Prevence sekundárních fraktur: multioborové konsenzuální stanovisko ke klinickým doporučením

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Autoři: Conley B Robert ¹; Adib Gemma ²; Robert; Adler ³; Kesson E Kristina ⁴; Alexander M Ivy ⁵; Amenta C Kelly ⁶; Blank D Robert ^7,8; Brox Timothy William ⁹; Carmody E Emily ¹⁰; Chapman-Novakofski Karen ¹¹; Clarke L Bart ¹²; Cody M Kathleen ¹³; Cooper Cyrus ¹⁴; Crandall J Carolyn ¹⁵; Dirschl R Douglas ¹⁶; Eagen J Thomas ¹⁷; Elderkin L Ann ¹⁸; Fujita Masaki ¹⁹; Greenspan L Susan ²⁰; Halbout Philippe ²¹; Hochberg C Marc ²²; Javaid Muhammad ²³; Jeray J Kyle ²⁴; Kearns E Ann ¹²; King Toby ²⁵; Koinis F Thomas ²⁶; Koontz Scott Jennifer ^27,28; Kužma Martin ²⁹; Lindsey Carleen ³⁰; Lorentzon Mattias ^31,32,33; Lyritis P George ³⁴; Michaud Boehnke Laura ³⁵; Miciano Armando ³⁶; Morin N Suzanne ³⁷; Mujahid Nadia ³⁸; Napoli Nicola ^39,40; Olenginski P Thomas ⁴¹; Puzas Edward J ¹⁰; Rizou Stavroula ³⁴; Rosen J Clifford ^42,43; Saag Kenneth ⁴⁴; Thompson Elizabeth ⁴⁵; Tosi L Laura ⁴⁶; Tracer Howard ⁴⁷; Khosla Sundeep ¹²; Kiel P Douglas ⁴⁸
Působiště autorů: Center for Medical Technology Policy, Baltimore, MD, USA ¹; Osteoporosis Centre, Damascus, Syria ²; McGuire VA Medical Center, Richmond, VA, USA ³; Lund University and Skåne University Hospital, Lund, Scania, Sweden ⁴; UConn School of Nursing, University of Connecticut, Storrs, CT, USA ⁵; Department of Physician Assistant Studies, Mercyhurst University, Erie, PA, USA ⁶; Department of Endocrinology, Metabolism and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA ⁷; Garvan Institute of Medical Research, Darlinghurst, NSW, Australia ⁸; UCSF Fresno, Fresno, CA, USA ⁹; Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA ¹⁰; Division of Nutritional Sciences, University of Illinois, Urbana, IL, USA ¹¹; Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Ro-chester, MN, USA ¹²; American Bone Health, Raleigh, NC, USA ¹³; University of Southampton, Southampton, UK ¹⁴; Department of Medicine, University of California, Los Angeles, CA, USA ¹⁵; Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL, USA ¹⁶; National Council on Aging, New York, NY, USA ¹⁷; American Society for Bone and Mineral Research, Washington, DC, USA ¹⁸; Science Department, International Osteoporosis Foundation, Nyon, Switzerland ¹⁹; Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA ²⁰; International Osteoporosis Foundation, Nyon, Switzerland ²¹; Division of Rheumatology, University of Maryland School of Medicine and VA Maryland Health Care System, Baltimore, MD, USA ²²; Nufﬁeld Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, USA ²³; Prisma Health Upstate (formerly Greenville Health System), Greenville, SC, USA ²⁴; US Bone and Joint Initiative, Rosemont, IL, USA ²⁵; Duke Primary Care Oxford, Oxford, NC, USA ²⁶; Orthopedics & Sports Medicine, Newton Medical Center, Newton, KS, USA ²⁷; Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, KS, USA ²⁸; Bones, Backs and Balance, LLC, Bristol Physical Therapy, LLC, Bristol, CT, USA ³⁰; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia ³¹; Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden ³²; Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ³³; Hellenic Osteoporosis Foundation, Athens, Greece ³⁴; The University of Texas MD Anderson Cancer Center, Houston, TX, USA ³⁵; Nevada Rehabilitation Institute, Las Vegas, NV, USA ³⁶; Department of Medicine, McGill University, Montreal, Canada ³⁷; Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA ³⁸; Department of Nutrition and Metabolic Disorders, Campus Bio-Medico University of Rome, Rome, Italy ³⁹; Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA ⁴⁰; HiROC Program/Rheumatology, Geisinger Health System, Danville, PA, USA ⁴¹; Tufts University School of Medicine, Boston, MA, USA ⁴²; Maine Medical Center Research Institute, Portland, ME, USA ⁴³; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA ⁴⁴; National Osteoporosis Foundation, Arlington, VA, USA ⁴⁵; Department of Orthopaedic Surgery and Sports Medicine, Children’s National Hospital, Washington, DC, USA ⁴⁶; Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD, USA ⁴⁷; Harvard Medical School, Musculoskeletal Research Center, Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA ⁴⁸; th Department of Internal Medicine, University Hospital, Comenius University, Bratislava, Slovakia ²⁹⁵
Vyšlo v časopise: Clinical Osteology 2020; 25(1): 7-25
Kategorie: Doporučené postupy

Souhrn

Fraktury související s osteoporózou jsou v současnosti nedostatečně léčeny („podléčeny“), a to z části pro mylné informace o doporučených postupech v péči o pacienty a z části pro rozdíly v doporučeních pro léčbu. Aby se zvrátil tento nevyhovující stav a zlepšily se léčebné výsledky pacientů, sestavila Americká společnost pro výzkum kostí a kostního minerálu širokou skupinu zainteresovaných odborníků ke koncipování klinických doporučení k optimalizaci prevence sekundárních fraktur v populaci osob ve věku 65 let a starších postižených frakturami krčku kosti stehenní nebo obratlů. Tato skupina připravila 13 doporučení (7 primárních a 6 sekundárních) přesvědčivě potvrzených důkazy z odborné literatury. Skupina doporučuje rozšíření a zintenzívnění komunikace s pacienty o problematice rizika fraktur, o mortalitní i morbiditních dopadech fraktur stejně jako o možnostech snížení tohoto rizika. Podle odhadu se může riziko (včetně pádů) objevovat v pravidelných intervalech v závislosti na fyzioterapii nebo ergoterapii, což je očekávatelné. Perorálně, intravenózně i subkutánně aplikované léky jsou účinné a mohou snížit riziko fraktur. Pacienti samozřejmě potřebují edukaci o přínosech i rizicích těchto různě aplikovaných léků, stejně jako o důsledcích neléčení. Perorální bisfosfonáty alendronát a risendronát představují léčbu první volby a jsou všeobecně dobře tolerovány; možné je zvážit i intravenózně podávanou kyselinu zoledronovou nebo subkutánně podávaný denosumab. Anabolika jsou nákladná, ale mohou být pro vybrané pacienty ve vysokém riziku přínosná. Optimální délka farmakoterapie není známa, ale protože je riziko sekundárních fraktur v raném období po fraktuře velmi vysoké, doporučuje se bezodkladná léčba. Samozřejmostí by měla být adekvátní dieta, případně suplementace vitamínem D stejně tak by měl být samozřejmostí přísun kalcia. Jednotlivci léčení na osteoporózu by měli být běžně opakovaně vyšetřováni vzhledem k riziku fraktur a opakovaně informování v rámci pacientské edukace o osteoporóze a riziku fraktur a o monitorování nežádoucích účinků léčby. Pacienti by měli být důrazně přesvědčováni, aby se vyvarovali kouření a co možná nejvíce omezili konzumaci alkoholu, věnovali se pravidelně fyzické aktivitě a přijali a dodržovali strategie prevence. Závěrem doporučení upozorňuje endokrinology a ostatní odborníky na osteoporózu, aby věnovali pozornost jedincům s opakovanými frakturami anebo úbytkem kostní hmoty a také jedincům s komplikujícími komorbiditami (např. hyperparatyreoidizmus nebo chronické onemocnění ledvin).

Klíčová slova:

stárnutí – anabolika – antirezorptiva – osteoporóza – sekundární fraktura prevence

Zdroje

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