Kanis J A
WHO Collaborating Centre for Metabolic Bone Diseases, Department of Human Metabolism and Clinical Biochemistry, University of Sheffield Medical School, United Kingdom.
Am J Med. 1995 Feb 27;98(2A):60S-66S.
Prevention of osteoporosis is better than cure. This intuitive wisdom is strengthened by knowledge that osteoporosis due to gonadal deficiency is associated with a disruption of skeletal architecture that is irreversible by current treatments. Moreover, it is commonly assumed that bone is lost more slowly in later life than in the several years after the menopause, so that factors other than decreasing bone mass are assumed to be of greater importance for fracture risk. With the exception of fluoride, current treatments have not been shown to restore skeletal mass in patients with osteoporosis. These views have suggested that the management of osteoporosis in the elderly is of limited value and have reinforced the importance of preventive measures. Notwithstanding, there are several reasons for believing that intervention late in the natural history of bone loss is worthwhile. Whereas cross-sectional studies suggest that bone loss declines in later years, prospective studies indicate that bone loss is progressive and indeed accelerates in extreme old age. Moreover, the measurement of bone mass predicts future fracture in the elderly as effectively as it does at the time of the menopause. There are also several reasons why preventive approaches at the time of the menopause have limited applicability. Since current preventive treatments cannot be given indefinitely, a crucial question concerns the extent to which reversal of effect occurs after treatment withdrawal. If catch-up bone loss does occur, it decreases markedly the cost-effectiveness of therapeutic intervention at the menopause and provides a convincing rationale for the use of interventions at a much later age. The optimum age for starting treatment is not yet determined but might be best directed 15 or so years after the menopause, well before the mean age of hip fracture. Since hip fracture provides the greatest socioeconomic impact of osteoporosis and since evidence is accumulating that treatments favorably affect hip fracture risk, it is suggested that greater attention should be given to the management of osteoporosis in the elderly.
预防骨质疏松症胜于治疗。由于性腺功能减退所致的骨质疏松症与骨骼结构破坏相关，而目前的治疗方法无法使其逆转，这一认识强化了这种直观的智慧。此外，人们通常认为，在生命后期骨质流失的速度比绝经后的几年要慢，因此除了骨量减少之外的其他因素被认为对骨折风险更为重要。除氟化物外，目前的治疗方法尚未显示能使骨质疏松症患者恢复骨量。这些观点表明，老年人骨质疏松症的管理价值有限，并强化了预防措施的重要性。尽管如此，有几个理由让人相信，在骨质流失的自然病程后期进行干预是值得的。横断面研究表明，在晚年骨质流失会减少，而前瞻性研究则表明骨质流失是渐进性的，在高龄时确实会加速。此外，骨量测量对预测老年人未来骨折的效果与绝经时一样有效。绝经时的预防方法适用性有限也有几个原因。由于目前的预防性治疗不能无限期进行，一个关键问题是停药后效果逆转的程度。如果确实发生了追赶性骨质流失，就会显著降低绝经时治疗干预的成本效益，并为在更晚年龄进行干预提供令人信服的理由。开始治疗的最佳年龄尚未确定，但可能最好在绝经后15年左右开始，远早于髋部骨折的平均年龄。由于髋部骨折对骨质疏松症的社会经济影响最大，而且越来越多的证据表明治疗对髋部骨折风险有积极影响，因此建议应更加重视老年人骨质疏松症的管理。
