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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