Post on 18-Feb-2018
transcript
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SPONDILOARTROPATII
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Definitie:
• Grup de boli cu elemente cliniceasemanatoare, ce asociaza alele LA!"#$
%& spondilita anc'ilozanta#& artrite reacti(e
)& spondilartrita*artrite psoriazica+& spondilartrita*artrite enteropatice& spondilartrite -u(enile
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Spondilita an.ilozanta /SA0:
• 1anifestari: %0 spondilita, #0 artrite periferice,)0 manifestari e2traarticulare
– debut #3!)3 ani
– raport "*4 5 )*% – susceptibilitatea la SA este 6enetica, )37
din componenta 6enetica este poziti(itateaLA!"#$
– 8 937 pacienti SA sunt LA!"#$ poziti(i – poziti(itatea LA!"#$ nu coreleaza cu
se(eritatea
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Pato6enie:
• Leziuni inflamatorii
– edem, infiltrat inflamator limfocite/;D+<,
;D=<, macrofa6e, TN4 – leziuni erozi(e, osificare – locul de atasare a li6amentelor pe os
/ent'esis0 – os si madu(a ososa adiacenta – sino(ia articulara
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Pato6enie:
• Teren 6enetic LA!"#$
– Infectii infestinale >
– autoimunitate fata de proteo6licani din
cartila6iu >
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Sacroileita:
•prima leziune – Initial fata ileala a articulatiei, apoi pe cea sacrata
– 6ranulom inflamator subcondral limfocite,
macrofa6e – sino(ita formare de panus fibrocartil6iu de
re6enarare ! obliterare spatiu articular – leziuni erozi(e articulare, osificarea articulatiei
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;oloana (ertebrala:
- ?esut de 6ranula?ie la -onc?iunea dintreinelul fibros al discului cartila6inos @i
mar6inea corpului (ertebral 5e2crescen? osoas 5 BsindesmofitC- Dez(&sindesmofitelor prin osificare
encondral continu unirea corpilor(ertebrali adiacen?i
- n stadiul a(ansat aspectul de Bcoloande bambusC radio6rafic
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• sino(iala 'iperpazie, infiltratie limfoida
/fara: (ili, depozite fibrina, ulceratii, plasmocite0• cartila6iu ! eroziuni centrale prin in(azia
subcondrala a tesutului de 6ranulatie
Articulatii periferice:
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;linic:
• Debut : – adolescenta tinerete, (arsta medie #) ani – 7 debut la 8 +3 ani
– insidios• dureri lombare, sacrate, 6luteale• redoare matinala, amelioarata dupa acti(itatea fizica• durere persistenta, bilaterala, e2acerbari nocturne• ri6idizarea coloanei (ertebrale
• Implicare cer(icala ! tardi(a
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;linic:
• In e(olutie :• artritearticulatii sterno! condrale
! limitare miscarilor respiratorii
artrite periferice – )37 pacienti, in orice stadiu de bola – asimetrice
• entezitespine sacro!iliace, tuberozitati isc'iadice,
tro'anter, etc• semne 6enerale:
astenie, scadere ponderala la (arstnici
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E2amen fizic etape initiale:
• limitarea fle2iei si e2tensiei coloana (ertebrala – Test Sc'ober F + cm /normal ≥ cm0
• limitarea e2pansiunii toracice – normal ≥cm
• artrite periferice – manifestare de obicei tardi(a – )37 cazuri – limitare miscari sacroiliace, sold, umar, etc
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• ster6erea lordozei lombare• cifoza toracala
• indice Bocciput pereteC 8• reducere in inaltime
• 'iperfle2ia compensatorie a 6enunc'ilor
Examen fizic stadii avansate
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1anifestari e2traarticulare:
• (eita anterioara – )37 cazuri, uni sau bilaterala:
• lacrimare, fotofobie, durere oculara
– ;ataracta, 6laucomul f rare• ;olopatie inflamatorie
– H37 cazuri• Insuficienta aortica, bloc A 6rad III,
insuficienta cardiaca• Disfunctie (entilatorie restricti(a• Sindrom de coada de cal
• 4ibroza retroperitoneala
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SA la femei:
• An.iloza lombara e rara• mai frec(ent localizare cer(icala
• frec(ent artrite periferice
• sarcina nu influenteaza e(olutia bolii
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Date laborator:
• LA "#$ poziti( la 937 pacienti
• S 8• Anemie medie• I6A 8• 4R si Atc antinucleari absenti
• Disfunctei (entilatorie restricti(a
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R2 coloana (ertebrala:
• Articulatii sacro!iliace
– initial :• ster6erea mar6inii articulare• eroziuni mar6inale• falsa lar6ire a spatiului articular
– e(olutie:• ster6erea si disparitia spatiului articular
osificarea articulatiilor sacro!iliace
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R2 coloana (ertebrala:
• ;oloana (ertebrala
– initial: rectitudine ster6erea lordozeilombare
– e(olutie :
• sindesmofite, coloana in Btrestie debambusC
• osteoporoza
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;T si R1N coloana (ertebrala:
• Sensibilitate crescuta – initiale : inflamatia intraarticulara sacro!iliaca
• indicatii
– suspiciune clinica SA cu R2 nedia6nostic
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Dia6nostic:
%& ;riterii radiolo6ice: sacroileita 6rd& 85# bilateral, )!+ unilateral#&;riterii clinice
a& durere BspateC,redoare mai mult de ) luniameliorata de efortb& limitarea miscarii in plan frontal si sa6ital a
coloanei lombarec& limitarea e2pansiunii cutiei toracice
Dia6nostic: Semne R2 certe de sacroileita <inca % criteriu clinic
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Dia6nostic:
• LA!"#$ – Nu este dia6nostic – Nu are (aloare pro6nostica – Are (aloare de suspiciune dia6nostica SA
! durerea inflamatorie, fara semneradiolo6ice de sacroileita
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Pro6nostic:
• SA pare sa nu influenteze supra(ietuirea
• Pro6nostic 6ra(
– debut in adolescenta – implicare precoce a soldului – se2ul masculin
• ;omplicatii 6ra(e – 4racturile (ertebrale la traumatisme
minore
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Dia6nostic diferential:
• Spondilartropatiile reacti(e
• iperostoza s'eletala idiopatica difuza – discurile inter(ertebrale ! prezer(ate
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Tratament:
• Terapie anti TN4 – Infli2imab /atc monoclonali anti TN4 0 – Etanercept / receptor solubil TN4 <
I6G0
– Eficienta: ameliorare clinica in toate
etapele de e(olutie
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Tratament:
• AINS – fenilbutazona #33!+33m6*zi • In'ibitori ;OJ#• Sulfasalazina #! )6*zi
• 1etotre2at
• (eita: ! corticoizi local
• ;o2artrita deformanta 'iperal6ica:proteza de sold
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Artrite reacti(e /AR0:Artrite reacti(e /AR0:
• Spondilartropatii de obicei la persoane
LA "#$ poziti(e /H3!=70 dupa infectiienterice sau uro6enitale: – Shigelle ( flexneri), Salmonella, Yersina,
Campylobacter, Chlamidia trahomatis
• Spondilartropatii in infectia I ! lacaucazieni de obicei la persoane LA "#$poziti(e si se accentueaza cu pro6resia bolii
• Spondilartropatii in infectia I ! la Africani, maifrec(ent LA "#$ ne6ati(i, spondilartropatiase amelioreaza cu pro6resia bolii
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Pato6enie AR :Pato6enie AR :
• Infec?ie intracelular a carei e2tinderede la locul infec?iei pare sa fie facilitatade poziti(itatea LA!"#$&
• Rspunsul LT la infec?ie determin
manifestri articulare
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1anifestari clinice AR :1anifestari clinice AR :
• Artrita: – asimetric – saltrea? – articula?iile membrelor inferioare ! de obicei,
– sacroileita de obicei asimetrica, – spondilodiscita de obicei cer(icala – tumefactii articulare, de6et BcKrnatC – apare:
• %!+ saptamani de la infec?ii• noul partener
• Tenosino(ite: – tendon Ac'ile – plantare
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1anifestari clinice AR :1anifestari clinice AR :
• 1anifestari uro6enitale: – retrite, prostatite – Salpin6ite, ane2ite, metrite
• ;ardiace: f rare – IA
• 1anifestari cutanate*mucoase*fanere: – ulceratii: balanita circinta, .eratoderma
blenora6ica pot domina tabloul clinic lainfectatii I
– onicoliza, 'iper.eratoza, un6'ii distal6albena
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R2 oase * articulatii in AR :R2 oase * articulatii in AR :
• Ster6erea spatiului articular
• Eroziuni mar6inale
• Osteoporoza
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Teste de laboraror in AR :Teste de laboraror in AR :
• LA "#$ poziti( la =7 pacienti
• S 8
• Anemie medie
• Lic'id sino(ial – identificarea 6ermenului
• culturi ! Yershina, Chlamidia
• serolo6ie - Yershina, Chlamidia, Salmonella
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Tratament AR :Tratament AR :
• antibioterapie
• AINS – Indometacin $m62 # ori*zi – 4enilbutazona %33m6 2 ) ori*zi
• In'ibitori ;OJ#• Sulfasalazina )6*zi
• Azatioprina !• 1etotre2at $, % m6*saptamana
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Artrita psoriazica /AP0 :Artrita psoriazica /AP0 :
• Epidemiolo6ie
– psoriazis 1-3% la Caucazieni – apare in
absenta infectiei HIV – 1-3% pacienti cu psoriazis au !"
– H#! C$ – asociat cu psoriazis
– H#! &'( – asociere cu spondilita psoriazica – H#! - )*(+ - ),3+ - &( - asociere cu !"
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Artrita psoriazica /AP0 :Artrita psoriazica /AP0 :
• Patolo6ie – sinovia inflamata+ evolutie spre fibroza –
asemanator celorlalte spondiloartropatii
– entezite
• Pato6enie – Inflamatie #./1 cu tri00er necunoscut
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1anifestari clinice in AP :1anifestari clinice in AP :
• Artrita
– H3!$37 cazuri AP dupa manifestarilecutanate de psoriazis
– e(olutie pro6resi(a, remisiuni spontane
– apare asociata cu putine leziunicutanate la cei neinfectati I
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Tipuri de manifestari articulare in AP Tipuri de manifestari articulare in AP
%& artrita articulatii interfalan6iene pro2imale#& poliartrita simetrica
– articulatii interfalan0iene+metacarpofalan0iene proximale – deformarisi telescopri di0itale
– osteoliza falan0iana+ cap metarpiene – leziuni proliferative la locul entezitei
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Tipuri de manifestari articulare in APTipuri de manifestari articulare in AP
)& oli6oartrita asimetrica+& bola a2iala
–spondilartrita - % cazuri
–sacroileita asimetrica
–leziuni cervicale subluxati atlanto-axiale+ osificariparavertebrale
–sindesmofite 2
& artropatia mutilanta
– aniloze+ telescopari osoase
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1anifestari clinice in AP :1anifestari clinice in AP :
• Entezite
• Tenosino(ite
• 1odificari un6'iale – onicoliza, un6'ii 6albene
• (eita anterioara
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Date de laborator in AP :Date de laborator in AP :
• H#!-&'( – -(% cazurile cu poliartrita
– 1-'% cazurile monoartrita
• V4H 5
• "C* 5
• *6
– "ot a7uta diferentierea "* de !" si 4! despondilartrita din !"
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Tratament :Tratament :
• !nti .89 α
– rezultate f bune
• metotrexat• sulfasalazina
• ciclosporina
• acid retinoic• psoralen : ultraviolete
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Spondilartrite -u(enile nediferentiate:Spondilartrite -u(enile nediferentiate:
• 4pondilartrite – debut (-1 ani – -;% baieti
– < sunt H#!-&'(pozitivi =H#!-&'( nu diferen>iaza de 4! ?????@
– Ali0oartrite+ entezite
• asimetrice+ membr inferioare+
– Banifestari extraarticulare - absente
• sinovite 0enunc/i
• dactilite
• tendinite =!c/ile@Absenta criteriilor SA
Tratament:! AINS! f se(ere anti TN4
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Artrite enteropatice:Artrite enteropatice:
• *ectocolita ulcero/emora0ica+ & C/ron
– !rtrita apare - (% H#!-&'( pozitiv
– Bediate imun prin mecanism necunoscut
– &oala intestinala poate apare dupa artrita
– Eroziuni osoase si defeormari articulare – absente de obicei
– .ipul I
• "utine articulatii
• !tacuri autolimitate
• *ecadere artritica cu recaderea bolii intestinale
– .ipul II• Bai multe articulatii+ simetric
• Evolutie cronica+ independenta de boala intestinala
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Artrite enteropatice:Artrite enteropatice:
• Manifestari extra articulare, extardigestive• eritem nodos• Bcubism di6italC• pioderma 6an6renosum• u(eite
Tratament :! infli2imab in artropatiile se(ere
Tratament :! infli2imab in artropatiile se(ere
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Osteoartrite de6enerati(e /artroze0Osteoartrite de6enerati(e /artroze0
Afectiune de6enerati(a articulara fara
manifestari sistemice
;ea mai frec(enta afectiune articulara
937 populatie leziuni radiolo6ice la +3 de ani
;ea mai frec(enta afectiune articulara
937 populatie leziuni radiolo6ice la +3 de ani
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Tablou clinic:Tablou clinic:
Debut insidios• Redoare articulara• Durere la mobilizare articulara cu caracter mecanic
Deformare articulara minima:an.iloza absenta
limitarea mobilitatii articulare
Deformare articulara minima:an.iloza absenta
limitarea mobilitatii articulare
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Boala artrozică –dg. diferential
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Tablou clinic:Tablou clinic:
Manifestari articulare
• ;repitatii la palparea articulatiei• idartroza minima• Inflamatie articulara discreta• 1anifestari sistemice absente
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4orme artrite:4orme artrite:
Articulatii interesate in forma primara :I4D,I4P, 14,;1;/de6et I01etatarsofalan6iana 'alucesold,6enunc'icoloana cer(icala si lombara
Articulatii interesate in forma secundara:orice articulatie
Articulatii interesate in forma secundara:orice articulatie
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Dia6nostic:Dia6nostic:
Biologic Absenta sindromului inflamator
Rd6&
•pensarea spatiului articular
•deformarea osului mar6inal,osteofite
•In6rosarea si densificarea osului subcondral
•;'isturi osoase
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Dia6nostic diferential:Dia6nostic diferential:
• Artrite•
Osteoporoza• 1etastaze osoase• 1ielom multiplu• Tumori osoase
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Tratament:Tratament:
A&1asuri 6enerale
"&1edicatie antial6ica si antiinflamatorie
Tratamentul c'irur6ical
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1asuri 6enerale:1asuri 6enerale:
• Mers pe os• Masuri dietetice
Tratament medicamentos:
! AINS!stimularea sintezei,pre(enirea de6radarii
cartila-ului
Tratament medicamentos:
! AINS!stimularea sintezei,pre(enirea de6radarii
cartila-ului
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Tratament c'irur6ical:Tratament c'irur6ical:
• !rote"a de sold, genunchi
• !rote"are artroscopica
• #ransplant autolog de condrocite
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OSTEOPOROMA
D fi itiD fi iti
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DefinitieDefinitie
• Reducerea masei sau densitatii osoasepe unitatea de (olum – deteriorare in structura s.eleton – risc crescut de fractura
• O1S
– densitate osoasa F #, de(iatia standard a(alorii medii pentru adultul de aceeasi rasa sise2
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Epidemiolo6ie
• ;ea mai comuna boala metabolica• ;auza frec(enta de morbiditate la (arstnici
• SA
– = mil femei, # mil barbati cu T scor F#, – %= mil persoane cu T scar F% risc crescut de
osteoporoza• mai frec(ent la femei in post menopauza• la persoane cu alti factori risc ptr osteoporoza
E id i l i
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Epidemiolo6ie
– 4racturi %, mil*an• radius la F 3 ani, platou pana la H3 ani, apoi
moderata crestere• )33333*an ! fracturi de sold 8 $3 ani rata de
mortalitate !#3 7! risc TEP #3!37 post operator • $33 333*an fracturi (ertebrale
– scadere in inaltime
– cifoza – disfunctie respiratorie – morbiditate 8
St t i t b li
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Structura si metabolism osos
• Sc'eletul
– Element de sustinere
– Rezer(or : ;a, 16, P', Na participa la'omeostazia acestor ioni
– %37 din debitul cardiac
– Remodelare continua• Osteoblaste sinteza os• Osteoclaste resorbtie osoasa
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• Sc'eletul
– matrice minerala • idro2iapatita 5 ;a, P'
– matrice or6anica ! 937 cola6en tip I / substitutiaunui sin6ur aminoacid osteo6eneza imperfecta0
! albumina ! proteine BlocaleC ! trombospondina,
! osteopontina,
! fibronectina! proteo6licani
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• Osteoblaste – sinteza matrice or6anica – contribuie la mineralizare fosfataza alcalina:
'idrolizeaza in'ibitori ai mineralizarii
• Osteocite – Senzori mecanici
• Osteoclaste – Atasate de componente ale matricei
/osteopontina0• Secreta proteaze: cat'epsina• Secreta acizi resorbtia mineralelor
D lt t bl t l i t l t l
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Dez(oltarea osteoblastelor si osteoclastelor
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• PT si (itamina D – cresc numarul si acti(itatea
osteoblastelor
• Estro6enii – descresc numarul si acti(itatea
osteoclastelor
• ;alcitonina – in'iba acti(itatea osteoclastelor
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*emodelarea osoasa
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Remodelarea osoasa
%& Reparatie microtraumatisme#& 4urnizeaza ;a pentru mentinerea concentratie
serice de ;a
%& Sistemici: estro6eni, andro6eni, (it D, PT#& Locali: IG4!I si II, TG4β, PTHrP, TNFα,
citokine pentru comunicarea osteolast ! osteoclast
• "#N$ sau osteoprotegrina
4actori re6latori ai remodelarii osoase
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omeostazia calciului
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Absorbtia calciu
• 7 pasi(• #3 $3 7 acti(, control %,#/O0#D
– Duoden, Intestinul pro2imal mai ales
• Absorbtie redusa – 'ipoaciditate/ca carbonic se absoarbe fputin0
– Insuficienta pancreatica, biliare nu desprind;a de pe suportul ac 6rasi
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E(olutia masei osoase
• Dez(oltarea osoasa – crestere in lun6ime – inc'iderea epifizelor
– consolidare osoasa cu dobandirea pea.!ului de masaosoasa si descrestrea porozitatii corticalei /)3!)ani0• rata de formare*resorbtie apro2imati( e6ala• BlocuriC de rezorbtie*formare distribuite probabil
randomizat• resorbtie osoasa in corticala
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• Rata de formare F rata de resorbtie• Descresterea masei osoase• +3!3 ani ! piedere de masa osoasa 3,#!3,)7 * an
– femei postmenopauza• pierderea corticala adau6ata la pierderea de (arsta
– rata de pierdere de masa osoasa
• #3!)37 barbati• +3!97 femei
E(olutia masei osoase
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Patolo6ia osteoporozei
• resorbtie osoasa crescuta *formare osoasa ce nu compenseaza resorbtia
• acti(itate osteoclastica crescuta * acti(itateosteoblastica insuficienta
• 4enomen fiziolo6ic, permanent, ine6al – 1ai e(ident pe os trabecular /(ertebre, radius, colul femural0 – Oase spon6ioase, corticala osoasa, supraf canalului medular
• lar6irea ca(itatii medulare
• subtierea corte2ului• Diametru osos normal
istolo6ie
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istolo6ie
– Descresterea 6rosimii corticalei, – Descresterea numar si marimea trabeculelor
• trabecule perforate apoi fracturate
•
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Deficienta estro6enica
• Post menopauza• Amenoree primara, secundara
• Receptori estro6enici ERs si β
osteolaste, precorsori osteoclaste
osteoclaste, osteocite,
macrofage, monocite,, mastocite
Deficienta estro6enica
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Deficienta estro6enica
• Osteoclastele! acti(ate
! lon6e(itate crescuta
• Osteoclastele! acti(ate
! lon6e(itate crescuta
• Osteoblastele! apoptoza crescuta
• Osteoblastele! apoptoza crescuta
• Remodelare in corticala ososa si zona trabeculara
• 4racturi (ertebrale
recrutare osteoclaste
TN4 IL!%
IL!H in osteoblaste
Aport ;a scazut F +33m6*zi
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• corectie
'ipo calcemie
p 6/aport normal %333! %#33m6*zi0
• PT 8
• 'ipo calcemie
• idro2ilarea it Din rinic'i
%,#/O0#D
• idro2ilarea it D in rinic'i
%,#/O0#D
• Absorbtie6astrointestinala
de ;a crescuta
• Absorbtie6astrointestinala
de ;a crescuta
• osteoclaste
acti(ate
cronic
acut
osteoporoza
Di t 'i t i
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• Efect citoto2ic pe pro6enitori medulari
Acoolismul
Deficienta de (it D
• iperparatiroidism secundar
• 1odifica metabolismul estro6enic
• Descreste e2ercitiul fizic
• Acidoza stimul osteoclastic
Diete 'iperproteica
Ati(itatea fizica
• Inacti(itaea fizica din copilarie, pubertate
• Stimul pentru mecanoreceptorii osteoblastici
Osteoporoza din boli cronice
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• Stari 'ipo6onadale• ;us'in6• iperparatiroidism• Tireoto2icoza• Diabet• Acrome6alie• Insuficienta suprarenaliana
• Poliartrita reumatoida
• Spondilita a.ilozanta
• "PO;• ;iroza biliara
Osteoporoza din boli cronice
Osteoporoza din boli cronice
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• Sindroame de malnutritie• "oli 'ematolo6ice
– 1ielom,limfoame, siclemia, 'emofilii• "oli 6enetice
– Osteo6eneza imperfecta – 1arfan – emocromatoza – porfiria
• Alte – Imobilizare – Sarcina – Amiloidoza – Sarcoidoza
Osteoporoza din boli cronice
1edicamente
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1edicamente
•;orticoizi• ;'imioterapice
• Anticon(ulsi(ante• eparina• Lit'iu
• Inacti(itatea fizica din copilarie, pubertate
Ostoporoza
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Ostoporoza
•Idiopatica – adolescenti si tineri cu functie 6onodala normala
• Osteoporoza tip !% – % si F $ ani – fracturi (ertebrale, antebrat distal
– iperparatiroidism secundar PT crescut – %,#/O0#D scazut
• Osteoporoza tip # – 8 $ ani
– 4racturi col femural, orice alte fracturi – iperparatiroidism secundar PT crescut – %,#/O0#D scazut
4actori de risc pentru fractura
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4actori de risc pentru fracturaosteoporotica
• Nemodificabili – APP fractura – A; fractura – se2 feminin, rasa caucaziana, (arsta 8
• 1odificabili – fumat – 6reutate F =.6 – deficienta estro6enica
• menopauza F +ani
• amenoree8 % an – Dieta: ;a insuficient /F +33m6*zi0, alcoolism – acti(itate fizica inadec(ata – caderi recurente
Date clinice
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Date clinice
•4racturi – prin cazatura pumn, sold, tibie, 'umerus – spontane (ertebrale
• Durere• Dificutate de miscare• "alonare• Deformari coloana (ertebrala colaps
(ertebral
• R2 6rafia coloana (ertebrala
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• R2 6rafia coloana (ertebrala
- coloana toracala inferioara,lombara superioara
- descresterea corticalei
- pierderea trabeculelor orizontale- corpi (ertebrali biconca(i
- colaps (ertebral (ertebra Bcodfis'C
- prabusire (ertebrala cu descrestereainaltimii anterioare
- fracturi (ertebrale
- osteofite anterioare fracturile (ec'i
• R2 6rafia oase lun6i
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- oasele lun6i
- descresterea corticalei prin resorbtiee2cesi(a a mar6inii interne
• R2 6rafia oasoasa
- nu este o metoda sensibila osteoporoza este apreciatadecat de la )37 pierdere masa osoasa
-nu diferentiaza intre osteoporoza si osteomalacie
- indicatie :
- post menopauza scadere asimptomatica #,!),=cm! simptome su6esti(e/ durere,cifoza,etc&&
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• ;T
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- coloana (ertabrala, antebrat, tibie
- poate e(alua
- trabeculele orizontale (ertebrale
- masa ososa * unitatea de (olum
- iradiere mare, costuri mari
• Eco6rafia osoasa
- putin sensibila, pote fi metoda Bscreenin6C
- poate aprecia masa osoasa prin- aprecierea atenuarii posterioare
- (iteza stimului prin os
• DEJA /dual*ener6 2 ra absorbtiometr0
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/ 6 0
- metoda standard de e(aluare a densitatii minerale osoase
"1D /bone mineral densit0- sensibila deceleaza %!#7 pierderi in masa osoasa
- iradiere mica / e2punere scurta, timp scurt de scanare0
- poate in(esti6a orice parte a sc'eletului
- (ertebral, radius, calcaneu, col femural, falan6e
- e(alueaza apro2imati( continutul mineral raportat la intre6ul
corp /DEJA apreciaza biplan, nu si antero!posterior - scor T compara cu populatia de aceiasi rasa si se2
- scor M compara cu populatia de aceiasi (arsta, rasa si se2
• DEJA /dual*ener6 2 ra absorbtiometr0
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- T scor F ! #, 5 osteoporoza
- M scor F ! % 5 osteoporoza
• DEJA ! indicatii
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- femeia deficienta estro6enic cu risc clinic de osteoporoza- anomalii (ertebrale R2 osteopenie, fracturi (ertebrale0
- 6lucocorticoizi: ec'i(alent de prednison 8$,m6*zi si 8 )
luni- 'iperparatiroidism primar
- monitorizarea raspunsului la medicatie
- repetarea "1D la 8 #) luni, mai repede daca este necesar
Criterii aprobate de $%A, &''
• Abordarea pacientului
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! calcemia
! calciuria! PT, TS, cortisolemie, teste de malbsorbtie, etc
– E2aminari B de rutinaC
! 4ormare osoasa ! fosfataza alcalina
! procalcinaser ! propeptid
cola6enului I
– 1ar.eri bioo6ici
! Resorbtie osoasa ! N telopeptid, ; telopeptid ser, urin
deo2piridinolina totala libera urina!
Informatii obtinute
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! hipocalcemia cu calciurie *+mg"i ! osteomalacie, malabsorbtie, denutritie
- calciurie .++mg"i ! pierdere renala de calciu! 'ipercalciurie absorbti(a cu crestere %,#/O0#Din boli 6ranulomatoase
! boli cu turno(er osos e2cesi( : Pa6et,'iperparatiroidism,'ipertiroidism
neoplazii 'ematolo6ic
/mielom, leucemii,
! hipercalcemia
! 'iperpartiroidism /PT crescut0! neoplazii /PT scazut0
! mar/eri de resorbtie
! e(aluarea eficientei terapiei antiresorbti(e
Tratament
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! Managementul fracturilor
! sold, oase lun6i c'irur6ie ortopedica! (ertebrale
! antial6ice: codeina, calcitonina! miorela2ante, caldura, ultrasunete
! (ertebroplastie !polimet'ilmet'acrlat
! 0educerea factorilor de risc %& aport de calciu ≤ H33m6*zi
/ calcium carbonat ! cu mancarea necesitacid pentru resorbtie calcium citrat oricand0
! calciurie inainte de calciu la pacienti cu litiaza urinara
! 0educerea factorilor de risc
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#& (itamina D# la #/O0D seric F 3mmol*l /#3n6*m
! #33m6*zi la adulti F 3 ani! +33m6*zi la adulti 3 ! $3 ani! H33 m6*zi la adulti 8 $3 ani
)& alte principii
! (itamina osteoporoza pacientilor cu tratament cronic
cumarinic
/(it carbo2ileaza osteocalcina0+& exercitiul fi"ic
! #erapii farmacologice
% Estro6enii
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%& Estro6enii ! reduc turno(erul osos si determina micicresteri in masa osoasa
! estro6en esterificat: 3,) m6*zi <! estro6en eQuin con-u6at 3,H#m6
pro6esteron! o,# 6*dl et'nil estradiol
! reduc cu 37 riscul de fractura, beneficiuldeclina la intreruperea tratamentului
! mecanism actiune:
reduc functia osteoclaselor
cresc functia osteoblastelor prin:cerstere a IGI !I,TG4!β%
scadere &l'(,&l'), TNF' ,
! #erapii farmacologice
% SER1s
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%& SER1s ! Ralo2ifen, tamo2ifen
#& "ifosfonati ! reduc functia si no osteoclaste /cresc apoptoza0! similitidinea cu pirofosfati, duce la inte6rare in os
Alendronat si 0isedronat
- Alendronat m6*zi # ani si %3m6*zi
! reduce riscul de fractura cu 37! esofa6ita de reflu2
! 0isedronat ) m6*saptamana
! fara efecte di6esti(e 6astrointestinale
! #erapii farmacologice
% ;alcitonina
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%& ;alcitonina ! intranasal, i(
! tratament: femei cu oteporoza si8 ani de menopauza si
#& !#1
- stimuleaza IG4!I si productia de cola6en, cresterecrutarea, reduce apoptoaza osteoblate
! creste tesutul osos si restaureaza microar'itectura
! PT se asociaza la estro6enidoza unica*zi ma2imum # ani
indictii ! la pacienti aflati la mare risc de fractura
! 2S#32!2024A 56%7SA %3 C20#5C2545
% ;us'in6
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%& ;us'in6#& ;orticoterapie
! dependent de doza si durata de tratament
! mecanisme: ! in'iba functia osteoblastelor,! creste apoptoza osteoblastelor
! scad absorbtia intestinalade ;a, independent de (it D! induc 'iperparatiroidism sec
! suprima functia o(ariana
! tratament: N fumat, N acool;a, (itamina D