2.1 6I�FI�2B?CM3F%�1ก���/ก@�C-4- �!C? "./0 !5$@��c3" 1. %�1!�F?c309�R!c3

− Cushing�s syndrome − .��� hypogonadism − ?c309!�3"�J27s-@ G − .���m3�J%0-@���9!�3"�JI/F

2. "� − ก&/%113�J? 13"�J − "�?R�-ก��6MbF?#�M3F2&h3� (heparin, warfarin) − "�ก#-4#ก 9�R6กc phenytoin, phenobarbital − "�ก�./0 1CR0ก#- 6&�"��#กG�0�2�bF

3. %�1!�F3�"C�ก��0 − %�19? − %�1?#�2�hi3�#F − .����/�o~03�B��e �7ก? (malabsorption) B�h3ec�?#�ก��2@��3�B�� − MR33#ก2I��/0�?3"�J

4. 3h$-� − M��I��3�B�� − %�10�2�bF 6&� multiple myeloma

− %�1 osteogenesis imperfecta

Page 12: Osteoporosis guideline2010

9

II-2 Risk factors for osteoporosis and osteoporotic fractures

2.1 Cg[[�1>�A21KJ?K3�=ก�,-;กX�O9B4,ก�,-;กN�ก[�ก3�=ก�,-;กX�O9 (Risk factors of osteoporosis and osteoporotic fracture)

2-h$3FA�ก3�=ก�,-;กX�O9<�กE<RB�-K?�ก��L/-CกP/[9ก.R�[,>ก/-ก�,-;กN�ก ,-ML�!5$20h$3@ A��L�,-24 F28�GH8�I?�J!�FI�K��LICM6&R� "#F90c051��01CR01c�!5$A�!Q�ก��?��A1#�ก�3F�R�"21�h$3F�#�1��0B-�6-c-ก���/ก (bone densitometer) ,-7��4�ก�%�"!#$�97!#iFB0� �#F-#i-ก��,4Rก��7��20 -7[AA#"2I5$"F (risk assessment) o~$F27s-21�h$3F0h3!5$,4R9�RFc�" I���ก 6&�7��B"#�,-!�F7a �#? 2@h$31R-B�e/R!5$057[AA#"2I5$"F!5$A�2ก �%�1ก���/ก@�C-B�h3ก���/กB#ก -c�A�27s-� K5ก��!5$2B0��I0ก�c�(2)

7[AA#"2I5$"FB&#ก!5$051��0I#0@#-KJก#�ก��2ก �%�1ก���/ก@�C-6&�ก���/กB#ก,-e/RB� F�#"B0�7��AQ�2�h3-05�#F-5i

&''(!)*+,!-�+,.�/*0�0�1 �(2) 3+,!.�4 (Non-modifiable risk factors) 1. I/F3�"C (3�"C?#iF6?c 65 7}M~i-97) 2. 2@8B� F 3. e/RB� Fe �M��6&�e/RB� F23245" 4. B0�7��AQ�2�h3-กc3-3�"C 45 7} (early menopause) o~$FB0�"��0w~Fe/R!5$w/ก?#��#F9Mc!#iFI3FMR�Fกc3-

B0�7��AQ�2�h3- 5. %1�FI�R�FM3F�c�Fก�"2&bก (small body build) 6. � �� 0���� @5$I��B�h3-R3FI��27s-%�1ก���/ก@�C-B�h3ก���/กB#กA�ก%�1ก���/ก@�C- 7. 21"ก���/กB#กA�ก.���ก���/ก27�����F (fragility fracture)

&''(!)*+,!-�+, �(2) 3+,!.�4 (Modifiable risk factors) 1. �� %.161&2o5"090c2@5"F@3 (inadequate calcium intake) 2. 90c1c3"9�R,4R6�Fก�" (sedentary lifestyle) 3. I/��CB�5$27s-7��AQ� 4. �h$0IC��2ก -M-��27s-7��AQ� 5. �h$0ก�6�2ก -M-��27s-7��AQ� 6. �#4-50�&ก�"?$Q�ก�c� 19 กก./?�0. 7. 05.���M��m3�J%0-23I%?�2A- (estrogen deficiency) กc3-2MR�I/c�#"B0�7��AQ�2�h3- 24c- ก��

9�R�#�"� gonadotropin releasing hormone (GnRH) analogue B�h3A�กก��33กกQ�&#Fก�"3"c�FB-#ก27s-��"�2�&�-�-

8. 051��02I5$"F?c3ก��Bก&R0 (propensity to falls) 24c- ก��03F2Bb-90c4#�2A- (impaired vision)

2.2 ก��C�,></9Cg[[�1>�A21KJ?Kก��>ก/-ก�,-;กN�ก[�ก3�=ก�,-;กX�O9 3-18@M FRAXTM J?K?K=^ก��?9�<�134ก (Risk assessment of osteoporotic fracture using WHO-FRAXTM)

WHO(3) 9�R!Q�ก��8~กG�%�"!Q� meta-analysis population-based cohorts B&�"ก��8~กG�A�ก7��2!8,-!�57"C%�7 320� ก�2B-h3 232o5" 6&� 33I2?�2�5" I�0��wกQ�B-�7[AA#"2I5$"F%�"1#�2&h3ก2|@��7[AA#"2I5$"F!5$05&#กGL��#F-5i1h3

Page 13: Osteoporosis guideline2010

10

1. Independent ?c3 BMD 2. 05B&#กH�-I-#�I-C-A�กB&�"� ก��8~กG�!5$4#�2A-�c�27s-7[AA#"2I5$"F!5$IQ�1#� 3. I�0��w adjusts IQ�B�#�3�"C, 2@8 6&�7��2.!M3Fก���/กB#ก9�R 4. 6@!"J2�47a �#? !#$�97I�0��w2MR�,A6&�,4R9�R3"c�FFc�"��" 5. e&A�กก���#กG��R�""�I�0��w&�1��02I5$"F2B&c�-5i9�R (2|@��ก�L51��02I5$"F!5$ modifiable)

!Q�,BR9�R 7[AA#"2I5$"F!5$IQ�1#�!#iFB0� 9 7[AA#"!5$2MR�?�0B&#ก2กL�J-5i ?�0?���F!5$ 2.2 %�"!5$��023�1c�1��0B-�6-c-ก���/ก (bone mass density, BMD) 2MR�9727s-7[AA#"2I5$"F3#-B-~$F�R�" %�",4R2|@��1c� femoral neck BMD 27s-B&#ก 6&�wR�3"/c,-Iw�-!5$!5$90cI�0��w?��A BMD 9�R ,BR,4R 1c� body mass index (BMI) 6!- %�"1c�!5$6!-&F,-7[AA#"2I5$"FIQ�1#�2B&c�-5i 27s-1c�!5$,BR2&h3ก�c� 05 B�h3 90c05 (yes/no) "ก2�R-3�"C 6&� BMD/BMI 2!c�-#i-!5$A�6!-�R�"1c�A� F P���K0A2 2.2 7[AA#"2I5$"FIQ�1#�!5$ WHO -Q�0�,4R,- FRAXTM

Age (yr) BMD(FN) / BMI (T-score or kg/M2) A prior fragility fracture (yes/no) Parental history of hip fracture (yes/no) Current tobacco smoking (yes/no) Ever long-term use of oral glucocorticoids (yes/no) Rheumatoid arthritis (yes/no) Other causes of secondary osteoporosis (yes/no) Daily alcohol consumption of three or more units daily (yes/no)

N<�1>NPO BMD(FN) = femoral neck bone mass density, BMI = bone mass density 0A2<� WHO task force conference held in Brussels, Belgium in May 2004

MR30/&6&�7[AA#"2I5$"F?c�F� 2B&c�-5iw/กกQ�B-�9�R6&�1Q�-�L%�"!Q�27s-%7�6ก�0IQ�2�bA�/7 o~$FA�I�0��w1Q�-�L33ก0�27s-1��0-c�A�27s-!5$A�2ก �ก���/กB#ก,-��"� 10 7} (10-year probability of fracture) 9�R %7�6ก�0 FRAXTM -5iI�0��w2MR�97,4R9�R!�F internet !5$ http://www.shef.ac.uk/FRAX(4) o~$FA� F� 6&R� 10-year probability -5i051��0e#-67�M~i-ก#�7��2!86&�24hi34�? ?c�F��R�" ,- website -5iกbA�05 FRAXTM M3F7��2!8?c�F� B&�"7��2!8 IQ�B�#�!�F 7��2!8,-6w�232o5"กb05 7��2!8�5$7Cu- A5- 6&� US-Asian o~$FA�9�Re&&#@KJ27s- 2 6��1h3 10-year probability of hip fracture 6&�10-year probability of other major osteoporotic fractures !#iF-5iI�0��w-Q�1c�!#iFI3F0�,4R7��20 -1��02I5$"FM3Fe/R7u�"2@h$3,4R2� $0ก���#กG�9�R (therapeutic threshold) 24c- ,-7��2!8320� ก�7[AAC�#- wR�e/R7u�""#F90c05 fracture B�h3 BMD "#F90c?$Q�ก�c� -2.5 A�,4Rก��1Q�-�LB�1c� 10-year probability of fracture 27s-?#�กQ�B-��c�A�,BR"��#กG�B�h390c 1h3 wR�e/R7u�"05 10-year probability of hip fracture ≥ 3% B�h3 10-year probability of other major osteoporotic fractures ≥ 20% กb,BR"��#กG�9�R(5)

7[AAC�#-"#F90c05MR30/&M3F7��4�ก�9!",-ก��1Q�-�L FRAX !�F0/&- K %�1ก���/ก@�C-6BcF7��2!89!"A~F9�R!Q�ก��8~กG�6&�!Q�ก��!�I3� FRAXTM %�"ก��3R�F3 FMR30/&,-4-4�� Asia ,-2�hi3F?R-@��c� ก��8@M FRAXTM J?KC�,@�ก�>@eQ?@�P/>?>@A1 E-MBกR US-Asian B4, Japan -c�A�051��02B0��I0

Page 14: Osteoporosis guideline2010

11

20h$3@ A��L�A�กMR30/&!�F������ !"�M3F%�1ก���/ก@�C-,-7��2!89!" 3"c�F9�กb?�02-h$3FA�ก"#F90c05ก��8~กG�1c�AC�?#�!5$2B0��I0,-ก��,BRก���#กG��R�""�,-1-9!" A~F6-�-Q�,BR,4R1c�AC�?#�?�01Q�6-�-Q�M3F NOF 1h3 10-year probability of hip fracture ≥ 3% B�h3 10-year probability of other major osteoporotic fractures ≥ 20% กb,BR"��#กG�9�R

II-3 Laboratory investigation and bone strength assessments

3.1 ก��P�.[0�KNM?KCo/��P/ก�� (Laboratory investigation)

<( 1 ��*-�=>?-ก0� �<'�0-@4?- A�2( �ก0� 1. 2@h$3"h-"#-ก��� - A|#"%�1ก���/ก@�C- 2. 2@h$37��20 -1��02I5$"F,-ก��2ก �ก���/กB#ก 3. 2@h$3B�I�2B?CM3F%�1ก���/ก@�C-4- �!C? "./0

B)2CD?- 4�<� �<'�0-@4?- A�2( �ก0� − Complete blood count (CBC) − Serum calcium, phosphate, albumin 6&� liver transaminases − Serum alkaline phosphatase − Renal function (blood urea nitrogen and creatinine) − Plain x-rays 6-�-Q�,BR?��Aก���/กI#-B&#FIc�-3ก6&�23��R�-MR�F (lateral thoraco-lumbar spine)

B�h3ก���/กI�%@ก�R�-B-R�-B&#F (antero-posterior hip) 20h$305MR3�cF45iB�h320h$3IFI#"�c�A�05ก���/กB#ก

3.2 ก��C�,></9=.�<BJpKBก�RKJ?Kก�,-;ก (Bone strength assessment)

1��06MbF6ก�cFM3Fก���/ก2ก �A�กI3F7[AA#"B&#ก 1h3 7� 0�LM3F0�&ก���/ก (bone mass) 6&�1CL.�@M3Fก���/ก (bone quality) o~$F,-7[AAC�#-"#F90c052!1%-%&"5,�!5$A�I�0��w-Q�0�7��20 -1CL.�@ก���/ก9�R3"c�Fw/ก?R3F60c-"Q�6&�-Q�97,4R,-!�F1& - ก9�R ก��7��20 -1��06MbF6ก�cFM3Fก���/ก,-!�F1& - กA~F,4Rก���#�1��0B-�6-c-ก���/ก27s-B&#ก 1. ก��?��A%�",4R plain x-ray 90cI�0��w�cF�3กก��&�&FM3F0�&ก���/ก9�R9�@3 2-h$3FA�ก.�@

x-ray !5$A�I�0��w6I�F,BR2Bb-ก����F&FM3Fก���/ก!5$�/9�R�R�"I�"?�-#i- 0�&ก���/กA�?R3F&�&F0�กก�c� 30% A�ก1c�7ก? 976&R�

2. Semi-quantitative method ,-ก��7��20 -.�@ plain film x-ray 24c- � K5 Singh�s index 27s-?R- 90cI�0��wA�1��1C01CL.�@ก��7��20 -9�R24c-ก#- %�"05 intra-observer 6&� inter-observer variation 0�กA~F90c6-�-Q�,BR-Q�0�,4R

3. Bone mass measurements !5$ WHO กb�N9-8NM>CW9<�P��]�989ก��./9/[q�1:�.,3�=ก�,-;กX�O9กp=e? axial dual-energy x-ray absorptiometry (axial DXA) >0R�9�Q9

4. Bone mass measurements �R�">0=39341A?e29r >@R9 quantitative ultrasonography (QUS) N�e? peripheral DXA (pDXA) E<R��<��u9b�<�8@M0-B09ก��P�.[-M.1 axial DXA >Xe2?ก��./9/[q�13�=ก�,-;กX�O9 6?c2!1%-%&"52B&c�-5iกb"#F057��%"4-JIQ�B�#�1#�ก�3Fe/R!5051��02I5$"FI/F?c3%�1ก���/ก@�C- 2@h$3ก��-Q�0�?��A"h-"#-�R�" axial DXA 35ก!5

Page 15: Osteoporosis guideline2010

12

II-4 Diagnostic criteria for osteoporosis

4.1 ก��P�.[=.�<N9�B9R9ก�,-;ก (Measurement of bone density)

1��0B-�6-c-ก���/ก (Bone mass density, BMD) 0521�h$3F0h3!5$,4R?��A�#�3"/cB&�"4- � �#F?c397-5i

Dual Energy X-ray Absorptiometry

ก��� - A|#"%�1ก���/ก@�C-,-e/RB� F3�8#"2กL�Jก��� - A|#"M3F3F1Jก��3-�0#"%&ก(6,7) ?�0?���F!5$ 2.3 o~$F3�8#"ก��27�5"�2!5"�1c� BMD !5$�#�9�Rก#�1c�2|&5$" BMD I/FIC� ,-e/RB� F�#"I�� 6&�,BRwh31c�!5$-R3"ก�c�B�h32!c�ก#� -2.5 2!c�M3F1c�2�5$"F2�-0�?�H�-,-ก��� - A|#"%�1ก���/ก@�C- %�"@�1��02I5$"FM3Fก��2ก �ก���/กB#ก2@ $0M~i- 1.4 - 2.6 2!c�!Cก� 1 2!c�M3F1c�2�5$"F2�-0�?�H�-!5$&�&F(8)

P���K0A2 2.3 ก��� - A|#"%�1ก���/ก@�C-?�01c�1��0B-�6-c-ก���/ก!5$�#��R�"21�h$3F DXA ก��./9/[q�1 ก��P�.[X� 7ก? (normal)

1��0B-�6-c-ก���/ก3"/c,-2กL�J7ก? 1h3051c�0�กก�c�B�h32!c�ก#� -1 2!c�M3F1c�2�5$"F2�-0�?�H�-20h$327�5"�2!5"�ก#�1c�2|&5$"0�&ก���/กI/FIC�,-e/RB� F�#"I�� (T-score ≥ -1)

ก���/ก��F (osteopenia) 1��0B-�6-c-ก���/ก?$Q�ก�c� -1 2!c�M3F1c�2�5$"F2�-0�?�H�-6?c0�กก�c� -2.5 2!c�M3F1c�2�5$"F2�-0�?�H�-20h$327�5"�2!5"�ก#�1c�2|&5$"0�&ก���/กI/FIC�,-e/RB� F�#"I�� ( -2.5 < T-score < -1)

ก���/ก@�C-(osteoporosis)

1��0B-�6-c-ก���/ก?$Q�ก�c�B�h32!c�ก#� -2.5 2!c�M3F1c�2�5$"F2�-0�?�H�-20h$327�5"�2!5"�ก#�1c�2|&5$"0�&ก���/กI/FIC�,-e/RB� F�#"I�� (T-score ≤ -2.5)

ก���/ก@�C-���#��C-6�F (severe/established osteoporosis)

1��0B-�6-c-ก���/ก?$Q�ก�c�B�h32!c�ก#� -2.5 2!c�M3F1c�2�5$"F2�-0�?�H�-20h$327�5"�2!5"�ก#�1c�2|&5$"0�&ก���/กI/FIC�,-e/RB� F�#"I�� (T-score ≤ -2.5) �c�0ก#�05ก���/กB#กA�ก1��027�����F (fragility fracture)

,-ก��?��A BMD 2@h$3� - A|#"%�1ก���/ก@�C--#i- ,BR?��A!5$ก���/กI#-B&#FIc�-23� (lumbar spine B�h3 L-spine) 6&�ก���/กI�%@ก (hip) 2!c�-#i- o~$F2�5"ก�c� axial DXA 90c051��0AQ�27s-?R3F?��A!5$ก���/ก7&�"6M- (peripheral DXA) "ก2�R-,-e/R7u�"!5$3R�-0�ก B�h390cI�0��w?��A axial DXA 9�R

1c�3R�F3 F!5$-Q�0�,4RIQ�B�#�27�5"�2!5"� PM?K8@M=R�>q4A21<.4ก�,-;ก�;K�O-89L;MN�/K.�1��. 0A2>CW9>@eQ?@�P/>-A1.ก�9 N�e?8ก4M>=A1Kก�9 (Asian female reference) ก#�e/Rw/ก?��A 2!c�-#i- 24c-,-1-9!" A� F� 6&R�?R3F,4R1c�2|&5$"0�&ก���/กI/FIC�,-e/RB� F�#"I��9!" 6?cกb3-C%&0,BR,4RM3F4���5$7Cu-B�h3A5-6!-9�R (6?c90c,4RM3F Caucasian)

IQ�B�#�,-ก�L5e/R4�" ก��� - A|#"%�1ก���/ก@�C-A�,4R2กL�J24c-2�5"�ก#-ก#�,-e/RB� F (�#F,-?���F!5$ 2.3) 6?cก��,4R1c�0�&ก���/กI/FIC�2|&5$"!5$,4R3R�F3 FIQ�B�#�27�5"�2!5"� (reference young adult mean) A�,4R1c�2|&5$"0�&ก���/กI/FIC�,-e/R4�"B-Cc0 (male reference) !5$27s-24hi34�? 2�5"�ก#- B�h3,ก&R215"Fก#-6!-ก��,4RM3Fe/RB� F (female reference)

Page 16: Osteoporosis guideline2010

13

>4?2/-�+DBก0�*/- �<' BMD �4<!)��C,?- axial DXA(9) 1. e/RB� F3�"C?#iF6?c 65 7}M~i-97 6&�e/R4�"3�"C?#iF6?c 70 7}M~i-97 2. IQ�B�#�e/RB� F!5$053�"C?$Q�ก�c� 65 7} 6&� e/R4�"!5$053�"C?$Q�ก�c� 70 7} !5$05057[AA#"2I5$"F�#F?c397-5i 3"c�F

-R3" 1 MR3 − B0�7��AQ�2�h3-กc3-3�"C 45 7} (early menopause) o~$FB0�"��0w~Fe/R!5$w/ก?#��#F9Mc!#iFI3FMR�F

กc3-B0�7��AQ�2�h3- − 05.���M��m3�J%0-23I%?�2A- (estrogen deficiency) กc3-2MR�I/c�#"B0�7��AQ�2�h3- ?c32-h$3F

-�-ก�c� 1 7} "ก2�R-ก�L5?#iF1��.J6&�,BR-0�C?� − 9�R�#�"�ก&/%113? 13"�J27s-��"�2�&�-�- (2@��- %o%&-�#-&� 7.5 0ก.B�h32!5"�2!c�27s-

��"�2�&�-�-ก�c� 3 2�h3-) − 057���#? � ��B�h30����ก���/กI�%@กB#ก − e/RB� F�#"B0�7��AQ�2�h3-!5$05�#4-50�&ก�"-R3"ก�c� 19 กก./?�0.

3. ?��A@�.���ก���/ก��FB�h3ก���/กI#-B&#Fe ��/7A�กก��wc�".�@�#FI523กo2�"J (radiographic osteopenia and / or vertebral deformity by x-ray)

4. 057���#? ก���/กB#กA�ก."#-?��"6��90c�C-6�F 5. 05Ic�-I/F&�&F 6. 3"/c,-ก&Cc0!5$051��02I5$"FI/F A�กก��?��A1#�ก�3F�R�" OSTA score(10), KKOS score(11) B�h3

nomogram 0�กก�c� 0.3 IQ�B�#�e/RB� F�#"B0�7��AQ�2�h3- (�/.�1e-�ก 2.2) (N<�1>NPO OSTA; Osteoporosis Self Assessment Tool for Asians, KKOS; Khon Kaen Osteoporosis Study score)

Quantitative Ultrasound (QUS)

�!��!M3F QUS !#iFก��� - A|#"6&�ก��? �?�0ก���#กG�"#F90c4#�2A- IQ�B�#�ก��� - A|#"@��c�ก��,4R QUS 3"c�F2�5"�051��09� (sensitivity) ?$Q� 6?c051��0AQ�2@�� (specificity) I/F 3"c�F9�กb?�0ก��-Q� QUS 0�,4R�c�0ก#� OSTA(10) 6&� KKOS(11) A�I�0��w2@ $01��09�6&�1��0AQ�2@��0�กM~i-(12) -3กA�ก-5i ก��,4R QUS �c�0ก#�3�"C6&�-iQ�B-#ก,-�/76��%-%06ก�0 (nomogram) A�4c�"!Q�-�"ก��2ก �%�1ก���/ก@�C-9�R�5M~i-(13) 3"c�F9�กb?�0ก��P�.[9AQE<R��<��u8@M89ก��./9/[q�13�=ก�,-;กX�O9E-M

4.2 -�@9A@A.>=<AJ?Kก�,�.9ก����M�KB4,�4�1ก�,-;ก (Biochemical markers of bone turnover)

�#4-5!�F45�2105M3Fก����-ก��I�R�F6&�I&�"ก���/ก E<RB9,9b�8NM8@M89ก��./9/[q�13�=ก�,-;กX�O9 2-h$3FA�ก1c�M3F0#-05ก��27&5$"-67&F9�RA�กB&�"� 7[AA#" 6&�3�AA�@�1��0e �7ก? 9�R,-B&�"� %�1!5$90c,4c%�1ก���/ก@�C- 6?cI�0��w,4R�c�0ก#� BMD ,-ก��7��20 -1��02I5$"FM3Fก��2ก �ก���/กB#ก9�R(14-16) 3"c�F9�กb?�0�#4-5�#Fก&c�� A�<AC�,31@989BKRJ?Kก��P/-P�<ก����ก\�(17) %�"6-�-Q�,BR7��20 -.�"B&#Fก���#กG�!5$ 3 2�h3-6&� 1 7} I�0��w,4R7��20 -ก��?3�I-3F?c3ก���#กG��R�""�9�R�5 6&�!���e&9�R���2�b�

IQ�B�#��#4-5!�F45�2105M3Fก��I&�"ก���/ก 9�R6กc urinary deoxypyridinoline (DPD), urinary N-telopeptide (NTx) 6&� serum C-telopeptide (CTx) Ic�-�#4-5!�F45�2105M3Fก��I�R�Fก���/ก 9�R6กc bone

Page 17: Osteoporosis guideline2010

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specific alkaline phosphatase (BSAP), osteocalcin, C-terminal propeptide of type 1 procollagen (P1CP) 6&� N-terminal propeptide of type 1 procollagen (P1NP)(18)

4.3 ก��P�.[=�-ก�?K (Screening)

ก��?��A1#�ก�3F%�1ก���/ก@�C-�R�" axial DXA IQ�B�#�7��4�4-!#$�9790c6-�-Q�2-h$3FA�ก90c1CR01c�,-24 F28�GH8�I?�J!�FI�K��LICM 6?c,-7[AAC�#-ก��?��A1#�ก�3F�R�" OSTA(10) B�h3 KKOS(11) I�0��wก��!Q�9�R2-h$3FA�ก90c051c�,4RAc�" I�0��w1R-B�e/R!5$051��02I5$"F,-ก��2ก �%�1ก���/ก@�C-2@h$3?��A BMD ?c3979�R (�/.�1e-�ก 2.1)

Page 18: Osteoporosis guideline2010

15

:�=L9.ก 2.1

OSTA (Osteoporosis Self-Assessment Tool for Asians)

%�"I/?�,-ก��1Q�-�L1��02I5$"F OSTA -#i- 2!c�ก#� 0.2 X (-iQ�B-#ก-3�"C) e&&#@KJ!5$9�R,BR?#�AC�!8- "033ก %�"3�"C,4RB-c�",4R27s-7} -iQ�B-#ก?#�,4RB-c�"27s-ก %&ก�#0

ก0�Q 3R3 OSTA index -R3"ก�c� -4 1��02I5$"FI/F ��B�c�F -4 w~F -1 1��02I5$"F7�-ก&�F ?#iF6?c -1 M~i-97 1��02I5$"F?$Q�

Page 19: Osteoporosis guideline2010

16

Khon Kaen Osteoporosis study score (KKOS)(13)

Age (y) Score Weight (kg) Score

< 45 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 z 89 > 90

+ 7.5 + 6.0 + 4.5 + 3.0 + 1.5 0 - 1.5 - 3.0 - 4.5 - 6.0 - 7.5

< 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 > 90

- 14 - 12 - 10 - 8 - 6 - 4 - 2 0 + 2 + 4 + 6 + 8 + 10 + 12

ก��1Q�-�L KKOS ,BR-Q�1c�1�6--A�ก3�"C (7}) 6&�-iQ�B-#ก (ก %&ก�#0) 0���กก#- KKOS < -1 : =.�<>�A21K89ก��>ก/-3�=ก�,-;กX�O9�;K KKOS > -1 : =.�<>�A21K89ก��>ก/-3�=ก�,-;กX�O9P2b�

(<?!/0-ก0��S0<T I?�53�"C 52 7}, -iQ�B-#ก 48 ก %&ก�#0 KKOS = (+ 4.5) + (- 6) = - 1.5 ..=..1��02I5$"FI/F

-3กA�ก-#i- KKOS "#FI�0��w1Q�-�L%3ก�IM3Fก��2ก �%�1ก���/ก@�C-9�R%�"�/A�ก?���F ,-ก�L5!5$?#iF6?c 80% M~i-97A#�3"/c,-ก&Cc01��02I5$"FI/F 21-79% A#�3"/c,-ก&Cc01��02I5$"F7�-ก&�F 6&�-R3"ก�c� 20% A#�3"/c,-ก&Cc01��02I5$"F?$Q�

Page 20: Osteoporosis guideline2010

17

�?ก0* (probability) Bก0�)ก�����ก����ก����!B�4 KKOS

Page 21: Osteoporosis guideline2010

18

:�=L9.ก 2.2

393<Bก�<89ก��0b�9�1ก��>ก/-3�=ก�,-;กX�O989�P�A.�1N<-C�,[b�>-e?93-18@M?�1O 9Qb�N9�กB4, QUS(15)

<�W+ก0��S0<T 1. &�ก2IR-A�ก6ก-3�"CM~i-97"#F6ก-1�6-- (point) 2. &�ก2IR-A�ก6ก--iQ�B-#ก97"#F6ก-1�6-- (point) 3. &�ก2IR-A�ก6ก- QUS 97"#F6ก-1�6-- (point) 4. -Q�!#iF 3 1�6--0���0ก#- (total points) 5. &�ก2IR-A�ก6ก-1�6--��0 (total points) &F0�"#F6ก-1��02I5$"FM3F%�1ก���/ก@�C- (risk of

osteoporosis) 6. ,-ก�L5!5$1��02I5$"FM3Fก��2ก �%�1ก���/ก@�C-?#iF6?c 0.3 M~i-97A#�27s-ก&Cc0!5$051��02I5$"FI/F,-ก��2ก �

%�1ก���/ก@�C- 1��IcF?��A BMD ?c397

(<?!/0-

e/RB� F3�"C 70 7} -iQ�B-#ก 50 ก %&ก�#0 e&?��A QUS T-score -3 SD

20h$3&�ก2IR-?�0M#i-?3-!5$ 1-3 A�9�R1�6-- 48, 67 6&� 78 ?�0&Q��#� %�"051�6--��02!c�ก#� 193 (M#i-?3-!5$ 4) 6&�20h$3&�ก2IR-A�ก6ก-1�6--��0 193 &F0�"#F6ก-1��02I5$"FM3F%�1ก���/ก@�C- A�9�R2!c�ก#� 0.5 (M#i-?3-!5$ 5)

ก��67&e&: ,-e/RB� F3�"C 70 7} -iQ�B-#ก 50 ก %&ก�#0 e&?��A QUS T-score -3 SD AQ�-�- 100 1- A�05%3ก�I2ก �%�1ก���/ก@�C- 50 1-

Page 22: Osteoporosis guideline2010

19

>?ก���?M�K?/K 1. Greenspan SL, Luckey MM. Evaluation of postmenopausal osteoporosis. In : Favus MJ,

editor. Primer on the metabolic bone diseases and disorders of mineral metabolism, 6th ed. Lippincott Raven Press; New York, NY, USA, 2006, pp.268-72.

2. Riggs BL, Melton LJ. Evidence for two distinct syndromes of involutional osteoporosis. Am J Med 1983;75:899-901.

3. Kanis JA, Black D, Cooper C, et al. on behalf of the IOF and the NOF USA. A new approach to the development of assessment guidelines for osteoporosis. Osteoporosis Int 2002;13:527-36.

4. FRAX-WHO fracture risk assessment tool, http://www.shef.ac.th/FRAX 5. NOF(National Osteoporosis Foundation). Clinician Guide for Prevention and Treatment of

Osteoporosis 2008. 6. Gallagher JC. The pathogenesis of osteoporosis. Bone Miner 1990;9(3):215-27. 7. National Osteoporosis Foundation. Osteoporosis: review of the evidence for prevention,

diagnosis, and treatment and cost-effectiveness analysis. Osteoporosis Int 1998; 8 (Suppl 4):S1-80.

8. World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. No. 843 of Technical Reports Series. Geneva: 1994.

9. Kanis JA, Melton LJ 3rd, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. J Bone Miner Res 1994 ;9:1137-41.

10. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996; 312(7041):1254-9.

11. WHO.1994. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical report series 843. Geneva: WHO

12. Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, et al. A simple tool to identify asian women at increased risk of osteoporosis. Osteoporosis Int 2001;12:699-705.

13. Pongchaiyakul C, Nguyen ND, Pongchaiyakul C, Nguyen TV. Development and validation of a new clinical risk index for prediction of osteoporosis in Thai women. J Med Assoc Thai 2004;87:910-6.

14. Pongchaiyakul C, Panichkul S, Songpatanasilp T. Combined clinical risk indices with quantitative ultrasound calcaneus measurement for identifying osteoporosis in Thai postmenopausal women. J Med Assoc Thai 2007;90(10):2016-23.

15. Pongchaiyakul C, Panichkul S, Songpatanasilp T, Nguyen TV. A nomogram for predicting osteoporosis risk based on age, weight and quantitative ultrasound measurement. Osteoporos Int 2007;18(4):525-31.

16. Gerdhem P, Ivaska KK, Alatalo SL, Halleen JM, Hellman J, Isaksson A, et al. Biochemical Markers of Bone Metabolism and Prediction of Fracture in Elderly Women. J Bone Miner Res 2004;19(3):386-93.

Page 23: Osteoporosis guideline2010

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17. Riis BJ, Hansen MA, Jensen AM, Overgaard K, Christiansen C. Low bone mass and fast rate of bone loss at menopause: equal risk factors for future fracture: a 15 year follow-up study. Bone 1996;19(1):9-12.

18. Riggs B, Melton LJ, O�Fallon WM. Drug therapy for vertebral fractures in osteoporosis: evidence that decreases in bone turnover and increases in bone mass both determine antifracture efficacy. Bone 1996;18:197S-201S.

Page 24: Osteoporosis guideline2010

21

Prevention of osteoporosis and falls ก��7t3Fก#-%�1ก���/ก@�C-1��0B0�"w~Fก��7t3Fก#-90c,BR0�&ก���/ก&�&F,-�C11&!5$"#F90c27s-%�1

ก���/ก@�C- ,-7[AAC�#-ก&"C!KJ,-ก��7t3Fก#-%�1ก���Cก@�C-A�2-R-97,-!�Fก��90c,4R"� (non-pharmacologic strategy) 2@���051��01CR01c�!�F28�GH8�I?�J0�กก�c� ก��7t3Fก#-6�cF33ก9�R27s-I3F4c�F2�&�1h3 ,-�#"2"��JA�27s-ก��I�R�F,BR0�&ก���/ก057� 0�L0�ก!5$IC� 6&�,-�#"!3F2@h$37t3Fก#-ก��&�&FM3F0�&ก���/ก ,-!5$-5i�#"!3FB0�"w~Fe/RB� F�#"B0�7��AQ�2�h3-6&�e/R4�"3�"C0�กก�c� 50 7}

III-1 Strategies to maximize peak bone mass

ก��2I� 0I�R�F0�&ก���/กI/FIC� (peak bone mass) ?#iF6?c"#F2"��J�#" 057��%"4-J0�ก,-ก��I�I0?R-!C-,BRก���/ก6MbF6�F6&�051CL.�@!5$�5 I�0��w!Q�9�R%�"

1. ก��33กกQ�&#Fก�"%�"ก��&F-iQ�B-#ก (weight bearing exercises) 6&�ก��33กกQ�&#Fก�"%�",4R6�F?R�- (resistive exercises)

2. ก���#�7��!�-3�B��!5$0561&2o5"0?�0MR3กQ�B-�,-6?c&��#" 3. ก���#�6IF6��3"c�F@32@5"F 2@h$3,BRe �B-#FI�R�F� ?�0 -�5 4. ก��&�@r? ก��02I5$"F?c3%�1ก���/ก@�C- 9�R6กc

4.1. F�I/��CB�5$ 4.2. F��h$0ก�6�B�h321�h$3F�h$0!5$05Ic�-eI0M3F1�2�35- 4.3. B&5ก2&5$"F3�B��21b0A#�6&�05%7�?5-I/F 4.4. 90c�h$0IC��2ก -M-��

5. 7�#�� w545� ?,BR05ก Aก��0ก��21&h$3-9B�!�Fก�" (physical activities) 6. 1��1C0%�12�hi3�#F!5$27s-7[AA#"2I5$"F?c3%�1ก���/ก@�C- 7. ��0#����#Fก��,4R"�!5$27s-7[AA#"2I5$"F?c3%�1ก���/ก@�C- 8. 1��1C0-iQ�B-#ก?#�,BR@32B0��%�"�#4-50�&ก�"3"/c��B�c�F 20-23 กก./?�0.

III-2 Strategies to prevent bone loss

B&#FA�ก!5$�c�Fก�"I�R�F0�&ก���/กI/FIC�6&R� 3#?��ก��I�R�Fก���/ก (rate of bone formation) A�4R�ก�c�3#?��ก��I&�"ก���/ก (rate of bone resorption) o~$F3#?���#Fก&c��A�2@ $0M~i-2�b�0�ก%�"2|@��3"c�F" $F,-e/RB� F�#"B0�7��AQ�2�h3- ,-4c�F�#Fก&c��2��I�0��w&�3#?��ก��I&�"ก���/ก9�R%�"

1. � K5ก��90c,4R"� (non-pharmacological management) o~$F27s-� K5!5$,4R,- III-1 !#iFB0� 2. � K5ก��,4R"� (pharmacological management) ก��,4R"�A�2&h3ก,4R,-e/R!5$05ก&Cc02I5$"FI/F?c3ก��27s-

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Page 25: Osteoporosis guideline2010

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ก��8NM�?�3<90-B09 (Hormone replacement therapy) 1. ก���#กG��R�"23I%?�2A- (estrogen therapy, ET) B�h3m3�J%0-!�6!- (hormone [replacement]

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2. ก��8~กG�!5$054h$3�c� Women Health Initiative (WHI) study(7) 9�R��"F�-e&ก��,4Rm3�J%0-23I%?�2A-4- �!5$27s- conjugated equine estrogen (CEE) �c�0ก#� medroxy progesterone acetate (MPA) 27s-2�&� 5 7} @��c�I�0��w&�3C�#? ก��LJM3Fก��B#กM3Fก���/กI#-B&#F6&�ก���/กI�%@ก!5$053�ก��!�F1& - ก&F9�R 34% 6&�&�ก��B#กM3Fก���/ก3h$-� 9�R 23%

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4. ก��,4Rm3�J%0-M-��?$Q�27s-2�&�-�-,-e/RB� F!5$053�ก��M��m3�J%0-6&�051��02I5$"F?c3ก��2ก �ก���/ก@�C-,-�#"B0�7��AQ�2�h3- I�0��w!Q�9�R wR�I?�5-#i-9�R�#�1Q�6-�-Q�,BR!���w~F7��%"4-J6&�1��02I5$"FM3Fก��,4Rm3�J%0-3"c�F&�235"�(9)

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III-3 Nutritional aspect in osteoporosis

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B=4>�A1< (Calcium)

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Page 26: Osteoporosis guideline2010

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P���K0A2 3.1 7� 0�L61&2o5"0!5$6-�-Q�,BR�#�7��!�-,-6?c&�ก&Cc03�"C 6-�-Q�%�" National Institutes of Health Consensus Panela ก4OR<?�1O Optimal calcium intake (mg/day) Infant

Birth- 6 months 6 months- 1 year

Children 1-5 years 6-10 years

Adolescents/young adults 11-24 years

Men 25-50 years Over 65 years

Women 25-50 years Over 50 years (postmenopausal)

− On estrogen − Not on estrogen

Over 65 years Pregnant and nursing

400 600 800 800-1200 1200-1500 1000 1500 1000 1000 1500 1500 1200-1500

0A2<� 1#�&3กA�ก a NIH Consensus Development Panel on Optimal Calcium Intake: Optimal Calcium Intake. JAMA 272:1942-1948; 1994.

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Page 27: Osteoporosis guideline2010

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P���K0A2 3.2 7� 0�L61&2o5"0!5$6-�-Q�?c3�#-,-6?c&�ก&Cc03�"C%�"ก��!��FI�K��LICMM3F7��2!89!" @.8. 2545

ก4OR< ?�1O C�/<�`B=4>�A1<0A2B9,9b�89BPR4,.�9 (</44/ก��<)

0-5 >-e?9 210 0��ก 6-11 >-e?9 270

1-3 CU 500 >-pก

4-8 CU 800

.�1�OR9 9-18 CU

1,000

19-50 CU 800 L;M8N�R

<�กก.R� 50 CU 1,000

N�/KP�QK=��:^∗∗∗∗ 800

N�/K8NM9<�OP�∗∗∗∗ 800

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Page 28: Osteoporosis guideline2010

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P���K0A2 3. 3 7� 0�L61&2o5"0,-3�B��7��AQ��#-M3F1-9!" @9/-J?K?�N�� C�/<�`0A2��/3:= B=4>�A1< (<ก.) -0I�,-0"/23I!5,@�I2A39�oJ -0%"2ก �J? กCRF6BRF?#�2&bก กCRF�3" ก�7� 7&�9IR?#- &/ก4 i-7&� 7&�I& � 9Mc27s� 9Mc9กc 9Mc-กก��!� F��Q�1#$� w#$�6�FB&�F,� � 2?R�B/R2B&h3F w#$�2B&h3FICก w#$�2M5"�ICก ,�"3 0�M�0�[กI� e#ก1�-R� w#$�&#-2?� 0�2Mh3@�F I�?3 2eh3ก

200 o5o5 (1 ก&c3F) 150 o5o5 (1 ก&c3F) 1 4R3-%?�� (4?) 1 4? 2 4R3-4� (44) 1/2 wR�"?�F(w?) 10 &/ก 1 ?#� 1 �3F 1 �3F 1 �3F 1 4? 1 4? 1 กR3- 10 4? 10 4? 1 w? 10 �[ก 1 w? 1 w? 1 w? 1 w? 4 4?

240 150 145 167 156 76 52 106 78 63 30 116 97 240 245 125 469 429 230 49 299 76 17

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Page 29: Osteoporosis guideline2010

26

./P�</9-A (Vitamin D) 1. � ?�0 -�527s-m3�J%0-IQ�1#�!5$!Q�B-R�!5$�c�0ก#�m3�J%0-3h$-� ,-ก���#กG����#�M3F61&2o5"06&�

�3I�3�#I ,-�c�Fก�",BR1F!5$ %�"33กr!K z2@ $0ก���/�o~061&2o5"06&��3I�3�#IA�ก&Q�9IR 6&�!Q�F�-�c�0ก#� parathyroid hormone ,-ก��1��1C0,BR���#�M3F61&2o5"06&��3I�3�#I,-ก��6I2&h3�7ก? � ?�0 -�5I�0��wก��?CR-,BR05ก��I&�"61&2o5"033กA�กe �M3Fก���/ก2MR�I/cก��6I2&h3� -3กA�ก-5i� ?�0 -�5"#F05�!��!IQ�1#�,-ก��I�R�Fก���/ก6&�ก��@3ก@/-6�cK�?C,-ก���/ก (bone formation and mineralization)

2. 6B&cF!5$0�M3F� ?�0 -�59�RA�ก!#iF3�B��6&�A�กก��I#F21���BJ!5$e �B-#FA�กก��ก��?CR-�R�"6IF�#FI52B-h30c�F4- ��5 (ultraviolet B, UVB) !�F�R�-3�B��9�R0�A�ก3�B��!5$05� ?�0 -�5 9�R6กc -0 6&�-iQ�0#-?#�7&� 27s-?R- Ic�-!5$9�RA�กe �B-#FA�0�กB�h3-R3"M~i-3"/cก#�ก��9�R�#�6IF�#FI52B-h30c�F4- ��5

3. � ?�0 -�5?�0K��04�? 1h3 ergocalciferol (� ?�0 -�5A�ก@h4) 6&� cholecalciferol (� ?�0 -�5A�กI#?�J) "#F27s-� ?�0 -!5$90c05r!K z A�!Q�,BR05r!K z9�R%�"ก��2@ $0 OH group I3F1�#iF 1�#iF6�ก2? 0 OH !5$?Q�6B-cF 25 ก&�"27s- 25-hydroxyvitamin D (25(OH)D B�h3 calcidiol B�h3 vitamin D2)ก����-ก��-5i2ก �M~i-!5$?#�6&�1�#iF!5$I3F2? 0 OH !5$?Q�6B-cF 1 ก&�"27s- 1,25-dihydroxyvitamin D (1,25(OH)2D B�h3 calcitriol B�h3 vitamin D3) o~$F27s-� ?�0 -�5!5$05r!K z (active form) ก����-ก��-5i2ก �M~i-!5$9?

4. 20h$32MR�I/c�#"4��20?��3& o~$0M3F� ?�0 -�56&�61&2o5"0A�05ก��27&5$"-67&FB&�"3"c�F9�R6กc − ก��I#F21���BJ 7-dehydrocholesterol o~$F27s-I��?#iF?R-M3F� ?�0 -�5 3 !5$e �B-#F,-e/RI/F3�"C&�&F

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?$Q�,-e/RI/F3�"C&�&F �R�"2B?C-5ie/RI/F3�"CA~F051��02I5$"F1c3-MR�FI/F?c3ก��M��� ?�0 -�5 6&�-Q�97I/c.��� secondary hyperparathyroidism 2@ $0ก��I&�"ก���/ก 2ก �.���%�1ก���/ก@�C-,-!5$IC�

5. A�กก��8~กG�,-1-9!".�135I�-(13,14) @��c�Ic�-,B�cM��� ?�0 -�5 6&�?�01Q�6-�-Q�M3FB&�"� B-c�"F�-@��c� ก��>��/<./P�</9-A.�94, 400-800 IU 27s-7� 0�L!5$2@5"F@3?c3ก��7t3Fก#-ก��M��� ?�0 -�5

Page 30: Osteoporosis guideline2010

27

P���K0A2 3.4 6I�F7� 0�L� ?�0 -�5,-3�B�� Food International Units (IU)

per serving Percent DV*

Cod liver oil, 1 Tablespoon 1,360 340 Salmon, cooked, 3 ounces 360 90 Mackerel, cooked, 3 ounces 345 90 Tuna fish, canned in oil, 3 ounces 200 50 Sardines, canned in oil, drained, 1 ounces 250 70 Milk, nonfat, reduced fat, and whole, vitamin D fortified, 1 cup

98 25

Margarine, fortified, 1 Tablespoon 60 15 Pudding, prepared from mix and made with vitamin D fortified milk, cup

50 10

Ready-to-eat cereals fortified with 10% of the DV for vitamin D, 1 cup servings (servings vary according to the brand)

40 10

Egg, 1 whole (vitamin D is found in egg yolk) 20 6 Liver, beef, cooked, 3 ounces 15 4 Cheese, Swiss, 1 ounce 12 4 N<�1>NPO * DV = daily value. DVs are reference numbers developed by the Food and Drug Administration

(FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for vitamin D is 400 IU (10 µg) for adults. Most food labels do not list vitamin D content unless a food has been fortified with this nutrient.

0A2<� 1#�&3กA�ก http://www.usda.gov/cnpp/pyramid2.htm.

./P�</9>= (Vitamin K) 1. � ?�0 -21,-K��04�? 05I3F4- �1h3 � ?�0 -21-1 (phylloquinone) 27s-� ?�0 -!5$0�A�ก@h4 6&�� ?�0 -

21-2 (menaquinone) 27s-� ?�0 -!5$I#F21���BJM~i-,-&Q�9IR,B�cM3FI#?�J 2. e#ก,�2M5"�A�I#F21���BJ phylloquinones %�" phylloquinone 27s-3F1J7��ก3�M3F chloroplasts

,-ML�!5$6�1!52�5" 6&� normal flora M3F&Q�9IR,B�c6&� spore-forming Actinomyces spp. ��F4- �I�0��wI#F21���BJ menaquinones 9�R

3. ,-e#ก,�2M5"�A�@�� ?�0 -21,-7� 0�LI/F ,-ML�!5$,-e&90R6&�K#�@h4A�@�-R3" Ic�-,-2-hi36&�-iQ�-0A�@�� ?�0 -21,-7� 0�L7�-ก&�F

4. 6�1!52�5",-&Q�9IRM3F0-CG"JA�I�R�F menaquinone 9�R 6?cก���/�o~0� ?�0 -21!5$�� 2�L-5iA�27s-6�� passive diffusion 6&�0#กA�90c1c3"9�R7� 0�L!5$0�ก@3

5. 2o&&JI�R�Fก���/ก (osteoblast) I�R�F collagen matrix 6&� osteocalcin o~$F27s- non-collagen matrix %�" osteocalcin ,-4c�F!5$w/กI�R�FM~i-,B0c"#F 27s- osteocalcin !5$ 90c05r!K zB�h32�5"ก27s- undercarboxylated osteocalcin (ucOC) .�"B&#FA�ก ucOC w/ก carboxylated ,BR27s- mature osteocalcin B�h3 carboxylated osteocalcin (Gla protein) o~$FA�2ก �M~i-9�R?R3F3�8#"� ?�0 -21 osteocalcin !5$2ก �,B0c-5iA�27s-I��IQ�1#�!5$A#�61&2o5"02MR�0�,-ก���/ก 2ก �ก��I�I06�cK�?C,-ก���/ก

Page 31: Osteoporosis guideline2010

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9�R �#F-#i-B�ก���#�M3F ucOC 2@ $0M~i- A�I�!R3-w~F���#�M3F� ?�0 -21!5$?$Q�B�h3ก��M��� ?�0 -21 o~$F05e&!Q�,BRก��I�R�Fก���/ก90c�5 %�"�/9�RA�ก1c�0�&ก���/ก!5$?$Q�6&�!Q�,BR2ก �ก���/กB#กFc�" 2��I�0��w,4R���#�M3F ucOC !5$I/F-5i27s-?#�!Q�-�"1��02I5$"F?c3ก���/กI�%@กB#ก,-I?�5I/F3�"C9�R

6. ,-9!"05ก��8~กG�!5$@��c� ���#�M3F ucOC !5$���#� 2.314 ng/mL wh327s-���#�M3Fก��M��� ?�0 -21(15) 6&�@��c�,-I?�5I/F3�"C!5$2MR��c�0ก��8~กG�-5i051��04CกM3Fก��M��� ?�0 -21I/F (B�h3 ucOC > 2.314 ng/mL) w~F 39.1% 6&�e/RI/F3�"C!5$05���#�M3F ucOC I/Fก�c� 2.314 ng/mL A�051c�0�&ก���/กM3F ultradistal radius 6&� distal 1/3 of radius 6&����#�M3F 25(OH)D ?$Q�ก�c�e/RI/F3�"C!5$05���#�M3F ucOC 7ก? 3"c�F05-#"IQ�1#� (p<0.05)

7. ?�01Q�6-�-Q�,BR�� %.13�B��7��AQ��#-IQ�B�#�1-9!"3�"C?#iF6?c 6 7}M~i-97 (Thai RDI) A#�!Q�%�" 1L�3-Cก��0ก��@ A��L�ก��6I�F1CL1c�!�F%.4-�ก���-|&�ก3�B�� @.8. 2538 6-�-Q�,BR�#�7��!�-� ?�0 -21�#-&� 80 µg o~$F051c�?$Q�ก�c�!5$6-�-Q�%�"7��2!8IB�#H320� ก� 1h3 6-�-Q�,BR� ?�0 -217��0�L�#-&� 2 01ก. ?c3-iQ�B-#ก?#� (27s-กก.) B�h37��0�L�#-&� 70-140 01ก.,-e/R,B�c

8. I��3�B��3h$-� 9�R6กc 60ก-52o5"0 !3F6�F I#Fก�I5 60Fก�-5I6&��3I�3�#I 0#ก90c@�ก��M��61&-,-�C11&7ก? "ก2�R-,-e/R!5$27s-%�12ก5$"�ก#�!�F2� -3�B�� 9�R6กc ,-e/R!5$27s-%�1@ GIC��2�hi3�#F 6&�%�1!5$051��0e �7ก? M3F&Q�9IR

P���K0A2 3.5 6I�F7� 0�L� ?�0 -21,-3�B��4- �?c�F� @9/-J?K?�N�� C�/<�`./P�</9>= (mcg/100 g) e#ก1�-R� (Kale) 817 e#ก%M0 (Spinach) 400 e#กI&#� (Endive) 231 Broccoli 205 ก�B&$Q�7&5 (Cabbage) 147 Soybean oil 193 Rapeseed oil 141 w#$�2-c� (Regular natto) 775

III-4 Life style modification and prevention of falls

4.1 ก��C���>C4A219X�P/ก��<0A2>�A21KPR?ก��>CW93�=ก�,-;กX�O9

ก��&�2& ก@r? ก��02I5$"F?c3%�1ก���/ก@�C-?c�F� %�"@"�"�07a �#? ?#��#F?c397-5i − F�I/��CB�5$ − F��h$0ก�6�B�h321�h$3F�h$0!5$05Ic�-eI0M3F1�2�35- − B&5ก2&5$"F3�B��21b0A#�6&�05%7�?5-I/F − 90c�h$0IC��2ก -M-�� − 7�#�� w545� ?,BR05ก Aก��0ก��21&h$3-9B�!�Fก�" (physical activities) − 1��1C0%�12�hi3�#F!5$27s-7[AA#"2I5$"F?c3%�1ก���/ก@�C- − ��0#����#Fก��,4R"�!5$27s-7[AA#"2I5$"F?c3%�1ก���/ก@�C-

Page 32: Osteoporosis guideline2010

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4.2 ก��C�?Kก�9ก��Nก4M<89L;MC�.13�=ก�,-;กX�O9

e/R7u�"%�1ก���/ก@�C-27s-ก&Cc02I5$"F!5$A�2ก �ก���/กB#ก9�RFc�" 2-h$3FA�ก0�&ก���/ก!5$&�&F6&�%1�FI�R�F!5$27&5$"-67&F97M3F2-hi3ก���/ก 3"c�F9�กb?�0ก��B#กM3Fก���/กIc�-,B�c0#กA�0�A�กก��Bก&R0 o~$F3C�#? ก��LJก��Bก&R0A�2@ $0M~i-?�03�"C %�"@��c�,-6?c&�7}B-~$F,-I�0M3Fe/R!5$053�"C0�กก�c� 65 7}6&�1�~$FB-~$FM3Fe/R!5$053�"C0�กก�c� 80 7} A�Bก&R0(16) ก&Cc0e/RI/F3�"C,-Iw�-@"���&053C�#? ก��LJBก&R0I/Fก�c�e/RI/F3�"C,-4C04-7��0�L 3 2!c� -3กA�ก-5ie/R!5$057���#? 21"Bก&R0 0#ก056-�%-R0!5$A�Bก&R0oiQ�0�กw~F 2-3 2!c� 0�กก�c� 40% M3Fe/RI/F3�"C057���#? Bก&R00�กก�c� 1 1�#iF,-6?c&�7}(17) Iw ? 2B&c�-5i"h-"#-w~FM-��7[�B�2�h$3Fก��Bก&R0,-e/RI/F3�"C ก��Bก&R027s-I�2B?C!Q�,BRe/RI/F3�"C?R3F-3-%�F@"���&0�กก�c�I�2B?C3h$-w~F 5 2!c� e/R7u�"?R3FI i-27&h3F1c�,4RAc�"I/F0�กB�ก2ก �MR3I�%@กB#ก�c�0�R�" 20h$32ก �ก���/กB#กM~i-6&R� 7[�B�A�?�00�35ก0�ก !#iF�R�-�c�Fก�" A ?,A 1CL.�@45� ? 6&�I.���!�F28�GHก AM3Fe/R7u�" 05��"F�-�c�1�~$FB-~$FM3Fe/RI/F3�"C!5$-3-%�F@"���&�R�"2�h$3Fก���/กI�%@กB#ก 90cI�0��wAQ�B-c�"ก&#��R�-9�R 6&�90cI�0��w4c�"2B&h3?-23F,-ก A�#?�7��AQ��#-9�R�#F2� 0(18) 35ก!#iF"#F27s-I�2B?C,BRe/RI/F3�"C2I5"45� ?กc3-�#"3#-1�� �#F-#i-ก��7t3Fก#-ก��Bก&R0A~F27s-I $FIQ�1#�!5$?R3Fก��!Q�3"c�F" $F%�"2|@��,-ก&Cc0e/RI/F3�"C!5$05%�1ก���/ก@�C-�c�0�R�"

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Page 33: Osteoporosis guideline2010

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IV-1 Goal of osteoporosis treatment

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ก0� X?-ก(���ก����ก��

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ก&c��6��Fc�"� 1h3 ก���#กG�%�1ก���/ก@�C-1h3ก��,BR"� B�h3 interventions ,�� ,-e/R7u�"!5$27s-%�1ก���/ก@�C-6&R� 2@h$37t3Fก#-90c,BR2ก �ก���/กB#ก-#$-23F

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2@h$3,BRก���/ก6MbF6�F 6&�B#ก"�กM~i- 3. !Q�,BR1CL.�@45� ?M3Fe/R7u�"�5M~i- %�"

ก. 3�ก��7��&�&F M. ก��21&h$3-9B�M3FIc�-?c�F� M3F�c�Fก�"27s-97?�07ก? 1. &�ก��@~$F@�e/R3h$-

3"c�F9�กb?�0�#?wC7��IF1JIQ�1#�!5$IC�,-ก���#กG�%�1ก���/ก@�C- 1h3 ก��&�1��02I5$"F,-ก��2ก �ก���/กB#กA�ก%�1ก���/ก@�C- 6&�>CW9>C��N<�1N4�ก0A21�8-r N�e? interventions 8-r [,ue?.R���<��u��ก\�3�=ก�,-;กX�O9E-M[,PM?KB�-K8NM>Np9=O`�<��P/9AQ >�A1ก.R� �anti-fracture efficacy�

1.3 B9.0�Kก��P�-�/98[8NMก����ก\�3�=ก�,-;กX�O9-M.1ก41O0_^ก��=M9N�L;M0A2<A=.�<>�A21K�;K 3-1 International Osteoporosis Foundation B4, National Osteoporosis Foundation

6-�!�Fo~$F27s-!5$- "0,-7[AAC�#- 054h$32�5"ก�c�ก&"C!KJก��1R-B�e/R!5$051��02I5$"FI/F B�h3 case finding strategy(1) %�"053F1Jก�M3Fe/R245$"�4���R�-%�1ก���/ก@�C- 2 3F1Jก�27s-e/R2I-36-�!�F 1h3

1. International Osteoporosis Foundation 9�R2I-3,BR,4R clinical risk factors (CRFs)(2) o~$F,-7} 1.8. 2007 3F1Jก��3-�0#"%&ก9�R-Q�0�,4RI�R�F21�h$3F0h3IQ�B�#�!Q�-�"1��0-c�A�27s-!5$

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39

A�2ก �ก���/กB#ก,-��"� 10 7} 21�h$3F0h3-5i054h$3�c� FRAX(3) �#Fก&c����"&�235"�9�R6&R�,-B#�MR3 II-2

2. National Osteoporosis Foundation ,-7} 1.8. 2008(4) 9�R7�#�7�CF guideline ,B0c%�"-Q� FRAX tool ,-ก��7��20 -1��02I5$"F6&�?#�I -,A,BRก���#กG��R�""� wR�1��0-c�A�27s-!5$A�2ก �ก���/กB#ก,-��"� 10 7} M3Fก���/กI�%@ก ≥ 3% B�h3 M3Fก���/ก3h$-� ≥ 20% กb,BRก���#กG�9�R6?cกb"#F1Fก��,BRก���#กG�e/R7u�"�R�""�9�R2&"%�"90c?R3F,4R FRAX 7��20 -,-I3Fก�L5

a. e/RB� FB�53e/R4�"!5$053�"C?#iF6?c 50 7}M~i-97!5$05ก���/กB#ก!5$ก���/กI#-B&#FB�h3ก���/กI�%@ก

b. e/RB� FB�53e/R4�"!5$053�"C?#iF6?c 50 7}M~i-97!5$?��A�#�1��0B-�6-c-ก���/ก�R�"21�h$3F DXA !5$ก���/กI#-B&#FB�h3ก���/ก13I�%@ก6&R�@��c� T-score ≤ -2.5 SD

1.4 B9.0�Kก��P�-�/98[8NMก����ก\�3�=ก�,-;กX�O9-M.1ก41O0_^ก��=M9N�L;M0A2<A=.�<>�A21K�;K 3-1<;49/_/3�=ก�,-;กX�O9BNRKC�,>0DE01�

>4?2/-�+D@3(ก (Primary indication)

IQ�B�#�e/RB� F!5$B0�7��AQ�2�h3-6&R� 6&�e/R4�"!5$053�"C > 50 7}M~i-97?R3F,BRก���#กG�%�1ก���/ก@�C- 20h$305MR3�cF45iMR3,�MR3B-~$FB�h3!#iFI3FMR3MR�F&c�F-5i

1. 05ก���/กI#-B&#FB#ก B�h3ก���/กI�%@กB#ก 3#-2-h$3F0�A�ก."#-?��"!5$90c�C-6�F 2. ?��A1��0B-�6-c-M3Fก���/ก�R�"21�h$3F axial DXA !5$ lumbar spine BMD B�h3 femoral

neck BMD B�h3 total hip BMD 6&R�@��c�05 T-score ≤ -2.5

>4?2/-�+D�?- (Secondary indication)

,-ก�L5!5$"#F90c05ก���/กI#-B&#FB�h3ก���/กI�%@กB#ก 6&�ก��?��A1��0B-�6-c-ก���/ก�R�"21�h$3F axial DXA 9�Re&3"/c,-2กL�Jก���/ก��F (T-score < -1.0 6?c >-2.5 !5$ lumbar spine BMD femoral neck BMD B�h3 total hip BMD) ก��,BR"��#กG�%�1ก���/ก@�C- 1��A�,BR20h$3057[AA#"MR�F&c�F-5i�c�0�R�"3"c�F-R3" 1 MR3

1. 05ก���/กB#ก3"c�F-R3"B-~$F6BcF!5$2ก �A�ก."#-?��"!5$90c�C-6�F.�"B&#F3�"C 40 7} ,-?Q�6B-cFB&#ก3h$-� !5$90c,4cก���/กI#-B&#F6&�ก���/กI�%@ก24c- ก���/กMR30h3B#ก (wrist fracture) ก���/ก24 Fก��-B#ก (pelvic fracture) ก���/ก�3�� B#�2Mc�B#ก (distal femur or proximal tibial fracture) ก���/ก?R-6M- (proximal humeral fracture) ก���/กMR32!R� (ankle fracture) x&x

2. 9�R�#�"� glucocorticoid ,-M-��!5$2!5"�2!c� prednisolone �#-&� 7.5 0ก. -�-ก�c� 3 2�h3- 3. 27s-%�1!5$!Q�,BR2ก �.��� secondary osteoporosis 24c- type-1 DM, thyrotoxicosis, rheumatoid

arthritis, SNSA(seronegative spondyloarthropathy) x&x 4. ?��A7��20 -%�",4R FRAXTM M3F US-Asian B�h3 Japan 6��90c,4R BMD 0�1Q�-�L�R�" 9�R10

year probability of hip fracture ≥ 3% B�h3 10 year probability of other major osteoporotic fractures ≥ 20%

5. 05 clinical risk factors(CRFs) 2B&c�-5i?#iF6?c 2 MR3M~i-97 ก. 27s-e/RB� F!5$053�"C ≥ 65 7} B�h3 e/R4�"!5$053�"C ≥ 70 7} M. 05�#4-50�&ก�" < 19 กก./?�0.

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40

1. 057���#? �c� � ��B�h30���� 05ก���/กI�%@กB#กA�ก%�1ก���/ก@�C- F. B0�7��AQ�2�h3-กc3-3�"C 45 7} A. I/��CB�5$A#�27s-7��AQ� |. �h$0IC��27s-3�A L

,-ก�L5!5$ก��?��A�#�1��0B-�6-c-ก���/ก%�"21�h$3F axial DXA 90cI�0��w!Q�9�R E<RB9,9b�8NM0b�8NMก����ก\�3�=ก�,-;กX�O93-18@MJM?<;4PR?EC9AQ

− CRFs 2@5"F3"c�F2�5"� − ก��?��A1��0B-�6-c-ก���/ก�R�"� K53h$-6?c2@5"F3"�F2�5"� (-3ก2B-h3A�ก axial DXA)

!#iF-5i2-h$3FA�ก"#F05MR30/&90c2@5"F@36&�3�AA�057[�B�2�h$3Fก���#กG�!5$0�ก2ก -1��0AQ�27s- 6&�3�AA�2ก �1��090c1CR01c�!�F28�GH8�I?�JI�K��LICM9�R

89ก� A0A2ก��P�.[.�-=.�<N9�B9R9ก�,-;ก3-1>=�e2?K axial DXA E<R��<��u0b�E-MA� F�2-h$3F90cI�0��wIcFe/R7u�"97?��A,-!5$!5$0521�h$3F9�R 6-�-Q�,BR�#กG�%�1ก���/ก@�C-%�"05MR3�cF45i�#F-5i

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e/R4�"!5$053�"C?#iF6?c 70 7}M~i-97�c�0ก#�ก�L5,�ก�L5B-~$F�#F?c397-5i −−−− .�@wc�"�#FI523กoJ @�.���ก���/ก��F%�"ก��� - A|#"A�ก�#FI56@!"J −−−− 1��02I5$"F?c3ก��2ก �ก���/กB#กA�กก��1Q�-�L%�",4R FRAXTM M3F US-Asian B�h3

Japan 6��90c,4R BMD 9�R10 year probability of hip fracture ≥ 3% B�h3 10 year probability of other major osteoporotic fractures ≥ 20%

IV-2 Pharmacological treatment of osteoporosis

ก��2&h3ก,4R"��#กG�%�1ก���/ก@�C-1��1Q�-~Fw~F ก&9กก��33กr!K zM3F"� ก��&�1��02I5$"F?c3ก��2ก �ก���/กB#กA�กMR30/&ก��8~กG�,-0-CG"J (clinical trial) 2!c�-#i- 3�ก��90c@5F7��IF1J!5$3�A2ก �M~i-(potential adverse events) 6&�!5$IQ�1#� 1h3 ,4R"�,BR2B0��I0ก#�e/R7u�"27s-��"� (tailor therapy) 2@���e/R7u�"6?c&�1-3�AA�2B0��I0ก#�"�1-&�?#�กb9�R

27t�B0�"B&#ก,-ก���#กG�%�1ก���/ก@�C- 1h3 ก��C�?Kก�9E<R8NM>ก/-ก�,-;กN�ก 2@���|�-#i-e&ก���#กG�!5$IQ�1#�,-ก��@ A��L�7��I !K .�@ (efficacy) M3F"�A�?R3F27s- anti-fracture efficacy(5) 2I03

Anti-fracture efficacy B0�"w~Fก��8~กG�,-0-CG"JM-��,B�c!5$27s- clinical trial phase-III o~$F6I�F,BR2Bb-3"c�F4#�2A-�c� "�-#i-� ��<��u4-=.�<>�A21KPR?ก��>ก/-ก�,-;กN�ก89Pb�BN9RK0A2�98[E-M ><e2?>0A1�ก�� placebo (relative risk reduction) B�h3wR�,-ก�L5M3F"�ก&Cc0 bisphosphonates I�0��w,4Rก��2!5"� BMD ก#�"� bisphosphonate P�.>-A1.ก�9 6?c1-&� dose �c�I�0��w2@ $0 BMD 9�R2!c�ก#- o~$F dose B-~$F!5$,4R27s-?#�2!5"�-#i- (control) A�?R3F21"6I�F,BR2Bb- anti-fracture efficacy 3"c�F4#�2A-20h$32!5"�ก#� placebo 0�6&R� ก��8~กG�,-ก�L5B&#F-5i2�5"ก�c� bridging study

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41

2.1 1�1��1�QKก���4�1ก�,-;ก (Inhibitors of bone resorption)

Bisphosphonates 1. Bisphosphonates 27s-"�ก&Cc0IQ�1#�!5$33กr!K z,-ก��"#�"#iFก��I&�"ก���/ก!5$6�F!5$IC�,-

!R3F?&��7[AAC�#- 9�R05ก��6�cF bisphosphonates Fc�"� 33ก27s-I3Fก&Cc0"c3" 1h3ก&Cc0M3F simple bisphosphonates 6&� ก&Cc0M3F nitrogen-containing bisphosphonates (5)

2. @��c�"�,-ก&Cc0 nitrogen-containing bisphosphonates A�05 action ,-ก��"#�"#iF osteoclastic bone resorption 9�R6�Fก�c�"�,-35กก&Cc0B-~$F 7[AAC�#-,-7��2!89!",-ML�-5i"�,-ก&Cc0 bisphosphonates !5$9�R�#�ก���#��3F6&R� %�"1L�ก��0ก��3�B��6&�"� ,BR,4R�#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3-053"/c 8 ?Q��#��R�"ก#- 1h3 Alendronate (10 �ก.) 6&� Risedronate (5 �ก.) (�#�7��!�-!Cก�#-) Alendronate Once Weekly (70 �ก.) 6&� Risedronate Once Weekly

(35 �ก.) (�#�7��!�-I#7��BJ&�1�#iF) 6&� Ibandronate Once Monthly (150 �ก.) (�#�7��!�-2�h3-&�1�#iF) 35ก?Q��#�B-~$F1h3 Alendronate plus o~$F27s-I/?�!5$05 Alendronate 70 0ก. ��0ก#� Cholecalciferol 2800 iu ,4R�#�7��!�-I#7��BJ&�1�#iF24c-2�5"�ก#- IQ�B�#�35ก 2 ?Q��#�IC�!R�" o~$F27s-?Q��#�IQ�B�#�"�!5$,BR%�"|5�2MR�2IR-2&h3��Q� 1h3 Ibandronate injection (3 �ก.) (IV infusion 2MR�2IR-2&h3��Q�!CกI�02�h3-) 6&� Zoledronate injection (5�ก.) (IV infusion 2MR�2IR-2&h3��Q�7}&�1�#iF)

)?*� �)' Q3� / @�C? � �)'* � 1. 23I%?�2A- 057��I !K .�@,-ก��&�ก��I/�2I5"2-hi3ก���/ก,-e/RB� F�#"B0�7��AQ�2�h3- e&A�ก

ก��8~กG�AQ�-�-0�ก@��c�23I%?�2A-I�0��w&�1��02I5$"F?c3ก��B#กM3Fก���/กI#-B&#F ก���/กI�%@ก 6&�ก���/กIc�-3h$-� 9�R7��0�L 30-40% (6,7)

2. MR30/&&c�IC�@��c�23I%?�2A-,-M-��?$Q�ก�c�!5$,4Rก#-%�"!#$�97 "#F1F05e&�5?c3ก���/ก,-e/RB� FIc�-0�ก 20h$31Q�-~Fw~F7��I !K .�@ 1��07&3�.#" 6&���1�6&R�23I%?�2A-A#�27s-"�!5$I01��2&h3ก,4R,-e/RB� F�#"B0�7��AQ�2�h3-!5$051��02I5$"FI/F?c3ก���/กB#ก6&�90c05MR3BR�0,-ก��,4R23I%?�2A-%�"2|@��e/RB� F3�"C?$Q�ก�c� 55 7} 6&�,-e/RB� F!5$B0����/กc3-กQ�B-� (premature menopause)

3. IQ�B�#�ก��,4R23I%?�2A-2@h$3�#?wC7��IF1J,-ก��7t3Fก#-ก���/กB#ก2@5"F3"c�F2�5"� ,-e/RB� F3�"C2ก - 60 7} I01��@ A��L�7��%"4-J6&�1��02I5$"F27s-��"� 97 %�"@��c�ก��,BR23I%?�2A-27s-��"�2�&�-�-� ,-e/RB� F!5$053�"C0�ก6&R�3�A2@ $01��02I5$"F?c3ก��2ก � cardiovascular diseases, stroke 6&� invasive breast cancer(8)

4. %7�2AI? -,4R�c�0ก#�23I%?�2A-2|@��,-e/RB� F!5$"#F050�&/ก3"/c2@h$37t3Fก#-2"h$3�C0�&/กB-�e �7ก? 6&�0�2�bF2"h$3�C0�&/ก2!c�-#i-

Selective estrogen receptor modulators (SERMs) 1. SERMs 27s-I��!5$90c,4c steroid o~$FA#�ก#� estrogen receptor %�"A�33กr!K z24c-2�5"�ก#�23I%?

�2A- (agonist) B�h333กr!K z?R�-23I%?�2A- (antagonist) 6?ก?c�Fก#-97,-2-hi32"h$3?c�F� raloxifene 27s- SERM 2@5"F4- �2�5"�,-7[AAC�#-!5$1L�ก��0ก��3�B��6&�"�M3F7��2!89!"�#��3F,BR,4RIQ�B�#��#กG�%�1ก���/ก@�C-,-e/RB� F�#"B0�7��AQ�2�h3-

2. A�กe&ก��8~กG�@��c� raloxifene I�0��w7t3Fก#-ก��I/�2I5"2-hi3ก���/กM3Fe/RB� F�#"B0�7��AQ�2�h3-6&�&�1��02I5$"F?c3ก��B#กM3Fก���/กI#-B&#F&F9�R 30�50% ,-e/RB� F!5$05ก���/ก

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��FB�h3@�C-(9) !#iF!5$21"05B�h390c21"057���#? ก���/กI#-B&#FB#ก0�กc3- A�กก��8~กG�-5i90c@��c� raloxifene &�1��02I5$"FM3Fก���/กB#ก,-Ic�-3h$-� -3กA�กก���/กI#-B&#F

3. Raloxifene 057��%"4-J,-�R�-3h$-9�R6กc &�1��02I5$"F?c3ก��2ก �%�10�2�bF2?R�-04- � invasive &F9�R 60% 6?c90c05e&?c3 cardiovascular diseases 6&� stroke(10,11)

Nasal spray calcitonin 1. Calcitonin 27s-m3�J%0-!5$I�R�FM~i-%�" C-cells M3F?c309!�3"�J 33กr!K z%�"A#�ก#� calcitonin

receptor M3F2o&&J osteoclast !Q�,BRก��I&�"ก���/กw/ก"#�"#iF 2. A�กก��8~กG�(12) o~$F,4R salmon calcitonin 6��@c-A0/ก�#-&� 100, 200, 400 IU 6&�"�B&3ก

@��c�I�0��w&�ก��2ก �ก���/กI#-B&#FB#ก,B0c9�R 36% ,-ก&Cc0!5$9�R�#� calcitonin 200 IU 20h$327�5"�2!5"�ก#�ก&Cc0"�B&3ก (RR = 0.64) 3"c�F9�กb?�0@��c�ก&Cc0 100 IU 6&� 400 IU 057��I !K .�@90c6?ก?c�FA�ก"�B&3ก 6&�90c@��c� calcitonin 6��@c-A0/ก-5iI�0��w&� non-vertebral fracture B�h3 hip fracture 9�R

3. Salmon calcitonin !#iF6��@c-A0/ก 6&�6��|5�2MR�ก&R�0 I�0��w&�3�ก��2Ab�7��3#-2-h$3F0�A�กก���/กI#-B&#FB#ก9�R(13) %�"057��I !K .�@,-ก��&�7��@3� ก#�ก��,4R"�ก&Cc0 NSAIDs

2.2 1�ก�,POM9ก����M�Kก�,-;ก8N<R (Stimulators of bone formation)

Recombinant human parathyroid hormone 1-34 (Teriparatide, TPTD) 1. 05ก��8~กG� 6�� prospective, randomized, double-blind, multinational, placebo-controlled ,-

e/RB� F�#"B0�7��AQ�2�h3- o~$F05ก���/กI#-B&#FB#ก3"/c6&R� AQ�-�- 1,637 1- 2@h$3�/7��I !K .�@M3F TPTD(14) ,-ก��&�1��02I5$"F?c3ก��2ก �ก���/กB#ก,B0c ,-4c�F��"�2�&� 3 7} %�"27�5"�2!5"���B�c�Fก&Cc0!5$�#กG��R�" TPTD �#-&� 20 01ก. (n = 541) ก&Cc0!5$9�R�#� TPTD �#-&� 40 01ก. (n=552) 6&�ก&Cc0!5$9�R�#� placebo (n=544) @��c� TPTD 20 01ก. I�0��w&�1��02I5$"F?c3ก��2ก �ก���/กI#-B&#FB#ก,B0c&F 65% 6&�&�1��02I5$"F?c3ก��2ก � non-vertebral fracture &F9�R 53%

2. 05ก��8~กG�,-&#กGL�M3F meta-analysis(15) 2@h$37��20 -e&M3F"�?c3ก��&�3�ก��7��B&#F ,-e/R7u�"%�1ก���/ก@�C-!5$05ก���/กI#-B&#FB#ก6&R� @��c�"� TPTD 20 01ก. 6&� 40 01ก. I�0��w&�AQ�-�-e/R7u�"!5$3�ก��7��B&#F6&�7��B&#F�C-6�F 9�R0�กก�c�"�,-ก&Cc0"#�"#iFก��I&�"ก���/ก��F?#� 24c- bisphosphonates 6&� hormone therapy

3. ก��!Q� carcinogenicity study ,-B-/ Fischer AQ�-�- 344 ?#� o~$F9�R�#� TPTD 24 2�h3- ,-M-��7��0�L 20 2!c� M3F!5$,4R,-1- 6&�,BR-�-ก�c� 20 2�h3-o~$F2กh3�2!c�ก#�4c�F45� ?M3FB-/ (70-80% M3F4c�F45� ?M3FB-/) @��c�1��02I5$"F?c3ก��2ก � osteosarcoma ,-B-/2@ $0M~i-,-&#กGL� dose dependent (16) 3"c�F9�กb?�090c@��c�2ก � osteosarcoma ,-1-!5$9�R�#� TPTD -�-!5$IC� 25 2�h3-,-ก��8~กG�B&#ก-#i-(14)

4. M-��!5$6-�-Q�1h3 |5� TPTD 2MR�,?Re �B-#F �#-&� 20 01ก. ,-2�&�,�กb9�R 6?c1��27s-2�&�!5$,ก&R215"Fก#-,-6?c&��#- Ic�-,B�c6-�-Q�,BR|5�,-2�&�กc3--3- 6&�90c1��,4R?c32-h$3Fก#--�-2ก -ก�c� 2 7}

2-h$3FA�ก"� TPTD 27s-"�!5$05��1�6@F6&� potential side effects ,-��"�"��"#F90c6-c4#� ก��,BR"�-5iA~FAQ�27s-?R3F05MR3�cF45i@ 28G!5$4#�2A-0�กก�c�ก��,4R"��#กG�%�1ก���/ก@�C-?#�3h$-

Page 46: Osteoporosis guideline2010

43

>4?2/-�+D��)cZ)d�0�ก0�B�4!0 teriparatide Bก0��(กZ0���ก���ก��

8@M89ก� A3�=ก�,-;กX�O9@9/-�O9B�K B4,<A=.�<>�A21K�;K<�กPR?ก��>ก/-ก�,-;กN�ก8N<R>0R�9�Q9 3-1L;MC�.1[,PM?K<A?�1OP�QKBPR 65 CUJVQ9EC B4,[,PM?K<AJM?�RK@AQJM?8-JM?N9V2KJM�K4R�K9AQ

1. BMD T-score %�" axial DXA !5$ก���/กI#-B&#FIc�-!5$2B&h3("#F90cB#ก)!5$?��A9�R(lumbar spine BMD) B�h3!5$ก���/กI�%@ก(femoral neck or total hip BMD) ≤ -2.5 SD �c�0ก#� ก��05ก���/กI#-B&#FB#กA�ก%�1ก���/ก@�C- AQ�-�-?#iF6?c 2 7&R3FM~i-97

2. BMD T-score %�" axial DXA !5$ก���/กI#-B&#FIc�-!5$2B&h3("#F90cB#ก)!5$?��A9�R(lumbar spine BMD) B�h3!5$ก���/กI�%@ก(femoral neck or total hip BMD) ≤ -2.5 SD �c�0ก#� ก��05ก���/กI�%@กB#กA�ก%�1ก���/ก@�C-

3. BMD T-score %�" axial DXA !5$ก���/กI#-B&#FIc�-!5$2B&h3("#F90cB#ก)!5$?��A9�R(lumbar spine BMD) B�h3!5$ก���/กI�%@ก(femoral neck or total hip BMD) ≤ -3.5 SD �c�0ก#� ก��05ก���/กI#-B&#FB#กA�ก%�1ก���/ก@�C-AQ�-�- 1 7&R3F

4. 05B&#กH�-!5$24h$39�R�c�ก���#กG�%�"ก��,4R"� bisphosphonate !5$ec�-0�&R02B&� (inadequate-response) (17) %�"05&#กGL��#F?c397-5i!#iFI3FMR3 • 05 vertebral fracture 2ก �M~i-,B0c 1 ?Q�6B-cFB�h30�กก�c� B�h3 vertebral fracture !5$053"/c05ก��

B#ก"C�2@ $0 B�h305ก���/กI�%@กB#ก2ก �M~i-,B0c !#iF-5iA�?R3F9�R�#�ก���#กG�-#i-0�กก�c� 2 7}6&R� • Lumbar spine BMD &�&F7}&� ≥ 3% B�h3M3FI�%@ก (total hip B�h3 femoral neck BMD)

&�&F7}&� ≥ 5% (%�",4Rก��1Q�-�LA�ก1c� least significant change-LSC)(17,18) .�"B&#F9�Rก���#กG�-#i-0�0�กก�c� 2 7}6&R�

,-MR3 4 -5iA�?R3F7��20 -กc3-2I03�c�e/R7u�"9�R�#�"� bisphosphonate -#i-3"c�Fw/ก?R3F 2@5"F@32B0��I0 6&�I0$Q�2I03 6&R�2!c�-#i- (patient with good compliance and persistence)

-3กA�ก-5iก��,4R teriparatide "#F1��!5$A�?R3F,4R.�",?R2Fh$3-9M@ 28G?�0MR3 IV-4-7.5 �R�"2I03

2.3 1�0A2??ก�0_/�0�QK�?K0�K (mixed action agents)

Vitamin D and vitamin D analogue 1. � ?�0 -�5 B�h3 � ?�0 -�5I#F21���BJA�I�0��w&�3C�#? ก��LJก��2ก �ก���/กB#ก&F9�Rกb?c320h$3

�#�7��!�-�c�0ก#�61&2o5"02!c�-#i- %�"!5$M-��� ?�0 -�5!5$,BR A�?R3F 90c?$Q�ก�c��#-&� 800 IU �c�0ก#� calcium ,-M-��90c?$Q�ก�c��#-&� 1,000 0ก.(19)

2. ก��,BR� ?�0 -�5 B�h3 � ?�0 -�5I#F21���BJ�c�0ก#�61&2o5"005e&,-ก��&�1��02I5$"F?c3ก��2ก � hip fracture 6&� nonvertebral fracture 9�R2&bก-R3" (< 20%) 6?c90c I�0��w&� vertebral fracture 9�R(19)

3. 3"c�F9�กb?�0e/R7u�"!5$A�?R3F9�R�#�ก���#กG��R�""��#กG�%�1ก���/ก@�C-3h$-� AQ�27s-3"c�F" $FA�?R3F9�R�#�61&2o5"06&�� ?�0 -�5,-M-��!5$2@5"F@3�c�097�R�"2I03

Menatetrenone 1. 05B&#กH�-�c� e/R7u�"05 high vitamin K intake 053#?��ก��2ก �ก���/กI�%@กB#ก-R3"ก�c�e/R!5$05 low

vitamin K intake (20,21) 6&�e/R!5$05 low vitamin K intake A�05 BMD !5$?$Q�ก�c�(22) 2. Menaquinone-4 B�h3 menatetrenone I�0��w&�ก��2ก �ก���/กI#-B&#FB#ก9�R7��0�L 50% 6?c

e&?c3ก��&� non-vertebral fracture 90c4#�2A-(23,24)

Page 47: Osteoporosis guideline2010

44

3. e/RB� F23245"�#"B0�7��AQ�2�h3-!5$�#�7��!�-"� menatetrenone M-���#-&� 45 0ก. �c�0ก#�61&2o5"0�#-&� 1,500 0ก. 6&�� ?�0 -�5I�0��w maintain BMD B�h3 2@ $0 BMD M3F Lumbar spine 9�R(25-27) 6&�I�0��w&� 7� 0�L undercarboxylated osteocalcin 9�R3"c�F05-#"IQ�1#�(25-28)

Strontium ranelate 1. ก��8~กG�2@h$3�/7��I !K .�@M3F"� strontium ranelate (SR) ,-ก��&�1��02I5$"F?c3ก��2ก �

ก���/กI#-B&#FB#ก27s-��"�2�&� 3 7} I�0��w&�1��02I5$"F?c3ก��2ก �ก���/กI#-B&#FB#ก,B0c9�R7��0�L 40-50%(29)

2. ก��8~กG�2@h$3�/7��I !K .�@M3F"�-5i,-ก��&�1��02I5$"F?c3 non-vertebral fractures @��c�&�&F16% 6&� @��c�1��02I5$"F?c3 hip fractures &�&F 36% ,-ก&Cc0!5$9�R�#�"� strontium ranelate 20h$32!5"�ก#�"�B&3ก(30)

3. 05ก��8~กG�!5$27s- integrated analysis(31) @��c� strontium ranelate 057��I !K .�@,-ก��&�1��02I5$"Fก���/กI#-B&#FB#ก,B0c9�R ,-ก&Cc0!5$I/F3�"C (>80 7}) 9�R 32% 6&�&� nonvertebral fracture 9�R,-ก&Cc0-5i 31% 35ก!#iF057��I !K .�@,-,-ก��&�1��02I5$"Fก���/กI#-B&#FB#ก,B0c9�R ,-ก&Cc0!5$27s-61c osteopenia 7��0�L 30-50%(32)

ก��,BR"��#กG�%�1ก���/ก@�C-!5$ก&c��97MR�F?R-!#iFB0� 90c�c�A�27s-ก&Cc0"�"#�"#iFก��I&�"ก���/ก B�h3 "�ก��?CR-ก��I�R�Fก���/ก ��0!#iF"�!5$33กr!K zI3F!�F !Cก?#�A�?R3F,BRe/R7u�"9�R�#�61&2o5$"06&�� ?�0 -�5 !5$2@5"F@3�R�"2I03 (?�01Q�6-�-Q�,-MR3 III-3) wR�1 ��c�e/R7u�"90c3�A9�R�#�61&2o5$"06&�� ?�0 -�5 !5$2@5"F@36&R� AQ�27s-?R3F,BR"�2I� 061&2o5$"0 6&�/B�h3 "�� ?�0 -�5 ,-7� 0�L!5$2B0��I0�R�"

IV-3 Alternative therapy and non-pharmacological treatment

3.1 Hip protector

05B&#กH�-2@5"F2&bก-R3"!5$I-#�I-C-�c� ก��,4R hip protector I�0��w&�1��02I5$"F,-ก��2ก � hip fracture 9�R,-Iw�-!5$!5$0 ,4c nursing home %�"7[�B�B&#ก 1h3 compliance ,-ก��,Ic(33-35)

IV-4 Potential adverse events, prerequisites and contraindications in using anti-osteoporotic agents

4.1 L4JM�K>=A1K JM?=.��,.�K B4,JM?NM�<89ก��8@M1���ก\�3�=ก�,-;กX�O9

Q�3)f+!� e&MR�F215"F6&�MR31�����#F!5$IQ�1#�1h3 − 3�ก��M3F����!�F2� -3�B�� !R3F3h� ACก2I5"� !R3Fe/ก 27s-I�2B?C!5$IQ�1#�M3Fก��B"C�"�

(36,37) − 05ก��8~กG�@��c�ก��,BR61&2o5"02@ $03C�#? ก��LJM3F%�1B#�,A6&�B&3�2&h3� (%�1B#�,AM��

2&h3� %�12IR-2&h3�I03F 6&�ก��?�"2|5"�@&#-) 20h$32!5"�ก#�"�B&3ก(38) 3"c�F9�กb?�0,-ก��8~กG�3h$-� 90c@��c� 3C�#? ก��LJ%�1B#�,A6&�B&3�2&h3�2@ $0M~i-(36,37,39)

Page 48: Osteoporosis guideline2010

45

<� 0���+Q3�?�(W=>?-<� 0���+ e&MR�F215"F6&�MR31�����#F!5$IQ�1#�1h3 − @�.������#�61&2o5"0,-2&h3�I/F6&����#�61&2o5"0,-7[II���I/FM~i-9�R 6?c@�9�R90c�c3"-#ก

%�"A�@�,-ก�L5!5$9�R�#�"�,-M-��I/F� 6&�ก��,BR"�,-�/7 active form 24c- calcitriol ก��8~กG�Ic�-0�ก90c@��c�3C�#? ก��LJM3F- $�,-9?2@ $0M~i-(40,41)

g?�=����Q� ()?*� �)' Q3�/@�C? � �)'* �) e&MR�F215"F6&�MR31�����#F!5$IQ�1#�1h3 − 1��02I5$"F?c3ก��2ก �0�2�bF2?R�-02@ $0M~i-2|@��,-ก&Cc0!5$9�R23I%?�2A-�c�0ก#� %7�2AI? -

(42,43) − 2IR-2&h3��Q�3C�?#- 2ก �9�R!#iFB&3�2&h3��Q�!5$M�6&�73� 1��02I5$"F,-ก&Cc0!5$9�R 23I%?�2A-

6&�%7�2AI? - 0�กก�c�ก&Cc0!5$9�R23I%?�2A-2@5"F3"c�F2�5"�(43,44) − @�1��02I5$"F,-ก��2ก �%�1B#�,AM��2&h3�2@ $0M~i-,-ก&Cc0!5$9�R23I%?�2A-6&�%7�2AI? - 6&�

1��02I5$"F-5iA�2@ $0M~i-20h$3e/R7u�"!5$3�"C0�กM~i-(43,45) − 1��02I5$"F,-ก��2ก �%�12IR-2&h3�I03FM��2&h3�2@ $0M~i-!#iF,-ก&Cc0!5$9�R23I%?�2A-2@5"F3"c�F

2�5"�(43) 6&�ก&Cc0!5$9�R23I%?�2A-6&� %7�2AI? -(46) 6&�@�9�R!Cก4c�F3�"C(47) -3กA�ก-5i"#F@��c�!#iFI3Fก&Cc02@ $01��02I5$"F,BRI03FIc�-�- (cognitive function) 6&�1��0I�0��w,-ก��AQ�&�&F (dementia) (48-51)

− 3�ก��3h$-� 24c-3�ก��1#�2?R�-06&�2&h3�33กe �7ก? !�F4c3F1&3�@�0�กM~i- − ก��,BR"�,-ก&Cc023I%?�2A-2@h$3�#กG�%�1ก���/ก@�C--5i e/R7u�"?R3FA�?R3F90c3"/c,-ก&Cc02I5$"F?c3

ก��27s- 0�2�bF2?R�-0 0�2�bF%@�F0�&/ก %�1B&3�2&h3�B#�,A6&�I03F %�12IR-2&h3��Q�3C�?#- !#iF-5iwR�AQ�27s-?R3F,4Rm3�J%0-1��A�?��A mammogram !Cก7}

Bisphosphonates e&MR�F215"F MR31�����#F 6&�MR3BR�0,4R!5$IQ�1#�1h3 − ����!�F2� -3�B�� !5$@�9�R,-"� 24c- alendronate, risedronate 6&� ibandronate o~$F27s-

"�6���#�7��!�- @�9�R-R3",-"� ibandronate 6&� zoledronate 6��|5� Ic�-,B�c053�ก��90c�C-6�FA�กก����1�"21h3FM3F!�F2� -3�B��Ic�-�-24c- non-ulcer dyspepsia .���ก��9B&"R3-ก&#� 1&h$-9IR 3�2A5"- 6&�6I�!R3F(52)

− ����B#�,A6&�B&3�2&h3� 05��"F�-ก��2ก � atrial fibrillation ,-ก&Cc0e/R7u�"!5$9�R"� bisphosphonate 0�กก�c�ก&Cc0!5$9�R"�B&3ก2&bก-R3" 3"c�F9�กb?�0B&#กH�-2B&c�-5i��0!#iFก&9ก!5$!Q�,BR2ก �2B?Cก��LJ"#F90c4#�2A-2@5"F@3 90c051��0AQ�27s-?R3F?��A ECG กc3-ก��,BR"�2B&c�-5i

− ����ก���/ก 05��"F�-ก��2ก �ก���/กM�ก��9ก�?�" (osteonecrosis of the jaws) o~$FIc�-0�ก@�,-1-9MR0�2�bFก��A�"?#�0�!5$ก���/ก!5$9�R�#�"� bisphosphonate 6��|5� 3"c�F9�กb?�005��"F�-ก��2ก �,-1-9MR%�1ก���/ก@�C-!5$9�R�#�"�2@h$3ก���#กG�%�1ก���/ก@�C-24c-ก#-(53) 6?c@�-R3"ก�c�27s-�R3"2!c� !#iF-5i2-h$3FM-��"�!5$,4RIQ�B�#�ก���#กG�%�1ก���/ก@�C--#i-?$Q�ก�c�w~F 10 2!c� 2@���|�-#i- ,-ก�L5,4R2@h$3�#กG�%�1ก���/ก@�C- 90c051��0AQ�27s-?R3F?��A24b1�[-กc3-ก��,BR"�-5i

− 05��"F�-ก��2ก �ก���/กB#ก4- �!5$e �7ก? (atypical fracture) 2ก �M~i-,-ก&Cc0!5$,4R"� bisphosphonate 27s-��"�2�&�-�-� (2|&5$" >5 7}) 05&#กGL�IQ�1#�1h327s- low-energy trauma fracture !5$27s- transverse configuration �� 2�L subtrochanteric B�h3 shaft of

Page 49: Osteoporosis guideline2010

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femur o~$FI�2B?C"#F90c6-c4#�(54,55) 3"c�F9�กb?�03C�#? ก��LJ!5$2ก �M~i-"#F-R3"0�ก20h$32!5"�ก#�AQ�-�-e/R!5$9�R�#�"�ก&Cc0-5i!#$�%&ก A~F1��2�t����#F20h$3,4R"�ก&Cc0-5i27s-��"�2�&�-�-ก�c� 5 7}

− @�7a ก � "�B&#F9�R�#�"� (post-dose reaction) o~$ F@�9�R�c3" %�"2|@��,-"� bisphosphonate 6��|5�(56,57) 6���#�7��!�-2�h3-&�1�#iFกb3�AA�@�9�R2&bก-R3" %�"053�ก��9MR 7��ก&R�02-hi36&�MR3 1&R�"27s-9MRB�#�,B�c 0#กA�@�,-ก��9�R�#�"�1�#iF6�ก 6&�&�&F0�ก,-ก���#�"�1�#iF?c3� 3�ก��2B&c�-5iA�97B�"9�R23F.�",-90c2ก - 2-3 �#-

− IQ�B�#�"�,-ก&Cc0 bisphosphonates -5iwR�27s-6�� oral form A�?R3F052กL�J,-ก���#�7��!�-"�!5$IQ�1#�I�07��ก��1h3 ก. A�?R3F�#�7��!�-,-?3-!5$!R3F�c�F!5$IC� 90c,BR053�B��B�h3"�,�� 3"/c,-ก��2@��3�B��

2&" o~$Fกb1h3?R3F�#�7��!�-,-?3-24R�B&#FA�ก?h$--3- %�"B&#F�#�7��!�-"�6&R� ½ w~F 1 4#$�%0FBR�0ก -3�B��B�h3"�!Cก4- �

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1. B&#F�#�7��!�-"�-5i6&R�!Q�ก Aก��0!Cก3"c�F9�R?�07ก? "ก2�R-BR�0-3-���27s-2�&� ½ w~F 1 4#$�%0F24c-ก#- 2-h$3FA�ก"� bisphosphonates 20h$36?ก?#�33ก6&R�wR�9B&"R3-ก&#�2MR�97,-B&3�3�B�� 3�A!Q�,BR2ก � 2"h$3�CB&3�3�B��3#ก2I�9�R (esophagitis)

−−−− IQ�B�#�"�,-ก&Cc0 bisphosphonates -5iwR�27s-6�� IV infusion 2MR�2IR-2&h3��Q� ?R3F,BR"�2MR�2IR-,-&#กGL� infusion 2!c�-#i- 6&� A�?R3F,BRB0�,-2�&�!5$90c2�b�ก�c� 15 -�!5,-6?c&�1�#iF 35ก!#iF1��,4R,-ก�L5!5$e/R7u�"90c057[�B�%�19? B�h3ก��!Q�F�-M3F9?e �7ก? 3-1 =R� GFR [,PM?K ≥ 30 mL/min (o~$F2��3�AA��#�27s- creatinine clearance กb9�R) !#iF-5i2-h$3FA�ก"�M#�!�F9?2!c�-#i- ,-ก�L5"�6�� infusion -5i 90c051��0AQ�27s-?R3FBR�0�#�7��!�-3�B�� B�h3BR�0-3-���6?c3"c�F,�

Raloxifene e&MR�F215"F6&�MR31�����#F!5$IQ�1#� 1h3 −−−− ก��3C�?#-M3FB&3�2&h3��Q� (venous thromboembolism) %�"1��02I5$"FA�I/F!5$IC�,-4c�F 2

7}6�กB&#F2� $0"�(58,59) A~F90c1��,4R,-e/R!5$051��02I5$"F?c3ก��2ก �.���2IR-2&h3��Q�3C�?#- e&MR�F215"F3h$-9�R6กc ก��05 hot flushes 2@ $0M~i-(59) ก��27s-?�1� �!5$M��c3"� (60)

Strontium e&MR�F215"F6&�MR31�����#F!5$IQ�1#�1h3 −−−− wc�"2B&�6?c90c@��c�27s-I�2B?CM3Fก��B"C�,4R"�(29,30,61) −−−− -3กA�ก-5i"#F05��"F�-�c�2@ $03C�#? ก��LJM3Fก��3C�?#-M3FB&3�2&h3��Q� (venous

thromboembolism)(61) %�"I�2B?C"#F90c!���6-c4#� A~F90c1��,4R,-e/R!5$051��02I5$"F?c3ก��2ก �.���2IR-2&h3��Q�3C�?#-

Teriparatide e&MR�F215"F MR31�����#F 6&�MR3BR�0,4R!5$@�9�R1h3 −−−− ���#�61&2o5"0,-2&h3�6&����#�61&2o5"0,-7[II���I/FM~i-2&bก-R3"B&#F9�R�#�"�6?c90c@��c�05

��"F�-ก��2ก �- $�,-9?2@ $0M~i-(62) −−−− ���#�ก��"/� 1,-2&h3�I/FM~i- 1�����#F,-ก��,4R,-e/R7u�"!5$27s-%�12ก��!J(63,64)

Page 50: Osteoporosis guideline2010

47

−−−− A�กMR30/&ก��8~กG�,-B-/!5$9�R�#�"� teriparatide 27s-2�&�0�กก�c� 20 2�h3-(16,65) @��c�05��"F�-ก��2ก � osteosarcoma 2@ $0M~i- 6?c2-h$3FA�ก27s-ก��,4R,-M-��7��0�L 20 2!c� M3F!5$,4R,-1- 6&�,BR-�-2กh3�2!c�ก#�4c�F45� ?M3FB-/(70-80% M3F4c�F45� ?M3FB-/) "�-5iA~F"#F,4R,-1-9�R�R�"1��0��0#����#F

−−−− MR30/&&c�IC�05��"F�-ก��2ก � osteosarcoma ,-1-B&#Fก��9�R�#� teriparatide 6&R� 2 ��"A�ก!#$�%&ก(66,67) 6?c2-h$3FA�ก7���#? 1��0I#0@#-KJก#�ก��,4R"�-5i90c4#�2A- 90c!����c�e/R7u�"!#iFI3F��"057���#? ก��27s-0�2�bF0�กc3-B�h390c ,-��"!5$I3F057���#? ก��|�"6IF!5$�� 2�L!5$2ก � osteosarcoma 0�กc3-(67) 35ก!#iFก��2ก �2@5"F 2 ��"A�กe/R,4R teriparatide !#$�%&ก7��0�Lก�c� 500,000 ��" o~$F90c0�ก97ก�c�3C�#? ก��LJ!#$�� 97M3Fก��2ก � osteosarcoma ,-e/R053�"C > 60 7} o~$F057��0�L7}&� 1 ?c3 250,000 ��"(66) A~Fwh3�c�"#F1F7&3�.#"6&�9�R7��%"4-J1CR01c�0�กก�c� (3��w7��%"4-J0�กก�c�1��02I5$"F) !5$A�,4R9�R,-ก���#กG�%�1ก���/ก@�C-,-1-(68) 6?c.�",?R2Fh$3-9M!5$@ 28G2|@��2!c�-#i-

−−−− 2Fh$3-9M@ 28G (prerequisite) ,-ก��,4R"� teriparatide ก. BR�090c,BR,4R teriparatide -�-2ก - 2 7} M. 90c1��,4R,-e/R7u�"!5$051��02I5$"F?c3ก��2ก � osteosarcoma 24c-

� 27s-%�1 Paget�s disease � e/R21"9�R�#�ก��|�"6IF�� 2�Lก���/ก � e/R05���#� alkaline phosphatase I/F%�"90c05I�2B?C6-c4#� � ,-2�bก!5$ epiphysis "#F90c7��

1. 90c6-�-Q�,BR,4R,-e/R7u�"057���#? 27s-%�10�2�bF.�",- 5 7} F. 2-h$3FA�ก27s-"�!5$05��1�6@F6&�05e&MR�F215"F!5$1c3-MR�F3#-?��" ก��,BR teriparatide

AQ�27s-?R3F05ก��?��A@ 28G 2@ $02? 0กc3-,BR�R�" 1h3 e& serum creatinine, serum calcium 6&� intact PTH A�?R3F7ก?

Calcitonin e&MR�F215"F!5$@�9�R�c3"1h3 − ก����1�"21h3FM3F2"h$3�CA0/ก 3�ก���R3-�/����(12,69)

Menatetrenone 90c@��c�05e&MR�F215"F!5$IQ�1#� − 3"c�F9�กb?�0?R3F���#Fก��,4R,-1-9MR!5$9�R�#�"� warfarin 2-h$3FA�กA�!Q�,BR warfarin !Q�F�-

&�&F(23,70)

IV-5 Monitoring treatment and duration of treatment

5.1 ก��P/-P�<B4,C�,></9L4ก����ก\�

ก��? �?�0ก���#กG�%�1ก���/ก@�C-2��A�?R3F7��20 - 2 0C003FB&#ก1h3 7��I !K e&M3F"� (effectiveness) 6&� ก��2ก �3�ก��90c@~F7��IF1J (adverse events)

ก0� ��)�� ��*��W�R3>?-!0 6�cF9�R27s-I3FIc�-1h3 1. ก0� ��)��ก0� ?2*?- /?!0 (drug response) 1h3ก��7��20 -�c�"�!5$,BR-#i-9�Re&�5A� Fก#�

e/R7u�"��"-#i-� B�h390c 2-h$3FA�ก27t�B0�"IQ�1#�,-ก���#กG�%�1ก���/ก@�C-1h3 ก��&�1��02I5$"F?c3ก��2ก �ก���/กB#ก o~$F3"c�F9�กb?�0,-7[AAC�#-90c05"�,�!5$I�0��w&�1��02I5$"F&F27s-8/-"J9�R

Page 51: Osteoporosis guideline2010

48

(1h390c2ก �ก���/กB#ก2&") 2@���|�-#i-ก��2ก �ก���/กB#กM~i-,-��B�c�Fก��,BR"�90c3�Aก&c��9�R�c� e/R7u�"90c?3�I-3F?c3"� B�h3 "�90c9�Re& 7[AAC�#-,-ก��?��A7��20 -�c�"�9�Re&B�h390c!Q�9�R 2 � K5%�" 1.1. ก��P�.[.�- BMD 3-1>=�e2?K axial DXA %�"B&#กก��1h3 1c� BMD A�?R3F2@ $0M~i- B�h3

3"c�F-R3"90c&�&F 20h$32!5"�ก#�กc3-,BR"� %�"!5$��"�Bc�F��B�c�Fก��?��A7��20 - 2 1�#iFA�?R3F90c-R3"ก�c� 1 7} 6&�21�h$3F?��A axial DXA -#i-A�?R3F27s-21�h$3F2� 0!5$,4R?��Aกc3-,BRก���#กG� 3"c�F9�กb?�02-h$3FA�กก��?��A BMD �R�"21�h$3F axial DXA A�2ก �1��0e �@&��A�กก���#�9�R�R�F wR� Lumbar spine BMD !5$�#�9�RI3F1�#iF &�&F7}&� ≥ 3% B�h3 total hip BMD B�h3 femoral neck BMD &�&F7}&� ≥ 5% (17,18) .�"B&#F9�Rก���#กG�-#i-� 0�-�-ก�c� 1 7}6&R� wh3�c�05ก��&�&FM3F BMD 2ก �M~i-A� F6&�e/R7u�"3�AA�90c?3�I-3F?c3"�-#i- (probable inadequate response) 2@���|�-#i-wR�ก��&�&FM3F BMD 90c0�ก97ก�c�2กL�J-5i"#Fwh3�c�"�-#i-9�Re&3"/c 3"c�F9�กb?�0wR�2ก �05ก���/กB#ก2ก �M~i-,-��B�c�Fก���#กG��c�0ก#�ก��&�&FM3F BMD !5$0�กก�c�2กL�J�#Fก&c��กbA�wh3�c� e/R7u�"��"-#i-E<RP?��9?KPR?1� (inadequate response) 6&�1��27&5$"-"�

1.2. ก��P�.[C�,></9-M.1 bone turnover markers %�"B&#กก��1h3 wR�27s-"�"#�"#iFก��I&�"ก���/ก,BR?��A bone resorption marker o~$FA�?R3F&�&F 6&�wR�27s-"�ก��?CR-ก��I�R�Fก���/ก,BR?��A bone formation marker o~$FA�?R3F2@ $0M~i- ��"�Bc�F��B�c�Fก��?��A7��20 - 2 1�#iF1h3 กc3-2� $0,BR"�o~$FAQ�27s-?R3F052I03 6&�B&#F,BR"�?R3F90c-R3"ก�c� 3 2�h3- ก��27&5$"-67&FM3F1c� bone turnover markers (BTMs) -5i A�?R3F050�กก�c� 30-40% A~Fwh3�c�05ก��27&5$"-67&F2ก �M~i-A� F 2-h$3FA�กก��?��A�#� BTMs 05 variation !5$0�กก�c� 6&�I���ก-R3"ก�c� 2-h$3FA�ก?R3F NPO e/R7u�" 12 4.0. กc3-2A��2&h3� 6&�,BR2A��2&h3�,-4c�F2�&�24R� (7.00-9.00 -.) %�"!5$?R3F27s-4c�F2�&�2�5"�ก#-!Cก1�#iF

2. ก0� ��)���<0�1�ก 4?-Q3�*�,S0)*�?Bก0�.�4�(2!0 1h3ก��7��20 -e/R7u�"-#i-9�R�#�"�6&��� B��"�9�Rw/ก?R3FB�h390c (compliance) 6&�1��0I0$Q�2I03M3Fก��9�R�#�"� (persistence) o~$F7[�B�-5iIc�-,B�cA�2ก �M~i-ก#�"�4- ��#�7��!�- 2��3�A!Q�9�R%�"ก��B0#$-w�0w~Fก���#77��!�-"��c�w/ก?R3F6&�I0$Q�2I03B�h390c3"/c2I03!Cก1�#iF!5$? �?�0ก���#กG� ก��?��A24b1�/�c�e/R7u�"A#�"�23FB�h305e/RA#�,BR�#�7��!�- ก��,BR-Q�23�ก&c3F���AC"�27&c�ก&#�0�,BR�/ x&x ก��9�R�#�"�!5$wh3�c�,4R9�R1h3?R3F9�R�#�"�3"c�Fw/ก?R3F3"c�F-R3" 80% ,-B-~$F7} (medication possession ratio: MPR ≥ 80%)

5.2 �,1,>.4�ก����ก\�

"#F90c05MR3?ก&F!5$6-c4#�,-2�h$3F��"�2�&�ก��,BR"� !#iF-5iM~i-3"/cก#�7[AA#"B&�"3"c�F24c- 7[AA#"M3F"�6?c&�?#�!5$90c2B0h3-ก#- 7[AA#"!5$2ก5$"�MR3Fก#�e/R7u�" e&ก��� A#"8~กG�,-0-CG"J4- �!5$27s- clinical trial x&x B&#กก��%�"!#$�971h3 ก��,BR"�?c32-h$3F?&3�97A-ก�c�1��02I5$"F?c3ก��2ก �ก���/กB#กM3Fe/R7u�"1--#i-&�&FA--c�@3,A AC�-5iA�กc3,BR2ก �7[�B�B&�"7��ก�� %�"2|@��7[�B�2�h$3F1c�,4RAc�" !#iF-5i2-h$3FA�ก27s-9790c9�R!5$A�&�1��02I5$"F?c3ก���/กB#กM3Fe/R7u�"&F27s-8/-"J 35ก3"c�FB-~$F1h32��90c05MR30/&,-��"�"�� 2-h$3FA�ก clinical study ,-0-CG"J!5$05ก��27�5"�2!5"�ก#�"�B&3กo~$FA�6I�F,BR2��2Bb-w~F anti-fracture efficacy 9�R 0#กA�90cI�0��w052ก - 5 7}9�R (e �A� "K��0ก��� A#",-0-CG"J) 2@���|�-#i-wR�e/R7u�"9�R�#�"�3"c�Fw/ก?R3FI0$Q�2I03 (good compliance and persistence) 90c05 new fracture 2ก �M~i-2&"��B�c�F!5$9�R�#�

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49

"� ก��?��A BMD %�" axial DXA 2@ $0M~i-,-2กL�J!5$-c�@3,A e/R7u�"05ก��?3�I-3F?c3"��5 I�0��wMA#�7[AA#"2I5$"F!5$I�0��w7�#�27&5$"-9�R97 6&�7�#�27&5$"-@r? ก��0,BR05ก��33กกQ�&#Fก�"6&�ก -3�B��!5$2B0��I0 กb��<��uN1O-1�0A2C�,<�` 5 CUE-M 3-1E<RN1O-ก��-;B4L;MC�.1 (drug holiday) %�"6@!"JA�?R3F?�0�/e/R7u�"97?&3� %�"��B�c�F-5iA�?R3F05ก��7��20 -1��02I5$"FM3Fe/R7u�"2I03� 3�AA�05ก��?��A BMD 6&�/B�h3 BTMs !Cก 1-2 7} 6&�20h$39�!5$e/R7u�"051��02I5$"Fก&#�0�35ก I�0��w2� $0,BR"�35ก9�R

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50

P���K0A2 4.1 N4�ก]�9B4,=b�B9,9b�89ก��8@M1���ก\�3�=ก�,-;กX�O9 Pb����1� Benefit and Indication for use JM?=/->Np9 Alendronate 10 mg (ALN)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3-(postmenopausal osteoporosis, PMO) -,4R,-ก���#กG�%�1ก���/ก@�C-!5$2ก �A�ก"�ก&/%113�J? 13"�J (Glucocorticoid-induced osteoporosis, GIO) -,4R,-ก���#กG�%�1ก���/ก@�C-,-e/R4�" (Male idiopathic osteoporosis, MIO)

- I�0��w&�1��02I5$"F?c3ก��B#ก(71-74) M3Fก���/กI#-B&#F (vertebral fracture),ก���/กI�%@ก (hip fracture) 6&� ก���/กIc�-3h$-!5$-3ก2B-h3A�กก���/กI#-B&#F (non-vertebral fracture) -,4R�#�7��!�-�#-&�1�#iF

Alendronate once weekly 70 mg (ALN-OW)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R24c-2�5"�ก#� ALN 10 mg

- 24c-2�5"�ก#� ALN 10 mg(75) -,4R�#�7��!�-I#7��BJ&�1�#iF

Alendronate plus ALN 70 mg + Cholecalciferol 2800 IU (ALN-plus)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R24c-2�5"�ก#� ALN 10 mg

- 24c-2�5"�ก#� ALN 10 mg - ,4R�#�7��!�-I#7��BJ&�1�#iF - 7��ก3��R�" vitamin D3 ,-M-�� 2800 IU ?c3I#7��BJ B�h3 = 400 IU/d 4c�"6กR7[�B�2�h$3F.��� hypovitaminosis D 6&� vitamin D deficiency(76)

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51

Pb����1� Benefit and Indication for use JM?=/->Np9 Risedronate 5 mg (RIS)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) - ,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO) - ,4R,-ก���#กG�%�1ก���/ก@�C-!5$2ก �A�ก"�ก&/%113�J? 13"�J (Glucocorticoid-induced osteoporosis, GIO) -,4R,-ก���#กG�%�1ก���/ก@�C-,-e/R4�" (Male idiopathic osteoporosis, MIO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(77,78)M3Fก���/กI#-B&#F(vertebral fracture),ก���/กI�%@ก (hip fracture) 6&� ก���/กIc�-3h$-!5$-3ก2B-h3 A�กก���/กI#-B&#F(non-vertebral fracture) -,4R�#�7��!�-�#-&�1�#iF

Risedronate once weekly 35 mg (RIS-OW)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R24c-2�5"�ก#� RIS 5 mg

-24c-2�5"�ก#� RIS 5mg(79) -,4R�#�7��!�-I#7��BJ&�1�#iF

Ibandronate Once monthly 150 mg (IBN-OM)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(80,81)

M3Fก���/กI#-B&#F(vertebral fracture), 6&� ก���/กIc�-3h$-!5$-3ก2B-h3A�กก���/กI#-B&#F(82) (non-vertebral fracture) - ,4R�#�7��!�-2�h3-&�1�#iF

Zoledronate infusion every 1 year 5 mg (ZOL)

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO) -,4R,-ก���#กG�%�1ก���/ก@�C-!5$2ก �A�ก"�ก&/%113�J? 13"�J(Glucocorticoid-induced osteoporosis, GIO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(56,57)

M3Fก���/กI#-B&#F(vertebral fracture), ก���/กI�%@ก (hip fracture) 6&� ก���/กIc�-3h$-!5$-3ก2B-h3 A�กก���/กI#-B&#F (non-vertebral fracture) - ,4R,BR!�FB&3�2&h3��Q�!Cก 1 7}

* IQ�B�#� Ibandronate ,4R,-ก��&�1��02I5$"F?c3ก��B#กM3Fก���/กI#-B&#F (vertebral fracture) 27s-B&#กH�-A�ก RCTs 6?c,-ก�L5&�1��02I5$"F?c3ก��B#กM3Fก���/กIc�-3h$-!5$-3ก2B-h3A�กก���/กI#-B&#F(non-vertebral fracture) 27s-B&#กH�-A�กก�� synthesis data A�ก pooled analysis M3F RCTs

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52

Pb����1� Benefit and Indication for use JM?=/->Np9 Estrogen

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(6,7,8) M3Fก���/กI#-B&#F(vertebral fracture), 6&� ก���/กI�%@ก (hip fracture) -,4R�#�7��!�-�#-&�1�#iF (3�AA�05 preparation 3h$- 24c- 6ec-67�e �B-#Fo~$F"#F90c05B&#กH�-!�F efficacy)

Raloxifene (RLX) 60 mg

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(9,83) M3Fก���/กI#-B&#F(vertebral fracture) -,4R�#�7��!�-�#-&�1�#iF

Calcitonin nasal spray 200 IU/puff

7t3Fก#- 6&� �#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(12) M3Fก���/กI#-B&#F(vertebral fracture) -,4R&�3�ก��7��2-h$3FA�กก���/กI#-B&#FB#กA�ก%�1ก���/ก@�C-(13) (90c2ก - 8 I#7��BJ) -@c-!�FA0/ก�#-&�1�#iF

Menatetrenone (MK-4) 15 mg

�#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" Japan FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(23) M3Fก���/กI#-B&#F(vertebral fracture) -,4R�#�7��!�-�#-&� 3 1�#iF (45 mg/d)

** IQ�B�#�23I%?�2A- I�0��w&�1��02I5$"F?c3ก��B#กM3Fก���/กI#-B&#F(vertebral fracture) 6&�&�1��02I5$"F?c3ก��B#กM3Fก���/กIc�-3h$-!5$-3ก2B-h3A�กก���/กI#-B&#F(non-vertebral fracture) 27s-B&#กH�-A�กก��8~กG� WHI o~$F,4R conjugate equine estrogen 90c9�R extend w~Fก��,4R23I%?�2A-,- preparation 3h$-

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53

Pb����1� Benefit and Indication for use JM?=/->Np9

Strontium ranelate 2 g/sachet

�#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" EMEA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

-I�0��w&�1��02I5$"F?c3ก��B#ก(29,30)

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�#กG�%�1ก���/ก@�C- MR3�cF45i,-ก��,4R (%�" US-FDA) -,4R,-ก���#กG�%�1ก���/ก@�C-,-I?�5�#"B0�7��AQ�2�h3- (postmenopausal osteoporosis, PMO)

- ,4R,-ก���#กG�%�1ก���/ก@�C-!5$2ก �A�ก"�ก&/%113�J? 13"�J(Glucocorticoid-induced osteoporosis, GIO)

-,4R,-ก���#กG�%�1ก���/ก@�C-,-e/R4�"(Male idiopathic osteoporosis, MIO)

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Page 57: Osteoporosis guideline2010

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Pb����1� Benefit and Indication for use JM?=/->Np9

� ?�0 -�5 400-800 IU / d

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,4R�c�0ก#�61&2o5"03�AA�4c�"&�ก��I&�"ก���/ก9�R

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-Alphacalcidol (0.5-1 90%1�ก�#0?c3�#-) -Calcitriol (0.25-0.5 90%1�ก�#0?c3�#-)

,4R,-ก���#กG�%�1ก���/ก@�C-!5$2ก �A�ก"�ก&/%113�J? 13"�J (Glucocorticoid-induced osteoporosis, GIO) (86,87) ,-M-��?$Q�IC� ,4R�c�0ก#�61&2o5"06&�"��#กG�%�1ก���/ก@�C-3h$-� ,-ก�L590c05� ?�0 -�5K��0�� B�h3,-ก�L5e/RI/F3�"C0�ก� (3�"C ≥ 65 7}) (88,89)

-20h$3,BR�c�0ก#�61&2o5"04c�"!Q�,BR0�&ก���/ก1F!5$B�h32@ $0M~i-2&bก-R3"(85) -���#Fก��2ก �.��� hypercalcemia 6&� hypercalcicuria(88)

>?ก���?M�K?/K 1. Kanis JA, Seeman E, Johnell O, Rizzoli R, Delmas P. The perspective of the international

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84. Sanders KM, Nowson CA, Kotowicz MA, Briffa K, Devine A, Reid IR. Calcium and bone health: position statement for the Australian and New Zealand Bone and Mineral Society,

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Osteoporosis Australia and the Endocrine Society of Australia. Med J Aust 2009;190:316�20.

85. Richy F, Schacht E, Bruyere O, Ethgen O, Gourlay M, Reginster JY. Vitamin D analogs versus native vitamin D in preventing bone loss and osteoporosis-related fractures: a comparative meta-analysis. Calcif Tissue Int 2005;76(3):176-86.

86. Richy F, Ethgen O, Bruyere O, Reginster JY. Efficacy of alphacalcidol and calcitriol in primary and corticosteroid-induced osteoporosis: a meta-analysis of their effects on bone mineral density and fracture rate. Osteoporos Int 2004;15(4):301-10.

87. de Nijs RN, Jacobs JW, Algra A, Lems WF, Bijlsma JW. Prevention and treatment of glucocorticoid-induced osteoporosis with active vitamin D3 analogues: a review with meta-analysis of randomized controlled trials including organ transplantation studies. Osteoporos Int 2004;15(8):589-602.

88. Avenell A, Gillespie WJ, Gillespie LD, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Syst Rev 2009;15(2):CD000227.

89. Ringe JD, Schacht E. Potential of alfacalcidol for reducing increased risk of falls and fractures. Rheumatol Int 2009;29(10):1177-85.

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Glucocorticoid-induced osteoporosis (GIO)

V-1 Introduction and epidemiology

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Page 68: Osteoporosis guideline2010

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>?ก���?M�K?/K 1. Van Staa TP, Leufkens HGM, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids

and risk of fractures. J Bone Miner Res 2000;15:993-1000. 2. Curtis JR, Westfall AO, Allison JJ, Becker A, Casebeer L, Freeman A, et al. Longitudinal

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5. Adachi JD, Bensen WG, Bianchi F, Cividino A, Pillersdorf S, Sebaldt RJ, et al. Vitamin D and calcium in the prevention of corticosteroid induced osteoporosis: a 3 year follow-up. J Rheumatol 1996;23(6):995-1000.

6. Van Staa TP, Leufkens HG, Cooper C. The epidemiology of corticosteroid-induced osteoporosis: a meta-analysis. Osteoporos Int 2002;13(10):777-87.

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16. Suzuki Y, Ichikawa Y, Saito E, Homma M. Importance of increased urinary calcium excretion in the development of secondary hyperparathyroidism of patients under glucocorticoid therapy. Metabolism 1983;32:151-6.

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27. Nawata H, Soen S, Takayanagi R, Tanaka I, Takaoka K, Fukunaga M, Matsumoto T, et al; The Subcommittee to Study Diagnostic Criteria for Glucocorticoid-Induced Osteoporosis. Guidelines on the management and treatment of glucocorticoid-induced osteoporosis of the Japanese Society for Bone and Mineral Research (2004). J Clin Endocrinol Metab 2005; 23(2): 105-9

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osteoporosis: a consensus document of the Belgian Bone Club. Osteoporos Int 2006; 17(1): 8-19.

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Osteoporosis in men

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1.3. Cg[[�1>�A21K

,-7[AAC�#-ก��7��20 -7[AA#"2I5$"FM3Fก��2ก �%�1ก���/ก@�C-,-e/R4�"?R3F7��20 -A�ก7[AA#"2I5$"F?c3ก��2ก �ก���/กB#ก?c�F� !5$05�c�0�R�" ��0!#iF7[AA#"2I5$"F?c3ก��I/�2I5"0�&ก���/ก 24c-2�5"�ก#�,-%�1ก���/ก@�C-,-e/RB� F�#"B0�7��AQ�2�h3- (7[AA#"2I5$"FIc�-,B�c1&R�"� ก#-) 7[AA#"2I5$"F2B&c�-5i9�R6กc

− Cg[[�1>�A21KPR?ก���;�>�A1<.4ก�,-;ก0A2E<R��<��uBกMEJE-M=e? 3�"C 6&� @#-KCก��0(18,19)

− Cg[[�1>�A21KPR?ก���;�>�A1<.4ก�,-;ก0A2��<��uBกMEJE-M=e? ก��I/��CB�5$(21-24) ก��,4Rก Aก��0!�Fก�"-R3" (physical inactivity) (20,25,26) ก��05�#4-50�&ก�"?$Q�(21,22,25) ก���h$063&ก3m3&J2ก -M-�� (27,28) 05.���@�c3F� ?�0 -�5 (29) 05.���@�c3F61&2o5"0(22,30) ก��9�R�#�7� 0�L%7�?5-?$Q�(31) ก��9�R�#�"�!5$05e&?c3ก��I/�2I5"0�&ก���/ก 9�R6กc "�I2?5"�3"�J "�ก#-4#ก(32) thiazolidinedione(33) "��#กG�.���o~028�R�ก&Cc0 SSRI(34)

VI-2 Assessment and diagnosis

2.1 ก��./9/[q�1

ก��� - A|#"%�1ก���/ก@�C-,-e/R4�"!Q�9�R%�"ก��?��A1��0B-�6-c-M3Fก���/ก (bone mineral density, BMD) %�"!#$�97A�?��A!5$ก���/กI#-B&#FIc�-23� (L-spine) 6&�!5$ก���/กI�%@ก ก��� - A|#"%�1ก���/ก@�C-,-e/R4�"!5$3�"C0�กก�c� 50 7}A�,4R1c�1��0B-�6-c-M3Fก���/กM3Fe/R7u�"2!5"�ก#�1c�2�5$"F2�-0�?�H�-M3F1��0B-�6-c-M3Fก���/กM3Fe/R4�"24hi34�? ,ก&R215"Fก#-!5$053�"C��B�c�F 30-35 7} wR�1c� T-score ≤ -2.5 I�C79�R�c�27s-%�1ก���/ก@�C-(35,36)

ก��� - A|#"%�1ก���/ก@�C-,-e/R4�"!5$3�"C-R3"ก�c� 50 7}1��2!5"�ก#�1c�2�5$"F2�-0�?�H�-M3F1��0B-�6-c-M3Fก���/กM3Fe/R4�"24hi34�? ,ก&R215"Fก#-!5$3"/c,-4c�F3�"C2!c�ก#- (Z-score) 0�กก�c�ก��,4R T-score(36)

2.2 ก��P�.[�R�Kก�1B4,ก��P�.[X/>D\

%�1ก���/ก@�C-,-e/R4�"6?ก?c�FA�ก,-e/RB� F1h37��0�L1�~$FB-~$FM3Fe/R7u�"A�@�I�2B?CM3F%�1ก���/ก@�C- (secondary osteoporosis) B�h3@/�Fc�"� �c�2��I�0��wB�I�2B?CM3Fก��!Q�,BR2ก �%�1ก���/ก@�C-9�R ก��7��20 -e/R7u�"7��ก3��R�"ก��o#ก7���#? ก��?��A�c�Fก�" 6&�ก��?��A!�FBR3F7a �#? ก��

ก0�f(ก ��<( �

9�R6กc ก��o#ก7���#? 2@h$37��20 -7[AA#"2I5$"FM3F%�1ก���/ก@�C- 3�ก��M3F%�1?c�F� !5$3�A27s-I�2B?CM3F secondary osteoporosis 6&�7[AA#"2I5$"F!5$!Q�,BR05ก���/กI�%@กB#ก9�R6กc ก��!�F?#�90c�5 6&�Bก&R0Fc�" 6&�7���#? ก��05ก���/กB#ก,-3�5?

ก0� �<'�/0-ก0!

9�R6กc ก���#�Ic�-I/F ก��4#$F-iQ�B-#ก ก��I#F2ก?!c�2� - 6&�ก��!�F?#�M3Fe/R7u�" ก��?��A%1�Fก���/ก!#$�97��0!#iFก���/กI#-B&#F2@h$3?��AB��c�05ก���/กB#กB�h390c ก��@��c�05Ic�-I/F&�&FA�ก2� 0 05 kyphosis B�h3 kyphoscoliosis �cF45i�c�e/R7u�"05 vertebral fracture -3กA�ก-5i1��?��A�c�05&#กGL� Cushingnoid habitus B�h390c ��0!#iFก��1&Q�?c309!�3"�J 6&�?��A�/�c�05 thyrotoxicosis B�h390c

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ก0� �<'�0-@4?- A�2( �ก0�

���(2�+, 1 ก0� �<'�0-@4?- A�2( �ก0�)2CD?- 4 (1��?��A!Cก��"2@h$3B�I�2B?CM3F%�1ก���/ก@�C-)

1. Complete blood count 2. Serum calcium, phosphorus 3. Serum albumin 4. Serum alkaline phosphatase 5. Serum creatinine 6&� liver transaminases 6. Thyroid stimulating hormone (TSH) 7. Testosterone

���(2�+, 2 ก0� �<')��,�) ��Bก�T+�+,ก0� �<'B���(2�+, 1 !(-.�/��02*0)@ (90cAQ�27s-?R3F?��A!Cก��")

1. Serum protein electrophoresis 2. Parathyroid hormone 3. Serum 25-hydroxy vitamin D 4. 24-hour urine calcium 5. 24-hour urine free cortisol

B��240-�+,�<�.�4�(2ก0�*/- �<'�<0�@0Q/>?-ก����ก

MR3�cF45i,-ก��,-ก��IcF?��A BMD ,-e/R4�"(36) 9�R6กc 1. e/R!5$05 hypogonadism 2. e/R!5$05ก���/กB#ก%�"90c05ก��ก��6!ก!5$�C-6�F 3. e/R!5$057[�B� malabsorption 4. e/R7u�" primary hyperparathyroidism 5. e/R!5$กQ�&#FA�9�R�#� B�h39�R�#�ก���#กG��R�" glucocorticoids ��"�"�� 6. e/R!5$กQ�&#FA�9�R�#�ก���#กG��R�" organ transplantation 7. e/R!5$?��A@��c�05ก���/ก��FA�ก.�@wc�"�#FI5

VI-3 Prevention

3.1 ก��C�?Kก�93�=ก�,-;กX�O989L;M@�1(37-39) − 90c1���h$0IC��27s-7��AQ� 90c1���h$063&ก3m3&J2ก -ก�c��#-&� 3 B-c�"0�?�H�- 1h3 AQ�-�-!5$�h$0

63&ก3m3&J wR�27s-2B&R�0�กก�c� 2 33-oJ, 9�-J 7 33-oJ 6&�2�5"�J 18 33-oJ (40)

− F�I/��CB�5$ − 33กกQ�&#Fก�"3"c�FI0$Q�2I036&�2-R-ก��33กกQ�&#Fก�"4- �&F-iQ�B-#ก 24c- 2� - B�h3 � $F 27s-?R-

,-e/RI/F3�"C1��33กกQ�&#Fก�"4- � balanced exercise 2@h$34c�"2@ $01��06MbF6�FM3Fก&R�02-hi3 ก��!�F?#� 6&�&�ก��Bก&R0

− �� %.161&2o5"0A�ก6B&cF3�B��6&�/B�h361&2o5"02I� 0,BR2@5"F@3 0�กก�c��#-&� 800 0ก. (elemental calcium)

Page 74: Osteoporosis guideline2010

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− 9�R�#�� ?�0 -�52I� 0�#-&� 400-800 IU B�h3 1��w/ก6IF6��3"c�F-R3"�#-&� 10 -�!5 − ,BR1��0�/R6&�1Q�6-�-Q�,-ก��,4R"�!5$IcFe&,BR2ก �ก��&�&FM3F0�&ก���/ก 24c- "�ก#-4#ก ก&/%113�J

? 13"�J "�?R�-ก��6MbF?#�M3F2&h3� m3�J%0-9!�3"�J "�?R�-m3�J%0-2@84�" 27s-?R- − ,BR1��0�/R2ก5$"�ก#�7[AA#"6&�%�1?c�F� !5$IcFe&,BR2ก �ก��I/�2I5"M3F0�&ก���/ก6&�3�A!Q�,BR2ก �

%�1ก���/ก@�C-9�R 2@h$3A�9�R�#�ก��7t3Fก#-!5$w/ก?R3F?c397

VI-4 Treatment and follow-up

4.1 B9.0�Kก����ก\�3�=ก�,-;กX�O989L;M@�1

"�!5$05ก��8~กG��c�I�0��w�#กG�.���ก���/ก@�C-,-4�"1h3 "�Ic�-,B�cI�0��w2&h3ก,4R9�R24c-2�5"�ก#�"�,-?���F!5$ 4.1 (�!!5$ IV) 6?c"�!5$1��2&h3ก,4R27s-3#-�#�6�ก1h3 bisphosphonate 9�R6กc alendronate(41) B�h3 risedronate (42) B�h3 zoledronic acid (43) 2-h$3FA�ก27s-"�!5$9�R�#�ก���#��3F,BR,4R�#กG�%�1ก���/ก@�C-,-e/R4�" %�"!5$e/R7u�"2B&c�-5iA�?R3F9�R�#�61&2o5"0!5$2@5"F@3 -3กA�ก-#i-"#F3�AA�05ก��,BR testosterone replacement therapy ,-2@84�"!5$@��c� 05���#�M3Fm3�J%0-2@84�" (testosterone) ?$Q��R�" ก���#กG�%�""�ก&Cc0-5iI�0��w�#กG�e/R7u�"ก���/ก@�C-,-4�"!5$2ก �A�กก��9�R�#�"�ก&/%113�J? 13"�J, androgen-deprived therapy, osteogenesis imperfecta, post-transplantation, stroke 9�R3"c�F057��I !K .�@35ก�R�"

IQ�B�#�"�ก&Cc03h$-!5$05ก��8~กG�1h3 parathyroid hormone (teriparatide) (44-47) o~$FI�0��w&�ก��2ก �ก���/กB#ก!5$I#-B&#F9�R6?c05MR3AQ�ก#�1h3 ��1�6@F ?R3F27s-�/7|5� 6&�90c1��,4R�c�0ก#� potent antiresorptive drugs(48) A~F1��2&h3ก,4R27s-3#-�#��3F&F0� 6&�1��,4R2|@��,-e/R7u�"!5$051��02I5$"FI/F1h3 21"05ก���/กB#กA�ก%�1ก���/ก@�C-B&�"?Q�6B-cF B�h3B#ก!5$MR3I�%@ก 6&�ก�L590c?3�I-3F?c3"� bisphosphonates !#iF-5i,BR,4RMR3�cF45i24c-2�5"�ก#�,-MR3 IV-2 2.2 (Teriparatide, TPTD)

"�,-ก&Cc0 SERMs, calcitonin, menatetrenone 6&� strontium ranelate "#F05B&#กH�-90c2@5"F@3IQ�B�#�ก��,4R�#กG�%�1ก���/ก@�C-,-e/R4�"

4.2 ก��P/-P�<L4ก����ก\�

6-�!�Fก��? �?�0e&ก���#กG�05�#F-5i(37-39) 1. ? �?�03�ก��6&�3�ก��6I�FM3F%�1ก���/ก@�C-6&�ก���/กB#ก 2. 2�t����#F6&�? �?�0.���6!�กoR3-!5$2ก �M~i-A�กก���#กG� 3. ,-ก�L5!5$e/R7u�"05.���m3�J%0-2@84�"?$Q� 6&�9�R�#�ก���#กG��R�"m3�J%0-!�6!- 9�R6กc

testosterone B�h3 androgen 1��9�R�#�ก��?��A�c�Fก�"6&�?��A!�FBR3F7a �#? ก���#F-5i − ?��A�#�1��0�#-%&B ?!Cก1�#iF!5$0�%�F@"���& − ?��A!�F!���B-#ก2@h$37��20 -1��0e �7ก? M3F?c30&/กB0�ก − ?��A���#�1��02MR0MR-M3F2&h3�6&����#�9M0#- 9�R6กc total cholesterol, triglyceride, HDL-

C and LDL-C !Cก 6-12 2�h3- − ?��A2&h3��#����#� prostate-specific antigen (PSA) !Cก 1 7} (,-e/R!5$053�"C 65 7}M~i-97)

4. MR36-�-Q�,-ก��?��A? �?�0.�"B&#Fก���#กG�05�#F-5i

Page 75: Osteoporosis guideline2010

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− ,-ก�L5!5$ T-score ?$Q�ก�c� -2.5 6&�9�R�#�"�2@h$3ก���#กG� 1��?��A7��20 -1��0B-�6-c-M3Fก���/กI#-B&#FIc�-23�6&�ก���/กI�%@กB&#Fก���#กG�6&R�7��0�L 1-2 7}

− ,-ก�L5!5$ T-score 3"/c��B�c�F -2.5 w~F -1 6&�057[AA#"2I5$"FM3F%�1ก���/ก@�C-B&�"3"c�F1��?��A1��0B-�6-c-M3Fก���/กI#-B&#FIc�-23�6&�ก���/กI�%@กB&#Fก���#กG�6&R�7��0�L 1-2 7}

− ,-ก�L5!5$ T-score 0�กก�c� �1 90cAQ�27s-?R3F?��A1��0B-�6-c-ก���/ก.�",-��"�2�&� 5 7} 2�R-6?c057[AA#"2I5$"F!�F1& - ก2@ $0M~i-

!#iF-5i2-h$3FA�กก��27&5$"-67&FM3F0�&ก���/ก2ก �4R�0�ก 60R�c�1c� coefficient of variation (CV) M3Fก��?��A�#�%�" DXA 051c�?$Q�(49) 6?cก��?��A�#�-#i-?R3Fก��ก��27&5$"-67&F!5$0�กก�c�1��0I�0��wM3F21�h$3F(49) �#F-#i- ก��? �?�0 BMD 90c1��!Q�2�b�ก�c� 1 7}

>?ก���?M�K?/K 1. Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a worldwide projection.

Osteoporos Int 1992;2:285-9. 2. Genant HK, Cooper C, Poor G, Reid I, Ehrlich G, Kanis J, et al. Interim report and

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41. Greenspan SL, Nelson JB, Trump DL, Resnick NM. Effect of once-weekly oral alendronate on bone loss in men receiving androgen deprivation therapy for prostate cancer: a randomized trial. Ann Intern Med 2007;146(6):416-24.

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