Definition, epidemiology, burden and etiology of osteoporosis .....1

I-1 Definition and concept ............................................................................................................1
I-2 Epidemiology of osteoporosis and osteoporotic fractures ....................................................1
2.1 !"!#$%&ก (Worldwide epidemiology) ...............................................................1
2.2 !",-./0.123245"6&72!89!" (Epidemiology in Asia and Thailand)........2
I-3 Burden and impact of osteoporosis and osteoporotic fractures ...........................................2
3.1 3#?ก?"6&@กAกก2กก/กB#กAก%1ก/ก@C- (Osteoporosis related
mortality and morbidity) .................................................................................................3
3.2 ก/กB#กAก%1ก/ก@C-,-24F28GH8I?J!FIKLICM (Health economic
aspect of osteoporotic fractures) ...................................................................................3
I-4 Pathogenesis and etiology .....................................................................................................4
4.1 @"KกQ2- (Pathogenesis) ...........................................................................................4
23กI3RF3F ......................................................................................................................................5
Diagnosis and bone mass assessment in osteoporosis .................8
II-1 History, physical examination and differential diagnosis .......................................................8
1.1 กAQ6-ก72.!M3F%1ก/ก@C- (Classification of osteoporosis) .........................8
II-2 Risk factors for osteoporosis and osteoporotic fractures ......................................................9
2.1 7[AA#"2I5$"FM3F%1ก/ก@C-6&ก/กB#กAก%1ก/ก@C- (Risk factors of
osteoporosis and osteoporotic fracture) ........................................................................9
2.2 ก720-7[AA#"2I5$"FM3Fก2กก/กB#กAก%1ก/ก@C- %",4R FRAXTM M3F
3F1Jก3-0#"%&ก (Risk assessment of osteoporotic fracture using WHO-FRAXTM) 9
II-3 Laboratory investigations and bone strength assessments ................................................11
3.1 ก?A!FBR3F7a#?ก (Laboratory investigation) ................................................11
3.2 ก720-106MbF6กcFM3Fก/ก (Bone strength assessment) ............................11
II-4 Diagnostic criteria for osteoporosis ......................................................................................12
4.1 ก?A10B-6-c-ก/ก (Measurement of bone density) ..................................12
4.2 #4-5452105M3Fก-กIRF6&I&"ก/ก (Biochemical markers of bone
turnover) .......................................................................................................................13
4.3 ก?A1#ก3F (Screening) .......................................................................................14
.1e-ก 2.1 ...................................................................................................................................15
OSTA (Osteoporosis Self-Assessment Tool for Asians) ...................................................15
Khon Kaen Osteoporosis study score (KKOS) ..................................................................16
.1e-ก 2.2 ...................................................................................................................................18
%-%06ก0,-ก!Q-"ก2ก%1ก/ก@C-,-I?5"# B07AQ2h3-%",4R3"C
-iQB-#ก6& QUS ...........................................................................................................18
23กI3RF3F ....................................................................................................................................19
Prevention of osteoporosis and prevention of falls .......................21
III-1 Strategies to maximize peak bone mass ............................................................................21
III-2 Strategies to prevent bone loss ...........................................................................................21
ก,BRm3J%0-!6!- (Hormone replacement therapy) .....................................................22
III-3 Nutritional aspect in osteoporosis ........................................................................................22
61&2o5"0 (Calcium) .............................................................................................................22
?0-5 (Vitamin D) ............................................................................................................26
?0-21 (Vitamin K) ...........................................................................................................27
III-4 Life style modification and prevention of fall .......................................................................28
4.1 ก7#27&5$"-@r?ก0!5$2I5$"F?c3ก27s-%1ก/ก@C- ............................................28
4.2 ก7t3Fก#-กBก&R0,-e/R7u"%1ก/ก@C- ................................................................29
.1e-ก 3.1 Falls Risk Assessment tool ............................................................................32
.1e-ก 3.2 ก33กกQ&#Fก"2@h$37t3Fก#-%1ก/ก@C- ....................................................33
ก33กกQ&#Fก"2@h$3IRF0&ก/ก6&&ก2กก/ก@C- ..........................................33
ก7t3Fก#-กBก&R06&&ก2กก/กB#ก ......................................................................34
23กI3RF3F ....................................................................................................................................34
Treatment of osteoporosis ................................................................38
IV-1 Goal of osteoporosis treatment ............................................................................................38
1.1 -"0M3Fก7t3Fก#-6&ก#กG%1ก/ก@C- .........................................................38
1.2 #?wC7IF1JM3Fก#กG%1ก/ก@C- ......................................................................38
1.3 6-!Fก?#I-,A,BRก#กG%1ก/ก@C-R"ก&"C!KJก1R-Be/R!05$ 5102I5$"FI/F
%" International Osteoporosis Foundation 6& National Osteoporosis Foundation 38
1.4 6-!Fก?#I-,A,BRก#กG%1ก/ก@C-R"ก&"C!KJก1R-Be/R!05$ 5102I5$"FI/F
%"0/&-K%1ก/ก@C-6BcF72!89!"x ....................................................................39
IV-2 Pharmacotherapy for osteoporosis ......................................................................................40
2.1 ""#"#Fi กI&"ก/ก (Inhibitors of bone resorption) ..............................................41
2.2 "ก?CR-กIRFก/ก,B0c (Stimulators of bone formation) ....................................42
2.3 "!5$33กr!Kz!#iFI3F!F (mixed action agents) ............................................................43
IV-3 Alternative therapy and non-pharmacological treatment .....................................................44
3.1 Hip protector .................................................................................................................44
IV-4 Potential adverse events, prerequisites and contraindications in using anti-osteoporotic
agents ..................................................................................................................................44
4.1 e&MRF215"F MR31#F 6&MR3BR0,-ก,4R"#กG%1ก/ก@C- ..........................44
IV-5 Monitoring treatment and duration of treatment ..................................................................47
5.1 ก??06&720-e&ก#กG ...............................................................................47
5.2 "2&ก#กG ........................................................................................................48
23กI3RF3F ....................................................................................................................................54
Glucocorticoid-induced osteoporosis (GIO) ...................................62
 V-1 Introduction and epidemiology .............................................................................................62
1.1 !-Q ............................................................................................................................62
1.2 !" ...................................................................................................................62
V-2 Pathophysiology and risk assessment .................................................................................62
2.1 ก&9กก2ก%1 ...........................................................................................................62
2.2 7[AA#"2I5$"F .....................................................................................................................63
V-3 Diagnosis ..............................................................................................................................63
V-4 Prevention and treatment .....................................................................................................63
4.1 6-!Fก7t3Fก#-6&#กG%1ก/ก@C-!5$2กAกก,4R"ก&/%113J?13"J ..........63
V-5 Monitoring treatment ............................................................................................................64
5.1 ก??0e&ก#กG .................................................................................................64
23กI3RF3F ....................................................................................................................................65
Osteoporosis in men ..........................................................................68
VI-1 Introduction and epidemiology .............................................................................................68
1.1 !-Q 6& 1QAQก#10 ..............................................................................................68
1.2 !" ...................................................................................................................68
1.3. 7[AA#"2I5$"F .....................................................................................................................69
VI-2 Assessment and diagnosis ..................................................................................................69
2.1 ก-A|#" ....................................................................................................................69
2.2 ก?AcFก"6&ก?A@28G ..............................................................................69
VI-3 Prevention .............................................................................................................................70
3.1 ก7t3Fก#-%1ก/ก@C-,-e/4R " ................................................................................70
VI-4 Treatment and follow-up ......................................................................................................71
4.1 6-!Fก#กG%1ก/ก@C-,-e/R4" .......................................................................71
4.2 ก??0e&ก#กG ..................................................................................................71
23กI3RF3F ....................................................................................................................................72
 1

Definition, epidemiology, burden and etiology of

osteoporosis
I-1 Definition and concept
,-7} @.8. 2543 National Institute of Health 6BcFIB#H320ก(1) 9R-"0%1ก/ก@C-#F-5i1h3
27s- %1M3Fก/ก !5$051 06MbF6กc FM3Fก/ก (bone strength) &&F IcF e&,BR2 @$0 102I5$" F?c 3
ก/กB#ก 106MbF6กcFM3Fก/ก,--"0-5i7ก3R" 2 Ic-B&#ก1h3 10B-6-c-M3Fก/ก
(bone density) 6&1CL.@M3Fก/ก (bone quality)

I-2 Epidemiology of osteoporosis and osteoporotic fractures

2.1 ,-./0102.34ก (Worldwide epidemiology)
,-7} @.8. 2536 9R05"F-Aกก74C0 Consensus Development Conference M3F 3F1Jก
3-0#"%&ก (WHO)(2) @c ,-IB#H320ก 05e/R!5$2ก.ก/กB#กAก%1ก/ก@C- (osteoporotic
fractures) I/Fw~F 1.3 &R"",-6?c&7} %"!5$,-AQ---5i 50% 27s-ก/กI#-B&#FB#ก (vertebral fractures)
25% 27s-ก/กI%@กB#ก (hip fractures) 6&!5$2B&h335ก 25% 27s-กB#ก!5$ก/กMR30h36&ก/ก3h$-€
-3กAก-#i-"#F05"F-c กc 30% M3Fe/RBF,-!57"C%7!5$053"C?#iF6?c 50 7}M~i-9727s-%1ก/ก@C-
Aกก8~กG National Health and Nutrition Survey (NHANES III) ,-IB#H320ก20h$37} @.8.
(3)
2540 9R05ก720-c 05e/RBF4320ก#-eMw~F 13-18% 27s-%1ก/ก@C- (osteoporosis) 6&
35ก 27-50% 3"/c,-.ก/กF (osteopenia) 3#?ก2ก%1ก/ก@C-,-e/RBF2B&c-5i2@$0M~i-20h$3
3"C0กM~i- 9R05ก720-9RcwR/2|@,-ก&Cc0e/RBF320ก#-eM!5$053"C2!cก#Bh30กกc 80 7}
M~i-97 A@c27s-%1ก/ก@C-w~F 70%
%"!#$97wR1Q-~Fw~F.ก/กB#ก%"06&R 3C#?กLJ (incidence) ,-e/R4"AI/Fกc,-
e/RBF3"cF4#2A- ?#iF6?c4cF#"Cc- (adolescence) A-w~F#"ก&F1- (middle life) I2B?CB&#ก,-4cF-5i1
A0Aก/76ก!QF- (working) 6&/76กQ2--45? (lifestyle) M3Fe/R4"o~$Fe%e-6&2I5$"F
3#-?"0กกc ก/กB#ก6-5i3A25"ก9Rc27s-ก/กB#กAก."#-?"6C-6F (high-energy
trauma) 6?c."B&#F4cF3"C 40-50 7} ก&#2กก27&5$"-67&FM3F6-%-R0ก/กB#ก97,-!F?Fก#-
MR0 3C#?กLJM3Fก/กB#ก,-B&"€ ?Q6B-cF 24c- ก/กI#-B&#F ก/กMR30h3 ก/ก24Fก- 6&
ก/กI%@ก x&x ,-e/RBFก&#2@$0I/FM~i-3"cF2b(4) ก/กB#ก2B&c-5i27s-e&Aก."#-?"690c
C-6F (low-energy trauma) Bh3ก/กB#กAกก/ก@C- (osteoporotic fractures) -#$-23F Aก
ก8~กG,-IB#H320ก e/R7u"ก/กI#-B&#FB#ก050กw~F7}&70L 500,000 "(4) %"@0ก,-
2@8BF0กกc2@84" w~F 10 2!c @/9Rc,-e/RBF4320ก#-eM!5$053"C0กกc 70 7} A05w~F
1~$FB-~$F!5$05Bh321"05ก/กI#-B&#FB#ก3"cF-R3"B-~$FMR3(4) IQB#3C#?กLJก2กก/กI%@กB#ก,-
e/RBFeM (Caucasian) @9RI/FIC w~F7}& 737 1#iF?c3 100,000 " ,-e/RBF4-3J2"J 6&?$QIC
70L7}& 280 1#iF?c3 100,000 " ,-e/RBF4‚ƒ-6&-J(5)
 2

2.2 ,-./0189:;</:=>?>@A1B4,C,>0DE01 (Epidemiology in Asia and

Thailand)
AกMR30/&&cIC,-7} @.8. 2551 3"CM#"2|&5$" (life expectancy) M3F74ก9!" 1h3 69.5 7},-
e/R4" 6& 76.3 7},-e/RBF(6) 9R05กIQA104Cก (prevalence) M3F%1ก/ก@C-,-e/RBF!5$0#
ก,-%F@"&M3F#HF6BcF 6&AกกICc0?Ae/RBF,-4C04-Aก!Cก.1M3F9!" ,-7}@.8.
2541(7) 6& @.8. 2544(8) ?0&Q#@c wR,4R2กL„Jก-A|#"%1ก/ก@C- o~$F3F1Jก3-0#"%&ก9R
กQB-9RcB0"w~F1c10B-6-c-ก/ก!5$2!cก#Bh3?$Qกc 2.5 2!cM3F1c25$"F2-0?H-Aก
1c2|&5$"M3F10B-6-c-ก/ก,-1-B-Cc0I (T-score ≤ -2.5) A@c70L 19-21% J?KL;MN/K0A2
<A?1OPQKBPR 40 CUJVQ9EC >CW93=ก,-;กXO90A2ก,-;ก
9N4K
R.9>?. (lumbar spine osteoporosis)
B4, 11-13% >CW93=ก,-;กXO90A2ก,-;ก=?
,3Xก (femoral neck osteoporosis)
,-72!89!" 05"F-กIQA!5$A#FB#245"F,B0cBcF7} @.8. 2540-2541(9) @3C#?กLJ
M3Fก/กI%@กB#ก,-74ก!#iFBF6&4" !5$053"C?#iF6?c 50 7}M~i-97 w~F7}& 162 1#iF?c3 100,000
" 6&A2@$0M~i-27s-7}& 851 1#iF?c3 100,000 " ,-74ก!5$053"C2ก- 75 7}M~i-97 wR6"ก@AL
2|@,-74ก2@8BF!5$3"C?#iF6?c 50 7}M~i-97 A@3C#?กLJM3Fก/กI%@กB#กw~F7}& 269 1#iF
?c3 100,000 " 6&A2@$027s-7}& 1,011 1#iF?c3 100,000 " wR3"C0กกc 75 7}M~i-97 3#?#Fก&c
,ก&R215"Fก#3C#?กLJM3Fก/I%@กB#ก,-e/RBF,-72!86w23245"B&"72!8 o~$FกIQA,-
72!82B&c-#i-!5$2&?cFก#-@6-%-R0ก2@$0M~i-M3F3C#?กLJก2กก/กI%@กB#ก3"cF4#2A-
24c- ก8~กG3C#?กLJก2กก/กI%@กB#ก,-e/RBF4A5-mc3FกF (Hong Kong Chinese) @
3C#?กLJ2@$0M~i-Aก7}& 179 1#iF?c3 100,000 " ,-7} @.8. 2508 27s-7}& 389 1#iF?c3 100,000 "
,-7} @.8. 2528 o~$F2@$0M~i-กc2!c?#(10) 6&AกกIQA,-72!85$7Cu-20h$32b€ -5i (@.8. 2545) @
ก2@$0M~i-M3FAQ--ก/กI%@กB#ก Aก7}& 92,400 " ,- 5 7}กc3-B-R-#i- 27s-7}& 117,900 "(11)
9R05ก1กLJ9Rc,-7} 1.8. 2050 Bh335ก70L 40 กc7}MRFB-R-5i A05ก2กก/กI%@กB#ก
2กM~i-!#$%&กw~F70Lกc 6 &R-" 6&1~$FB-~$FBh370L 3 &R-"M3F!#iFB0-5i A2ก3"/c,-
72!86w23245"(10)

I-3 Burden and impact of osteoporosis and osteoporotic fractures

%"!#$976&R%1ก/ก@C-27s-%1!5$90c053ก,€ 6?ce&!5$?00Bh3 clinical consequence
!5$IQ1#M3F%1-5iกb1h3 ก2กก/กB#ก9RFc" o~$F6cF33ก9R27s- 2 กL5 1h3
1. ก,-;กNก[ก:19P1BE<RO9BK (low-energy trauma) 24c- ก/กI%@กB#กAกก
Bก&R0Aก!c"h- Bh3?กAก!5$I/F,-#,ก&R215"Fก#ก&R0Aก!c"h- 27s-?R-
2. ก,-;กNก3-1E<R<ABKก,B0ก[ก:19?ก 24c- ก/กI#-B&#FB#กAกกกR0?# Bh3ก"ก
M3FB-#ก 27s-?R-
ก/ ก B# ก 2B&c  -5i 2 A25 " กc  0€ c  ก/ ก B# ก Aก%1ก/ ก @C - Bh 3 osteoporotic
fractures o~$F27s-e&&#@KJB&#ก!5$2กM~i-Aกก!5$ก/กI/2I5"106MbF6กcF97 ก/กB#กAก%1ก/ก
@C--5i23F!5$27s-?#กc3,BR2ก. (burden) 6&e&ก! (impact) ?00
 3

3.1 ?PกP1B4,X/ก[กก>ก/-ก,-;กNก[ก3=ก,-;กXO9
(Osteoporosis related mortality and morbidity)
1. ก2กก/กI#-B&#FB#กAก%1ก/ก@C- (osteoporotic vertebral fractures) 0#กA2กAกก
!QF-?07ก?Bh3กA#?7AQ#- %"!5$0#กA90c057#?9R#3C#?2B?C,€ A~F27s-2B?Ce&c05
2@5"F 40% M3Fe/RBF!5$05ก/กI#-B&#FB#ก2B&c-5i2!c-#i-!5$/R?#c27s-
2. ก/กI#-B&#FB#กAก%1ก/ก@C- 3AA053ก2@5"F61c72&bก-R3"97A-w~F70กA-?R3F
-3-%F@"&กb9R 6?c%"!#$976&Re/R!5$05ก/กI#-B&#FB#กAก%1ก/ก@C-A053#?ก
2Ab7u" (morbidity)(12) 6&3#?ก?" (mortality)(13) 0กกce/R!5$"#F90c05ก/กB#ก3"cF4#2A-
e/R7u"A053ก7B&#F2hi3#F ?#2?5i"&F (height loss) B&#F1c30 (kyphosis) B&#F1 (scoliosis)
!R3F3h 2h$33B 2-h$3FAก10AC4c3F!R3F&&F 6&3AA053ก7232-h$3FAกก/ก4"
%1F&F0ก!ก#ก/ก24Fก-
3. กI/2I5"10I0w,-ก!QกA#?7AQ#- (functional disability) ก05AQ--7&R3FMR3
ก/กI#-B&#F!5$B#กB&"7&R3F "$F0ก2!c9กbA"$F2@$0 morbidity 6& mortality 0กM~i-2!c-#i-
(12-14)
6&"#F2@$0102I5$"F!5$A2กก/กI#-B&#FB#ก,-7&R3F!5$2B&h3 6&ก/กI%@กB#กR"(14)
4. ก/กI%@กB#ก (hip fractures) 27s-ก/กB#กAก%1ก/ก@C-!5$057[B0ก!5$IC -3กAก
ก!5$053#??"!5$I/F0ก?0B&#FกB#ก6&R "#F0510@ก6&กI/2I5"10I0w,-ก
!QกA#?7AQ#-,-3#?!5$I/F35กR" -3กAก-#i-1c,4RAc",-ก/6&#กGB&#Fก/กI%@ก
B#กกb"#FI/F0กกcก/กB#ก!5$3h$-€ 2-h$3FAกwR90c9R#กec?##กGe/R7u"A90cI0w2-9R
35ก!#iF%16&.6!กoR3-B&#Fec?#กb@9Rc3"6&C-6F
5. 9R05ก8~กG3#?ก?"6& 3#?ก2Ab7u"."B&#Fก/กI%@กB#ก,-1-eMI/F3"C(15-
16)
@3#?ก?"I/Fw~F70L 20% .",- 1 7}B&#Fก/กB#ก IQB#e/R!5$345?@c 30%
A0510@ก2กM~i-6w (permanent disability) ?R3F9R#ก/6&Aกe/R3h$- Bh3 3"/c,-
Iw-@"& (nursing home) 40% 90cI0w2-9R3"cF7ก??R3F,4R21h$3F4c"2-3"cF,
3"cFB-~$F 6& 80% 90cI0w7a#?กA#?7AQ#-3"cF-R3"B-~$F3"cF !5$21"!Q9R23Fกc3-
ก/กI%@กB#ก
6. ,-72!89!" 3#?ก?"."B&#Fก/กI%@กB#กAกก8~กG!5$A#FB#245"F,B0c(17) @c
2.1% ?"BcF"#F#กG?#,-%F@"& 6& 3#??"B&#FAกก/กI%@กB#ก!5$ 3 2h3-, 6
2h3- 6& 1 7} 2!cก# 9%, 12% 6& 17% ?0&Q# IQB#ก8~กG2ก5$"ก#1CL.@45?B&#F
ก/กI%@กB#ก,-1-9!"(18) @cB-~$F,-BRM3Fe/R7u" (22%) 90cI0w2-9R 23% ?R3F,4R
wheel chair ,-ก21&h$3-"R" -3กAก-#i-e/R7u"2B&c-5i"#F?R3F9R#ก4c"2B&h3,-ก7a#?
กA#?7AQ#-?cF€ ,-3#?!5$I/F 24c- 11% ?R3F4c"3-iQ 10% ?R3F4c"6?cF?# 22% ?R3F
4c",-กM#wc" 6& 5% ?R3F4c",-ก#7!-3B

3.2 ก,-;กNก[ก3=ก,-;กXO989>@/K>D\]D
P^0K
_`
OJ
(Health economic aspect of osteoporotic fractures)
1. Aก"F-M3F International Osteoporosis Foundation (IOF) !5$9RIQA1c,4RAc" (cost) ,-
ก/6&#กGก/กB#กAก%1ก/ก@C- (osteoporotic fractures) ,-"C%7(19) @cIB.@
"C%7,4RAc"2F-,-ก/6&#กGก/กB#กAก%1ก/ก@C-I/Fw~F7}& 25 @#-&R-"/% AกMR30/&
 4

M3F72!83#FกrG72!825"@c05ก,4R2F-,-ก/6&#กGก/กB#กAก%1ก/ก@C-
w~F7}& 1.8 @#-&R-73-J(20) ก70L%" National Osteoporosis Foundation (NOF) M3F
IB#H320ก,-7} 1.8. 1995(21) @c1c,4RAc",-ก/6&#กGก/กB#กAก%1ก/ก@C-
-cAI/Fw~F7}& 17 @#-&R-2B5"IB#H
2. ,-72!89!""#F90c05ก720-7[B-5i,-#72!8 6?c05ก70L1c,4RAc",-ก/6&
#กGก/กI%@กB#ก?c3e/R7u"B-~$F"3"/c!5$70L 120,000 !?c37}(22)

I-4 Pathogenesis and etiology

4.1 X1_/กb>9/- (Pathogenesis)
1. %1ก/ก@C-2กAกก!5$0&ก/ก6&1CL.@M3Fก/ก&&F %" 2 I2B?CB&#ก,Bc€ 1h3
70L0&ก/ก!5$II09R05-R3"กc!5$1A27s- Bh3 05กI&"ก/ก0กกc7ก? ,-4cF
?#iF6?c6ก2กA05ก2@$0M~i-M3F0&ก/กAกกIRFก/ก!5$0กกcกI&"ก/ก !Q,BR
052-hi3ก/ก2@$0M~i-2h$3"€ A-w~FACB-~$Fก2@$0M~i-M3F0&ก/กAB"C&F 70L0&ก/ก
A051cI/FIC2!c!5$C11&-#i-€A059R25"กc 0&ก/กI/FIC (peak bone mass) o~$F0&ก/ก
I/FIC,-74ก9!"3"/c!5$4cF3"C70L 30-34 7}(8) B&#FAก-#i-กIRF6&กI&"ก/ก
AI0C&ก#-!Q,BR0&ก/ก1F!5$ ?c30!5$3"C70L 40-45 7} กbA2$005กI&"ก/ก0กกc
กIRFก/ก!Q,BR0&ก/ก2$0&&F,-3#?4R€ 6?cB&#FAก-#i-20h$3e/RBF2MRI/c#"B0
7AQ2h3- 3#?กI&"ก/ก (rate of bone loss) AI/FM~i-3"cF0ก !Q,BRcFก"05ก
I/2I5"0&ก/ก3"cF?c32-h$3F 6&R,-!5$IC0&ก/กกbA&&F?$QA-w~F2กL„J!5$!Q,BR102I5$"F
?c3ก/กB#ก2@$0M~i-0ก 25"กc2ก%1ก/ก@C--#$-23F #F-#i-กก!Q,€กb?0!5$!Q,BR
0&ก/กI/FIC2@$0M~i- Bh3ก4&33#?กI&"ก/ก,BR&-R3"&F9R กbAI0w&10
2I5$"F?c3ก2ก%1ก/ก@C-&&F9R
2. 7[AA#"!5$05e&?c30&ก/กI/FIC 9R6กc 24hi34? @c4?!5$050&ก/ก0ก!5$IC9R6กc 4eQ
?0R"4eM 6&e2B&h3F?0&Q# @#-KCก0 @c10B-6-c-M3F0&ก/ก,-
00510I#0@#-KJก#0&ก/กI/FICM3FC?(23-25) ก33กกQ&#Fก"6&F-iQB-#ก,-#"2bก
6&#"Cc-!Q,BR050&ก/กI/FIC2@$0M~i-(26,27) ก#7!-61&2o5"0,-#"2bก6&#"Cc-A4c"
2@$00&ก/กI/FIC(28,29) กI/CB5$6&h$063&ก3m3&J!Q,BR0&ก/กI/FIC&&F(30)
3. กI&"M3Fก/ก,-e/RBF2กM~i-3"cF2b6&C-6F,-4cF 10 7}6กB&#FB07AQ2h3-
25"กc postmenopausal bone loss %"A053#?ก&&FM3F0&ก/กw~F7}& 3-5% 3#-27s-
e&Aกก&&FM3Fm3J%0-23I%?2A- IcFe&,BR2o&&JI&"ก/ก(osteoclast) 05ก!QF-
2@$0M~i-3"c F0ก,-4cF-5i A~F 05กI&"M3Fก/ก0กกc กIRFก/ ก %"A2กM~i- !5$
ก/ก%7cF(cancellous or trabecular bone) 0กกcก/ก!~ (cortical bone) #F-#i-ก/กB#ก
!5$2กAก%1ก/ก@C-,-e/RBF#"B07AQ2h3-A~F0#กA2กM~i-กc3-,-?Q6B-cF!5$0570L
ก/ก%7cF0ก 24c- ก/กI#-B&#F 20h$3ec-4cF-5i970&ก/กAI/2I5",-3#?!5$4R&F 2B&h3
@3€ ก#3#?กI/2I5"0&ก/ก,-2@84"(31) 3"cF9กb5 e/RBFF1-กb"#F05กI/2I5"
ก/ก,-3#?ก!5$I/F3"/c?&34cF3"Cกb9R
4. กI/2I5"0&ก/ก,-e/R4"2กM~i-,-3#?!5$?$Qกce/RBF 1h3 053#?7}& 1-2% %"2$0M~i-
?#iF6?c"cF2MRI/c3"C 40-50 7} ,-e/R4"!#iFB0 6& ,-e/RBFF1-!5$B07AQ2h3-0--6&R
(24c - 3"C >70 7} ) I2B?C IQ  1#  !5$ !Q  ,BR 0 &ก/ ก &&F2ก Aกก!5$ 2 o&&J I R  Fก/ ก
 5

(osteoblast) 05ก!QF-!5$2Ih$30w3"&FAก3"C!5$2@$00กM~i- Bh3 กI/2I5"0&ก/ก6-5i

25"กc age-related bone loss
5. !#iFI3F2@8A053C#?กLJM3Fก2กก/กB#กAก%1ก/ก@C-2@$0M~i- %",-e/RBFA2@$0
I/FM~i-?#iF6?c3"C70L 65 7} 6?c,-e/R4"A2@$0M~i-?#iF6?c3"C 70-75 7} 3#?ก2@$0M~i-M3F
ก/กB#กAก%1ก/ก@C-A27s-6 exponential Bh33-Cก02M1L? -#$-1h3A2@$0M~i-3"cF
2b20h$33"C0กM~i-
6. 7[AA#"3h$-€ !5$2cFกI&"ก/ก9R6กc ก,4R"ก&/%113J?13"J กM?0-5 %1!F?c30
9R!c324c- m3J%0-9!3"J6&@9!3"J0ก2ก-97 6&%1MR33#ก2I/0?3"J 27s-?R- A!Q
,BR27s-%1ก/ก@C-9R2bM~i-
7. I2B?CIQ1#M3Fก2กก/กB#กAก%1ก/ก@C-1h3 ก056Fก!Q."-3ก o~$FIc-,Bc
0AกกBก&R0 7[AA#"!5$2ก5$"MR3Fก#ก&R0 (factors of fall)(32) 9R6กc ก11C0 postural
reflexes ?cF€ ก coordination M3Fก&R02-hi3 ก03F2Bb- 0!#iF fat padding 3€ ก/ก
!5$AI0w&6Fก6!ก9R A2Bb -c?F-5i3"CA2MR005!!3"cF0ก!525"  !#iF -5i
2-h$3FAก20h$31-220h$3053"C0กM~i--3กAกก/กA@C-6&R ก&9กก7t3Fก#-ก&R0กbA6"c&F
?097R" 102I5$"F!5$A2กก/กB#กA~F050กM~i-

>?ก
?MK?/K
1. Osteoporosis prevention, diagnosis and therapy. NIH consensus statements 2000; 17: 1-36.
2. Consensus Development Conference: prophylaxis and treatment of osteoporosis. Am J Med
1991;90:107-10.
3. Johnell O. The socioeconomic burden of fracture: today and in the 21st century. Am J Med
1997;103(suppl 2A):S20-5.
4. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. How many women have
osteoporosis? J Bone Miner Res 1992;7(9):1005-10.
5. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in elderly; a cross-
national analysis. Osteoporosis Int 1991;1:232-41.
6. Mahidol Population Gazette. Institute of Population and Social Research, Mahidol
University, 2008.
7. Taechakraichana N, Angkawanich P, Panyakhamlerd K, Limpaphayom K. Postmenopausal
osteoporosis: what is the real magnitude of problem? J Med Assoc Thai 1998;81:397-401.
8. Limpaphayom K, Taechakraichana N, Jaisamrarn U, Bunyavejchevin S, Chaikittisilpa S,
Poshyachinda M, et al. Prevalence of osteopenia and osteoporosis in Thai women.
Menopause 2001;8:65-9.
9. Lau EM, Lee JK, Suriyawongpaisal P, Saw SM, Das De S, Khir A, et al. The incidence of
hip fracture in four Asian Countries: the Asian Osteoporosis Study (AOS). Osteoporosis Int
2001;12:239-43.
 6

10. Lau EM, The epidemiology of osteoporosis in Asia. In: Lau EM, Ho SC, Leung S, Woo J,
(eds). Osteoporosis in Asia: crossing the frontiers. Singapore World Scientific, 1997:1-20.
11. Orimo H, Nakamura T, Fukunaga M. The Japanese guidelines for prevention and treatment
of osteoporosis. (Translated abridged edition). Life Science Publishing, 2006:5.
12. Nevitt MC, Ettinger B, Black DM, et al. The association of radiographically detected
vertebral fractures with back pain and function: a prospective study. Ann Intern Med 1998;
128:793-800.
13. Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR, for the Study of
Osteoporotic Fractures Research Group. Vertebral fractures and mortality in older women; a
prospective study. Arch Intern Med 1999;159:1215-20.
14. Pongchaiyakul C, Nguyen ND, Jones G, Center JR, Eisman JA, Nguyen TV. Asymptomatic
vertebral deformity as a major risk factor for subsequent fractures and mortality: a long-term
prospective study. J Bone Miner Res 2005;20:1349-55.
15. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major
types of osteoporotic fracture in men and women: an observational study. Lancet
1999;353:878-82.
16. Scaf-Klomp W, van Sonderen E, Sanderman R, Ormel J, Kempen GI. Recovery of physical
function after limb injuries in independent older people living at home. Aging 2001;30:213-9.
17. Chariyalertsak S, Suriyawongpaisal P, Thakkinstain A. Mortality after hip fracture in
Thailand. Int Orthop 2001;25:294-7.
18. Suriwongpaisal P, Chariyalertsak S, Wanvarie S. Quality of life and functional status of
patients with hip fractures in Thailand. Southeast Asian J Trop Med Public Health
2003;34:427-32.
19. European Union Osteoporosis Consultation Panel. Osteoporosis in the European
Community: Action plan, 2003.
20. Burge RT, Worley D, Johansen A, Bhattacharyya S, Bose U. The cost of osteoporotic
fractures in the UK: projections for 2000-2020. J Med Econ 2001;4:51-62.
21. Ray NF, Chan JK, Thamler M, Melton LJ-III. Medical expenditures for the treatment of
osteoporotic fractures in the United States in 1995: report from the National Osteoporosis
Foundation. J Bone Miner Res 1997;12:24-35.
22. Woratanarat P, Wajanavisit W, Lertbusayanukul C, Loahacharoensombat W,
Ongphiphatanakul B. Cost analysis of osteoporotic hip fracture. J Med Assoc Thai 2005;
88(5):S96-104.
23. Krall EA, Dawson-Hughes B. Heritable and life style determinants of bone mineral density. J
Bone Miner Res 1993;8(1):1-9.
24. Brown MA, Haughton MA, Grant SF, Gunnell AS, Henderson NK, Eisman JA. Genetic
control of bone density and turnover: role of the collagen 1alpha1, estrogen receptor, and
vitamin D receptor genes. J Bone Miner Res 2001;16(4):758-64.
25. Ralston SH. Genetics of osteoporosis. Rev Endocr Metab Disord 2001;2(1):13-21.
 7

26. Taaffe DR, Robinson TL, Snow CM, Marcus R. High-impact exercise promotes bone gain in
well-trained female athletes. J Bone Miner Res 1997;12(2):255-60.
27. Kemper HC, Twisk JW, van Mechelen W, Post GB, Roos JC, Lips P. A fifteen-year
longitudinal study in young adults on the relation of physical activity and fitness with the
development of the bone mass: The Amsterdam Growth And Health Longitudinal Study.
Bone 2000;27(6):847-53.
28. Matkovic V, Fontana D, Tominac C, Goel P, Chesnut CH, 3rd. Factors that influence peak
bone mass formation: a study of calcium balance and the inheritance of bone mass in
adolescent females. Am J Clin Nutr 1990;52(5):878-88.
29. Johnston CC Jr, Miller JZ, Slemenda CW, Reister TK, Hui S, Christian JC, et al. Calcium
supplementation and increases in bone mineral density in children. N Engl J Med
1992;327(2):82-7.
30. Välimäki MJ, Kärkkäinen M, Lamberg-Allardt C, Laitinen K, Alhava E, Heikkinen J, et al.
Exercise, smoking, and calcium intake during adolescence and early adulthood as
determinants of peak bone mass. Cardiovascular Risk in Young Finns Study Group. BMJ
1994;309:230-5.
31. Garnero P, Sornay-Rendu E, Chapuy MC, Delmas PD. Increased bone turnover in late
postmenopausal women is a major determinant of osteoporosis. J Bone Miner Res 1996;
11(3):337-49.
32. Bouxsein ML, Myers ER, Hayes WC. Biomechanics of age-related fractures. In Marcus R,
Feldmen D, Kelsey J. (eds). Osteoporosis. Academic Press 1996, San Diego, CA.
 8

Diagnosis and bone mass assessment in osteoporosis

II-1 History, physical examination and differential diagnosis

1.1 ก[bB9กC,>:0J?K3=ก,-;กXO9(1)
(Classification of osteoporosis)
%1ก/ก@C-AQ6-ก33ก9R27s-

กก

  (Primary osteoporosis) o~$F6cF"c3"27s-
1. 3=ก,-;กXO989L;MN/K.1N<-C,[b>-e?9 (postmenopausal osteoporosis) 2กก
I/2I5"0&ก/กAก.Mm3J%0-23I%?2A-27s-B&#ก
2. 3=ก,-;กXO989.1
;K?1O (age-related Ne? senile osteoporosis) 2ก9R!#iF,-e/R4"6&
e/RBF o~$F27s-7[BAกกIRFก/ก9R-R3"&FAก102Ih$30M3F2o&&JIRFก/ก

กก

 ! (Secondary osteoporosis) ?0?F!5$ 2.1

PK0A2 2.1 6IFI2B?CM3F%1ก/ก@C-4-!C?"./0!5$@c3"

1. %1!F?c309R!c3
− CushingŽs syndrome
− . hypogonadism
− ?c309!3"J27s-@G
− .m3J%0-@9!3"JI/F
2. "
− ก&/%113J?13"J
− "?R-ก6MbF?#M3F2&h3 (heparin, warfarin)
− "ก#-4#ก 9R6กc phenytoin, phenobarbital
− "ก./01C0R ก#- 6&"#กG02bF
3. %1!F3"Cก0
− %19?
− %1?#2hi3#F
− ./o~03Be7ก? (malabsorption) Bh3ec?#ก2@3B
− MR33#ก2I/0?3"J
4. 3h$-€
− MI3B
− %102bF 6& multiple myeloma
− %1 osteogenesis imperfecta
 9

II-2 Risk factors for osteoporosis and osteoporotic fractures

2.1 Cg[[1>
A21KJ?K3=ก,-;กXO9B4,ก,-;กNก[ก3=ก,-;กXO9
(Risk factors of osteoporosis and osteoporotic fracture)
2-h$3FAก3=ก,-;กXO9<กE<RB
-K?กL/-CกP/[9ก.R[,>ก/-ก,-;กNก ,-ML!5$20h$3
@AL,-24F28GH8I?J!FIKLICM6&R "#F90c05101CR01c!5$A!Qก?A1#ก3FR"21h$3F#
10B-6-c-ก/ก (bone densitometer) ,-74ก%"!#$97!#iFB0 #F-#i-ก,4Rก720-7[AA#"
2I5$"F (risk assessment) o~$F27s-21h$3F0h3!5$,4R9RFc" Iก 6&7B"#,-!F7a#? 2@h$31R-Be/R!5$05
7[AA#"2I5$"F!5$A2ก%1ก/ก@C-Bh3ก/กB#ก -cA27s-K5ก!5$2B0I0กc(2)
7[ A A# " 2I5$ " FB&# ก !5$ 05 1 0I# 0 @# - KJ ก#  ก2ก %1ก/ ก @C - 6&ก/ ก B# ก ,-e/R B  F# " B0
7AQ2h3-05#F-5i
&''(!)*+,!-+,./*001 (2) 3+,!
.4 (Non-modifiable risk factors)
1. I/F3"C (3"C?#iF6?c 65 7}M~i-97)
2. 2@8BF
3. e/RBFeM6&e/RBF23245"
4. B07AQ2h3-กc3-3"C 45 7} (early menopause) o~$FB0"0w~Fe/R!5$w/ก?##F9Mc!#iFI3FMRFกc3-
B07AQ2h3-
5. %1FIRFM3FcFก"2&bก (small body build)
6.  0 @5$IBh3-R3FI27s-%1ก/ก@C-Bh3ก/กB#กAก%1ก/ก@C-
7. 21"ก/กB#กAก.ก/ก27F (fragility fracture)
&''(!)*+,!-+, (2) 3+,!
.4 (Modifiable risk factors)
1. %.161&2o5"090c2@5"F@3 (inadequate calcium intake)
2. 90c1c3"9R,4R6Fก" (sedentary lifestyle)
3. I/CB5$27s-7AQ
4. h$0IC2ก-M-27s-7AQ
5. h$0ก6‚2ก-M-27s-7AQ
6. #4-50&ก"?$Qกc 19 กก./?0.
7. 05.Mm3J%0-23I%?2A- (estrogen deficiency) กc3-2MRI/c#"B07AQ2h3- 24c- ก
9R#" gonadotropin releasing hormone (GnRH) analogue Bh3Aกก33กกQ&#Fก"3"cF
B-#ก27s-"2&--
8. 05102I5$"F?c3กBก&R0 (propensity to falls) 24c- ก03F2Bb-90c4#2A- (impaired vision)
2.2 กC,></9Cg[[1>
A21KJ?Kก>ก/-ก,-;กNก[ก3=ก,-;กXO9 3-18@M FRAXTM
J?K?K=^ก?9<134ก
(Risk assessment of osteoporotic fracture using WHO-FRAXTM)
WHO(3) 9R!Qก8~กG%"!Q meta-analysis population-based cohorts B&"ก8~กGAก
72!8,-!57"C%7 320ก2B-h3 232o5" 6& 33I2?25" I0wกQB-7[AA#"2I5$"F%"1#2&h3ก2|@
7[AA#"2I5$"F!5$05&#กGL#F-5i1h3
 10

1. Independent ?c3 BMD

2. 05B&#กH-I-#I-C-AกB&"€ ก8~กG!5$4#2A-c27s-7[AA#"2I5$"F!5$IQ1#
3. I0w adjusts IQB#3"C, 2@8 6&72.!M3Fก/กB#ก9R
4. 6@!"J247a#?!#$97I0w2MR,A6&,4R9R3"cFFc""
5. e&Aกก#กGR""I0w&102I5$"F2B&c-5i9R (2|@กL5102I5$"F!5$ modifiable)
!Q,BR9R 7[AA#"2I5$"F!5$IQ1#!#iFB0 9 7[AA#"!5$2MR?0B&#ก2กL„J-5i ?0?F!5$ 2.2 %"!5$023
1c10B-6-c-ก/ก (bone mass density, BMD) 2MR9727s-7[AA#"2I5$"F3#-B-~$FR" %",4R2|@1c
femoral neck BMD 27s-B&#ก 6&wR3"/c,-Iw-!5$!5$90cI0w?A BMD 9R ,BR,4R 1c body mass index
(BMI) 6!- %"1c!5$6!-&F,-7[AA#"2I5$"FIQ1#2B&c-5i 27s-1c!5$,BR2&h3กc 05 Bh3 90c05 (yes/no) "ก2R-3"C
6& BMD/BMI 2!c-#i-!5$A6!-R"1cAF

PK0A2 2.2 7[AA#"2I5$"FIQ1#!5$ WHO -Q0,4R,- FRAXTM

Age (yr)
BMD(FN) / BMI (T-score or kg/M2)
A prior fragility fracture (yes/no)
Parental history of hip fracture (yes/no)
Current tobacco smoking (yes/no)
Ever long-term use of oral glucocorticoids (yes/no)
Rheumatoid arthritis (yes/no)
Other causes of secondary osteoporosis (yes/no)
Daily alcohol consumption of three or more units daily (yes/no)
N<1>NPO BMD(FN) = femoral neck bone mass density, BMI = bone mass density
0A2< WHO task force conference held in Brussels, Belgium in May 2004

MR30/&6&7[AA#"2I5$"F?cF€ 2B&c-5iw/กกQB-9R6&1Q-L%"!Q27s-%76ก0IQ2bA/7 o~$FA

I0w1Q-L33ก027s-10-cA27s-!5$A2กก/กB#ก,-" 10 7} (10-year probability of fracture)
9R %76ก0 FRAXTM -5iI0w2MR97,4R9R!F internet !5$ http://www.shef.ac.uk/FRAX(4) o~$FAF€ 6&R
10-year probability -5i0510e#-67M~i-ก#72!86&24hi34??cF€R" ,- website -5iกbA05 FRAXTM
M3F72!8?cF€ B&"72!8 IQB#!F 72!8,-6w232o5"กb05 72!85$7Cu- A5- 6& US-Asian o~$F
A9Re&&#@KJ27s- 2 61h3 10-year probability of hip fracture 6&10-year probability of other major
osteoporotic fractures !#iF-5iI0w-Q1c!#iFI3F0,4R720-102I5$"FM3Fe/R7u"2@h$3,4R2$0ก#กG9R
(therapeutic threshold) 24c- ,-72!8320ก7[AAC#- wRe/R7u""#F90c05 fracture Bh3 BMD "#F90c?$Qกc
-2.5 A,4Rก1Q-LB1c 10-year probability of fracture 27s-?#กQB-cA,BR"#กGBh390c 1h3 wR
e/R7u"05 10-year probability of hip fracture ≥ 3% Bh3 10-year probability of other major osteoporotic
fractures ≥ 20% กb,BR"#กG9R(5)
7[AAC#-"#F90c05MR30/&M3F74ก9!",-ก1Q-L FRAX !F0/&-K%1ก/ก@C-6BcF
72!89!"A~F9R!Qก8~กG6&!Qก!I3 FRAXTM %"ก3RF3FMR30/&,-4-4 Asia ,-2hi3F?R-
@c ก8@M FRAXTM J?KC,@ก>@eQ?@P/>?>@A1 E-MBกR US-Asian B4, Japan -cA05102B0I0
 11

20h$3@ALAกMR30/&!F!"M3F%1ก/ก@C-,-72!89!" 3"cF9กb?02-h$3FAก"#F90c05
ก8~กG1cAC?#!5$2B0I0,-ก,BRก#กGR"",-1-9!" A~F6--Q,BR,4R1cAC?#?01Q6--Q
M3F NOF 1h3 10-year probability of hip fracture ≥ 3% Bh3 10-year probability of other major
osteoporotic fractures ≥ 20% กb,BR"#กG9R

II-3 Laboratory investigation and bone strength assessments

3.1 กP.[0KNM?KCo/P/ก (Laboratory investigation)
<( 1 *-=>?-ก0 <'0-@4?- A2( ก0
1. 2@h$3"h-"#-ก-A|#"%1ก/ก@C-
2. 2@h$3720-102I5$"F,-ก2กก/กB#ก
3. 2@h$3BI2B?CM3F%1ก/ก@C-4-!C?"./0
B
)2CD?- 4
< <'0-@4?- A2( ก0
− Complete blood count (CBC)
− Serum calcium, phosphate, albumin 6& liver transaminases
− Serum alkaline phosphatase
− Renal function (blood urea nitrogen and creatinine)
− Plain x-rays 6--Q,BR?Aก/กI#-B&#FIc-3ก6&23R-MRF (lateral thoraco-lumbar spine)
Bh 3 ก/ ก I%@กR  -B-R  -B&# F (antero-posterior hip) 20h$ 3 05 MR 3 c F 45i B h 3 20h$ 3 IFI# " c  A05
ก/กB#ก
3.2 กC,></9=.<BJpKBกRKJ?Kก,-;ก (Bone strength assessment)
106MbF6กcFM3Fก/ก2กAกI3F7[AA#"B&#ก 1h3 70LM3F0&ก/ก (bone mass) 6&
1CL.@M3Fก/ก (bone quality) o~$F,-7[AAC#-"#F90c052!1%-%&"5,!5$AI0w-Q0720-1CL.@
ก/ก9R3"cFw/ก?R3F60c-"Q6&-Q97,4R,-!F1&-ก9R ก720-106MbF6กcFM3Fก/ก,-!F
1&-กA~F,4Rก#10B-6-c-ก/ก27s-B&#ก
1. ก?A%",4R plain x-ray 90cI0wcF3กก&&FM3F0&ก/ก9R9@3 2-h$3FAก.@
x-ray !5$AI0w6IF,BR2Bb-กF&FM3Fก/ก!5$/9RR"I"?-#i- 0&ก/กA?R3F&&F
0กกc 30% Aก1c7ก?976&R
2. Semi-quantitative method ,-ก720-.@ plain film x-ray 24c- K5 SinghŽs index 27s-?R-
90cI0wA11C01CL.@ก720-9R24c-ก#- %"05 intra-observer 6& inter-observer
variation 0กA~F90c6--Q,BR-Q0,4R
3. Bone mass measurements !5$ WHO กbN9-8NM>CW9<P]989ก./9/[q1:.,3=
ก,-;กXO9กp=e? axial dual-energy x-ray absorptiometry (axial DXA) >0R9Q9
4. Bone mass measurements R">0=39341A?e29r >@R9 quantitative ultrasonography (QUS)
Ne? peripheral DXA (pDXA) E<R
<u9b<8@M0-B09กP.[-M.1 axial DXA >Xe2?ก
./9/[q13=ก,-;กXO9 6?c2!1%-%&"52B&c-5iกb"#F057%"4-JIQB#1#ก3Fe/R!505102I5$"FI/F
?c3%1ก/ก@C- 2@h$3ก-Q0?A"h-"#-R" axial DXA 35ก!5
 12

II-4 Diagnostic criteria for osteoporosis

4.1 กP.[=.<N9B9R9ก,-;ก (Measurement of bone density)
10B-6-c-ก/ก (Bone mass density, BMD) 0521h$3F0h3!5$,4R?A#3"/cB&"4-
#F?c397-5i
Dual Energy X-ray Absorptiometry
ก-A|#"%1ก/ก@C-,-e/RBF38#"2กL„Jก-A|#"M3F3F1Jก3-0#"%&ก(6,7) ?0?F
!5$ 2.3 o~$F38#"ก275"2!5"1c BMD !5$#9Rก#1c2|&5$" BMD I/FIC ,-e/RBF#"I 6&,BRw3h 1c!5-$ 3R "
กcBh32!cก# -2.5 2!cM3F1c25$"F2-0?H-,-ก-A|#"%1ก/ก@C- %"@102I5$"FM3Fก
2กก/กB#ก2@$0M~i- 1.4 - 2.6 2!c!Cก€ 1 2!cM3F1c25$"F2-0?H-!5$&&F(8)

PK0A2 2.3 ก-A|#"%1ก/ก@C-?01c10B-6-c-ก/ก!5$#R"21h$3F DXA

ก./9/[q1 กP.[X
7ก? 10B-6-c-ก/ก3"/,c -2กL„J7ก? 1h3051c0กกcBh32!cก#
(normal) -1 2!cM3F1c25"$ F2-0?H-20h$3275"2!5"ก#1c2|&5$"0&ก/กI/FIC
,-e/RBF#"I (T-score ≥ -1)
ก/กF (osteopenia) 10B-6-c-ก/ก?$Qกc -1 2!cM3F1c25"$ F2-0?H-6?c0กกc
-2.5 2!cM3F1c25$"F2-0?H-20h$3275"2!5"ก#1c2|&5$"0&ก/ก
I/FIC,-e/RBF#"I ( -2.5 < T-score < -1)
ก/ก@C- 10B-6-c-ก/ก?$QกcBh32!cก# -2.5 2!cM3F1c25"$ F2-0?H-
(osteoporosis) 20h$3275"2!5"ก#1c2|&5$"0&ก/กI/FIC,-e/RBF#"I
(T-score ≤ -2.5)
ก/ก@C-#C-6F 10B-6-c-ก/ก?$QกcBh32!cก# -2.5 2!cM3F1c25"$ F2-0?H-
(severe/established 20h$3275"2!5"ก#1c2|&5$"0&ก/กI/FIC,-e/RBF#"I
osteoporosis) (T-score ≤ -2.5) c0ก#05ก/กB#กAก1027F (fragility fracture)

,-ก?A BMD 2@h$3-A|#"%1ก/ก@C--#i- ,BR?A!5$ก/กI#-B&#FIc-23 (lumbar spine

Bh3 L-spine) 6&ก/กI%@ก (hip) 2!c-#i- o~$F25"กc axial DXA 90c0510AQ27s-?R3F?A!5$ก/ก
7&"6M- (peripheral DXA) "ก2R-,-e/R7u"!5$3R-0ก Bh390cI0w?A axial DXA 9R
1c3RF3F!5$-Q0,4RIQB#275"2!5" PM?K8@M=R>q4A21<.4ก,-;ก
;K
O-89L;MN/K.1
. 0A2>CW9
>@eQ?@P/>-A1.ก9 Ne?8ก4M>=A1Kก9 (Asian female reference) ก#e/Rw/ก?A 2!c-#i- 24c-,-1-9!" AF€
6&R?R3F,4R1c2|&5$"0&ก/กI/FIC,-e/RBF#"I9!" 6?cกb3-C%&0,BR,4RM3F45$7Cu-Bh3A5-6!-9R (6?c
90c,4RM3F Caucasian)
IQB#,-กL5e/R4" ก-A|#"%1ก/ก@C-A,4R2กL„J24c-25"ก#-ก#,-e/RBF (#F,-?F!5$
2.3) 6?cก,4R1c0&ก/กI/FIC2|&5$"!5$,4R3RF3FIQB#275"2!5" (reference young adult mean) A,4R
1c2|&5$"0&ก/กI/FIC,-e/R4"B-Cc0 (male reference) !5$27s-24hi34?25"ก#- Bh3,ก&R215"Fก#-6!-ก,4R
M3Fe/RBF (female reference)
 13

>4?2/-+DB
ก0*/- <' BMD 4<!)C,?- axial DXA(9)
1. e/RBF3"C?#iF6?c 65 7}M~i-97 6&e/R4"3"C?#iF6?c 70 7}M~i-97
2. IQB#e/RBF!5$053"C?$Qกc 65 7} 6& e/R4"!5$053"C?$Qกc 70 7} !5$05057[AA#"2I5$"F#F?c397-5i 3"cF
-R3" 1 MR3
− B07AQ2h3-กc3-3"C 45 7} (early menopause) o~$FB0"0w~Fe/R!5$w/ก?##F9Mc!#iFI3FMRF
กc3-B07AQ2h3-
− 05.Mm3J%0-23I%?2A- (estrogen deficiency) กc3-2MRI/c#"B07AQ2h3- ?c32-h$3F
--กc 1 7} "ก2R-กL5?#iF1.J6&,BR-0C?
− 9R#"ก&/%113?13"J27s-"2&-- (2@-%o%&-#-& 7.5 0ก.Bh32!5"2!c27s-
"2&--กc 3 2h3-)
− 057#?Bh30ก/กI%@กB#ก
− e/RBF#"B07AQ2h3-!5$05#4-50&ก"-R3"กc 19 กก./?0.
3. ?A@.ก/กFBh3ก/กI#-B&#Fe/7Aกกwc".@#FI523กo2"J (radiographic
osteopenia and / or vertebral deformity by x-ray)
4. 057#?ก/กB#กAก."#-?"690cC-6F
5. 05Ic-I/F&&F
6. 3"/c,-ก&Cc0!5$05102I5$"FI/F Aกก?A1#ก3FR" OSTA score(10), KKOS score(11) Bh3
nomogram 0กกc 0.3 IQB#e/RBF#"B07AQ2h3- (/.1e-ก 2.2)
(N<1>NPO OSTA; Osteoporosis Self Assessment Tool for Asians, KKOS; Khon Kaen
Osteoporosis Study score)
Quantitative Ultrasound (QUS)
!!M3F QUS !#iFก-A|#"6&ก??0ก#กG"#F90c4#2A- IQB#ก-A|#"@c
ก,4R QUS 3"cF25"05109 (sensitivity) ?$Q 6?c0510AQ2@ (specificity) I/F 3"cF9กb?0ก-Q
QUS 0,4Rc0ก# OSTA(10) 6& KKOS(11) AI0w2@$01096&10AQ2@0กM~i-(12) -3กAก-5i
ก,4R QUS c0ก#3"C6&-iQB-#ก,-/76%-%06ก0 (nomogram) A4c"!Q-"ก2ก%1ก/ก
@C-9R5M~i-(13) 3"cF9กb?0กP.[9AQE<R
<u8@M89ก./9/[q13=ก,-;กXO9E-M
4.2 -@9A@A.>=<AJ?Kก,.9ก
MKB4,
41ก,-;ก
(Biochemical markers of bone turnover)
#4-5!F452105M3Fก-กIRF6&I&"ก/ก E<RB9,9b8NM8@M89ก./9/[q13=ก,-;ก
XO9 2-h$3FAก1cM3F0#-05ก27&5$"-67&F9RAกB&"€ 7[AA#" 6&3AA@10e7ก?9R,-B&"€
%1!5$90c,4c%1ก/ก@C- 6?cI0w,4Rc0ก# BMD ,-ก720-102I5$"FM3Fก2กก/กB#ก9R(14-
16)
3"cF9กb?0#4-5#Fก&c A<AC,31@9^89BKRJ?KกP/-P<กก\(17) %"6--Q,BR720-
."B&#Fก#กG!5$ 3 2h3-6& 1 7} I0w,4R720-ก?3I-3F?c3ก#กGR""9R5 6&!
e&9R2b
IQB##4-5!F452105M3FกI&"ก/ก 9R6กc urinary deoxypyridinoline (DPD), urinary N-
telopeptide (NTx) 6& serum C-telopeptide (CTx) Ic-#4-5!F452105M3FกIRFก/ก 9R6กc bone
 14

specific alkaline phosphatase (BSAP), osteocalcin, C-terminal propeptide of type 1 procollagen

(P1CP) 6& N-terminal propeptide of type 1 procollagen (P1NP)(18)
4.3 กP.[=-ก?K (Screening)
ก?A1#ก3F%1ก/ก@C-R" axial DXA IQB#744-!#$9790c6--Q2-h$3FAก90c
1CR01c,-24F28GH8I?J!FIKLICM 6?c,-7[AAC#-ก?A1#ก3FR" OSTA(10) Bh3 KKOS(11)
I0wก!Q9R2-h$3FAก90c051c,4RAc" I0w1R-Be/R!5$05102I5$"F,-ก2ก%1ก/ก@C-2@h$3?A
BMD ?c3979R (/.1e-ก 2.1)
 15

:=L9.ก 2.1
OSTA (Osteoporosis Self-Assessment Tool for Asians)

%"I/?,-ก1Q-L102I5$"F OSTA -#i- 2!cก# 0.2 X (-iQB-#ก-3"C) e&&#@KJ!5$9R,BR?#AC

!8-"033ก %"3"C,4RB-c",4R27s-7} -iQB-#ก?#,4RB-c"27s-ก%&ก#0
ก0Q 3R3
OSTA index -R3"กc -4 102I5$"FI/F
BcF -4 w~F -1 102I5$"F7-ก&F
?#iF6?c -1 M~i-97 102I5$"F?$Q
 16

Khon Kaen Osteoporosis study score (KKOS)(13)

Age (y) Score Weight (kg) Score

< 45 + 7.5 < 30 - 14
45 - 49 + 6.0 30 - 34 - 12
50 - 54 + 4.5 35 - 39 - 10
55 - 59 + 3.0 40 - 44 -8
60 - 64 + 1.5 45 - 49 -6
65 - 69 0 50 - 54 -4
70 - 74 - 1.5 55 - 59 -2
75 - 79 - 3.0 60 - 64 0
80 - 84 - 4.5 65 - 69 +2
85 z 89 - 6.0 70 - 74 +4
> 90 - 7.5 75 - 79 +6
80 - 84 +8
85 - 89 + 10
> 90 + 12

ก1Q-L KKOS ,BR-Q1c16--Aก3"C (7}) 6&-iQB-#ก (ก%&ก#0) 0กก#-

KKOS < -1 : =.<>
A21K89ก>ก/-3=ก,-;กXO9
;K
KKOS > -1 : =.<>
A21K89ก>ก/-3=ก,-;กXO9P2b

<( ?!/0-ก0S0
<T
I?53"C 52 7}, -iQB-#ก 48 ก%&ก#0
KKOS = (+ 4.5) + (- 6) = - 1.5 ..=..102I5$"FI/F

-3กAก-#i- KKOS "#FI0w1Q-L%3กIM3Fก2ก%1ก/ก@C-9R%"/Aก?F ,-

กL5!5$?#iF6?c 80% M~i-97A#3"/c,-ก&Cc0102I5$"FI/F 21-79% A#3"/c,-ก&Cc0102I5$"F7-ก&F 6&-R3"กc
20% A#3"/c,-ก&Cc0102I5$"F?$Q
 17

?ก0* (probability) B
ก0)ก
กก

!B4 KKOS
 18

:=L9.ก 2.2
393<Bก<89ก0b91ก>ก/-3=ก,-;กXO989
PA.1N<-C,[b>-e?93-18@M
?1O 9QbN9กB4, QUS(15)

<W+ก0S0
<T
1. &ก2IR-Aก6ก-3"CM~i-97"#F6ก-16-- (point)
2. &ก2IR-Aก6ก--iQB-#ก97"#F6ก-16-- (point)
3. &ก2IR-Aก6ก- QUS 97"#F6ก-16-- (point)
4. -Q!#iF 3 16--00ก#- (total points)
5. &ก2IR-Aก6ก-16--0 (total points) &F0"#F6ก-102I5$"FM3F%1ก/ก@C- (risk of
osteoporosis)
6. ,-กL5!5$102I5$"FM3Fก2ก%1ก/ก@C-?#iF6?c 0.3 M~i-97A#27s-ก&Cc0!50$ 5102I5$"FI/F,-ก2ก
%1ก/ก@C- 1IcF?A BMD ?c397
(<?!/0-
e/RBF3"C 70 7} -iQB-#ก 50 ก%&ก#0 e&?A QUS T-score -3 SD
20h$3&ก2IR-?0M#i-?3-!5$ 1-3 A9R16-- 48, 67 6& 78 ?0&Q# %"0516--02!cก#
193 (M#i-?3-!5$ 4) 6&20h$3&ก2IR-Aก6ก-16--0 193 &F0"#F6ก-102I5$"FM3F%1ก/ก@C- A
9R2!cก# 0.5 (M#i-?3-!5$ 5)
ก67&e&: ,-e/RBF3"C 70 7} -iQB-#ก 50 ก%&ก#0 e&?A QUS T-score -3 SD AQ-- 100
1- A05%3กI2ก%1ก/ก@C- 50 1-
 19

>?ก
?MK?/K
1. Greenspan SL, Luckey MM. Evaluation of postmenopausal osteoporosis. In : Favus MJ,
editor. Primer on the metabolic bone diseases and disorders of mineral metabolism, 6th ed.
Lippincott Raven Press; New York, NY, USA, 2006, pp.268-72.
2. Riggs BL, Melton LJ. Evidence for two distinct syndromes of involutional osteoporosis. Am J
Med 1983;75:899-901.
3. Kanis JA, Black D, Cooper C, et al. on behalf of the IOF and the NOF USA. A new
approach to the development of assessment guidelines for osteoporosis. Osteoporosis Int
2002;13:527-36.
4. FRAX-WHO fracture risk assessment tool, http://www.shef.ac.th/FRAX
5. NOF(National Osteoporosis Foundation). Clinician Guide for Prevention and Treatment of
Osteoporosis 2008.
6. Gallagher JC. The pathogenesis of osteoporosis. Bone Miner 1990;9(3):215-27.
7. National Osteoporosis Foundation. Osteoporosis: review of the evidence for prevention,
diagnosis, and treatment and cost-effectiveness analysis. Osteoporosis Int 1998; 8 (Suppl
4):S1-80.
8. World Health Organization. Assessment of fracture risk and its application to screening for
postmenopausal osteoporosis. No. 843 of Technical Reports Series. Geneva: 1994.
9. Kanis JA, Melton LJ 3rd, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of
osteoporosis. J Bone Miner Res 1994 ;9:1137-41.
10. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral
density predict occurrence of osteoporotic fractures. BMJ 1996; 312(7041):1254-9.
11. WHO.1994. Assessment of fracture risk and its application to screening for postmenopausal
osteoporosis. Technical report series 843. Geneva: WHO
12. Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, et al. A simple tool to
identify asian women at increased risk of osteoporosis. Osteoporosis Int 2001;12:699-705.
13. Pongchaiyakul C, Nguyen ND, Pongchaiyakul C, Nguyen TV. Development and validation
of a new clinical risk index for prediction of osteoporosis in Thai women. J Med Assoc Thai
2004;87:910-6.
14. Pongchaiyakul C, Panichkul S, Songpatanasilp T. Combined clinical risk indices with
quantitative ultrasound calcaneus measurement for identifying osteoporosis in Thai
postmenopausal women. J Med Assoc Thai 2007;90(10):2016-23.
15. Pongchaiyakul C, Panichkul S, Songpatanasilp T, Nguyen TV. A nomogram for predicting
osteoporosis risk based on age, weight and quantitative ultrasound measurement.
Osteoporos Int 2007;18(4):525-31.
16. Gerdhem P, Ivaska KK, Alatalo SL, Halleen JM, Hellman J, Isaksson A, et al. Biochemical
Markers of Bone Metabolism and Prediction of Fracture in Elderly Women. J Bone Miner
Res 2004;19(3):386-93.
 20

17. Riis BJ, Hansen MA, Jensen AM, Overgaard K, Christiansen C. Low bone mass and fast
rate of bone loss at menopause: equal risk factors for future fracture: a 15 year follow-up
study. Bone 1996;19(1):9-12.
18. Riggs B, Melton LJ, OŽFallon WM. Drug therapy for vertebral fractures in osteoporosis:
evidence that decreases in bone turnover and increases in bone mass both determine
antifracture efficacy. Bone 1996;18:197S-201S.
 21

Prevention of osteoporosis and falls

ก7t3Fก#-%1ก/ก@C-10B0"w~Fก7t3Fก#-90c,BR0&ก/ก&&F,-C11&!5$"#F90c27s-%1
ก/ ก @C - ,-7[ A AC # - ก&"C ! KJ , -ก7t 3 Fก# - %1กC ก @C - A2-R - 97,-!Fก90c , 4R "  (non-
pharmacologic strategy) 2@05101CR01c!F28GH8I?J0กกc ก7t3Fก#-6cF33ก9R27s-I3F
4cF2&1h3 ,-#"2"JA27s-กIRF,BR0&ก/ก0570L0ก!5$IC 6&,-#"!3F2@h$37t3Fก#-ก&&F
M3F0&ก/ก ,-!5$-5i#"!3FB0"w~Fe/RBF#"B07AQ2h3-6&e/R4"3"C0กกc 50 7}

III-1 Strategies to maximize peak bone mass

ก2I0IRF0&ก/กI/FIC (peak bone mass) ?#iF6?c"#F2"J#" 057%"4-J0ก,-กII0
?R-!C-,BRก/ก6MbF6F6&051CL.@!5$5 I0w!Q9R%"
1. ก33กกQ&#Fก"%"ก&F-iQB-#ก (weight bearing exercises) 6&ก33กกQ&#Fก"%",4R6F
?R- (resistive exercises)
2. ก#7!-3B!50$ 561&2o5"0?0MR3กQB-,-6?c&#"
3. ก#6IF63"cF@32@5"F 2@h$3,BReB-#FIRF?0-5
4. ก&@r?ก02I5$"F?c3%1ก/ก@C- 9R6กc
4.1. FI/CB5$
4.2. Fh$0ก6‚Bh321h$3Fh$0!5$05Ic-eI0M3F12‚35-
4.3. B&5ก2&5$"F3B21b0A#6&05%7?5-I/F
4.4. 90ch$0IC2ก-M-
5. 7#w545?,BR05กAก0ก21&h$3-9B!Fก" (physical activities)
6. 11C0%12hi3#F!5$27s-7[AA#"2I5$"F?c3%1ก/ก@C-
7. 0##Fก,4R"!5$27s-7[AA#"2I5$"F?c3%1ก/ก@C-
8. 11C0-iQB-#ก?#,BR@32B0%"#4-50&ก"3"/cBcF 20-23 กก./?0.

III-2 Strategies to prevent bone loss

B&#FAก!5$cFก"IRF0&ก/กI/FIC6&R 3#?กIRFก/ก (rate of bone formation) A4R
กc3#?กI&"ก/ก (rate of bone resorption) o~$F3#?#Fก&cA2@$0M~i-2b0ก%"2|@3"cF"$F
,-e/RBF#"B07AQ2h3- ,-4cF#Fก&c2I0w&3#?กI&"ก/ก9R%"
1. K5ก90c,4R" (non-pharmacological management) o~$F27s-K5!5$,4R,- III-1 !#iFB0
2. K5ก,4R" (pharmacological management) ก,4R"A2&h3ก,4R,-e/R!5$05ก&Cc02I5$"FI/F?c3ก27s-
%1ก/ก@C- o~$F7ก3R"ก,4R",-ก&Cc0
2.1. m3J%0-!6!-
2.2. 61&2o5"06&?0-5
 22

ก8NM?^3<90-B09 (Hormone replacement therapy)

1. ก#กGR"23I%?2A- (estrogen therapy, ET) Bh3m3J%0-!6!- (hormone [replacement]
therapy, H[R]T) ,-ก#กGe/RBF#"B07AQ2h3-9R#ก#3F,BR,4R ,-"!5$AQ27s-?R3F#กG
3กB07AQ2h3-R"24c- R3-/ 3ก4c3F1&36BRF 6&,4R2@h$37t3Fก#-.ก/ก@C-
(1-6)
ก,BRm3J%0-23I%?2A-,-1-!5$"#F90c9R?#0&/ก A?R3F05m3J%0-%72AI?- c0R"2@h$3
7t3Fก#-.2"h$3C0&/กB-?#
2. ก8~กG!5$054h$3c Women Health Initiative (WHI) study(7) 9R"F-e&ก,4Rm3J%0-23I%?2A-
4-!5$27s- conjugated equine estrogen (CEE) c0ก# medroxy progesterone acetate (MPA) 27s-
2& 5 7} @cI0w&3C#?กLJM3FกB#กM3Fก/กI#-B&#F6&ก/กI%@ก!5$053ก!F
1&-ก&F9R 34% 6&&กB#กM3Fก/ก3h$-€ 9R 23%
3. ,-ML25"ก#- WHI study 9R"F-w~Fe&2I5"M3Fก,4Rm3J%0-!6!-c!Q,BR05102I5$"F,-
ก-A|#"%102bF2?R-02@$0M~i- 6&!Q,BR2กB&32&h3Q3C?#-6&%1B&32&h3B#,A 2@$0M~i-
B&#FAก-#i-9R05ก21BJMR30/&20M3F WHI M~i-0,B0c ก&#@c ก,4Rm3J%0-!6!-4-
0 (CEE c0ก# MPA) ,-e/RBF!5$B07AQ2h3--R3"กc 10 7} A&102I5$"F,-ก2ก%1
B&32&h3B#,A9R 6&wR27s-ก,4R23I%?2A-4-25"??c3ก#-27s-2& 7.1 7} ก&#@c 10
2I5$"FM3Fก2ก02bF2?R-0-R3"กce/R!5$90c9R,4Rm3J%0- 3"cF9กb?0 "#F90c9R05ก8~กGw~Fe&5
6&e&2I5"M3F23I%?2A- Bh3 %72AI?-4-3h$-€ 275"2!5"ก# CEE 6& MPA #F-#i-A~F3-C0-
c 102I5$"F?cF€ -cA2B0h3-ก#- 6--Qcก,4Rm3J%0-23I%?2A- 6& / Bh3 c0ก#%72AI
?- A~F1,4R,-70L!5$-R3"!5$IC!5$A2กe&5?c3ก#กG6&,4R,-4cF2&!5$I#i-!5$IC2!c!5$AQ27s-(8, 9)
4. ก,4Rm3J%0-M-?$Q27s-2&--,-e/RBF!5$053กMm3J%0-6&05102I5$"F?c3ก2กก/ก
@C-,-#"B07AQ2h3- I0w!Q9R wRI?5-#i-9R#1Q6--Q,BR!w~F7%"4-J6&102I5$"F
M3Fก,4Rm3J%0-3"cF&235"(9)
5. กB"Cm3J%0-A!Q,BR2กก2I5"0&ก/ก7}& 3% w~F 6% 05MR30/&"h-"#-cB&#FAกB"C,4R
m3J % 0- 7%"4-J , -ก&102I5$ " FM3Fก2ก ก/ ก B# ก AB0973"c  F2b  (catch-up
phenomenon) 6&3C#?กLJM3Fก/กB#กA2@$0M~i-A-2!cก#1-!5$90c9R,4Rm3J%0-.",-"2&
B-~$F7}B&#FB"C,4Rm3J%0-(10) A~F?R3F1Q-~Fw~FMR3-5iR"2I0320h$3A,4Rm3J%0-!6!-

III-3 Nutritional aspect in osteoporosis

3B!5$015 0IQ1#?c3ก-ก2I0IRF6&oc306o0ก/ก9R6กc %7?5- ?0-o5
?0-5 ?0-21 0!#Fi 6cK?C?cF€ 9R6กc 61&2o5"0 60ก-52o5"0 !3F6F I#FกI5 60Fก-5I6&
‚3I‚3#I 27s-?R-
B=4>A1< (Calcium)
10?R3Fก61&2o5"0,-6?c&#-?01Q6--QM3F NIH 72!8IB#H320ก6IF9R#F?F
(11)
!5$ 3.1
 23

PK0A2 3.1 70L61&2o5"0!5$6--Q,BR#7!-,-6?c&ก&Cc03"C 6--Q%" National Institutes of

Health Consensus Panela
ก4OR<?1O Optimal calcium intake (mg/day)
Infant
Birth- 6 months 400
6 months- 1 year 600
Children
1-5 years 800
6-10 years 800-1200
Adolescents/young adults
11-24 years 1200-1500
Men
25-50 years 1000
Over 65 years 1500
Women
25-50 years 1000
Over 50 years (postmenopausal)
− On estrogen 1000
− Not on estrogen 1500
Over 65 years 1500
Pregnant and nursing 1200-1500
0A2< 1#&3กAก a NIH Consensus Development Panel on Optimal Calcium Intake: Optimal Calcium Intake. JAMA
272:1942-1948; 1994.

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 27

PK0A2 3.4 6IF70L?0-5,-3B

Food International Units (IU) Percent
per serving DV*
Cod liver oil, 1 Tablespoon 1,360 340
Salmon, cooked, 3 ounces 360 90
Mackerel, cooked, 3 ounces 345 90
Tuna fish, canned in oil, 3 ounces 200 50
Sardines, canned in oil, drained, 1 ounces 250 70
Milk, nonfat, reduced fat, and whole, vitamin D fortified, 1 98 25
cup
Margarine, fortified, 1 Tablespoon 60 15
Pudding, prepared from mix and made with vitamin D 50 10
fortified milk, cup
Ready-to-eat cereals fortified with 10% of the DV for vitamin 40 10
D, 1 cup servings (servings vary according to the brand)
Egg, 1 whole (vitamin D is found in egg yolk) 20 6
Liver, beef, cooked, 3 ounces 15 4
Cheese, Swiss, 1 ounce 12 4
N<1>NPO * DV = daily value. DVs are reference numbers developed by the Food and Drug Administration
(FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for
vitamin D is 400 IU (10 µg) for adults. Most food labels do not list vitamin D content unless a food
has been fortified with this nutrient.
0A2< 1#&3กAก http://www.usda.gov/cnpp/pyramid2.htm.

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 28

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?MK?/K
1. Bush TL, Wells HB, James MK, et al. Effects of hormone therapy on bone mineral density:
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 37

42. Gardner MM, Robertson MC, Campbell AJ. Exercise in preventing falls and fall related
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Bone Miner Res 1998; 13: 483œ90
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2. National Osteoporosis Foundation ,-7} 1.8. 2008(4) 9R7#7CF guideline ,B0c%"-Q
FRAX tool ,-ก720-102I5$"F6&?#I-,A,BRก#กGR"" wR10-cA27s-!5$A
2กก/กB#ก,-" 10 7} M3Fก/กI%@ก ≥ 3% Bh3 M3Fก/ก3h$-€ ≥ 20% กb,BRก
#กG9R6?cกb"#F1Fก,BRก#กGe/R7u"R""9R2&"%"90c?R3F,4R FRAX 720-,-I3F
กL5
a. e/RBFB53e/R4"!5$053"C?#iF6?c 50 7}M~i-97!5$05ก/กB#ก!5$ก/กI#-B&#FBh3ก/ก
I%@ก
b. e/RBFB53e/R4"!5$053"C?#iF6?c 50 7}M~i-97!5$?A#10B-6-c-ก/กR"21h$3F
DXA !5$ก/กI#-B&#FBh3ก/ก13I%@ก6&R@c T-score ≤ -2.5 SD
1.4 B9.0KกP-
/98[8NMกก\3=ก,-;กXO9-M.1ก41O0_^ก=M9NL;M0A2<A=.<
>
A21K
;K 3-1<;49/_/3=ก,-;กXO9BNRKC,>0DE01Œ
>4?2/-+D@3(ก (Primary indication)
IQB#e/RBF!5$B07AQ2h3-6&R 6&e/R4"!5$053"C > 50 7}M~i-97?R3F,BRก#กG%1ก/ก
@C- 20h$305MR3cF45iMR3,MR3B-~$FBh3!#iFI3FMR3MRF&cF-5i
1. 05ก/กI#-B&#FB#ก Bh3ก/กI%@กB#ก 3#-2-h$3F0Aก."#-?"!5$90cC-6F
2. ?A10B-6-c-M3Fก/กR"21h$3F axial DXA !5$ lumbar spine BMD Bh3 femoral
neck BMD Bh3 total hip BMD 6&R@c05 T-score ≤ -2.5
>4?2/-+D?- (Secondary indication)
,-กL5!5$"#F90c05ก/กI#-B&#FBh3ก/กI%@กB#ก 6&ก?A10B-6-c-ก/กR"21h$3F
axial DXA 9Re&3"/c,-2กL„Jก/กF (T-score < -1.0 6?c >-2.5 !5$ lumbar spine BMD femoral neck
BMD Bh3 total hip BMD) ก,BR"#กG%1ก/ก@C- 1A,BR20h$3057[AA#"MRF&cF-5ic0R"3"cF-R3"
1 MR3
1. 05ก/กB#ก3"cF-R3"B-~$F6BcF!5$2กAก."#-?"!5$90cC-6F."B&#F3"C 40 7} ,-?Q6B-cFB&#ก
3h$-€ !5$90c,4cก/กI#-B&#F6&ก/กI%@ก24c- ก/กMR30h3B#ก (wrist fracture) ก/ก24Fก-
B#ก (pelvic fracture) ก/ก3€ B#2McB#ก (distal femur or proximal tibial fracture) ก/ก?R-
6M- (proximal humeral fracture) ก/กMR32!R (ankle fracture) x&x
2. 9R#" glucocorticoid ,-M-!5$2!5"2!c prednisolone #-& 7.5 0ก. --กc 3 2h3-
3. 27s-%1!5$!Q,BR2ก. secondary osteoporosis 24c- type-1 DM, thyrotoxicosis, rheumatoid
arthritis, SNSA(seronegative spondyloarthropathy) x&x
4. ?A720-%",4R FRAXTM M3F US-Asian Bh3 Japan 690c,4R BMD 01Q-LR" 9R10
year probability of hip fracture ≥ 3% Bh3 10 year probability of other major osteoporotic
fractures ≥ 20%
5. 05 clinical risk factors(CRFs) 2B&c-5i?#iF6?c 2 MR3M~i-97
ก. 27s-e/RBF!5$053"C ≥ 65 7} Bh3 e/R4"!5$053"C ≥ 70 7}
M. 05#4-50&ก" < 19 กก./?0.
 40

1. 057#?c Bh30 05ก/กI%@กB#กAก%1ก/ก@C-

F. B07AQ2h3-กc3-3"C 45 7}
A. I/CB5$A#27s-7AQ
|. h$0IC27s-3AL
,-กL5!5$ก?A#10B-6-c-ก/ก%"21h$3F axial DXA 90cI0w!Q9R E<RB9,9b8NM
0b8NMกก\3=ก,-;กXO93-18@MJM?<;4PR?EC9AQ
− CRFs 2@5"F3"cF25"
− ก?A10B-6-c-ก/กR"K53h$-6?c2@5"F3"F25" (-3ก2B-h3Aก axial DXA)
!#iF-5i2-h$3FAก"#F05MR30/&90c2@5"F@36&3AA057 [ B2h$3Fก#กG!5$0ก2ก-10AQ27s- 6&
3AA2ก1090c1CR01c!F28GH8I?JIKLICM9R
89ก`A0A2กP.[.-=.<N9B9R9ก,-;ก3-1>=e2?K axial DXA E<R
<u0bE-MAF€2-h$3F
90cI0wIcFe/7R u"97?A,-!5$!5$0521h$3F9R 6--Q,BR#กG%1ก/ก@C-%"05MR3cF45i#F-5i
1. 05ก/กI#-B&#FBh3ก/กI%@กB#ก
2. 05ก/กB#ก!5?$ Q6B-cF3h$-€Aก."#-?"!5$90cC-6F,-e/RBF!50$ 53"C?F#i 6?c 65 7}M~i-97Bh3
e/R4"!50$ 53"C?#iF6?c 70 7}M~i-97c0ก#กL5,กL5B-~$F#F?c397-5i
− .@wc"#FI523กoJ @.ก/กF%"ก-A|#"Aก#FI56@!"J
− 102I5$"F?c3ก2กก/กB#กAกก1Q-L%",4R FRAXTM M3F US-Asian Bh3
Japan 690c,4R BMD 9R10 year probability of hip fracture ≥ 3% Bh3 10 year
probability of other major osteoporotic fractures ≥ 20%

IV-2 Pharmacological treatment of osteoporosis

ก2&h3ก,4R"#กG%1ก/ก@C-11Q-~Fw~F ก&9กก33กr!KzM3F" ก&102I5$"F?c3
ก2กก/กB#กAกMR30/&ก8~กG,-0-CG"J (clinical trial) 2!c-#i- 3ก90c@5F7IF1J!5$3A2กM~i-
(potential adverse events) 6&!5$IQ1# 1h3 ,4R",BR2B0I0ก#e/R7u"27s-"€ (tailor therapy) 2@
e/R7u"6?c&1-3AA2B0I0ก#"1-&?#กb9R
27tB0"B&#ก,-ก#กG%1ก/ก@C- 1h3 กC†?Kก9E<R8NM>ก/-ก,-;กNก 2@|-#i-
e&ก#กG!5$IQ1#,-ก@AL7I!K.@ (efficacy) M3F"A?R3F27s- anti-fracture efficacy(5)
2I03
Anti-fracture efficacy B0"w~Fก8~กG,-0-CG"JM-,Bc!5$27s- clinical trial phase-III o~$F6IF
,BR2Bb-3"cF4#2A-c "-#i-€
<u4-=.<>
A21KPR?ก>ก/-ก,-;กNก89PbBN9RK0A2
98[E-M ><e2?
>0A1ก placebo (relative risk reduction) Bh3wR,-กL5M3F"ก&Cc0 bisphosphonates I0w,4Rก
2!5" BMD ก#" bisphosphonate P.>-A1.ก9 6?c1-& dose cI0w2@$0 BMD 9R2!cก#- o~$F dose
B-~$F!5$,4R27s-?#2!5"-#i- (control) A?R3F21"6IF,BR2Bb- anti-fracture efficacy 3"cF4#2A-20h$32!5"ก#
placebo 06&R ก8~กG,-กL5B&#F-5i25"กc bridging study
 41

2.1 111QKก
41ก,-;ก (Inhibitors of bone resorption)

Bisphosphonates
1. Bisphosphonates 27s - "ก&Cc 0 IQ  1#  !5$ 3 3กr!Kz , -ก"#  "#i F กI&"ก/ ก !5$ 6 F!5$ IC  ,-
!R3F?&7[AAC#- 9R05ก6cF bisphosphonates Fc"€ 33ก27s-I3Fก&Cc0"c3" 1h3ก&Cc0M3F
simple bisphosphonates 6& ก&Cc0M3F nitrogen-containing bisphosphonates (5)
2. @c",-ก&Cc0 nitrogen-containing bisphosphonates A05 action ,-ก"#"#iF osteoclastic
bone resorption 9R 6Fกc ",-35ก ก&Cc 0B-~$F 7[A AC# -,-72!89!",-ML-5i ",-ก&Cc 0
bisphosphonates !5$9R#ก#3F6&R %"1Lก0ก3B6&" ,BR,4R#กG%1ก/ก
@C-,-I?5#"B07AQ2h3-053"/c 8 ?Q#R"ก#- 1h3 Alendronate (10 ก.) 6& Risedronate
(5 ก.) (#7!-!Cก#-) Alendronate Once Weekly (70 ก.) 6& Risedronate Once Weekly
(35 ก.) (#7!-I#7BJ&1#iF) 6& Ibandronate Once Monthly (150 ก.) (#7!-
2h3-&1#iF) 35ก?Q#B-~$F1h3 Alendronate plus o~$F27s-I/?!5$05 Alendronate 70 0ก. 0ก#
Cholecalciferol 2800 iu ,4R#7!-I#7BJ&1#iF24c-25"ก#- IQB#35ก 2 ?Q#IC!R" o~$F
27s-?Q#IQB#"!5$,BR%"|52MR2IR-2&h3Q 1h3 Ibandronate injection (3 ก.) (IV infusion
2MR2IR-2&h3Q!CกI02h3-) 6& Zoledronate injection (5ก.) (IV infusion 2MR2IR-2&h3Q7}&
1#iF)
)?*
)'
Q3 / @C?
)'* 

1. 23I%?2A- 057I!K.@,-ก&กI/2I5"2-hi3ก/ก,-e/RBF#"B07AQ2h3- e&Aก

ก8~กGAQ--0ก@c23I%?2A-I0w&102I5$"F?c3กB#กM3Fก/กI#-B&#F ก/ก
I%@ก 6&ก/กIc-3h$-€ 9R70L 30-40% (6,7)
2. MR30/&&cIC@c23I%?2A-,-M-?$Qกc!5$,4Rก#-%"!#$97 "#F1F05e&5?c3ก/ก,-e/RBFIc-0ก
20h$31Q-~Fw~F7I!K.@ 107&3.#" 6&16&R23I%?2A-A#27s-"!5$I012&h3ก,4R,-e/RBF
#"B07AQ2h3-!5$05102I5$"FI/F?c3ก/กB#ก6&90c05MR3BR0,-ก,4R23I%?2A-%"2|@
e/RBF3"C?$Qกc 55 7} 6&,-e/RBF!5$B0/กc3-กQB- (premature menopause)
3. IQB#ก,4R23I%?2A-2@h$3#?wC7IF1J,-ก7t3Fก#-ก/กB#ก2@5"F3"cF25" ,-e/RBF3"C2ก-
60 7} I01@AL7%"4-J6&102I5$"F27s-"€ 97 %"@cก,BR23I%?2A-27s-"
2&--€ ,-e/RBF!5$053"C0ก6&R3A2@$0102I5$"F?c3ก2ก cardiovascular diseases, stroke
6& invasive breast cancer(8)
4. %72AI?-,4Rc0ก#23I%?2A-2|@,-e/RBF!5$"#F050&/ก3"/c2@h$37t3Fก#-2"h$3C0&/กB-e7ก?6&
02bF2"h$3C0&/ก2!c-#i-
Selective estrogen receptor modulators (SERMs)
1. SERMs 27s-I!5$90c,4c steroid o~$FA#ก# estrogen receptor %"A33กr!Kz24c-25"ก#23I%?
2A- (agonist) Bh333กr!Kz?R-23I%?2A- (antagonist) 6?ก?cFก#-97,-2-hi32"h$3?cF€
raloxifene 27s- SERM 2@5"F4-25",-7[AAC#-!5$1Lก0ก3B6&"M3F72!89!"
#3F,BR,4RIQB##กG%1ก/ก@C-,-e/RBF#"B07AQ2h3-
2. Aกe&ก8~กG@c raloxifene I0w7t3Fก#-กI/2I5"2-hi3ก/ก M3Fe/RBF#" B0
7AQ 2h3 -6&&102I5$"F?c3กB#กM3Fก/ก I#-B&#F &F9R 30œ50% ,-e/RBF!5$05ก/ก
 42

FBh3@C-(9) !#iF!5$21"05Bh390c21"057#?ก/กI#-B&#FB#ก0กc3- Aกก8~กG-5i90c@c

raloxifene &102I5$"FM3Fก/กB#ก,-Ic-3h$-€ -3กAกก/กI#-B&#F
3. Raloxifene 057%"4-J,-R-3h$-9R6กc &102I5$"F?c3ก2ก%102bF2?R-04- invasive &F
9R 60% 6?c90c05e&?c3 cardiovascular diseases 6& stroke(10,11)
Nasal spray calcitonin
1. Calcitonin 27s-m3J%0-!5$IRFM~i-%" C-cells M3F?c309!3"J 33กr!Kz%"A#ก# calcitonin
receptor M3F2o&&J osteoclast !Q,BRกI&"ก/กw/ก"#"#iF
2. Aกก8~กG(12) o~$F,4R salmon calcitonin 6@c-A0/ก#-& 100, 200, 400 IU 6&"B&3ก
@cI0w&ก2กก/กI#-B&#FB#ก,B0c9R 36% ,-ก&Cc0!5$9R# calcitonin 200 IU 20h$3
275"2!5"ก#ก&Cc0"B&3ก (RR = 0.64) 3"cF9กb?0@cก&Cc0 100 IU 6& 400 IU 05
7I!K.@90c6?ก?cFAก"B&3ก 6&90c@c calcitonin 6@c-A0/ก-5iI0w& non-
vertebral fracture Bh3 hip fracture 9R
3. Salmon calcitonin !#iF6@c-A0/ก 6&6|52MRก&R0 I0w&3ก2Ab73#-
2-h$3F0Aกก/กI#-B&#FB#ก9R(13) %"057I!K.@,-ก&7@3€ ก#ก,4R"ก&Cc0
NSAIDs
2.2 1ก,POM9ก
MKก,-;ก8N<R (Stimulators of bone formation)
Recombinant human parathyroid hormone 1-34 (Teriparatide, TPTD)
1. 05ก8~กG 6 prospective, randomized, double-blind, multinational, placebo-controlled ,-
e/RBF#"B07AQ2h3- o~$F05ก/กI#-B&#FB#ก3"/c6&R AQ-- 1,637 1- 2@h$3/7I!K.@M3F
TPTD(14) ,-ก&102I5$"F?c3ก2กก/กB#ก,B0c ,-4cF"2& 3 7} %"275"2!5"
BcFก&Cc0!5$#กGR" TPTD #-& 20 01ก. (n = 541) ก&Cc0!5$9R# TPTD #-& 40 01ก.
(n=552) 6&ก&Cc0!5$9R# placebo (n=544) @c TPTD 20 01ก. I0w&102I5$"F?c3ก
2กก/กI#-B&#FB#ก,B0c&F 65% 6&&102I5$"F?c3ก2ก non-vertebral fracture &F9R
53%
2. 05ก8~กG,-&#กGLM3F meta-analysis(15) 2@h$3720-e&M3F"?c3ก&3ก7B&#F ,-
e/R7u"%1ก/ก@C-!5$05ก/กI#-B&#FB#ก6&R @c" TPTD 20 01ก. 6& 40 01ก. I0w&
AQ--e/R7u"!5$3ก7B&#F6&7B&#FC-6F 9R0กกc",-ก&Cc0"#"#iFกI&"ก/กF
?# 24c- bisphosphonates 6& hormone therapy
3. ก!Q carcinogenicity study ,-B-/ Fischer AQ-- 344 ?# o~$F9R# TPTD 24 2h3- ,-M-
70L 20 2!c M3F!5$,4R,-1- 6&,BR--กc 20 2h3-o~$F2กh32!cก#4cF45?M3FB-/ (70-80%
M3F4cF45?M3FB-/) @c102I5$"F?c3ก2ก osteosarcoma ,-B-/2@$0M~i-,-&#กGL dose
dependent (16) 3"cF9กb?090c@c2ก osteosarcoma ,-1-!5$9R# TPTD --!5$IC 25 2h3-
,-ก8~กGB&#ก-#i-(14)
4. M-!5$6--Q1h3 |5 TPTD 2MR,?ReB-#F #-& 20 01ก. ,-2&,กb9R 6?c127s-2&!5$
,ก&R215"Fก#-,-6?c&#- Ic-,Bc6--Q,BR|5,-2&กc3--3- 6&90c1,4R?c32-h$3Fก#---2ก-
กc 2 7}
2-h$3FAก" TPTD 27s-"!5$0516@F6& potential side effects ,-"""#F90c6-c4# ก,BR
"-5iA~FAQ27s-?R3F05MR3cF45i@28G!5$4#2A-0กกcก,4R"#กG%1ก/ก@C-?#3h$-
 43

>4?2/-+D)cZ)d0ก0B4!0 teriparatide B

ก0(กZ0
ก ก

8@M89ก`A3=ก,-;กXO9@9/-O9BK B4,<A=.<>
A21K
;K<กPR?ก>ก/-ก,-;กNก8N<R
>0R9Q9 3-1L;MC‡.1[,PM?K<A?1OPQKBPR 65 CUJVQ9EC B4,[,PM?K<AJM?RK@AQJM?8-JM?N9V2KJMK4RK9AQ
1. BMD T-score %" axial DXA !5$ก/กI#-B&#FIc-!5$2B&h3("#F90cB#ก)!5$?A9R(lumbar spine
BMD) Bh3!5$ก/กI%@ก(femoral neck or total hip BMD) ≤ -2.5 SD c0ก# ก05ก/กI#-
B&#FB#กAก%1ก/ก@C- AQ--?#iF6?c 2 7&R3FM~i-97
2. BMD T-score %" axial DXA !5$ก/กI#-B&#FIc-!5$2B&h3("#F90cB#ก)!5$?A9R(lumbar spine
BMD) Bh3!5$ก/กI%@ก(femoral neck or total hip BMD) ≤ -2.5 SD c0ก# ก05ก/ก
I%@กB#กAก%1ก/ก@C-
3. BMD T-score %" axial DXA !5$ก/กI#-B&#FIc-!5$2B&h3("#F90cB#ก)!5$?A9R(lumbar spine
BMD) Bh3!5$ก/กI%@ก(femoral neck or total hip BMD) ≤ -3.5 SD c0ก# ก05ก/กI#-
B&#FB#กAก%1ก/ก@C-AQ-- 1 7&R3F
4. 05B&#กH-!5$24h$39Rcก#กG%"ก,4R" bisphosphonate !5$ec-0&R02B& (inadequate-
response) (17) %"05&#กGL#F?c397-5i!#iFI3FMR3
• 05 vertebral fracture 2กM~i-,B0c 1 ?Q6B-cFBh30กกc Bh3 vertebral fracture !5$053"/c05ก
B#ก"C2@$0 Bh305ก/กI%@กB#ก2กM~i-,B0c !#iF-5iA?R3F9R#ก#กG-#i-0กกc 2 7}6&R
• Lumbar spine BMD &&F7}& ≥ 3% Bh3M3FI%@ก (total hip Bh3 femoral neck BMD)
&&F7}& ≥ 5% (%",4Rก1Q-LAก1c least significant change-LSC)(17,18) ."B&#F9R
ก#กG-#i-00กกc 2 7}6&R
,-MR3 4 -5iA?R3F720-กc3-2I03ce/R7u"9R#" bisphosphonate -#i-3"cFw/ก?R3F 2@5"F@3
2B0I0 6&I0$Q2I03 6&R2!c-#i- (patient with good compliance and persistence)
-3กAก-5iก,4R teriparatide "#F1!5$A?R3F,4R.",?R2Fh$3-9M@28G?0MR3 IV-4-7.5 R"2I03
2.3 10A2??ก…0_/0QK
?K0K (mixed action agents)
Vitamin D and vitamin D analogue
1. ?0-5 Bh3 ?0-5 I#F21BJAI0w&3C# ?กLJก2กก/กB#ก&F9Rกb?c320h$ 3
#7!-c0ก#61&2o5"02!c-#i- %"!5$M-?0-5!5$, BR A?R3F 90c?$Qกc#-& 800 IU
c0ก# calcium ,-M-90c?$Qกc#-& 1,000 0ก.(19)
2. ก,BR?0-5 Bh3 ?0-5I#F21BJc0ก#61&2o5"005e&,-ก&102I5$"F?c3ก2ก hip
fracture 6& nonvertebral fracture 9R2&bก-R3" (< 20%) 6?c90c I0w& vertebral fracture 9R
(19)

3. 3"cF9กb?0e/R7u"!5$A?R3F9R#ก#กGR""#กG%1ก/ก@C-3h$-€ AQ27s-3"cF"$FA?R3F
9R#61&2o5"06&?0-5,-M-!5$2@5"F@3c097R"2I03
Menatetrenone
1. 05B&#กH-c e/R7u"05 high vitamin K intake 053#?ก2กก/กI%@กB#ก-R3"กce/R!5$05 low
vitamin K intake (20,21) 6&e/R!5$05 low vitamin K intake A05 BMD !5$?$Qกc(22)
2. Menaquinone-4 Bh3 menatetrenone I0w&ก2กก/กI#-B&#FB#ก9R70L 50% 6?c
e&?c3ก& non-vertebral fracture 90c4#2A-(23,24)
 44

3. e/RBF23245"#"B07AQ2h3-!5$#7!-" menatetrenone M-#-& 45 0ก. c0ก#

61&2o5"0#-& 1,500 0ก. 6&?0-5I0w maintain BMD Bh3 2@$0 BMD M3F Lumbar
spine 9R(25-27) 6&I0w& 70L undercarboxylated osteocalcin 9R3"cF05-#"IQ1#(25-28)
Strontium ranelate
1. ก8~กG2@h$3/7I!K.@M3F" strontium ranelate (SR) ,-ก&102I5$"F?c3ก2ก
ก/กI#-B&#FB#ก27s-"2& 3 7} I0w&102I5$"F?c3ก2กก/กI#-B&#FB#ก,B0c9R
70L 40-50%(29)
2. ก8~กG2@h$3/7I!K.@M3F"-5i,-ก&102I5$"F?c3 non-vertebral fractures @c&&F
16% 6& @c102I5$"F?c3 hip fractures &&F 36% ,-ก&Cc0!5$9R#" strontium ranelate
20h$32!5"ก#"B&3ก(30)
3. 05ก8~กG!5$27s- integrated analysis(31) @c strontium ranelate 057I!K.@,-ก&10
2I5$"Fก/กI#-B&#FB#ก,B0c9R ,-ก&Cc0!5$I/F3"C (>80 7}) 9R 32% 6&& nonvertebral fracture 9R
,-ก&Cc0-5i 31% 35ก!#iF057I!K.@,-,-ก&102I5$"Fก/กI#-B&#FB#ก,B0c9R ,-ก&Cc0!5$27s-
61c osteopenia 70L 30-50%(32)
ก,BR"#กG%1ก/ก@C-!5$ก&c97MRF?R-!#iFB0 90ccA27s-ก&Cc0""#"#iFกI&"ก/ก
Bh3 "ก?CR-กIRFก/ก 0!#iF"!5$33กr!KzI3F!F !Cก?#A?R3F,BRe/R7u"9R#61&2o5$"06&
?0-5 !5$2@5"F@3R"2I03 (?01Q6--Q,-MR3 III-3) wR1ce/R7u"90c3A9R#61&2o5$"06&?0-5
!5$2@5"F@36&R AQ27s-?R3F,BR"2I061&2o5$"0 6&/Bh3 "?0-5 ,-70L!5$2B0I0R"

IV-3 Alternative therapy and non-pharmacological treatment

3.1 Hip protector
05B&#กH-2@5"F2&bก-R3"!5$I-#I-C-c ก,4R hip protector I0w&102I5$"F,-ก2ก hip
fracture 9R,-Iw-!5$!5$0,4c nursing home %"7[BB&#ก 1h3 compliance ,-ก,Ic(33-35)

IV-4 Potential adverse events, prerequisites and contraindications in

using anti-osteoporotic agents
4.1 L4JMK>=A1K JM?=.,.K B4,JM?NM<89ก8@M1ก\3=ก,-;กXO9
Q3)f+! e&MRF215"F6&MR31#F!5$IQ1#1h3
− 3กM3F!F2-3B !R3F3h ACก2I5" !R3Fe/ก 27s-I2B?C!5$IQ1#M3FกB"C"
(36,37)

− 05ก8~กG@cก,BR61&2o5"02@$03C#?กLJM3F%1B#,A6&B&32&h3 (%1B#,AM
2&h3 %12IR-2&h3I03F 6&ก?"2|5"@&#-) 20h$32!5"ก#"B&3ก(38) 3"cF9กb?0,-
ก8~กG3h$-€ 90c@c 3C#?กLJ%1B#,A6&B&32&h32@$0M~i-(36,37,39)
 45

< 0
+Q3?
(
W=>?-< 0
+ e&MRF215"F6&MR31#F!5$IQ1#1h3
− @.#61&2o5"0,-2&h3I/F6&#61&2o5"0,-7[III/FM~i-9R 6?c@9R90cc3"-#ก
%"A@,-กL5!5$9R#",-M-I/F€ 6&ก,BR",-/7 active form 24c- calcitriol
ก8~กGIc-0ก90c@c3C#?กLJM3F-$,-9?2@$0M~i-(40,41)
g?=

Q
()?*
)'
Q3/@C?
)'* 
) e&MRF215"F6&MR31#F!5$IQ1#1h3
− 102I5$"F?c3ก2ก02bF2?R-02@$0M~i-2|@,-ก&Cc0!5$9R23I%?2A-c0ก# %72AI?-
(42,43)

− 2IR-2&h3Q3C?#- 2ก9R!#iFB&32&h3Q!5$M6&73 102I5$"F,-ก&Cc0!5$9R 23I%?2A-

6&%72AI?- 0กกcก&Cc0!5$9R23I%?2A-2@5"F3"cF25"(43,44)
− @102I5$"F,-ก2ก%1B#,AM2&h32@$0M~i-,-ก&Cc0!5$9R23I%?2A-6&%72AI?- 6&
102I5$"F-5iA2@$0M~i-20h$3e/R7u"!5$3"C0กM~i-(43,45)
− 102I5$"F,-ก2ก%12IR-2&h3I03FM2&h32@$0M~i-!#iF,-ก&Cc0!5$9R23I%?2A-2@5"F3"cF
25"(43) 6&ก&Cc0!5$9R23I%?2A-6& %72AI?-(46) 6&@9R!Cก4cF3"C(47) -3กAก-5i"#F
@c!#iFI3Fก&Cc02@$0102I5$"F,BRI03FIc-- (cognitive function) 6&10I0w,-
กAQ&&F (dementia) (48-51)
− 3ก3h$-€ 24c-3ก1#2?R-06&2&h333กe7ก?!F4c3F1&3@0กM~i-
− ก,BR",-ก&Cc023I%?2A-2@h$3#กG%1ก/ก@C--5i e/R7u"?R3FA?R3F90c3"/c,-ก&Cc02I5$"F?c3
ก27s- 02bF2?R-0 02bF%@F0&/ก %1B&32&h3B#,A6&I03F %12IR-2&h3Q3C?#-
!#iF-5iwRAQ27s-?R3F,4Rm3J%0-1A?A mammogram !Cก7}
Bisphosphonates e&MRF215"F MR31#F 6&MR3BR0,4R!I5$ Q1#1h3
− !F2-3B !5$@9R,-" 24c- alendronate, risedronate 6& ibandronate o~$F27s-
"6#7!- @9R-R3",-" ibandronate 6& zoledronate 6|5 Ic-,Bc053ก
90cC-6FAกก1"21h3FM3F!F2-3BIc--24c- non-ulcer dyspepsia .ก
9B&"R3-ก&# 1&h$-9IR 32A5"- 6&6I!R3F(52)
− B#,A6&B&32&h3 05"F-ก2ก atrial fibrillation ,-ก&Cc0e/R7u"!5$9R"
bisphosphonate 0กกcก&Cc0!5$9R"B&3ก2&bก-R3" 3"cF9กb?0B&#กH-2B&c-5i0!#iF
ก&9ก!5$!Q,BR2ก2B?CกLJ"#F90c4#2A-2@5"F@3 90c0510AQ27s-?R3F?A ECG กc3-ก,BR
"2B&c-5i
− ก/ก 05"F-ก2กก/กMก9ก?" (osteonecrosis of the jaws) o~$F
Ic-0ก@,-1-9MR02bFกA"?#0!5$ก/ก!5$9R#" bisphosphonate 6|5 3"cF9
กb?005"F-ก2ก,-1-9MR%1ก/ก@C-!5$9R#"2@h$3ก#กG%1ก/ก@C-24c-ก#-
(53)
6?c@-R3"กc27s-R3"2!c !#iF-5i2-h$3FM-"!5$,4RIQB#ก#กG%1ก/ก@C--#i-?$Q
กcw~F 10 2!c 2@|-#i- ,-กL5, 4R2@h$3#กG%1ก/ก@C- 90c0510AQ27s-?R3F
?A24b1‚[-กc3-ก,BR"-5i
− 05 "F-ก2ก ก/ก B# ก4- !5$e 7ก? (atypical fracture) 2ก M~i -,-ก&Cc 0 !5$, 4R " 
bisphosphonate 27s-"2&--€ (2|&5$" >5 7}) 05&#กGLIQ1#1h327s- low-energy
trauma fracture !5$27s- transverse configuration 2L subtrochanteric Bh3 shaft of
 46

femur o~$FI2B?C"#F90c6-c4#(54,55) 3"cF9กb?03C#?กLJ!5$2กM~i-"#F-R3"0ก20h$32!5"ก#

AQ--e/R!5$9R#"ก&Cc0-5i!#$%&ก A~F12”t#F20h$3,4R"ก&Cc0-5i27s-"2&--กc 5 7}
− @7a ก  "B&# F 9R #  " (post-dose reaction) o~$ F @9R c 3 " %"2|@,-"
(56,57)
bisphosphonate 6|5 6#7!-2h3-&1#iFกb3AA@9R2&bก-R3" %"05
3ก9MR 7ก&R02-hi36&MR3 1&R"27s-9MRB#,Bc 0#กA@,-ก9R#"1#iF6ก 6&
&&F0ก,-ก#"1#iF?c3€ 3ก2B&c-5iA97B"9R23F.",-90c2ก- 2-3 #-
− IQB#",-ก&Cc0 bisphosphonates -5iwR27s-6 oral form A?R3F052กL„J,-ก#7!-
"!5$IQ1#I07ก1h3
ก. A?R3F#7!-,-?3-!5$!R3FcF!5$IC 90c,BR053BBh3",€ 3"/c,-ก2@3B
2&" o~$Fกb1h3?R3F#7!-,-?3-24RB&#FAก?h$--3- %"B&#F#7!-"6&R ½ w~F
1 4#$%0FBR0ก-3BBh3"!Cก4-
M. ก#7!-"2B&c-5i?R3F!-ก#-iQ?R0ICกK02!c-#i- (BR0ก-ก#-iQ!5$2Ah37- 24c-
-iQB- -iQe&90R -iQ6c -0 4 Bh3ก6‚) 6&BR0" B#ก20b" Bh3215i"20b"-5i
%"2bM 2@20b"!5$6?ก33ก3A!Q,BR2-hi3"I#0e#Iก#2"h$3C7ก Bh32"h$3CB&3
3B!Q,BR2กก3#ก2I!5$2L-#i-9R
1. B&#F#7!-"-5i6&R!QกAก0!Cก3"cF9R?07ก? "ก2R-BR0-3-27s-2& ½
w~F 1 4#$%0F24c-ก#- 2-h$3FAก" bisphosphonates 20h$36?ก?#33ก6&RwR9B&"R3-ก&#
2MR97,-B&33B 3A!Q,BR2ก 2"h$3CB&33B3#ก2I9R (esophagitis)
− IQB#",-ก&Cc0 bisphosphonates -5iwR27s-6 IV infusion 2MR2IR-2&h3Q ?R3F,BR"2MR
2IR-,-&#กGL infusion 2!c-#i- 6& A?R3F,BRB0,-2&!5$90c2bกc 15 -!5,-6?c&1#iF
35ก!#iF1,4R,-กL5!5$e/R7u"90c057[B%19? Bh3ก!QF-M3F9?e7ก? 3-1 =R GFR
[,PM?K ≥ 30 mL/min (o~$F23AA#27s- creatinine clearance กb9R) !#iF-5i2-h$3FAก"M#
!F9?2!c-#i- ,-กL5"6 infusion -5i 90c0510AQ27s-?R3FBR0#7!-3B Bh3
BR0-3-6?c3"cF,
Raloxifene e&MRF215"F6&MR31#F!5$IQ1# 1h3
− ก3C?#-M3FB&32&h3Q (venous thromboembolism) %"102I5$"FAI/F!5$IC,-4cF 2
7} 6 กB&# F 2$ 0 " (58,59) A~ F 90c 1 ,4R , -e/R !5$ 05 1 02I5$ " F?c 3 ก2ก .2IR - 2&h 3 Q  3C  ?# -
e&MRF215"F3h$-9R6กc ก05 hot flushes 2@$0M~i-(59) ก27s-?1!5$Mc3"€ (60)
Strontium e&MRF215"F6&MR31#F!5$IQ1#1h3
− wc"2B&6?c90c@c27s-I2B?CM3FกB"C,4R"(29,30,61)
− -3กAก-5i "# F 05  "F-c  2@$ 0 3C # ? กLJ M 3Fก3C  ?# - M3FB&32&h 3 Q  (venous
thromboembolism)(61) %"I2B?C"#F90c!6-c4# A~F90c1,4R,-e/R!5$05102I5$"F?c3ก2ก
.2IR-2&h3Q3C?#-
Teriparatide e&MRF215"F MR31#F 6&MR3BR0,4R!@5$ 9R13h
− #61&2o5"0,-2&h36&#61&2o5"0,-7[III/FM~i-2&bก-R3"B&#F9R#"6?c90c@c05
"F-ก2ก-$,-9?2@$0M~i-(62)
− #ก"/1,-2&h3I/FM~i- 1#F,-ก,4R,-e/R7u"!5$27s-%12ก•!J(63,64)
 47

− AกMR30/&ก8~กG,-B-/!5$9R#" teriparatide 27s-2&0กกc 20 2h3-(16,65) @c05

"F-ก2ก osteosarcoma 2@$0M~i- 6?c2-h$3FAก27s-ก,4R,-M-70L 20 2!c M3F
!5$,4R,-1- 6&,BR--2กh32!cก#4cF45?M3FB-/(70-80% M3F4cF45?M3FB-/) "-5iA~F"#F,4R
,-1-9RR"100##F
− MR30/&&cIC05"F-ก2ก osteosarcoma ,-1-B&#Fก9R# teriparatide 6&R 2 "Aก
!#$%&ก(66,67) 6?c2-h$3FAก7#?10I#0@#-KJก#ก,4R"-5i90c4#2A- 90c!ce/R7u"!#iFI3F
"057#?ก27s-02bF0กc3-Bh390c ,-"!5$I3F057#?ก|"6IF!5$2L!5$2ก
osteosarcoma 0กc3-(67) 35ก!#iFก2ก2@5"F 2 "Aกe/R,4R teriparatide !#$%&ก70L
กc 500,000 " o~$F90c0ก97กc3C#?กLJ!#$€ 97M3Fก2ก osteosarcoma ,-e/R053"C
> 60 7} o~$F0570L7}& 1 ?c3 250,000 "(66) A~Fwh3c"#F1F7&3.#"6&9R7%"4-J
1CR01c0กกc (3w7%"4-J0กกc102I5$"F) !5$A,4R9R,-ก#กG%1ก/ก@C-,-
1-(68) 6?c.",?R2Fh$3-9M!5$@28G2|@2!c-#i-
− 2Fh$3-9M@28G (prerequisite) ,-ก,4R" teriparatide
ก. BR090c,BR,4R teriparatide --2ก- 2 7}
M. 90c1,4R,-e/R7u"!5$05102I5$"F?c3ก2ก osteosarcoma 24c-

27s-%1 PagetŽs disease

e/R21"9R#ก|"6IF2Lก/ก

e/R05# alkaline phosphatase I/F%"90c05I2B?C6-c4#

,-2bก!5$ epiphysis "#F90c7ƒ
1. 90c6--Q,BR,4R,-e/R7u"057#?27s-%102bF.",- 5 7}
F. 2-h$3FAก27s-"!5$0516@F6&05e&MRF215"F!5$1c3-MRF3#-?" ก,BR teriparatide
AQ27s-?R3F05ก?A@28G 2@$02?0กc3-,BRR" 1h3 e& serum creatinine, serum
calcium 6& intact PTH A?R3F7ก?
Calcitonin e&MRF215"F!5$@9Rc3"1h3
− ก1"21h3FM3F2"h$3CA0/ก 3กR3-/(12,69)
Menatetrenone 90c@c05e&MRF215"F!5$IQ1#
− 3"cF9กb?0?R3F#Fก,4R,-1-9MR!5$9R#" warfarin 2-h$3FAกA!Q,BR warfarin !QF-
&&F(23,70)

IV-5 Monitoring treatment and duration of treatment

5.1 กP/-P<B4,C,></9L4กก\
ก??0ก#กG%1ก/ก@C-2A?R3F720- 2 0C 003FB&#ก1h3 7I!Ke&M3F"
(effectiveness) 6& ก2ก3ก90c@~F7IF1J (adverse events)
ก0 )
*WR3>?-!0 6cF9R27s-I3FIc-1h3
1. ก0 )
ก0 ?2*
?- /?!0 (drug response) 1h3ก720-c"!5$,BR-#i-9Re&5AFก#
e/R7u""-#i-€ Bh390c 2-h$3FAก27tB0"IQ1#,-ก#กG%1ก/ก@C-1h3 ก&102I5$"F
?c3ก2กก/กB#ก o~$F3"cF9กb?0,-7[AAC#-90c05",!5$I0w&102I5$"F&F27s-8/-"J9R
 48

(1h390c2กก/กB#ก2&") 2@|-#i-ก2กก/กB#กM~i-,-BcFก,BR"90c3Aก&c9Rc
e/R7u"90c?3I-3F?c3" Bh3 "90c9Re& 7[AAC#-,-ก?A720-c"9Re&Bh390c!Q9R 2
K5%"
1.1. กP.[.- BMD 3-1>=e2?K axial DXA %"B&#กก1h3 1c BMD A?R3F2@$0M~i- Bh3
3"cF-R3"90c&&F 20h$32!5"ก#กc3-,BR" %"!5$"BcFBcFก?A720- 2 1#iF
A?R3F90c-R3"กc 1 7} 6&21h$3F?A axial DXA -#i-A?R3F27s-21h$3F20!5$,4R?Aกc3-,BR
ก#กG 3"cF9กb?02-h$3FAกก?A BMD R"21h$3F axial DXA A2ก10
e@&Aกก#9RRF wR Lumbar spine BMD !5$#9RI3F1#iF &&F7}& ≥ 3% Bh3
total hip BMD Bh3 femoral neck BMD &&F7}& ≥ 5% (17,18) ."B&#F9Rก#กG-#i-€
0--กc 1 7}6&R wh3c05ก&&FM3F BMD 2กM~i-AF6&e/R7u"3AA90c?3I-3F?c3
"-#i- (probable inadequate response) 2@|-#i-wRก&&FM3F BMD 90c0ก97กc
2กL„J-5i"#Fwh3c"-#i-9Re&3"/c 3"cF9กb?0wR2ก05ก/กB#ก2กM~i-,-BcFก#กG
c0ก#ก&&FM3F BMD !5$0กกc2กL„J#Fก&cกbAwh3c e/R7u""-#i-E<RP?
9?K
PR?1 (inadequate response) 6&127&5$"-"
1.2. กP.[C,></9-M.1 bone turnover markers %"B&#กก1h3 wR27s-""#"#iFกI&"
ก/ก,BR?A bone resorption marker o~$FA?R3F&&F 6&wR27s-"ก?CR-กIRF
ก/ก,BR?A bone formation marker o~$FA?R3F2@$0M~i- "BcFBcFก?A720-
2 1#iF1h3 กc3-2$0,BR"o~$FAQ27s-?R3F052I03 6&B&#F,BR"?R3F90c-R3"กc 3 2h3- ก
27&5$"-67&FM3F1c bone turnover markers (BTMs) -5i A?R3F050กกc 30-40% A~Fwh3c05
ก27&5$"-67&F2กM~i-AF 2-h$3FAกก?A# BTMs 05 variation !5$0กกc 6&Iก
-R3"กc 2-h$3FAก?R3F NPO e/R7u" 12 4.0. กc3-2A2&h3 6&,BR2A2&h3,-4cF2&24R
(7.00-9.00 -.) %"!5$?R3F27s-4cF2&25"ก#-!Cก1#iF
2. ก0 )
<01ก 4?-Q3*,S0)*?B
ก0.4(2!0 1h3ก720-e/R7u"-#i-9R#"6&
B"9Rw/ก?R3FBh390c (compliance) 6&10I0$Q2I03M3Fก9R#" (persistence) o~$F
7[B-5iIc-,BcA2กM~i-ก#"4-#7!- 23A!Q9R%"กB0#$-w0w~Fก#77!-
"cw/ก?R3F6&I0$Q2I03Bh390c3"/c2I03!Cก1#iF!5$??0ก#กG ก?A24b1/ce/R7u"A#"
23FBh305e/RA#,BR#7!- ก,BR-Q23ก&c3FAC"27&cก&#0,BR/ x&x ก9R#"!5$wh3c
,4R9R1h3?R3F9R#"3"cFw/ก?R3F3"cF-R3" 80% ,-B-~$F7} (medication possession ratio: MPR
≥ 80%)
5.2 ,1,>.4กก\
"#F90c05MR3?ก&F!5$6-c4#,-2h$3F"2&ก,BR" !#iF-5iM~i-3"/cก#7[AA#"B&"3"cF24c- 7[AA#"M3F"
6?c&?#!5$90c2B0h3-ก#- 7[AA#"!5$2ก5$"MR3Fก#e/R7u" e&กA#"8~กG,-0-CG"J4-!5$27s- clinical trial x&x
B&#กก%"!#$971h3 ก,BR"?c32-h$3F?&397A-กc102I5$"F?c3ก2กก/กB#กM3Fe/R7u"1--#i-
&&FA--c@3,A AC-5iAกc3,BR2ก7[BB&"7ก %"2|@7[B2h$3F1c,4RAc" !#iF-5i2-h$3FAก27s-97
90c 9 R !5$ A&102I5$ " F?c 3 ก/ ก B# ก M3Fe/R 7u  "&F27s - 8/- "J 35 ก3"c  FB-~$F 1h 3 290c 05 MR 30/ & ,-""
2-h$3FAก clinical study ,-0-CG"J!5$05ก275"2!5"ก#"B&3กo~$FA6IF,BR22Bb-w~F anti-fracture
efficacy 9R 0#กA90cI0w052ก- 5 7}9R (eA"K0กA#",-0-CG"J) 2@|-#i-wRe/R7u"9R#"
3"cFw/ก?R3FI0$Q2I03 (good compliance and persistence) 90c05 new fracture 2กM~i-2&"BcF!5$9R#
 49

" ก?A BMD %" axial DXA 2@$0M~i-,-2กL„J!5$-c@3,A e/R7u"05ก?3I-3F?c3"5 I0wMA#

7[AA#"2I5$"F!5$I0w7#27&5$"-9R97 6&7#27&5$"-@r?ก0,BR05ก33กกQ&#Fก"6&ก-3B!5$
2B0I0 กb
<uN1O-10A2C,<` 5 CUE-M 3-1E<RN1O-ก-;B4L;MC‡.1 (drug holiday) %"6@!"J
A?R3F?0/e/R7u"97?&3 %"BcF-5iA?R3F05ก720-102I5$"FM3Fe/R7u"2I03€ 3AA05ก?A
BMD 6&/Bh3 BTMs !Cก 1-2 7} 6&20h$39!5$e/R7u"05102I5$"Fก&#035ก I0w2$0,BR"35ก9R
 50

PK0A2 4.1 N4ก]9B4,=bB9,9b89ก8@M1ก\3=ก,-;กXO9

Pb1 Benefit and Indication for use JM?=/->Np9
Alendronate 7t3Fก#- 6& #กG%1ก/ก@C- - I0w&102I5$"F?c3กB#ก(71-74) M3F
10 mg MR3cF45i,-ก,4R (%" US-FDA) ก/กI#-B&#F (vertebral fracture),ก/ก
(ALN) -,4R,-ก#กG%1ก/ก@C-,-I?5#" I%@ก (hip fracture) 6& ก/กIc-3h$-!5$
B07AQ2h3-(postmenopausal -3ก2B-h3Aกก/กI#-B&#F (non-
osteoporosis, PMO) vertebral fracture)
-,4R,-ก#กG%1ก/ก@C-!5$2กAก -,4R#7!-#-&1#iF
"ก&/%113J?13"J (Glucocorticoid-
induced osteoporosis, GIO)
-,4R,-ก#กG%1ก/ก@C-,-e/R4"
(Male idiopathic osteoporosis, MIO)
Alendronate 7t3Fก#- 6& #กG%1ก/ก@C- - 24c-25"ก# ALN 10 mg(75)
once weekly MR3cF45i,-ก,4R24c-25"ก# ALN 10 -,4R#7!-I#7BJ&1#iF
70 mg mg
(ALN-OW)
Alendronate 7t3Fก#- 6& #กG%1ก/ก@C- - 24c-25"ก# ALN 10 mg
plus MR3cF45i,-ก,4R24c-25"ก# ALN 10 - ,4R#7!-I#7BJ&1#iF
ALN 70 mg mg - 7ก3R" vitamin D3 ,-M- 2800
+ IU ?c3I#7BJ Bh3 = 400 IU/d 4c"
Cholecalcifer 6กR7[B2h$3F. hypovitaminosis D
ol 2800 IU 6& vitamin D deficiency(76)
(ALN-plus)
 51

Pb1 Benefit and Indication for use JM?=/->Np9

Risedronate 7t3Fก#- 6& #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก
(77,78)
5 mg MR3cF45i,-ก,4R (%" US-FDA) M3Fก/กI#-B&#F(vertebral
(RIS) - ,4R,-ก#กG%1ก/ก@C-,-I?5 fracture),ก/กI%@ก (hip fracture)
#"B07AQ2h3- (postmenopausal 6& ก/กIc-3h$-!5$-3ก2B-h3 Aก
osteoporosis, PMO) ก/กI#-B&#F(non-vertebral fracture)
- ,4R,-ก#กG%1ก/ก@C-!5$2ก -,4R#7!-#-&1#iF
Aก"ก&/%113J?13"J
(Glucocorticoid-induced osteoporosis,
GIO)
-,4R,-ก#กG%1ก/ก@C-,-e/R4"
(Male idiopathic osteoporosis, MIO)
Risedronate 7t3Fก#- 6& #กG%1ก/ก@C- -24c-25"ก# RIS 5mg(79)
once weekly MR3cF45i,-ก,4R24c-25"ก# RIS 5 mg -,4R#7!-I#7BJ&1#iF
35 mg
(RIS-OW)
Ibandronate 7t3Fก#- 6& #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(80,81)
Once MR3cF45i,-ก,4R (%" US-FDA) M3Fก/กI#-B&#F(vertebral fracture),
monthly -,4R,-ก#กG%1ก/ก@C-,-I?5#" 6& ก/กIc-3h$-!5$-3ก2B-h3Aก
150 mg B07AQ2h3- (postmenopausal ก/กI#-B&#F(82) (non-vertebral
(IBN-OM) osteoporosis, PMO) fracture)
- ,4R#7!-2h3-&1#iF
Zoledronate 7t3Fก#- 6& #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(56,57)
infusion MR3cF45i,-ก,4R (%" US-FDA) M3Fก/กI#-B&#F(vertebral fracture),
every 1 year -,4R,-ก#กG%1ก/ก@C-,-I?5#" ก/กI%@ก (hip fracture) 6& ก/ก
5 mg B07AQ2h3- (postmenopausal Ic-3h$-!5$-3ก2B-h3 Aกก/กI#-B&#F
(ZOL) osteoporosis, PMO) (non-vertebral fracture)
-,4R,-ก#กG%1ก/ก@C-!5$2กAก - ,4R,BR!FB&32&h3Q!Cก 1 7}
"ก&/%113J?13"J(Glucocorticoid-
induced osteoporosis, GIO)
* IQB# Ibandronate ,4R, -ก&102I5$"F?c3กB#กM3Fก/กI#-B&#F (vertebral fracture) 27s-
B&#กH-Aก RCTs 6?c,-กL5&102I5$"F?c3กB#กM3Fก/กIc-3h$-!5$-3ก2B-h3Aกก/กI#-B&#F
(non-vertebral fracture) 27s-B&#กH-Aกก synthesis data Aก pooled analysis M3F RCTs
 52

Pb1 Benefit and Indication for use JM?=/->Np9

Estrogen 7t3Fก#- 6& #กG%1ก/ก@C-
MR3cF45i,-ก,4R (%" US-FDA)
-,4R,-ก#กG%1ก/ก@C-,-I?5
#"B07AQ2h3-
(postmenopausal osteoporosis,
PMO)
-I0w&102I5$"F?c3กB#ก(6,7,8)
M3Fก/กI#-B&#F(vertebral fracture),
6& ก/กI%@ก (hip fracture)
-,4R#7!-#-&1#iF
(3AA05 preparation 3h$- 24c- 6ec-67
eB-#Fo~F$ "#F90c05B&#กH-!F efficacy)

Raloxifene 7t3Fก#- 6& #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(9,83) M3F

(RLX) 60 mg MR3cF45i,-ก,4R (%" US-FDA) ก/กI#-B&#F(vertebral fracture)
-,4R,-ก#กG%1ก/ก@C-,-I?5 -,4R#7!-#-&1#iF
#"B07AQ2h3-
(postmenopausal osteoporosis,
PMO)
Calcitonin 7t3Fก#- 6& #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(12) M3F
nasal spray MR3cF45i,-ก,4R (%" US-FDA) ก/กI#-B&#F(vertebral fracture)
200 IU/puff -,4R,-ก#กG%1ก/ก@C-,-I?5 -,4R&3ก72-h$3FAกก/กI#-B&#F
#"B07AQ2h3- B#กAก%1ก/ก@C-(13) (90c2ก- 8
(postmenopausal osteoporosis, I#7BJ)
PMO) -@c-!FA0/ก#-&1#iF

Menatetrenone #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(23) M3F

(MK-4) 15 mg MR3cF45i,-ก,4R (%" Japan FDA) ก/กI#-B&#F(vertebral fracture)
-,4R,-ก#กG%1ก/ก@C-,-I?5 -,4R#7!-#-& 3 1#iF (45 mg/d)
#"B07AQ2h3-
(postmenopausal osteoporosis,
PMO)

** IQB#23I%?2A- I0w&102I5$"F?c3กB#กM3Fก/กI#-B&#F(vertebral fracture) 6&&10

2I5$"F?c3กB#กM3Fก/กIc-3h$-!5$-3ก2B-h3Aกก/กI#-B&#F(non-vertebral fracture) 27s-B&#กH-Aก
ก8~กG WHI o~$F,4R conjugate equine estrogen 90c9R extend w~Fก,4R23I%?2A-,- preparation 3h$-
 53

Pb1 Benefit and Indication for use JM?=/->Np9

Strontium #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(29,30)
ranelate MR3cF45i,-ก,4R (%" EMEA) M3Fก/กI#-B&#F(vertebral fracture)
2 g/sachet -,4R,-ก#กG%1ก/ก@C-,-I?5 6& ก/กIc-3h$-!5$-3ก2B-h3Aก
#"B07AQ2h3- ก/กI#-B&#F (non-vertebral fracture)
(postmenopausal osteoporosis, -,4R#7!-#-&1#iF
PMO)

Teriparatide #กG%1ก/ก@C- -I0w&102I5$"F?c3กB#ก(14,15)

20 µg/inject MR3cF45i,-ก,4R (%" US-FDA) M3Fก/กI#-B&#F(vertebral fracture),
-,4R,-ก#กG%1ก/ก@C-,-I?5 ก/กI%@ก (hip fracture) 6&
#"B07AQ2h3- ก/กIc-3h$-!5$-3ก2B-h3 Aกก/ก
(postmenopausal osteoporosis, I#-B&#F (non-vertebral fracture)
PMO) -,4R|5,?ReB-#F#-&1#iF
- ,4R,-ก#กG%1ก/ก@C-!5$2ก
Aก"ก&/%113J?13"J
(Glucocorticoid-induced
osteoporosis, GIO)
-,4R,-ก#กG%1ก/ก@C-,-e/R4"
(Male idiopathic osteoporosis, MIO)
61&2o5"0 6--Q,-e/R7u "!Cก" ,-กL5!5$1c ,4R2@5"F3"cF25"90c7t3Fก#-กI&"
90c2ก-1,200 e/R7u"A9RAก3B90c2@5"F@3(84) ก/กBh3&ก2กก/กB#ก
mg/d
(Elemental
Calcium)
 54

Pb1 Benefit and Indication for use JM?=/->Np9

?0-5 6--Q,-e/R7u "!Cก"%",4Rc 0ก# ,4Rc0ก#61&2o5"03AA4c"&ก
400-800 61&2o5"06&"3h$-€ "ก2R-1-!5$9R I&"ก/ก9R
IU / d 3-C@#-KJM3F?0-5
3-C@#-KJM3F ,4R,-ก#กG%1ก/ก@C-!52$ ก -20h$3,BRc0ก#61&2o5"04c"!Q,BR0&
?0-5 Aก"ก&/%113J?13"J ก/ก1F!5$Bh32@0$ M~i-2&bก-R3"(85)
-Alphacalcidol (Glucocorticoid-induced -#Fก2ก. hypercalcemia 6&
(0.5-1 osteoporosis, GIO) (86,87) hypercalcicuria(88)
90%1ก#0?c3 ,-M-?$QIC ,4Rc0ก#61&2o5"06&
#-) "#กG%1ก/ก@C-3h$-€ ,-กL590c
-Calcitriol 05?0-5K0 Bh3,-กL5e/RI/F3"C
(0.25-0.5 0ก€ (3"C ≥ 65 7}) (88,89)
90%1ก#0?c3
#-)

>?ก
?MK?/K
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of risedronate for the treatment of postmenopausal osteoporosis. Endocr Rev 2002;23:517-
23.
79. Brown JP, Kendler DL, McClung MR, Emkey RD, Adachi JD, Bolognese MA, et al. The
efficacy and tolerability of risedronate once a week for the treatment of postmenopausal
osteoporosis. Calcif Tissue Int 2002;71:103-11.
80. Chesnut-III C, Skag A, Christiansen C, Recker R, Stakkestad JA, Hoiseth A, et al. Effect of
oral Ibandronate administered daily or intermittently on fracture risk in postmenopausal
osteoporosis. J Bone Miner Res 2004;19:1241-49.
81. Reginster JY, Adami S, Lakatos P, Greenwald M, Stepan JJ, Silverman C, et al. Efficacy
and tolerability of once-monthly oral ibandronate in postmenopausal osteoporosis: 2 year
results from the MOBILE study. Ann Rheum Dis 2006;65:654-61.
82. Adachi R, et al. J Bone Miner Res 2007; 22(suppl 1):S210-S211(Abstract).
83. Cranney A, Tugwell P, Zytaruk N, Robinson V, Weaver B, Adachi J, et al. for the
Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group. Meta-
analyses of therapies for postmenopausal osteoporosis. IV. Meta-analysis of raloxifene for
the prevention and treatment of postmenopausal osteoporosis. Endocr Rev. 2002;23(4):
524-8.
84. Sanders KM, Nowson CA, Kotowicz MA, Briffa K, Devine A, Reid IR. Calcium and bone
health: position statement for the Australian and New Zealand Bone and Mineral Society,
 61

Osteoporosis Australia and the Endocrine Society of Australia. Med J Aust 2009;190:316œ
20.
85. Richy F, Schacht E, Bruyere O, Ethgen O, Gourlay M, Reginster JY. Vitamin D analogs
versus native vitamin D in preventing bone loss and osteoporosis-related fractures: a
comparative meta-analysis. Calcif Tissue Int 2005;76(3):176-86.
86. Richy F, Ethgen O, Bruyere O, Reginster JY. Efficacy of alphacalcidol and calcitriol in
primary and corticosteroid-induced osteoporosis: a meta-analysis of their effects on bone
mineral density and fracture rate. Osteoporos Int 2004;15(4):301-10.
87. de Nijs RN, Jacobs JW, Algra A, Lems WF, Bijlsma JW. Prevention and treatment of
glucocorticoid-induced osteoporosis with active vitamin D3 analogues: a review with meta-
analysis of randomized controlled trials including organ transplantation studies. Osteoporos
Int 2004;15(8):589-602.
88. Avenell A, Gillespie WJ, Gillespie LD, O'Connell D. Vitamin D and vitamin D analogues for
preventing fractures associated with involutional and post-menopausal osteoporosis.
Cochrane Database Syst Rev 2009;15(2):CD000227.
89. Ringe JD, Schacht E. Potential of alfacalcidol for reducing increased risk of falls and
fractures. Rheumatol Int 2009;29(10):1177-85.
 62

Glucocorticoid-induced osteoporosis (GIO)

V-1 Introduction and epidemiology
1.1 09b
ก&/ % 113J ?13"J (glucocorticoids) 27s - "!5$ 05, 4R ก# - 0ก 2-h$ 3 FAก05 1C L I0# ? M3F anti-
inflammatory 6& immunosuppressive 05ก,4R,-ก#กG%1B&"€  24c- eB-#F !F2-B",A
9? %1!FMR36&/0?Io#$0 (rheumatic disease) 27s-?R- 6?c3"cF9กb?0 "ก&/%113J?13"J กb05
e&MRF215"F1c3-MRF0ก 24c- !Q,BR-iQ?&,-2&h3I/F 27s-?R3กAก 6&%1ก/ก@C- 27s-?R- -3กAก-5i
"#F27s-I2B?C3#-#?R-€ M3F secondary osteoporosis 05ก8~กG@c "ก&/%113J?13"J 2@$010
2I5$"F?c3ก/กB#ก27s- 1.33 2!c IQB# non-vertebral fracture 1.61 2!c IQB#ก/กI%@กB#ก 6& 2.6
2!cIQB#ก/กB#ก!5$ก/กI#-B&#F 102I5$"FA2@$0M~i-?0M-M3F"!5$,4R 6&102I5$"F?c3ก/กB#ก
A&&F3"cF2b B&#FAกB"C"ก&/%113J?13"J(1,2)
1.2 ,-./01
Aกก8~กG@c ,-1-!5$3"C0กกc 50 7} 057#?ก,4R"ก&/%113J?13"J70L 1-
(3)
3% 05ก8~กG,-72!83#FกrG ,-e/R7u"!5$3"C0กกc 55 7} @c 057#?ก,4R"ก&/%113J?
13"J 1 ,- 70 1- (70L 1.4%) 6&,4R"?c32-h$3Fก#-3"cF-R3" 3 2h3-M~i-97 %"05"2&2|&5$"3"/c
!5$ 3 7}(4)
ก4-4KJ?K<.4ก,-;ก>ก/-JVQ9?1RK.->p.:189 6-12 >-e?9N4K>/2<1ก4; 3 ==?^ P/
=?1-^ %"M-""$FI/F0ก2!c9กI/2I5"0&ก/กกbA2กM~i-2b?097R"(5) กI/2I5"0&
ก/กA2กM~i-!5$2Lก/กI#-B&#F6&ก/กI%@ก o~$FIc-,Bc7ก397R"ก/ก trabecular
3#?กI/2I5"0&ก/ก2|&5$"A70L 5% ,-7}6ก 6& 70L 1-2% ,-7}?c3€ 0(6,7) -3กAก-5i
"#F@cก&&FM3F0&ก/กI#0@#-KJก#M-II0M3F"ก&/% 113J? 13"J (cumulative dose)
0กกcM-"!5$,BR?c3#- (daily dose)

V-2 Pathophysiology and risk assessment

2.1 ก4Eกก>ก/-3=
@"KI5!"M3F glucocorticoid-induced osteoporosis (GIO) 1c3-MRFo#oR3- 2-h$3FAก05
B&"7[AA#"2MR02ก5$"MR3F !#iFM-M3F" M-II0 6&"2&!5$9R#" &R-05e&?c3ก2ก
GIO(8-9) -3กAก-#i-ก/กB#ก!5$2ก,-e/R7u"2B&c-5i ,-1c10B-6-c-ก/ก!5$2!cก#- e/R!5$9R#"ก&/%1
13J?13"JA05102I5$"F?c3ก/กB#กI/Fกce/R!5$2MR#"B07AQ2h3-2|"€(10-11) A~F1,BRก7t3Fก#-
Bh3#กG?#iF6?c"6ก€ B&#F9R#"ก&/%113J?13"J -3กAก-5i?#M3F%1!5$AQ27s-?R3F,4R"ก&/%113J
?13"J23F กb05Ic-!Q,BR2ก%1ก/ก@C-9R3"/c6&R 24c- %1MR33#ก2I/0?3"J(8) %1MR3ก/กI#-B&#F
3#ก2I"~?(ankylosing spondylitis) 7[AA#"3h$-€ กb05e&R" 9R6กc 3"C 2@8 .กB07AQ2h3- 1c
0&ก/กกc3-9R#"(12)
 63

ก&9ก!5$ ก&/% 113J?13"J!Q ,BR2 กก/ก@C -กb1h3 ก!Q ,BRก IR Fก/ก&&F กI&"
ก/ก2@$0M~i-(13) 05e&!Q,BR2ก secondary hyperparathyroidism(14) &ก/o~0M3F61&2o5"0Aก&Q9IR
(15)
6&2@$0กM#wc"61&2o5"033ก!F7[II(16) "#"#iFก!QF-M3F2o&&JIRFก/ก (osteoblast)
c0ก#ก2@$03#??" (apoptosis) M3F osteoblast 6&2o&&JI&"ก/ก (osteoclast)(14,17) 2@$0AQ--
M3F receptor activator M3F NF-KB ligand (RANKL) &AQ--M3F osteoprotegerin (OPG)(18) กก
!QF-M3F hypothalamic pituitary gonad axis 05e&&กIRFm3J%0-23I%?2A-(19) testosterone(20)
6& adrenal androgen(21) o~$F05e&?c3กIRFก/ก I2B?C2B&c-5i%"0ก#-!Q,BR05e&?c3ก2ก%1
ก/ก@C-
2.2 Cg[[1>
A21K
,-7[AAC#-ก720-7[AA#"2I5$"F,-ก2กก/กB#กAกก,4R"ก&/%113J?13"J?R3F720-Aก
7[AA#"2I5$"F?c3ก2กก/กB#ก?cF€ !5$05c0R"24c-25"ก#,-%1ก/ก@C-,-#"B07AQ2h3-
7[AA#"2I5$"F2B&c-5i9R6กc 3"C!5$0กM~i-(≥ 65 7})(22) I?5#"B07AQ2h3- .#4-50&ก"ก"?$Q (low
body mass index) 6&e/R!5$27s-%1!5$2I5$"F?c3ก2ก%1ก/ก@C-(24c-%1MR33#ก2I/0?3"J)(23-24) %1
732hi3#F (chronic lung disease)(25) e/R!5$9R#ก27&5$"-wc"3#" (organ transplantation)(26) c097ก#
ก720-Aกก?A#10B-6-c-ก/กML!5$2$09R#" #F!5$ก&c06&RMRF?R-c,-e/R7u"!5$
9R#"ก&/%113J?13"JA05%3กI2กก/กB#ก!5$1c10B-6-c-ก/ก!5$I/FกcC11&!#$97 %"10
2I5$"FA2@$03"cF0ก20h$31c T Score < -1.0 e/R!5$9R#"ก&/%113J?13"J3AA05ก&&FM3F10
B-6-c-ก/ก9R3"cF2b %"053#?ก&F&FI/Fw~F 10% Bh3 1 standard deviation (SD) ,-4cF 1
7}6ก#F-#i- guideline M3FB&"€ 72!8A~F6--Q,BR ,4R T-score < -1.0 27s-B-~$F,-MR3cF45,i -ก#ก
#กG,-e/R7u"!5$9R#"ก&/%113J?13"J

V-3 Diagnosis
ก-A|#"%1ก/ก@C-!5$2กAกก,4R"ก&/%113J?13"J 90c05K5!5$-3ก2B-h397Aก,-2h$3F
M3F%1ก/ก@C-K0 2@5"F6?c38#"7#?M3Fก9R#""ก&/%113J?13"J c0ก# BMD T-
score ≤ -2.5 SD !5$?Q6B-cF L-spine, femoral neck Bh3 total hip 27s-B&#ก

V-4 Prevention and treatment

4.1 B9.0KกC†?Kก9B4,ก\3=ก,-;กXO90A2>ก/-[กก8@M1ก4;3==?^P/=?1-^
ก7t3Fก#-6&#กG%1ก/ก@C-Aก"ก&/%113J?13"J 05B&#กก24c-25"ก#,-2h$3F%1
ก/ก@C-,-e/RBF#"B07AQ2h3- #FI0w2@$02?09R#F?c397-5i
1. ก7a#??-%"!#$97 1!Q,-e/R7u"!Cก"
1.1. ,4R"ก&/%113J?13"J,-M-!5$?$Q!5$IC ,4R",-"2&!5$I-#i !5$IC 6&,4R"2|@!5$ wR27s-97
9R 2!c!5$A11C0%1B&#ก,BR9R
1.2. 33กกQ&#Fก"3"cFI0$Q2I03
1.3. &Bh3FกI/CB5$ 6&กh$0IC
1.4. 7t3Fก#-กBก&R0
 64

1.5. ,BR9R#70L61&2o5"0,-70L!5$2@5"F@3 3"cF-R3"#-& 1,200 0ก. M3F elemental

calcium
1.6. ,BR9R#?0-5#-& 800 IU
2. ก,4R" ,BR,4R20h$31c?R3F,BR" ก&/ % 113J ? 13"J M-2!5"2!cก#2@-%o%&-#-& 7.5 0ก.
M~i-97--?#iF6?c 3 2h3-M~i-97 c0ก#ก057[AA#"2I5$"F Bh31c10B-6-c-ก/ก BMD T-score ?$Q
กc -1.0
"Ic-,BcI0w2&h3ก,4R9R24c-25"ก#",-?F!5$ 4.1(!!5$ IV)
2.1. "!5$12&h3ก,4R27s-&Q#6ก(27-29)
2.1.1. Alendronate
2.1.2. Risedronate
2.1.3. Zoledronate
2.2. "!5$12&h3ก,4R27s-&Q#!5$I3F (wR90cI0w,4R",-ก&Cc06ก9R)(27,28)
2.2.1. 3-C@#-KJM3F?0-5 24c- alphacalcidol, calcitriol
2.2.2. m3J%0-2@8
2.2.2.1. Estrogen replacement therapy ,- premature menopause
2.2.2.2. Testosterone replacement therapy ,-2@84"!5$@c 05 #M3Fm3J%0-
testosterone ?$Q
2.2.3. Teriparatide 2|@,-1-9MR!5$05102I5$"FI/F(30) 1h3 21"05ก/กB#กAก%1ก/ก@C-
B&"?Q6B-cF Bh3B#ก!5$MR3I%@ก 6&กL590c?3I-3F?c3" bisphosphonates !#Fi -5,i BR,4R
MR3cF45i24c-25"ก#,-MR3 IV-2 2.2 (Teriparatide, TPTD)
2.3. " SERMs, calcitonin, menatetrenone 6& strontium ranelate "#F05 evidence 90c2@5"F@3,-
ก,4R#กG%1ก/ก@C-Aก"ก&/%113J?13"J

V-5 Monitoring treatment

5.1 กP/-P<L4กก\
1. 2-h$3FAก%1ก/ก@C-!5$2กAกก,4R"ก&/%113J?13"J 053#?กI/2I5"0&ก/กI/F A~F
I0w6--Q,BR05ก?A0&ก/กoiQ!Cก 6-12 2h3-9R ,-1-!5$90c9R#ก#กGR"",-ก&Cc0
bisphosphonates Bก9R#"6&R1?AoiQ,- 1 7} ,-กL590c?3I-3F?c3ก#กG ,BR7~กG
e/R245$"4
2. IQB#"2&,-ก#กG 1,BR"#กG%1ก/ก@C-,-e/R7u"!5$,4R"ก&/%113J?13"J A-กc
AB"C"ก&/%113J?13"J (31)
 65

>?ก
?MK?/K
1. Van Staa TP, Leufkens HGM, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids
and risk of fractures. J Bone Miner Res 2000;15:993-1000.
2. Curtis JR, Westfall AO, Allison JJ, Becker A, Casebeer L, Freeman A, et al. Longitudinal
patterns in the prevention of osteoporosis in glucocorticoid-treated patients. Arthritis Rheum
2005;52(8):2485-94.
3. Ettinger B, Presman A, Shah H. Who bears responsibility for glucocorticoid-exposed
patients in a large health maintenance organization. J Manag Care Pharm 2001;7(3):228-
32.
4. Walsh LJ, Wong CA, Pringle M, Tattersfield AE. Use of oral corticosteroids in the
community and the prevention of secondary osteoporosis: a cross sectional study. BMJ
1996;313:344-6.
5. Adachi JD, Bensen WG, Bianchi F, Cividino A, Pillersdorf S, Sebaldt RJ, et al. Vitamin D
and calcium in the prevention of corticosteroid induced osteoporosis: a 3 year follow-up. J
Rheumatol 1996;23(6):995-1000.
6. Van Staa TP, Leufkens HG, Cooper C. The epidemiology of corticosteroid-induced
osteoporosis: a meta-analysis. Osteoporos Int 2002;13(10):777-87.
7. Baxter JD. Advances in glucocorticoid therapy. Adv Intern Med 2000;45:317-49.
8. Reid DM, Kennedy NSJ, Smith MA, Tothill P, Nuki G. Total body calcium in rheumatoid
arthritis: effects of disease activity and corticosteroid treatment. Br Med J 1982;285:330-2.
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10. Kanis JA, Johansson H, Oden A, Johnell O, de Laet C, Melton LJ III, et al. A meta-analysis
of prior corticosteroid use and fracture risk. J Bone Miner res 2004; 19: 893-9.
11. Luengo M, Picado C, Del Rio L, Guanabens N, Montserrat JM, Setoain J. Vertebral
fractures in steroid dependent asthma and involutional osteoporosis: a comparative study.
Thorax 1999; 46: 803-6.
12. Saville PD, Kharmosh O. Osteoporosis of rheumatoid arthritis: influence of age, sex and
corticosteroids. Arthritis Rheum 1967;10:423-30.
13. Prummel MF, Wiersinga WM, Lips P, Sanders GTB, Sauerwein HP. The course of
biochemical parameters of bone turnover during treatment with corticosteroids. J Clin
Endocrinol Metab 1991;72:382-6 .
14. Bressot C, Meunier PJ, Chapuy MC, Lejeune E, Edouard C, Dardy AJ. Histomorphometric
profile, pathophysiology and reversibility of corticosteroid-induced osteoporosis. Metab Bone
Dis Relat Res 1979;1:303-11.
15. Morris HA, Need AG, OŽLoughlin PD, Horowitz M, Bridges A, Nordin BEC. Malabsorption of
calcium in cortico-steroid-induced osteoporosis. Calcif Tissue Int 1990;46:305-8.
 66

16. Suzuki Y, Ichikawa Y, Saito E, Homma M. Importance of increased urinary calcium

excretion in the development of secondary hyperparathyroidism of patients under
glucocorticoid therapy. Metabolism 1983;32:151-6.
17. Weinstein RS, Jilka RL, Parfitt AM, Manolagas SC. Inhibition of osteoblastogenesis and
promotion of apoptosis of osteoblasts and osteocytes by glucocorticoids. Potential
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18. Hofbauer LC, Gori F, Riggs BL, Lacey DL, Dunstan CR, Spelsberg TC, et al. Stimulation of
osteoprotegerin ligand and inhibition of osteoprotegerin production by glucocorticoids in
human osteoblastic lineage cells: potential paracrine mechanisms of glucocorticoid-induced
osteoporosis. Endocrinology 1999;140:4382-89.
19. Montecucco C, Caporali R, Caprotti P, Caprotti M, Notario A. Sex hormones and bone
metabolism in postmenopausal rheumatoid arthritis treated with two different
glucocorticoids. J Rheumatol 1992;19(12):1895-900.
20. MacAdams MR, White RH, Chipps BE. Reduction of serum testosterone levels during
chronic glucocorticoid therapy. Ann Intern Med 1986;104:648-51.
21. Hampson G, Bhargava N, Cheung J, Vaja S, Seed PT, Fogelman I. Low circulating
estradiol and adrenal androgens concentrations in men on glucocorticoids: a potential
contributory factor in steroid-induced osteoporosis. Metabolism 2002;51(11):1458-62.
22. Kanis JA, Johansson H, Oden A, Johnell O, de Laet C, Melton LJ III, et al. A meta-analysis
of prior corticosteroid use and fracture risk. J Bone Miner Res 2004;19:893-9.
23. Hooyman J, Melton L, Nelson A, OŽFallon /w, Riggs B. Fractures after rheumatoid arthritis:
a population-based study. Arthritis Rheum 1984;27:1353-61.
24. van Everdingen A, Jacobs J, Siewertsz Van Reesema D, Bijlsma J. Low-dose prednisone
therapy for patients with early active rheumatoid arthritis: clinical efficacy, disease-modifying
properties, and side effects: a randomized, double-blind, placebo-controlled clinical trial. Ann
Intern Med 2002;136:1-12.
25. Walsh LJ, Lewis SA, Wong CA, Cooper S, Oborne J, Cawte SA, et al. The impact of oral
corticosteroid use on bone mineral density and vertebral fracture. Am J Respir Crit Care
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26. Mikuls T, Julian B, Bartolucci A, Saag K. Bone mineral density changes within six months of
renal transplantation. Transplantation 2003:49-54.
27. Nawata H, Soen S, Takayanagi R, Tanaka I, Takaoka K, Fukunaga M, Matsumoto T, et al;
The Subcommittee to Study Diagnostic Criteria for Glucocorticoid-Induced Osteoporosis.
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28. Devogelaer JP, Goemaere S, Boonen S, Body JJ, Kaufman JM, Reginster JY, et al.
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 67

osteoporosis: a consensus document of the Belgian Bone Club. Osteoporos Int 2006; 17(1):
8-19.
29. Reid DM, Devogelaer JP, Saag K, et al for the HORIZON Investigators. Zoledronic acid and
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2003;32:135-57.
 68

Osteoporosis in men
VI-1 Introduction and epidemiology
1.1 09b B4, =b[bก-=.<
S0'S0ก(<0
%1ก/ก@C-,-e/R4" (Osteoporosis in men) B0"w~F %1!5$050&M3Fก/ก&&F 05%1FIRF
M3Fก/กe7ก? !Q,BRก/ก27F 6&B#กFc"!5$2กM~i-,-e/R4"
2
S0
3=ก,-;กXO9X89L;MN/K<กก.R89L;M@1 2-h$3FAกe/R4"05#0&ก/กI/FIC,-#"B-Cc0
I0กกce/RBF 6&05ก&&FM3F0&ก/ก4Rกce/RBF !Q,BR6@!"J0CcF2-R-ก#กG%1ก/ก@C-
,-e/RBF#"B07AQ2h3- 6&BFI/F3"C27s-Ic-,Bc 3"cF9กb?0Aกก8~กG!F!"
@c 30% M3Fก2กก/กI%@กB#ก 6& 20% M3Fก2กก/กI#-B&#FB#ก!#$%&ก2กM~i-,-e/R4"(1)
9R05ก70LกLJ9Rc,-7} 1.8. 2025 A05AQ--e/R4"!5$ก/กI%@กB#ก2!cก#AQ--e/RBF!5$05
ก/กI%@กB#ก,-7[AAC#-(1,2) -3กAก-5i "#F@cL;M@10A2<Aก,-;ก
,3Xก Ne?ก,-;ก
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IQ1#!FIKLICM24c-25"ก#- 6&A!510IQ1#0กM~i-2h$3"€ 2-h$3FAก74ก053"C"h-0กM~i-
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2กก/กB#ก!#$%&กA2@$0M~i-3"cF0ก%"2@$0Aก 0.5 &R-1-27s- 1.8 &R-1-,-7} 1.8. 2050 -5i
2-h$3FAกก2@$0M~i-M3F74กI/F3"C(1,4) AกกIQAMR30/&M3F72!8IB#H320ก@c e/R4"!5$
3"C?#iF6?c 50 7}M~i-97@ 6% A2กก/กI%@กB#ก6& 5% A@ก/กI#-B&#FB#กAก%1ก/ก@C-(5)
%" 1 ,- 8 A@ก/กB#กAก%1ก/ก@C-
ก>ก/-ก,-;กNก89L;M@1[ก3=ก,-;กXO9 [,>ก/-@Mก.RL;MN/KC,<` 5-10 CU %"
e/RBFA053C#?กLJM3Fก2กก/กB#กI/FM~i-20h$33"C 65 7},-ML!5$e/R4"A2$0I/FM~i-20h$33"C70L
70-75 7} !#iF-5i2กAกก!5$e/R4"050&ก/กI/Fกce/RBF !Q,BR2กกB#ก4Rกc(6,7) -3กAก-#i-"#F@c
e/R4"A05ก/ก,Bcกce/RBF กI/2I5"0&ก/กกbA27s-973"cF4R€ 2-h$3FAก90c05ก27&5$"-67&F
M3Fm3J%0-2@8&&F3"cF2b2B0h3-,-e/RBF
Aกก8~กG@c3C#?กLJก2กก/กI%@กB#ก,-ก&Cc072!823245"?$Qกc72!8!F
(8-16)
?#-?ก IQB#MR30/&,-72!89!"Aกก8~กG,- Asian Osteoporosis Study (AOS) @c
3C#?กLJM3Fก/กI%@กB#ก,-e/R4"2!cก# 114 ?c374ก 100,000 1- ,-ML!5$e/RBF2!cก# 289
?c374ก 100,000 1- IQB#3C#?กLJM3Fก/กI#-B&#FB#ก6&ก/ก6M-B#ก,-72!89!""#F90c05
ก8~กG0กc3- Ic-104CกM3F%1ก/ก@C-,-e/R4"9!"@c!5$ก/กI%@ก 12.6% !5$ก/กI#-
B&#FIc-23 4.6% 6&!#iFI3F?Q6B-cF 3.9%(17)
 69

1.3. Cg[[1>
A21K
,-7[AAC#-ก720-7[AA#"2I5$"FM3Fก2ก%1ก/ก@C-,-e/R4"?R3F720-Aก7[AA#"2I5"$ F?c3
ก2กก/กB#ก?cF€ !5$05c0R" 0!#iF7[AA#"2I5$"F?c3กI/2I5"0&ก/ก 24c-25"ก#,-%1ก/ก
@C-,-e/RBF#"B07AQ2h3- (7[AA#"2I5$"FIc-,Bc1&R"€ ก#-) 7[AA#"2I5$"F2B&c-5i9R6กc
− Cg[[1>
A21KPR?ก
;>
A1<.4ก,-;ก0A2E<R
<uBกMEJE-M=e? 3"C 6& @#-KCก0(18,19)
− Cg[[1>
A21KPR?ก
;>
A1<.4ก,-;ก0A2
<uBกMEJE-M=e? กI/CB5$(21-24) ก,4RกAก0
!Fก"-R3" (physical inactivity) (20,25,26) ก05#4-50&ก"?$Q(21,22,25) กh$063&ก3m3&J2ก-
M- (27,28) 05.@c3F?0-5 (29) 05.@c3F61&2o5"0(22,30) ก9R#70L%7?5-?$Q(31)
ก9R#"!5$05e&?c3กI/2I5"0&ก/ก 9R6กc "I2?5"3"J "ก#-4#ก(32) thiazolidinedione(33)
"#กG.o~028Rก&Cc0 SSRI(34)

VI-2 Assessment and diagnosis

2.1 ก./9/[q1
ก-A|#"%1ก/ก@C-,-e/R4"!Q9R%"ก?A10B-6-c-M3Fก/ก (bone mineral
density, BMD) %"!#$97A?A!5$ก/กI#-B&#FIc-23 (L-spine) 6&!5$ก/กI%@ก ก-A|#"%1
ก/ก@C-,-e/R4"!5$3"C0กกc 50 7}A,4R1c10B-6-c-M3Fก/กM3Fe/R7u"2!5"ก#1c25$"F2-
0?H-M3F10B-6-c-M3Fก/กM3Fe/R4"24hi34?,ก&R215"Fก#-!5$053"CBcF 30-35 7} wR1c T-
score ≤ -2.5 IC79Rc27s-%1ก/ก@C-(35,36)
ก-A|#"%1ก/ก@C-,-e/R4"!5$3"C-R3"กc 50 7}12!5"ก#1c25$"F2-0?H-M3F
10B-6-c-M3Fก/กM3Fe/R4"24hi34?,ก&R215"Fก#-!5$3"/c,-4cF3"C2!cก#- (Z-score) 0กกcก,4R
T-score(36)
2.2 กP.[RKก1B4,กP.[X/>D\
%1ก/ก@C-,-e/R4"6?ก?cFAก,-e/RBF1h370L1~$FB-~$FM3Fe/R7u"A@I2B?CM3F%1
ก/ก@C- (secondary osteoporosis) Bh3@/Fc"€ c2I0wBI2B?CM3Fก!Q,BR2ก%1ก/ก
@C-9R ก720-e/R7u"7ก3R"กo#ก7#? ก?AcFก" 6&ก?A!FBR3F7a#?ก
ก0f(ก <( 
9R6กc กo#ก7#?2@h$3720-7[AA#"2I5$"FM3F%1ก/ก@C- 3กM3F%1?cF€ !5$3A27s-
I2B?CM3F secondary osteoporosis 6&7[AA#"2I5$"F!5$!Q,BR05ก/กI%@กB#ก9R6กc ก!F?#90c5 6&Bก
&R0Fc" 6&7#?ก05ก/กB#ก,-35?
ก0 <'/0-ก0!
9R6กc ก#Ic-I/F ก4#$F-iQB-#ก กI#F2ก?!c2- 6&ก!F?#M3Fe/R7u" ก?A%1F
ก/ก!#$970!#iFก/กI#-B&#F2@h$3?ABc05ก/กB#กBh390c ก@c05Ic-I/F&&FAก20 05
kyphosis Bh3 kyphoscoliosis cF45ice/R7u"05 vertebral fracture -3กAก-5i1?Ac05&#กGL
Cushingnoid habitus Bh390c 0!#iFก1&Q?c309!3"J 6&?A/c05 thyrotoxicosis Bh390c
 70

ก0 <'0-@4?- A2( ก0

(2+, 1 ก0 <'0-@4?- A2( ก0)2C?D - 4

(1?A!Cก"2@h$3BI2B?CM3F%1ก/ก@C-)
1. Complete blood count
2. Serum calcium, phosphorus
3. Serum albumin
4. Serum alkaline phosphatase
5. Serum creatinine 6& liver transaminases
6. Thyroid stimulating hormone (TSH)
7. Testosterone
(2+, 2 ก0 <'),) B
กT++,ก0 <'B
(2+, 1 !(-./02*0)@
(90cAQ27s-?R3F?A!Cก")
1. Serum protein electrophoresis
2. Parathyroid hormone
3. Serum 25-hydroxy vitamin D
4. 24-hour urine calcium
5. 24-hour urine free cortisol
B240-+,<.4(2ก0*/- <'<0@
0Q
/
>?-กก
MR3cF45i,-ก,-กIcF?A BMD ,-e/R4"(36) 9R6กc
1. e/R!5$05 hypogonadism
2. e/R!5$05ก/กB#ก%"90c05กก6!ก!5$C-6F
3. e/R!5$057[B malabsorption
4. e/R7u" primary hyperparathyroidism
5. e/R!5$กQ&#FA9R# Bh39R#ก#กGR" glucocorticoids ""
6. e/R!5$กQ&#FA9R#ก#กGR" organ transplantation
7. e/R!5$?A@c05ก/กFAก.@wc"#FI5

VI-3 Prevention
3.1 กC†?Kก93=ก,-;กXO989L;M@1(37-39)
− 90c1h0$ IC27s-7AQ 90c1h$063&ก3m3&J2ก-กc#-& 3 B-c"0?H- 1h3 AQ--!5$0h$
63&ก3m3&J wR27s-2B&R0กกc 2 33-oJ, 9-J 7 33-oJ 6&25"J 18 33-oJ (40)
− FI/CB5$
− 33กกQ&#Fก"3"cFI0$Q2I036&2-R-ก33กกQ&#Fก"4-&F-iQB-#ก 24c- 2- Bh3 $F 27s-?R-
,-e/RI/F3"C133กกQ&#Fก"4- balanced exercise 2@h$34c"2@$0106MbF6FM3Fก&R02-h3i
ก!F?# 6&&กBก&R0
− %.161&2o5"0Aก6B&cF3B6&/Bh361&2o5"02I0,BR2@5"F@3 0กกc#-& 800 0ก.
(elemental calcium)
 71

− 9R#?0-52I0#-& 400-800 IU Bh3 1w/ก6IF63"cF-R3"#-& 10 -!5

− ,BR10/6R &1Q6--Q,-ก,4R"!5$IcFe&,BR2กก&&FM3F0&ก/ก 24c- "ก#-4#ก ก&/%113J
?13"J "?R-ก6MbF?#M3F2&h3 m3J%0-9!3"J "?R-m3J%0-2@84" 27s-?R-
− ,BR10/R2ก5$"ก#7[AA#"6&%1?cF€ !5$IcFe&,BR2กกI/2I5"M3F0&ก/ก6&3A!Q,BR2ก
%1ก/ก@C-9R 2@h$3A9R#ก7t3Fก#-!5$w/ก?R3F?c397

VI-4 Treatment and follow-up

4.1 B9.0Kกก\3=ก,-;กXO989L;M@1
"!5$ 05 ก 8~ ก Gc  I0w# ก G.ก/ ก @C - ,-4"1h 3 "Ic  -,Bc I 0w2&h 3 ก,4R 9 R
24c-25"ก#",-?F!5$ 4.1 (!!5$ IV) 6?c"!5$12&h3ก,4R27s-3#-#6ก1h3 bisphosphonate 9R6กc
alendronate(41) Bh3 risedronate (42) Bh3 zoledronic acid (43) 2-h$3FAก27s-"!5$9R#ก#3F,BR,4R#กG
%1ก/ก@C-,-e/R4" %"!5$e/R7u"2B&c-5iA?R3F9R#61&2o5"0!5$2@5"F@3 -3กAก-#i-"#F3AA05ก,BR
testosterone replacement therapy ,-2@84"!5$@c 05#M3Fm3J%0-2@84" (testosterone) ?$QR"
ก#กG%""ก&Cc0 -5iI0w#ก Ge/R 7u"ก/ก@C-,-4"!5$2 กAกก9R# "ก&/% 113J ?13"J ,
androgen-deprived therapy, osteogenesis imperfecta, post-transplantation, stroke 9R3"cF05
7I!K.@35กR"
IQB#"ก&Cc03h$-!5$05ก8~กG1h3 parathyroid hormone (teriparatide) (44-47) o~$FI0w&ก
2ก ก/ ก B# ก !5$ I# - B&# F 9R 6 ?c 05 MR 3 AQ  ก#  1h 3 16@F ?R 3 F27s - / 7 |5  6&90c 1 ,4R c  0ก#  potent
antiresorptive drugs(48) A~F12&h3ก,4R27s-3#-#3F&F0 6&1,4R2|@,-e/R7u"!5$05102I5$"FI/F1h3
21"05 ก / ก B# ก Aก%1ก/ ก @C - B&"?Q  6B-c F Bh 3 B# ก !5$ MR 3 I%@ก 6&กL5 9 0c ? 3I-3F?c 3 "
bisphosphonates !#iF-5i,BR,4RMR3cF45i24c-25"ก#,-MR3 IV-2 2.2 (Teriparatide, TPTD)
",-ก&Cc0 SERMs, calcitonin, menatetrenone 6& strontium ranelate "#F05B&#กH-90c2@5"F@3
IQB#ก,4R#กG%1ก/ก@C-,-e/R4"
4.2 กP/-P<L4กก\
6-!Fก??0e&ก#กG05#F-5i(37-39)
1. ??03ก6&3ก6IFM3F%1ก/ก@C-6&ก/กB#ก
2. 2”t#F6&??0.6!กoR3-!5$2กM~i-Aกก#กG
3. ,-กL5 !5$ e/R 7u  "05 . m3J % 0-2@84"?$Q  6&9R #  ก# ก GR  "m3J % 0-!6!- 9R 6 กc
testosterone Bh3 androgen 19R#ก?AcFก"6&?A!FBR3F7a#?ก#F-5i
− ?A#10#-%&B?!Cก1#iF!5$0%F@"&
− ?A!F!B-#ก2@h$3720-10e7ก?M3F?c30&/กB0ก
− ?A#102MR0MR-M3F2&h36&#9M0#- 9R6กc total cholesterol, triglyceride, HDL-
C and LDL-C !Cก 6-12 2h3-
− ?A2&h3## prostate-specific antigen (PSA) !Cก 1 7} (,-e/R!5$053"C 65 7}M~i-97)
4. MR36--Q,-ก?A??0."B&#Fก#กG05#F-5i
 72

− ,-กL5!5$ T-score ?$Qกc -2.5 6&9R#"2@h$3ก#กG 1?A720-10B-6-c-

M3Fก/กI#-B&#FIc-236&ก/กI%@กB&#Fก#กG6&R70L 1-2 7}
− ,-กL5!5$ T-score 3"/cBcF -2.5 w~F -1 6&057[AA#"2I5$"FM3F%1ก/ก@C-B&"3"cF1
?A10B-6-c-M3Fก/กI#-B&#FIc-236&ก/กI%@กB&#Fก#กG6&R70L
1-2 7}
− ,-กL5!5$ T-score 0กกc œ1 90cAQ27s-?R3F?A10B-6-c-ก/ก.",-"2& 5 7}
2R-6?c057[AA#"2I5$"F!F1&-ก2@$0M~i-
!#iF-5i2-h$3FAกก27&5$"-67&FM3F0&ก/ก2ก4R0ก 60Rc1c coefficient of variation (CV)
M3Fก?A#%" DXA 051c?$Q(49) 6?cก?A#-#i-?R3Fกก27&5$"-67&F!5$0กกc10I0w
M3F21h$3F(49) #F-#i- ก??0 BMD 90c1!Q2bกc 1 7}

>?ก
?MK?/K
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