Guidelines for diagnosis and treatment of primary osteoporosis in China (2011)

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The Chinese Medical Association of osteoporosis and bone mineral diseaseI. overview(1) definition and classificationOsteoporosis (osteoporos


The Chinese Medical Association of osteoporosis and bone mineral disease

I. overview

(1) definition and classification

Osteoporosis (osteoporosis, OP) is a kind of low bone mass and bone microstructure damage, leading to bone fragility and susceptibility to fracture systemic disease characterized (WHO). In 2001 the U.S. National Institutes of Health (NIH) of osteoporosis is characterized by increased risk of fractures in the skeletal system diseases with decreased bone strength, bone strength, reflect the two main aspects of the bone, the bone mineral density and bone quality.

The disease can occur at different gender and age, but more common in postmenopausal women and older men. Osteoporosis can be divided into two categories: primary and secondary. Primary osteoporosis can be divided into 3 types: postmenopausal osteoporosis (type I), senile osteoporosis (type II) and idiopathic osteoporosis (including juvenile type). Postmenopausal osteoporosis usually occurs in 5-10 years after menopause; senile osteoporosis generally refers to the age of 70 after the occurrence of osteoporosis; secondary osteoporosis caused by any means of metabolic bone disease or drug osteoporosis; idiopathic osteoporosis occurs mainly in young. Of unknown etiology.

(two) epidemiology

Osteoporosis is a degenerative disease that increases with age. With the extension of human life and the arrival of aging society, osteoporosis has become an important health problem for human beings. At present, China's population over the age of 60, about 173 million, is the world's largest number of elderly population. A nationwide epidemiological survey conducted in 2003-2006 showed that the prevalence of osteoporosis in women aged 50 years and above, based on the bone mineral density of the femoral neck and the femoral neck, was about 20.7%, and that of the male was about 14.4%. The prevalence of osteoporosis was significantly higher in women over 60 years old, especially in women. According to the survey estimated that in 2006 the national population of people over the age of 50 in about 69 million 440 thousand people suffering from osteoporosis, about 210 million people have low bone mass.

Estimated in the next few decades, Chinese people will significantly increase the rate of hip fracture. The risk of osteoporotic fracture in women (40%) was higher than that of breast cancer, endometrial cancer and ovarian cancer.

The serious consequence of osteoporosis is the occurrence of osteoporotic fractures (brittle fractures), that is, in the event of minor trauma or daily activities can occur in the fracture. The most common sites of osteoporotic fractures are the spine, hip and forearm. Osteoporotic fracture has great harmfulness, lead to increased morbidity and mortality. Such as the occurrence of hip fracture after 1 years, died of complications was 20%, and about 50% survivors of disability, life can not take care of themselves, the quality of life was significantly decreased. Moreover, the treatment and nursing of osteoporosis and fracture need to invest huge manpower and material resources, and the cost is very high, resulting in heavy family, social and economic burden.

It is worth emphasizing that osteoporotic fracture is preventable and treatable. Early prevention of osteoporosis and fractures. Even if there is a fracture, as long as the use of appropriate and reasonable treatment can effectively reduce the risk of re fracture. Therefore, it is very important to popularize the knowledge of osteoporosis, so as to realize the early diagnosis, to predict the risk of fracture and to take the measures of prevention and cure.

Two, clinical manifestation

The most typical clinical manifestations of osteoporosis are pain, spinal deformity and brittle fracture. However, many patients with osteoporosis often do not have obvious symptoms in the early stage, often found in the bone fracture after X-ray or bone density examination found osteoporosis.


Patients can have back pain or whole body bone pain, the increasing of load increasing pain or restricted activity, serious when turning over, sitting up and have difficulty walking.

Spinal deformity

Osteoporosis can have serious height and kyphosis, spinal deformity and stretching limited. Compression fractures of the thoracic spine can lead to deformity of the chest. Fractures of the lumbar spine may alter the anatomy of the abdomen, causing constipation, abdominal pain, bloating, loss of appetite and premature satiety.


A brittle fracture is a fracture of a low energy or non violent fracture, such as a daily activity. The common sites for thoracic and lumbar vertebrae, hip, radial distal ulna and proximal humerus. Other parts of the fracture can also occur. After a brittle fracture, the risk of re fracture was significantly increased.

Three. Risk factors and risk assessment of osteoporosis

(a) risk factors for osteoporosis

1 inherent factors: Race (white and yellow risk of osteoporosis than blacks), aging, menopause, maternal family history.

2 non natural factors: low birth weight, sex hormone, low smoking, excessive drinking, drinking too much coffee, lack of physical activity, dietary protein nutritional imbalance, excessive or insufficient, high sodium diet, calcium and vitamin D deficiency (or) (light or less intake of less), the influence of drugs on bone metabolism disease and application effect of bone metabolism.

(two) risk assessment of osteoporosis

There are many methods to evaluate the risk of osteoporosis in clinic, and two simple and sensitive methods are recommended for screening.

1 International Osteoporosis Foundation (IOM) osteoporosis test for 1 minutes

(1) have you ever hurt your bones because of a slight collision or fall?

(2) have your parents ever had a minor impact or fall?

(3) do you often continuously for more than 3 months of taking cortisone, prednisone and other hormone drugs?

(4) your height is lower than the younger than 75px?

(5) do you often drink a lot?

(6) do you smoke more than 20 cigarettes a day?

(7) do you often have diarrhea? (of digestive disease or enteritis)

(8) the woman replied: do you have a menopause before the age of 45?

(9) the lady replied: have you ever had a period of not more than 12 months? (except during pregnancy)

(10) the man replied: have you had any symptoms of impotence or lack of libido?

As long as one of the answers is "yes", that is positive.

2 Asian osteoporosis self screening tool (Osteoporosis Self Tool for Asian, OSTA) (Assessment)

OSTA index = (body weight) * 0.2

Risk level OSTA index

Low > -1

From -1 to -4

High < -4< span=" " >

(three) risk of osteoporosis

WHO recommends the use of fracture risk prediction tool (FRAX) to calculate the risk of hip fracture and any significant osteoporotic fracture in the next 10 years. Current fracture risk prediction tool FRAX can be obtained from the following website:

Application of 1FRAX

The calculation of the tool includes femoral neck BMD and clinical risk factors. In the absence of femoral neck bone density can be replaced by total hip bone mineral density, however, in this calculation, it is not recommended to use non hip bone mineral density. In the absence of conditions for bone mineral density measurement, FRAX also provides a computational method for the assessment of body mass index (BMI) and clinical risk factors.

The common risk factors for fracture in FRAX?:

Age: fracture risk increases with age


Low bone mineral density

Low body mass index: less than 19kg/m2

Previous history of brittle fracture, especially the history of hip, ulna, radius, and vertebral fractures

The parents of hip fracture

Receive corticosteroid therapy: take 3 months or more for any dose.


excessive drinking

Combined with other causes of secondary osteoporosis

Rheumatoid arthritis

Because of the lack of systematic study of pharmacoeconomics in China, there is no treatment threshold based on FRAX results. The clinical reference to other countries, as mentioned American guidelines in the FRAX tool to calculate the probability of more than 3% hip fracture or any osteoporotic fracture probability of more than 20% important were classified as high-risk patients with osteoporotic fracture.

Problems and limitations in 2FRAX applications

(1) application population

Not suitable for the crowd: the clinical diagnosis of osteoporosis, that is, bone mineral density (T) of less than -2.5, or have a brittle fracture, should start treatment in a timely manner, do not have to use FRAX assessment.

Applicable to the crowd: there has not been a fracture and low bone mass groups (T > 2.5), due to the clinical difficult to make treatment decisions for FRAX tools, can easily calculate the absolute risk of individual fracture, provide the basis for the development of therapeutic strategies. Suitable for the crowd of 40 to 90 years old men and women, < age of and > the age of individuals, respectively, according to the age of 40 and 90 years of age.

(four) falls and their risk factors

1 environmental factors

Dark light

Obstacles on the road

Slippery road

Carpet loose

Toilet handrails

2 health factors


Female sex


Poor eyesight

Emergency incontinence

Past fall history

Orthostatic hypotension

Action barrier

Drugs (sleep medications, anticonvulsants and psychotropic drugs)


Lack of exercise


Mental and cognitive disorders

Anxious and impulsive

Vitamin D deficiency [blood 25 hydroxy vitamin D< 30ng/mL (75nmol/L)]


3 neuromuscular factors

Poor balance

Muscle weakness



4 fear falls

Four, diagnosis and differential diagnosis

The clinical diagnosis of osteoporosis should include two aspects: determining osteoporosis and excluding other diseases that affect bone metabolism.

(a) diagnosis of osteoporosis

The general criteria for the diagnosis of osteoporosis in clinical practice are: brittle fracture and / or low bone density. At present, there is a lack of direct measurement of bone strength. Therefore, the measurement of bone mineral density and bone mineral content is an objective quantitative index for clinical diagnosis and evaluation of the degree of osteoporosis.

1 brittle fracture

Refers to the non traumatic or minor trauma fracture, which is a clear manifestation of the decline in bone strength, but also the final result of osteoporosis and complications. The occurrence of brittle fracture, clinical diagnosis of osteoporosis.

2 diagnostic criteria (based on bone mineral density)

The occurrence of osteoporotic fracture is related to the decrease of bone strength. Bone mineral density was about 70% of bone strength, and low bone density and other risk factors could increase the risk of fracture. Due to the current lack of direct measurement or assessment of bone strength is an ideal method, the clinical use of bone mineral density (BMD) measurement as the best quantitative criteria for the diagnosis of osteoporosis, risk prediction, monitoring and evaluation of therapeutic effect of drug intervention on the natural course of osteoporotic fracture.

Bone mineral density (BMD) is defined as the volume per unit volume (volume density) or area per unit area (area density), and the two are measured by noninvasive technique.

There are many methods to measure bone density and bone. Different methods are used in the diagnosis of osteoporosis, the monitoring of therapeutic effect and the evaluation of fracture risk. Clinical application of dual energy X-ray absorptiometry (DXA), peripheral dual energy X-ray absorptiometry (pDXA) and quantitative computed tomography (QCT). The DXA measurement is the gold standard for osteoporosis diagnosis in the international academic circles.

Diagnostic criteria based on bone mineral density measurement

Recommended reference WHO (WHO) recommended diagnostic criteria. Based on the DXA determination of bone density was lower than the same sex, racial normal adult peak bone less than 1 standard deviation is normal; reduce 1 ~ 2.5 standard deviation for osteopenia (osteopenia); reduce the degree is equal to or greater than 2.5 standard deviations for osteoporosis. Meet the diagnostic criteria of osteoporosis

One or more fractures were severe osteoporosis.

Bone mineral density is usually expressed as T-Score (T), T = (measured value - peak bone) / normal adult bone mineral density standard deviation.


The value of T


> -1


-1 ~ -2.5


< -2.5

T values for bone mineral density in postmenopausal women and men over 50 years of age. For children, premenopausal women and men under the age of 50, the bone mineral density was suggested to be Z.

Z = (measured value - mean bone density of peers) / standard deviation of bone mineral density

Clinical indication of bone mineral density measurement

Bone mineral density measurement in line with any of the following recommendations:

- women over the age of 65 and men over the age of 70, regardless of whether there are other risk factors for osteoporosis;

- women under 65 years of age and men under the age of 70 have one or more risk factors for osteoporosis;

- men and women with a history of brittle fracture and / or a family history of a brittle fracture;

- male and female adults with low levels of sex hormones;

X - ray film has been found to have osteoporosis;

- osteoporosis treatment and monitoring;

- have a history of bone metabolism or the use of drugs affecting bone metabolism;

-IOF one minute test questions to answer positive results;

The results of -OSTA = -1

(two) differential diagnosis and laboratory examination of osteoporosis

1 differential diagnosis of osteoporosis

Osteoporosis can be caused by a variety of causes. In the diagnosis of primary osteoporosis, we must attach importance to the exclusion of other diseases affecting bone metabolism, in order to avoid missed diagnosis and misdiagnosis. To identify the diseases such as endocrine disorders affecting bone metabolism (gonad and adrenal gland, parathyroid and thyroid disease), rheumatoid arthritis and other autoimmune diseases, the effects of calcium and vitamin D absorption and regulation of intestinal and renal disease, multiple myeloma and other diseases, long-term use of corticosteroids or other drugs affecting bone metabolism, as well as a variety of innate and acquired abnormal bone metabolism diseases.

2 basic inspection items

(1) skeletal X-ray: attention to the relationship between any radiographic changes of bone and disease

(2) laboratory examination: blood and urine routine, liver and kidney function, calcium, phosphorus, alkaline phosphatase, serum protein electrophoresis, etc.. Primary osteoporosis patients usually calcium, phosphorus and alkaline phosphatase values in the normal range, when there is a fracture, serum alkaline phosphatase levels increased slightly. If the above examination found abnormal, need to further check or go to the relevant specialist for further differential diagnosis.

3, check item: the need for further diagnosis, may selectively check the following, such as: ESR, gonadal hormone, 25OHD, 1,25 (OH) 2D, parathyroid hormone, calcium and phosphorus, urinary cortisol, thyroid function, blood gas analysis, urine light chain, tumor marker, and radionuclide bone scanning, or bone marrow puncture biopsy.

4 biochemical markers of bone turnover

Biochemical markers of bone turnover (biochemical markers of turnover) is the metabolism of bone tissue itself (decomposition and synthesis), referred to as bone (bone markers). Bone formation markers and bone resorption markers. The former represents the osteogenic activity of osteoblasts and the bone formation of bone formation, which represents the metabolism of osteoclast activity and bone resorption.

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