Morin Suzanne N, Leslie William D, Schousboe John T
Department of Medicine, McGill University, Montreal, Quebec, Canada.
Department of Medicine, University of Manitoba, Winnipeg, Canada.
JAMA. 2025 Sep 9;334(10):894-907. doi: 10.1001/jama.2025.6003.
Osteoporosis is characterized by low bone mass, increased bone fragility, and increased susceptibility to fracture, which is associated with substantial morbidity, mortality, and economic costs. Worldwide, 1 in 3 women and 1 in 5 men older than 50 years of age experience osteoporotic fractures in their lifetime.
Risk factors for osteoporosis include older age, female sex, prior fractures, prior falls, low body weight, history of hip fracture in a parent, glucocorticoid use, cigarette smoking, excess alcohol consumption, certain comorbidities (eg, inflammatory bowel disease, rheumatoid arthritis, and chronic liver and kidney disease), and low level of bone mineral density (BMD; measured by dual-energy x-ray absorptiometry). The fracture risk assessment algorithm combines these clinical risk factors and BMD measurement to estimate the 10-year absolute fracture risk for hip, spine, shoulder, and forearm fractures. For patients at high risk of fracture, such as those with a T score of -2.5 or less (equivalent to a bone mass that is ≥2.5 SDs below that of young adults) for BMD, history of vertebral or hip fracture, multiple fractures, or high 10-year absolute fracture risk (eg, ≥20%), antiresorptive agents (bisphosphonates or, if contraindicated, denosumab) are recommended to reduce vertebral fractures (risk difference, -52 [95% CI, -95 to -18 per 1000 person-years]) and hip fractures (risk difference, -6 [95% CI, -11 to -1 per 1000 person-years]). Anabolic medications (teriparatide, abaloparatide, and romosozumab) should be considered in very high-risk individuals (eg, recent vertebral fractures, hip fracture with a T score of ≤-2.5 for BMD), followed by an antiresorptive agent. The use of fracture liaison services (comprehensive inpatient or outpatient management program for patients after a fracture) was shown to increase medication initiation and adherence by 38% compared with 17% for patients who did not receive fracture liaison services (risk difference, 20% [95% CI, 16% to 25%]) and these benefits may reduce the rates of subsequent fracture. Patients are recommended to follow appropriate intake of calcium (1000 to 1200 mg) and vitamin D (600 to 800 IU) guidelines and to pursue a regimen of muscle resistance exercises (eg, squats, push-ups) and balance exercises (eg, heel raises, standing on 1 foot).
Osteoporosis is a common condition among older adults that leads to increased susceptibility to fracture, which is associated with substantial morbidity and mortality. Antiresorptive agents such as bisphosphonates or denosumab are recommended for patients at high fracture risk. Anabolic treatment with parathyroid hormone analogs (such as teriparatide and abaloparatide) and sclerostin inhibitors (such as romosozumab) can be considered for very high-risk individuals.
骨质疏松症的特征是骨量低、骨脆性增加以及骨折易感性增加，这与相当高的发病率、死亡率和经济成本相关。在全球范围内，50岁以上的女性中三分之一、男性中五分之一在其一生中会发生骨质疏松性骨折。
骨质疏松症的风险因素包括年龄较大、女性、既往骨折、既往跌倒、体重过低、父母有髋部骨折病史、使用糖皮质激素、吸烟、过量饮酒、某些合并症（如炎症性肠病、类风湿性关节炎以及慢性肝肾疾病）以及骨矿物质密度（BMD；通过双能X线吸收法测量）水平低。骨折风险评估算法将这些临床风险因素与BMD测量相结合，以估计髋部、脊柱、肩部和前臂骨折的10年绝对骨折风险。对于骨折高风险患者，如BMD的T值为-2.5或更低（相当于骨量比年轻人低≥2.5个标准差）、有椎体或髋部骨折病史、多次骨折或10年绝对骨折风险高（如≥20%）的患者，建议使用抗吸收药物（双膦酸盐类药物，若有禁忌则使用地诺单抗）以降低椎体骨折（风险差值，每1000人年-52[95%CI，-95至-18]）和髋部骨折（风险差值，每1000人年-6[95%CI，-11至-1]）的风险。对于极高风险个体（如近期椎体骨折、髋部骨折且BMD的T值≤-2.5），应考虑使用促合成代谢药物（特立帕肽、阿巴洛帕肽和罗莫佐单抗），随后再使用抗吸收药物。与未接受骨折联络服务（骨折后患者的综合住院或门诊管理项目）的患者相比，使用骨折联络服务可使药物起始使用和依从性提高38%，而未接受服务的患者为17%（风险差值，20%[95%CI，16%至25%]），这些益处可能会降低后续骨折发生率。建议患者遵循适当的钙（1000至1200毫克）和维生素D（600至800国际单位）摄入指南，并进行肌肉抗阻运动（如深蹲、俯卧撑）和平衡运动（如踮脚跟、单脚站立）。
骨质疏松症在老年人中很常见，会导致骨折易感性增加，这与相当高的发病率和死亡率相关。对于骨折风险高的患者，建议使用双膦酸盐类药物或地诺单抗等抗吸收药物。对于极高风险个体，可考虑使用甲状旁腺激素类似物（如特立帕肽和阿巴洛帕肽）和硬化蛋白抑制剂（如罗莫佐单抗）进行促合成代谢治疗。
