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7/17/2019 Osteoporoza Diagnostic Si Tratament
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Osteoporoza – diagnostic si tratament.Exista vreo exagerare?
Cristian Baicus
Medicina Interna Colentinawww.baicus.ro
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Diagnostic
• HTA, diabet, colesterol crescut, osteoporoza
– Aceste boli sunt definite printr-un numar (prag),
nu prin simptome
– Medicii incearca sa o ia inaintea simptomelor – dg
precoce, pentru a preveni efectele
– Supradiagnostic (overdiagnosis)
– Multi dintre pacienti nu vor dezvolta niciodata
simptome si nu vor muri din cauza afectiunii
– Nu exista nici un RCT care sa demonstreze
beneficiile screening-ului pentru osteoporoza
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Diagnostic
• inainte de 1992, osteoporoza se diagnostica in
momentul unei fracturi vertebrale dureroase• Masurarea densitatii osoase
– Scorul T normal (0): BMD medie a unei femei de20-29 ani
– 1992: OMS+Intl Osteoporosis Found. (orgnonprofit, Advisory Board 31 companiimedicamente & echipamente medicale):osteoporoza = BMI<-2,5; osteopenia: -1, -2,5.
– 1997: Testul: rambursat de asigurari
– 2003: National Osteoporosis Foundation: <2
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• National Osteoporosis Foundation:
“Osteoporoza este deseori denumita “boala tacuta”, pentruca pierderea osoasa are loc fara simptome. Oamenii nustiu ca au osteoporoza pana cand oasele lor devin atat deslabe, incat o tensiune, lovitura sau cadere brustedetermina o fractura, sau prabusirea unei vertebre”
National Osteoporosis Foundation. Viewed at http://
www.nof.org/ osteoporosis/ stats.htm.
– 20% dintre femeile >50a (40%, osteopenie)
– 25% >65a
– 50% >75a
Abramson, John . Overdosed America: The Broken Promiseof American Medicine.
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Efectul scaderii pragului diagnostic asupra numarului de americani “bolnavi”
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Kanis 2012, Ghid European, Osteoporosis Int
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fractură de şold
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Kanis 2012, Ghid European, Osteoporosis Int
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Is too much intervention recommnded in the ACP
osteoporosis treatment guidelines?
P Alonso-Coello, L Pencille, V Montori
• Recomandat tratamentul in osteoporoza sau
fracturi
• “osteoporoza afecteaza 44 milioane = 55% din
indivizii >50a”
– Chiar vor sa spuna ca trebuie sa ia medicamente ½ din
populatia SUA? – pacienta de 50 de ani cu osteoporoza: risc <9%/<3%
– De ce nu se foloseste evaluarea riscului (FRAX)/ decizia
impartasita?
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RASPUNS
• FRAX poate fi un instrument util
• Totusi, nu exista RCT care sa arate eficacitatea
tratamentului la pacientii selectati pe baza FRAX• Aproape toate studiile care au demonstrat beneficiu
au inrolat pacienti pe baza BMD (scor T) +/- fracturi
de fragilitate in antecedente
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• Testele de densitate minerala identifica o mica partedin riscul de fractura de şold
• Femei 60-80a:
– 1/6 din risc e identificat de BMD
– La fel de importanţi: fragilitate ( frailty ), slăbiciune
musculară, efectele adverse ale altor medicaţii, scădereavederii, fumatul
DeLaiet 1997, BMJ.
• 2/3 fracturi de şold la >80a
• 90% din fracturile de şold: din căderi.
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http://www.nice.org.uk/nicemedia/live/13857/60400/60400.pdf
POOR
FAIRBMD nu aduce nimic semnificativ pe lângă FRAX
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http://www.nice.org.uk/nicemedia/live/13857/60400/60400.pdf
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http://www.nice.org.uk/nicemedia/live/13857/60400/60400.pdf
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10 30%
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10-30%
http://shareddecisions.mayoclinic.org/files/2012/06/Osteo_DA_elevated.pdf
>30%
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>30%
http://shareddecisions.mayoclinic.org/files/2012/06/Osteo_DA_high.pdf
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TRATAMENT
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Cea mai mică dobândă dar cel mai mare
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RRR
(dobânda)
RAR
(câştigul)
NNT
(câştigul)
Riscul bazal
%
RANELAT DE STRONTIU
(SOTI)
41 % 11,9 % 9
ALENDRONAT (FIT) 47 % 7 % 15RISEDRONAT (VERT-NA) 41 % 5 % 20
IBANDRONAT (BONE) 62 % 4,9 % 21
DENOSUMAB (FREEDOM) 68 % 4,9 % 21
Ringe & Doherty, Rheumatol Int 2010
Cea mai mică dobândă, dar cel mai mare
câştig!?
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NNH = 250 + 250 = 125
NNT: 200 (fr nonvert); 67 (fr vert); 2500 (fr sold) !!!???
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NNT: 200 (fr nonvert); 67 (fr vert); 2500 (fr sold) !!!???
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NNT: 200 (fr nonvert); 67 (fr vert); 2500 (fr sold) !!!???
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• Boala coronariană: pragul de risc de la care se începe tratamentul: 10% / 10 ani, risc de decescardiovascular
Ghidurile societăţilor europene şi americane de
cardiologie
• Osteoporoza: pragul de risc de la care se începe
tratamentul: 3% / 10 ani, risc de fractură de şold Ghidurile de osteoporoză