Throughout the world, life expectancy is increasing, and now the task of the doctor is not only to ensure a long life for his patients, but also to help maintain a high quality of life and health throughout all these years. A special role in ensuring active longevity is occupied by endocrinology - a field of medicine that studies the structure and functions of the endocrine glands, the ways in which hormones are formed and act on the human body, as well as diseases caused by dysfunction of the endocrine glands or the action of hormones.
The Department of Active Longevity and Endocrinology of the National Medical Research Center of the Republic of Kazakhstan of the Ministry of Health of the Russian Federation is the first and leading division in the country, the main activity of which is the development and implementation of methods of medical rehabilitation, restorative medicine and physiotherapy of endocrine diseases, systemic osteoporosis and their complications. The department actively develops and implements personalized active aging programs, which include screening and prevention of major diseases associated with age (overweight, carbohydrate metabolism disorders, including diabetes mellitus, systemic osteoporosis, etc.).
DEPARTMENT EMPLOYEES
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MARCHENKOVA LARISA ALEKSANDROVNA Head of the Department of Active Longevity and Endocrinology, Head of the Department of Rehabilitation of Patients with Somatic Diseases, Head of the Center for the Treatment and Rehabilitation of Patients with Osteoporosis and Metabolic Skeletal Diseases, Endocrinologist, Candidate of Medical Sciences.
Specialist in clinical endocrinology, osteoporosis, pathology of calcium-phosphorus metabolism and menopause. Awarded with certificates of honor “For a great contribution to the development of educational, methodological and scientific work on the problem of osteoporosis in the Russian Federation” and “For a great personal contribution to the activities of the Russian Association for Osteoporosis. |
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KOCHEMASOVA TATYANA VLADIMIROVNA senior researcher, endocrinologist, candidate of medical sciences. Medical specialties: "Endocrinology", "Physiotherapy". |
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DOBRITSYNA MARINA ANDREEVNA researcher, endocrinologist. Medical specialties: "Endocrinology", "Diabetology", "Physiotherapy". |
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MAKEENKO VALERIA ALEKSANDROVNA junior researcher, endocrinologist.
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MAKAROVA EKATERINA VLADIMIROVNA junior researcher, endocrinologist. Medical specialties: "Endocrinology", "Therapy". |
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SHAKUROVA LILIA RAFILIEVNA endocrinologist. Medical specialty: Endocrinology. |
DIRECTIONS OF SCIENTIFIC AND CLINICAL WORK
- development and implementation of personalized programs for active longevity and a healthy lifestyle;
- development and application of new methods of treatment and rehabilitation of patients with endocrine diseases using pharmacological and non-drug methods;
- treatment and rehabilitation of patients with diabetes mellitus type 1 and 2 using various medicinal and physical methods of treatment;
- complex therapy of obesity;
- treatment and rehabilitation of patients with thyroid diseases, including after surgical interventions;
- treatment and rehabilitation of patients with various nosological forms of primary and secondary osteoporosis.
EQUIPMENT, DIAGNOSTIC AND TREATMENT CAPABILITIES OF THE DEPARTMENT
The Department of Active Aging and Endocrinology is equipped with unique equipment, in particular BOD POD camera. BOD POD is a special body composition analyzer system that allows you to determine the percentage of fat mass and the level of basal metabolic rate in just 4 minutes. For calculations, the subject is placed in a chamber, and by the difference in air volumes in an empty chamber and in a chamber with a person, a computer program calculates numerous indicators: the volume of the subject's body, measures his mass, body density, and then calculates the ratio of adipose and muscle tissue. The data obtained as a result of the study allow us to calculate the optimal calorie content of the daily diet to reduce or maintain body weight, which is extremely important in the treatment of many endocrinological diseases and obesity.
Also, the Department has and installs devices for continuous subcutaneous insulin infusion - insulin pumps. As you know, the main task of patients with diabetes of both the first and second types is to maintain an optimal level of blood glucose. Insulin pumps allow you to immediately correct your blood glucose levels without multiple daily injections. An insulin pump is a small computer that contains a reservoir of insulin, a battery, and a remote control that allows the patient to control how much insulin is being injected. The pump is used continuously because insulin must be delivered 24 hours a day. In our department, you will be given a unique chance to use the pump for a few days to see if this method of insulin therapy is right for you.
Also in the Department of Active Aging and Endocrinology, patients with diabetes have an amazing opportunity to find out what happens to their blood glucose levels over several days. Devices for continuous glycemic monitoring CGMS about 240 measurements per day are carried out, presenting the information obtained about the blood sugar level in the form of graphs, which allows diagnosing hidden hypoglycemia, the “dawn” phenomenon, hyperglycemia after eating, and correcting hypoglycemic therapy quickly and efficiently, and achieving optimal carbohydrate metabolism.
For express determination of the level of glycated hemoglobin in the blood, the ratio of microalbumin / creatinine in the urine, the Department of Active Aging and Endocrinology has an automatic analyzer, which allows specialists to conduct a study directly in the presence of patients and prescribe effective and safe treatment as soon as possible.
CENTER FOR THE TREATMENT AND REHABILITATION OF PATIENTS WITH OSTEOPOROSIS AND METABOLIC DISEASES OF THE SKELETON
The Center for the Treatment and Rehabilitation of Patients with Osteoporosis and Metabolic Skeletal Diseases is organized on the basis of the Department of Active Longevity and Endocrinology and the Department of Rehabilitation of Patients with Somatic Diseases in order to improve the quality of specialized medical care for patients with osteoporosis and metabolic diseases of the skeleton.
Osteoporosis is one of the most common diseases of mankind, which is characterized by bone fragility and an increased risk of fractures. Most often, osteoporosis develops in older people and postmenopausal women.
Approximately one in three women in the world and one in eight men over the age of 50 have bone fractures associated with osteoporosis. According to the Russian Association for Osteoporosis, about 14 million people in Russia are prone to this disease, and 34 million people (almost 24% of the population of our country) are in the potential risk group.
Bone fractures in osteoporosis occur even with a small injury, for example, when falling from a height of human growth. The most serious fractures are those of the femoral neck, which usually occur in debilitated elderly patients. However, most people are not even aware that they have osteoporosis until a fracture occurs. If time does not take up the prevention and treatment of osteoporosis, the disease progresses rapidly and leads to serious complications.
The Center for the Treatment and Rehabilitation of Patients with Osteoporosis and Metabolic Skeletal Diseases provides highly effective specialized medical care for the treatment and medical rehabilitation of patients with osteoporosis and metabolic skeletal diseases, develops and implements modern methods and procedures for the treatment and rehabilitation of patients with osteoporosis and metabolic diseases at the National Medical Research Center of the Republic of Kazakhstan. skeletal diseases in order to reduce the risk of complications and improve the quality of life.
The specialists of the Center have many years of experience in the field of diagnostics, treatment and medical rehabilitation of patients with osteoporosis and metabolic diseases of the skeleton, members of the Russian Association for Osteoporosis.
Diagnosis and treatment osteoporosis at the highest level is possible not only due to the skill of the specialists of the Department of Active Aging and Endocrinology, but also the equipment of the center with a modern X-ray densitometer, computed tomography, magnetic resonance imaging and the ability of the center's laboratory to determine all the necessary indicators of bone metabolism and calcium-phosphorus metabolism.
HEALTH SCHOOLS FOR PATIENTS
- Health School "Ideal Weight". Excess weight is not only an aesthetic problem, but also a disease, which in some cases can lead to serious complications. Classes will allow you to determine the type of eating behavior, form the right eating habits, adjust your lifestyle in order not only to safely reduce weight, but also to keep it off for many years.
- Health School "Healthy Bones", in which older patients receive answers to the most important questions for themselves: what is osteoporosis and how it manifests itself, what are the risk factors and causes of its development, why falls and fractures occur and how can they be prevented. In addition, you can learn and master through practical exercises the principles of nutrition, exercise and lifestyle necessary for the prevention of osteoporosis and fractures.
- School of health "Active longevity", which teaches the principles of a healthy lifestyle, determines the main physiological indicators that need to be monitored at different age periods of a person, develops individual personalized nutrition programs, physical activity, physiotherapy, drug therapy to maintain a high quality of life and health for many years.
Scientists say that one hour a day spent on health care can add 15-20 years of life, we help you start your path to active longevity today!
Dissertation abstractin medicine on the topic Differentiated approach to hormonal therapy for postmenopausal osteoporosis
G "G B od ¿3 l YuYa
As a manuscript
MARCHENKOVA Larisa Alexandrovna
DIFFERENTIAL APPROACH TO HORMONAL THERAPY OF POSTMENOPAUSAL OSTEOPOROSIS
Moscow -1999
The work was performed at the Moscow Regional Research Clinical Institute named after V.I. M.F.Vladimirsky
Scientific adviser:
doctor of medical sciences, professor Dreval A.V.
Scientific consultant:
Honored Worker of Science of the Russian Federation, Corresponding Member. RAMS, doctor of medical sciences, professor Onoprienko G.A.
Official opponents: MD, professor
Marova E.I.
The defense of the dissertation will take place on October 5, 1999 at 10 o'clock at a meeting of the dissertation council (K.074.04.03) at the Russian Medical Academy of Postgraduate Education (123836, Moscow, Barrikadnaya st., 2)
The dissertation can be found in the library of the Russian Medical Academy of Postgraduate Education
Candidate of Medical Sciences, Professor Potemkin V.V.
Leading organization: Moscow Medical Dental
Scientific Secretary of the Dissertation Council Candidate of Medical Sciences, Associate Professor
Okulov A.B.
GENERAL DESCRIPTION OF WORK
Relevance of the research topic. Postmenonasal osteoporosis is a severe, common, but insufficiently studied disease of middle-aged and older women, which develops against the background of estrogen deficiency in menopause. In the last decade, there has been an increase in women's life expectancy, which is accompanied by a steady increase in the incidence of osteoporosis. According to epidemiological studies, approximately 28% of Moscow residents over 50 years of age suffer from osteoporosis, and almost 50% of women have osteopenia, i.e. high risk of developing osteoporosis [Spirtus T.D., Mikhailov E.E., Benevolenskaya L.I., 1997].
The clinical picture and complications of postmenopausal osteoporosis are associated with bone fractures. The material costs for the treatment and rehabilitation of women with fractures are enormous, therefore, it is very relevant to study the information content of these densitometry methods for assessing the risk of osteoporotic fractures.
According to a number of researchers, a more complete picture of the nature of the course of the disease and the activity of the pathological process in the body is given by the study of the enzymatic activity of leukocytes, primarily lymphocytes and ceitrophils [Maltsev SV, 1970; Komissarova I.A., 1983; Bakuev M.M., 1991; Narcissov R.P., 1997]. The enzymatic status of these cells is considered as a kind of enzymatic "mirror" - the state of many tissues [Komissarova I.A., 1983], including bone [Maltsev S.V., 1970]. Therefore, in our opinion, the study of the enzymatic activity of leukocytes in postmenopausal osteopenia undoubtedly opens up new opportunities for developing diagnostic criteria and evaluating the effectiveness of osteoporosis therapy.
The treatment of osteoporosis and its prevention have not yet been finally developed [Rozhinskaya L.Ya., 1998], therefore, the results of the search for new methods of treating osteoporosis can significantly increase the length and quality of life of women in menopause. In this regard, the study of clinical effects of hormonal treatments for postmenopausal osteoporosis, such as hormone replacement therapy (HRT), calcitonin therapy, and active vitamin D metabolites.
HRT is considered the "gold standard" for the treatment of postmenopausal osteoporosis and menopausal disorders. However, even the combination of estrogens with progestogens does not fully eliminate the risk of oncological complications of HRT associated with the proliferative effect of estrogens on estrogen-dependent organs, which is the reason for the increased interest in the symptomatic treatment of menopausal disorders.
In this aspect, preparations of natural metabolites (GEM) glycine and limontar deserve attention. In our opinion, PEM, due to the specifics of the pharmacological action, alone or in combination with HRT, could have a beneficial effect on bone metabolism and the course of some menopausal disorders.
Purpose of the study. To evaluate the clinical efficacy of various types of hormonal therapy for postmenopausal osteoporosis; to develop criteria for choosing hormonal therapy depending on the characteristics of the course of the disease and the nature of the skeletal lesion.
Research objectives.
1. To study the state of bone mineral density in postmenopausal women.
2. Evaluate the information content of dual-energy x-ray absorptiometry of the axial and peripheral skeleton to determine the risk of osteoporotic fractures.
3. To investigate the clinical efficacy of various types of hormonal therapy for postmenopausal osteoporosis - hormone replacement therapy, alfacalcidol and a combination of capcitonin and alfacalcidol - with short treatment periods; to develop criteria for choosing hormonal therapy depending on the characteristics of the course of the disease and the nature of the skeletal lesion.
4. To study the clinical efficacy of a combination of preparations of natural metabolites of glycine and lnmontar in postmenopausal osteoporosis and menopausal syndrome; to develop principles for the treatment of menopausal syndrome using drugs glycine and limontar.
5. To study the features of the enzymatic activity of peripheral blood leukocytes in postmenopausal osteopenia and develop a methodology for identifying individuals with an increased risk of osteoporosis based on cytochemical tests.
Scientific novelty of the work. The informativity of dual-energy x-ray absorptiometry of the axial skeleton for assessing the risk of compression fractures in the thoracic and lumbar spine was studied; For the first time, the information content of dual-energy X-ray absorptiometry of the distal forearm was assessed to determine the risk of vertebral compression fractures.
A comparative analysis of the clinical efficacy of various types of hormonal therapy for postmenopausal osteoporosis was carried out and the selectivity of their effect on bone mineral density in various areas of the skeleton was studied for short treatment periods. For the first time, the clinical efficacy of preparations of natural metabolites of glycine and limontar in postmenopausal osteopenia and menopausal syndrome was studied.
For the first time in world practice, the features of the metabolic state of leukocytes in postmenopausal osteopenia were studied and it was demonstrated that therapy with drugs that affect bone tissue metabolism causes specific changes in the enzyme profile of leukocytes.
Practical value of the work. Possibilities are defined. dual-energy x-ray absorptiometry of the axial and peripheral skeleton to assess the risk of vertebral compression fractures.
Criteria for the choice of hormonal therapy for postmenopausal osteoporosis based on the characteristics of the course of the disease and the nature of the lesion have been developed.
skeleton. In addition, principles have been developed for the treatment of menopausal syndrome with a combination of hormone replacement therapy and preparations of natural metabolites glycine and limontar.
Approbation of work. The results of the study were reported and discussed at the interdepartmental scientific conference of MONIKI (December 22, 1998), the scientific and practical conference "Alfacalcidol in the treatment of osteoporosis and other diseases" (December 9, 1998, Moscow), the meeting of the Moscow Regional Society of Endocrinologists "Modern methods of osteoporosis therapy” (04/07/1999), 6 Russian National Congress “Man and medicine” (04/20/1999, Moscow) and the International conference “Actual problems of osteoporosis” (09/2/1999, Yevpatoria ). The materials of the dissertation were used to create a manual for doctors and included in the training course of the Department of Endocrinology of the Faculty of Education and Science of MONIKI.
The structure and scope of the dissertation. The dissertation consists of an introduction, literature review, description of clinical material and research methods, 4 chapters of own research, discussion of the results, conclusions and practical recommendations.
The dissertation is presented on 151 pages of typewritten text, illustrated with 35 tables and 15 figures. The bibliography contains 165 literary sources, including 25 domestic and 140 foreign authors.
MATERIAL AND RESEARCH METHODS
The surveyed group was formed from among women in perimenopause or postmenopause aged 45 to 70 years without risk factors for secondary osteoporosis, who applied to MONIKI with various complaints. For the study, 64 women were selected, whose average age was 56.08±1.04 years, and the average duration of postmenopause was 7.12±0.89 years.
Examination of women was carried out in the following areas: 1. Evaluation of clinical symptoms of osteoporosis and menopausal syndrome;
2. Study of bone mineral density (BMD) and radiographic picture of osteoporosis;
3. Study of biochemical parameters of calcium-phosphorus metabolism and bone metabolism;
4. Gynecological examination and mammography;
5. Cytochemical study of the enzymatic activity of leukocytes.
The study of the clinical symptoms of osteoporosis included an assessment
the intensity of the specific pain syndrome in the bones and the associated astheno-neurotic syndrome.
The study of the clinical manifestations of the climacteric syndrome was carried out by assessing the severity of the climacteric syndrome in general, as well as the severity of certain types of climacteric disorders: neurovegetative, psycho-emotional and urogenital.
BMD was examined by DRA method. MIIKT of the lumbar spine (L,-L4), proximal femur with selective assessment of BMD in its individual zones (femoral neck, Ward's area and greater trochanter), as well as the entire skeleton with determination of the average bone density of the arms, legs, trunk and pelvis was examined on a DPX densitometer manufactured by Lunar (USA) in the osteodensitometry room of the City Clinical Hospital No. Medsantrud (Head - Candidate of Medical Sciences Rubin MP.) - BMD of the distal forearm was determined on a DTX-200 densitometer from the company "Ostcometer" - (Denmark) in the Department of Therapeutic Endocrinology of MONIKI (head of the department - MD. , Prof. Dreval A.B.).
BMD was quantitatively expressed in absolute values (g/cm2) and in the form of T-criger (the ratio of the actual bone density of the examined woman to the bone tissue density of healthy women aged 25-30 years, calculated as a percentage and expressed in standard deviations (SD)). In order to more accurately assess the nature of the effect of therapy on BMD in various areas of the skeleton, after 6 months of treatment, the dynamics of bone density was assessed not only in the group as a whole, but also in each patient. Since the reproducibility error of the used densitometers is less than 2% [Bagap D.T., Faulkner K.G. et al., 1997], an increase or decrease in T-crisis in a particular patient by 2% or more was regarded, respectively, as an increase or decrease in BMD. The change in the T-criterion in the patient is not more than 1%, i.e. within the reproducibility error of the method, was regarded as the absence of BMD dynamics.
The radiological picture of osteoporosis was assessed visually by lateral radiographs of the thoracic and lumbar spine. X-ray examination was carried out in the department of radiology MONIKI (head of the department - MD, prof. Portnoy L.M.).
The state of kalysh-phosphorus metabolism was determined by the level of total calcium (norm 2.20-2.74 mmol/l) and ionized (1.08-1.31 mmol/l). inorganic phosphorus (0.65-1.29 mmol / l) and narathyreoid hormone (PTH, 15-60 pg / ml) in blood plasma, as well as the ratio of calcium excretion to creatinine excretion in the morning portion of urine (0.2-0.8 ) .
The intensity of bone metabolism was assessed by the level of total alkaline phosphatase in blood plasma (norm 80-295 units/l).
Biochemical parameters were studied on a Hitachi-511 autoanalyzer using kits from Boehringer Mannheim, and PTH was studied using radioimmunoassay kits from Elsa. Biochemical and hormonal studies were carried out in the biochemical laboratory of MONIKI (head of the laboratory, MD, Prof. Tishenina R.C.)
Gynecological examination and mammography were performed before the start of therapy in order to exclude contraindications to the appointment of estrogens and after 6 months of HRT treatment to identify possible complications. Examination of the vagina and cervix in the mirrors, oncocytological examination of the smear and ultrasound examination of the pelvic organs were carried out at the Department of Obstetrics and Gynecology, 2nd Faculty of Medicine, Moscow Medical Academy. I.M. Sechenov (Head of the Department - Doctor of Medical Sciences, Prof. Strizhakov), and mammography - in the Department of Radiology of MONIKI (Head of the Department - Doctor of Medical Sciences, Prof. Portnoy L.M. ).
For a cytochemical study to study the enzymatic activity of leukocytes in postmenopausal osteopenia, 49 aged women were selected from the general group of the examined. 45-70 years old, without diseases or other factors affecting the results of cytochemical tests [Komissarova I.A., 1983. Narcissov R.P., 1997J. 39 patients with diagnosed osteoporosis or osteopenia constituted the "osteoenia" group, and 10 women with normal BMD values - the control group.
The cytochemical study included the determination of the activity of myeloperoxidase in neutrophils (MPN), alkaline phosphatase in neutrophils (ALP), succinate dehydrogenase in lymphocytes (SDHL) and succinate:cytochrome C-oxidoreductase in lymphocytes (CCOPJI). The choice of these enzymes was due to the fact that, being in various cellular organelles and participating in versatile metabolic processes, they quite fully characterize the metabolic state of neutrophils and lymphocytes [Komissarova IA, 1983; Hayhow F.G.D., Quaglino D., 1983].
MPN activity was determined using the oxidation reaction of benzidine with hydrogen peroxide according to the Graham Knoll method [Heihou FGD, Kwaglinno D., 1983]. ALP activity was studied by azo coupling with nafgol-Na-Mx-phosphate as a substrate and diazotized pararosapilin. SDGL activity was determined using para-Nitrotetrazolium violet [Narcissov R.P., 1969]. The activity of CCOPJI was studied using para-Nitrotetrazolium blue [Heihou FGD, Quaglino D., 1983]. The activity of MP, ALP, and SSORL was quantified by the Keplow index [Heihou F.G.D., Kvaglino D., 1983], and SDGL - as the average number of formazan granules in 1 lymphocyte [Narcissov R.P., 1969].
Cytochemical study of leukocytes was carried out in the laboratory of the Medical Research and Production Complex "Biotiki" (Head - Doctor of Medical Sciences Komissarova I.A.).
Forty-eight patients diagnosed with postmeiopausal osteopenia or osteoporosis were prescribed 6 months of therapy with hormonal drugs that affect bone metabolism - HRT, alfacalcidol, or a combination of calcitonin and alfacalcidol. We attributed alfacalcidol to hormonal drugs, since it is a synthetic analog of the active metabolites of vitamin D3, which is currently considered a steroidal D-hormone that is part of the endocrine D-system [Schwartz G.Ya., 1998].
HRT was received by 22 women aged 45-60 years with osteopenia, climacteric syndrome and no contraindications to estrogen administration. Women in perimenopause (12) were prescribed cyclic therapy. (climei, "Schering", Germany), and for postmenopausal patients (10) - a prolonged form of HRT intramuscularly 1 time in 40 days (gynodian-depot, "Schering", Germany).
In 11 out of 22 patients (cyclic HRT-6, parenteral-5) HRT was combined with PEM (manufactured by MNPK Biotiki, Russia) - glycine (amino acid glycocol, 400 mg/day) and limontar (citric acid 400 mg/day. and succinic acid 100 mg/day). Initially, only PEM was prescribed for 2 weeks (in order to assess their independent effect in menopausal disorders), then for 6 months glycine and limontar were combined with HRT (to assess the effectiveness of combined therapy with HRT and PEM).
Therapy with alfacalcndolom (alpha-Dz, TEVA, Israel) at a dose of 0.5 mcg/day. was prescribed to 14 women aged 45-67 years with varying severity of osteopenia and the presence of contraindications to the appointment of estrogens.
Combination therapy with calcitonin (miacalcic, Novartis, Switzerland) and alfacalcidol was received by 12 patients aged 59-70 years with severe osteoporosis accompanied by severe pain and astheno-neurotic syndromes. Patients received alfacalcidol for 6 months at a dose of 0.5 mcg/day, and calcitonin during the first 3 months of treatment intramuscularly at a dose of 50 IU.
Statistical processing of the results was carried out using the Microsoft Statistica 5.0 package using the methods of variation statistics and
correlation analysis. The significance of the difference in indicators was calculated using the Student's I-test, and the correlation coefficient r was calculated using the Pearson method. The indicators were considered statistically significant with the p reliability criterion.<0,05.
RESULTS AND DISCUSSION
The state of bone tissue in postmenopausal women according to deisitometry and radiography
The results of a Denet o metric survey of a random sample of women 4570 years old (n=64) showed that the incidence of osteoporosis in different areas of the skeleton varies significantly (Fig. 1): the highest is observed in the spine and Ward region of the femur (in 32% and 26% cases, respectively), and the smallest - in the greater trochanter of the femur (in 8% of cases).
Spine (L1- Femoral neck Varda area Greater trochanter Forearm L4)
□ Normal BMD
□ Osteopenia
In Osteoporosis
Figure 1. Results of densitometric examination of women aged 45-70 years (n=64)
Osteopenia, i.e. a high risk of developing osteoporosis was found in every second woman in all parts of the skeleton, with the exception of the greater trochanter of the femur, where the majority of those examined were diagnosed with normal bone density (Fig. 1).
The results obtained on the frequency of osteoporosis and osteonia among women of this age group living in the Moscow region are consistent with the data of foreign studies, as well as with the data of an epidemiological survey of women in Moscow" [Spirtus T.V., Mikhailov E.E., Benevolenskaya L. .I., 1997].
Table 1. Correlation
(d) between BMD of different areas
inn prigitlirtpii (n=f\A * _ n^ft fi^
Areas of study Femoral neck Varda area Greater trochanter Forearm
g % g % g % g %
LrU 0.68* 23 . 0.74* 8 0.59* 54 0.17 35
Femoral neck - - 0.92* 15 0.84* "38 -0.01 42
Varda region - - - - 0.81* 54 0.06 28
Greater trochanter - - - - - - - -0.37 71
A positive correlation between the BMD of the spine and all areas of the thigh shows that in the postmenopausal period, bone loss in the spine and proximal femur occurs simultaneously (Table 1), but the rate of this process is different, as indicated by the unequal incidence of osteoporosis in these areas (Fig. 1). Obviously, the high frequency of coincidence of densitometry results at compared points, for example, in the spine and Ward's area (Table 1), reflects an equal rate of loss of bone minerals, which ultimately leads to the simultaneous development of osteoporosis.
An analysis of the state of BMD in women with different duration of postmenopause showed that in menopause, bone loss is most intense in the spine, Ward's area and greater trochanter of the femur, i.e. in bone sections with a predominantly trabecular type of structure (Fig. 2).
BMD (T-test, BE)
0 Postmenopausal up to 10 years (n=43) □ Postmenopause more than 10 years (yy=21)
Figure 2. The state of bone mineral density in women with different duration of postmenopause (* - p<0,05)
A significant relationship between the duration of postmenopause and the severity of osteopenia in the spine and Ward's area is also confirmed by the results of the correlation analysis (Table 2).
Table 2. Correlation between BMD values (T-test, %) and age indicators (n=64)
Areas of study Age, years Length of postmenopause, years
and -0.60 (p<0,05) -0,54 (р<0,05)
12 -0.63 (p<0,05) -0,68 (р<0,05)
and -0.60 (p<0,05) -0,65 (р<0,05)
b4 -0.59 (p<0,05) -0,62 (р<0,05)
0.64 (p<0,05) -0,66 (р<0,05)
Femoral neck -0.35 -0.35
Varda region -0.47 (p<0,05) -0,42 (р<0,05)
Greater trochanter -0.24 -0.35
Forearm -0.40 0.23
A high percentage of discrepancies in the results of densitometry (Table 1) and a different frequency of detection of pathology in certain areas of the skeleton show (Figure 1) that it is virtually impossible to judge the nature of skeletal damage and the severity of osteoporosis in general based on the results of a study of any one area. This dictates the need to conduct a simultaneous densitometric study of all areas "critical" for osteoporosis, primarily the spine and Ward's area, where the risk of developing osteoporosis is highest.
According to the results of x-rays, signs of osteoporosis in the lumbar spine were found in 28% of the examined patients, including 8% - compression deformities of the vertebral bodies. In the thoracic spine, according to radiography, osteoporosis was detected 2.5 times more often than in the lumbar (in 68% of cases, p<0,05), а компрессионные деформации позвонков - в 4,5 раза чаще (в 36% случаев, р<0,05).
Table 3. Comparison of the results of densitometry of the lumbar vertebrae and radiography of the spine (n=64)
Result X-ray signs Including compression
densitometry Li-Li osteoporosis (1-4 points) deformities of the vertebral bodies (3-4 points)
Lumbar spine
Norm No No
Ostsopenia 11% No
Osteoporosis 100% 38% " "
Thoracic calving of the spine
Norm 50% 28%
Osteopenia 72% 30%
Osteoporosis 100% 76%
Changes on radiographs of the lumbar spine generally corresponded to the degree of decrease in bone density in the lumbar vertebrae according to densitometry data (Table 3). At the same time, 50% of women with normal values of L1-L4 BMD showed radiographic signs of osteoporosis of the thoracic vertebrae, including 28% of patients with compression fractures.
Thus, the standard DXA program for the lumbar spine (L]-L4) accurately assesses only the risk of lumbar vertebral fractures, but does not give an objective idea of the risk of compression fractures in the thoracic spine. According to a number of researchers, the detection of compression fractures in the thoracic spine by radiography or X-ray morphometric analysis completely eliminates the need for spinal densitometry.
To assess the diagnostic information content of DXA of the distal forearm, we compared the results of densitometry of the forearm and densitometry of the spine and proximal femur (Table 1). No correlation was found between the BMD of the forearm and other bone sections, and a high percentage of discrepancies in the results of densitometry was found (28% - 71%).
However, comparison of DXA data of the forearm and radiography of the spine showed that they were osteoporotic. deformities of the vertebral bodies are present in all examined patients, in whom, according to the results of densitometry, osteoporosis was detected in the forearm.
Thus, peripheral DXA does not give an idea of the state of BMD of the spine and proximal femur, however, the presence of osteoporosis in the distal forearm indirectly indicates the development of severe osteoporosis in the spine.
complicated by compression deformities of the vertebral bodies. Therefore, in postmenopausal women, DXA of the forearm can be used not only to assess the risk of fracture of the radius in a typical location, but also to roughly assess the risk of vertebral compression fractures.
Evaluation of the effectiveness of hormonal methods of therapy for postmenopausal osteoporosis
The clinical efficacy of treatment was assessed by the dynamics of pain and astheno-neurotic syndromes, the nature of changes in BMD, calcium-phosphorus metabolism, and the intensity of bone remodeling processes.
Hormone Replacement Therapy
The results of the study demonstrated that in postmenopausal osteopenia, HRT has a pronounced clinical effect and has the most powerful effect on the level of BMD compared to other methods of therapy.
In women who received only HRT, after 6 months there was a significant increase in the density of the bones of the forearm (from 85.5 + 1.4% to 93.1 ± 3.0%, p<0,05), туловища (с 93,7±3,9% до 106,0+4,0%, р<0,05) и таза (с 94,6+7,2% до 119,3+7,9%, р<0.05). Кроме того, у большинства женщин на фоне лечения увеличилась костная плотность всех исследуемых областей скелета, за" исключением большого вертела бедренной кости, где МПКТ повысилась у 36.4% больных и не изменилась - у 45,5% (рис. 3). Принимая во внимание акгивную потерю костных минералов в постменопаузе, связанную с эстрогенным дефицитом , отсутствие отрицательной динамики МПКТ большого вертела у большинства больных свидетельствует о замедлений процесса потери костной массы в этом отделе.
Percentage of patients (n=l 1)
□ Decreased BMD
□ Lack of changes in BMD Q Increased BMD
Figure 3. Dynamics of BMD (T-test, %) in patients receiving HRT
The effectiveness of HRT in postmenopausal osteopenia is primarily due to the antiresorptive effect of estrogens, which inhibit the activity of osteoclasts. An indirect indication of a weakening of the activity of bone resorption is a decrease in the level of inorganic phosphorus in blood plasma after 6 months of treatment - from 0.94 ± 0.05 to 0.85 ± 0.03 mmol / l, p<0,05 .
Thus. HRT, by suppressing bone resorption, prevents bone loss in the greater trochanter and promotes an increase in bone density in all other areas of the skeleton, most intensively in the dietary forearm, trunk and pelvic bones.
Cyclic HGH was better tolerated than parenteral - in the latter case, moderately severe adverse reactions were noted in 50% of patients.
The addition of glycine and limontar to HRT had a significant effect only on the state of the MG1CT of the forearm, where there was no increase in bone density, which was observed in most patients on the background of HRT. In addition, G1EM in combination with HRT had an impact on the dynamics of biochemical parameters - after 6 months, the levels of alkaline phosphatase decreased (from 183.5±16.7 to 130.7+12.8 mmol/l, p<0,05) и общего кальция в плазме крови (с 2.58+0,03 до 2,4110,07 ммоль/л, р<0,05) при неизменном уровне неорганического фосфора (0,9210,05 и 0,98+0,16 ммоль/л соответственно, р>0.05), as well as increased urinary calcium excretion (from 0.30+0.15 to 0.94+0.22, p<0,05).
The absence of a positive effect of PEM on BMD is most likely due to the action of citric acid, which in bone tissue serves as a source of formation of acetyl and citryl phosphates. Apparently, an increase in the concentration of these substances in the bone substance leads to a weakening of the process of bone formation, as evidenced by a decrease in the level of alkaline phosphatase in the blood plasma. The hypocalcemic effect of combination therapy is probably due to the active binding of calcium ions in plasma by citric acid and its excretion through the kidneys in the form of citrate, resulting in an increase in calcium excretion in the urine. A negative calcium balance may also indicate an increase in bone tissue resorption under the influence of PEM.
Taking into account the obtained data on the effect of PEM on bone tissue metabolism and calcium-phosphorus metabolism, the appointment of glycine and limontar in patients with postmenopausal osteopenia or osteoporosis is inappropriate.
It was not possible to judge the effect of HRT and PEM on the dynamics of pain and aeteno-neurotic syndromes in osteoporosis. The average intensity of the pain syndrome in both groups of women who took 31T did not statistically differ from zero (0.3 ± 0.15 points). Accordingly, the astheno-neurotic symptoms in these groups were not associated with bone pain in osteoporosis, but were the result of menopausal violations.
Therapy with low doses of alfacaliidol
The results of the study demonstrated the clinical efficacy of low doses of alfacalcidol in postmenopausal osteoporosis with severe pain and psychoemotional disorders. A decrease in pain syndrome was observed during the first month of treatment (from 1.2310.26 to 0.92±0.11 points, p<0,05), а уменьшение интенсивности астено-невротического синдрома было отмечено через 3 месяца (с 1,23+0,26 до 0,92+0,11 балла, р<0,05).
Alfacalcidol does not have a direct analgesic effect, however, according to some reports, it has the ability to induce the synthesis of calcitonin, which in turn has analgesic activity. In addition, alfacalcidol promotes the repair of microstructural damage in the bones and improves the "quality" of bone tissue [Dambacher MA, Shakht E., 1996]. All this, obviously, causes a significant reduction in bone pain and an improvement in the psycho-emotional status of patients with osteoporosis.
According to the results of densitometry, after 6 months of treatment with alfacalnidol, a significant increase in only pelvic BMD was found (T-criterion before treatment and after the end of therapy 89.31±3.53% and 99.45±3.08%, respectively, p<0,05). Оценка динамики МПКТ у больных показала выраженный эффект альфакальцидола на костную массу тазовых костей, где МПКТ увеличилась у 92,3% больных, а также костную массу области Варда - повышение МПКТ в 61.5% случаев (рис. 4). В позвонках, шейке бедра, большом вертеле, нижних конечностях и туловище у большинства женщин на фоне лечения динамики МПКТ обнаружено не было, что можно расценивать как замедление процесса снижения костной массы в этих отделах.
Percentage of patients (n=14)
Psivpnochnik Hip neck Region. Varda Bol skewered Forearm Arms Legs Torso Taj Whole skeleton
□ Decreased BMD
□ Lack of BMD dynamics
□ Increased BMD
Figure 4. Dynamics of BMD (T-crit, %) in patients treated with alfacalcidol
The density of the bone tissue of the hands and, in particular, the distal forearm decreased in 46.2% of cases, i.e. the effect of therapy on BMD of these areas of the skeleton was absent in almost half of the patients. Similar data were obtained in a retrospective study of 81pgak1 M., No P. et al. (1993), who showed that even long-term treatment with alfacalcidol increased the density of the radius in only half of the patients with osteoporosis.
During therapy with alfacalcidol, significant changes in calcium homeostasis were detected (Table 4). The increase in plasma calcium levels during treatment is due to an increase in calcium absorption in the intestine due to the activation of the synthesis of calcium-binding proteins under the influence of alfacalcidol. Increased excretion of calcium in the urine, in turn, is a natural consequence of hypercalcemia [Dambacher M.A.. Shakht E., 1996].
Against the background of treatment with alfacalcidol, the intensity of bone remodeling processes probably decreases, as evidenced by a significant decrease in the level of alkaline phosphatase in the blood plasma (Table 4). the results of other studies indicating a decrease in the level of alkaline phosphatase in patients with postmenopausal osteoporosis receiving alfacalcidol [Bygak!
Table 4. Indicators of calcium-phosphorus metabolism and bone. metabolism in patients treated with alfacalcidol (n=14)
Indicator Before treatment 3 months. treatment 6 ms. treatment
Total calcium in blood plasma, mmol/l 2.58±0.03 2.82±0.07* 2.55±0.06U
Ionized calcium in blood plasma, mmol/l 1.18±0.02 1.30±0.02* 1.22±0.02U
Phosphorus, inorganic, mmol/l 0.92±0.05 1.001:0.05 0.89±0.05
Alkaline phosphatase, U/L 233.3±22.2 201.6±20.9 163.1±14.8*
PTH, pg/ml 30.50±3.14 25.8±3.85 34.91±4.08
Urinary calcium / urinary creatinine 0.36±0.08 0.91 ±0.21* 0.82±0.17*
* - R<0,05 по отношению к уровню до лечения V - р<0,05 по отношению к уровню через 3 месяца лечения
No adverse reactions were observed during treatment with alfacalcidol. Good tolerability of the drug is also noted by many foreign and domestic authors. In particular, according to Opsho P. (1994), the complication rate of alfacalcidol therapy does not exceed 1.1%. including hypscalcemia - 0.22%.
Combination therapy with calcitonin and alfacalcidol In patients with severe postmenopausal osteoporosis treated with a combination of calcitonin and alfacalcidol, a decrease in the intensity of pain syndrome (from 2.00±0.39 to 1.40±0.37 points, p<0,05) и астено-невротического синдрома (с 1,4010,34 до 0,60±0,27 балла, р<0,05) отмечалось уже после первого месяца терапии. Кальцитонин обладает прямым анальгетическим эффектом, в первую очередь, за счет способности повышать уровень бета-эндорфинов в плазме крови, с чем, очевидно, связано более быстрое купирование астено-невротических нарушений на фоне комбинированной терапии по сравнению с монотерапией альфакальцидолом.
Although the dynamics of mean BMD values during treatment was unreliable, after 6 months, most patients showed an increase in bone density of the vertebrae (in 66.7% of cases), Ward's area (66.7%) and greater trochanter (50.0%), those. bone sections with a predominantly trabecular type of structure (Fig. 5).
Percentage of patients (n=12)
Half-hearted Neck bs, 1ra Obl Barla Beal igrts "1 Forearm Hands Legs Torso Pelvis Whole skeleton
th Decrease in BMD P No changes in BMD C Increase in BMD
Figure 5. Dynamics of BMD (T-score, %) in patients receiving combination therapy with calcitonin and alfacalcidol
The combination of katzitosh and alfacalcidel had a more moderate effect on the bone mass of the cortical substance - in the femoral neck, BMD increased only in 33.3% of patients, and in the bones of the distal calving of the forearm, the effect of therapy was virtually absent - in 58.33% of patients, bone density decreased (Fig. . 5).
The average mineral density of the skeleton as a whole did not change in 100% of cases, however, there was a tendency to redistribute the mineral saturation of its individual segments - to increase the BMD of the pelvis and limbs and reduce the density of the trunk bones (Fig. 5).
Thus, combination therapy with calcitonin and alfacalcvdol improves the mineral saturation of trabecular bone tissue, bones of the extremities and pelvis, slows down bone loss in the femoral neck and does not have any effect on BMD of the trunk and distal forearm.
In contrast to therapy with alfacalcidol, plasma alkaline phosphatase levels remained unchanged, i.e. the intensity of bone remodeling in patients receiving combination therapy probably did not change significantly in general. However, during treatment with calcitonin, a decrease in the level of inorganic phosphorus in blood plasma was observed (from 0.95±0.05 to 0.81±0.02 mmol/l, p<0,05), косвенно свидетельствующее об ослаблении костной резорбции . Кроме того, во всех случаях, когда до лечения были выявлены повышенные значения общего кальция (у 25,0% больных), щелочной фосфатазы (33,3%) или ПТГ в плазме крови (8,3%), через 6 месяцев терапии отмечалась нормализация данных показателей.
Moderate adverse reactions after injections of calcitonin were observed in 33.3% of cases, and one patient (8.3%) developed an anaphylactic reaction after the first injection of calcitonin, and therefore the drug was discontinued.
Thus, the results of the study showed that certain types of hormonal therapy for postmenopausal osteoporosis have different clinical effects and, in particular, the specific effects on BMD of various areas of the skeleton, calcium phosphorus metabolism and bone remodeling processes. Better data can probably serve as criteria for choosing hormonal therapy for postmenopausal osteoporosis based on the characteristics of the course of the disease and the nature of the skeletal lesion in a particular patient.
Enzymatic activity of leukocytes as a biochemical marker of postmenopausal osteopenia
According to the results of a cytochemical study in osteopenia, ALP activity was significantly increased by 2.8 times compared with the control (47.20±6.75 and 17.20±4.47, respectively, p<0,05), а активность СДГЛ - в 1,2 раза (21,38±0,66 и 18,13±1,08 соответственно, р<0,05). Различий средних значений активности ССОРЛ (141,42±3,54 и 145,20±6,99 соответственно, р>0.05) and MPN (193.68±5.89 and 189.20±10.96, respectively, p>0.05) were not detected in the groups.
A significant increase in the activity of ALP and SDGL in postmenopausal osteopenia could be associated either with a longer duration of postmenopause in women in this group compared to the control (7.34±0.96 and 3.50±1.19 years, respectively, p<0,05), либо с наличием самого остеопснического синдрома.
To clarify the degree of relationship between the activity of the studied leukocyte enzymes and the duration of postmenopause, all women selected for cytochemical studies, regardless of BMD, were divided into three groups according to the duration of postmenopause: postmenopause 1-3 years, postmenopause 4-10 years and postmenopause more than 10 years.
A significant difference in ALP activity (1.9 times) was found only in women with a postmenopausal duration of 1-3 years and more than 10 years (31.21 ± 4.41 and 60.69 ± 9.91, respectively, p<0,05); но средним значениям МПКТ и интенсивности болевого синдрома в костях достоверно различались (р<0,05) также только эти группы.
Thus, in the selected groups, which significantly differed in the duration of the post-spagm pause, a change in ALP activity was detected only when the groups significantly differed in the severity of osteopenia. Therefore, the main factor stimulating the ALP activity of neutrophils in postmenopause is precisely osteopenia, and not the duration of postmenopause.
ALP is a specific biochemical marker of the functional activity of neutrophils. Since the state of neutrophils in the body to a certain extent reflects the course of destruction processes [Komissarova IA, 1983; Basin B.L., Kornesv B.V., Zakharov N.P., 1992], an increase in the average values of ALP in postmenopausal osteopenia can, apparently, be considered a natural reaction of neutrophils to an increase in the intensity of bone resorption.
The activity of SDGL, M1N and COOPJI did not change significantly with the increase in the duration of postmenopause. The absence of a change in the activity of SDGL as the postmenopause lengthens can be explained by the influence of the age factor - after 50 years, but as we age, the activity of SDGL decreases physiologically [Komissarova IA, 1983]. Age and osteopenia probably have a multidirectional effect on the activity of SDGL, which is the reason for the moderate increase in the level of SDGL in osteopenia compared with a significant increase in ALP activity.
SDGL activity reflects the functional state of mitochondria and the course of energy reactions in the cell [Komissarova I.A., Narcissov Ya.R., Burbenskaya N.M., 1996]. Therefore, the revealed increase in SDGL activity indicates the activation of energy-consuming intracellular processes in osteopenia.
To clarify the relationship between the enzymatic activity of leukocytes and the pathological manifestations of osteopenia, the data obtained were subjected to a correlation analysis. As a result, a negative correlation was found between ALP activity and BMD of Lb L3 and Li-L4 segment, as well as between SDGL activity and BMD of the femoral neck (Table 5). In addition, a positive correlation was found between SDGL activity and forearm BMD.
Thus, in postmenopausal women, ALP activity is probably more associated with the severity of osteopenia in the spine, and SDHL - in the femoral neck. Negative values of the correlation coefficient indicate that the activity of these enzymes is the higher, the more osteopenia is expressed. A positive correlation between SDGL activity and BMD of the forearm, with a simultaneous negative correlation between SDGL activity and BMD of the femoral neck, is probably due to different rates of loss of bone minerals in the forearm and other parts of the skeleton.
The nature of the correlation between SDGL and ALP activity and BMD values varies depending on the duration of postmenopause (Table 5). The largest number of significant correlations between the activity of the studied enzymes and BMD of the vertebrae was found in the first three years of postmenopause, when structural changes in the spine are the smallest, and the intensity of bone loss is the greatest. Therefore, the identified changes in the activity of SDGL and ALP are not a response to chronic macro- and microfractures of the vertebrae in osteoporosis, i.e. inflammation per se, but are due to an increase in the intensity of bone loss in postmenopausal women.
Table 5. Correlation between BMD of different areas of the skeleton (g/cm2) and activity of SDGL and ALP (* - р<0,05)__
Areas Enzyme Study Groups
Postmenopause Postmenopause Postmenopause All women
Skeleton 1-3 years (n=19) 4-10 years (n-14) >10 years (n=16) (n=49)
and SDGL -0.10 -0.54* -0.11 -0.25
NPP -0.37 -0.19 -0.56* -0.35
and SDGL -0.42* -0.34 -0.34 -0.32
NPP -0.58* -0.33 -0.27 -0.41*
and SDGL -0.58* -0.41* -0.14 -0.29
NPP -0.49* -0.36 -0.67* -0.49*
and SDGL -0.64* -0.31 -0.15 -0.27
NPP -0.27 -0.50* -0.32 -0.38
b]-b4 SDGL -0.49* -0.41* -0.01 -0.30
NPP -0.47* -0.35 -0.49* -0.44*
Femoral neck SDGL 0.05 -0.16 -0.70* -0.48*
NPP 0.09 -0.48* -0.07 -0.08
SDGL region -0.02 -0.24 0.04 -0.14
Varda NPH 0.05 -0.71* -0.57* -0.33
Large SDGL 0.16 -0.17 0.06 -0.11
spit NAP -0.15 -0.26 -0.22 -0.21
Forearm SDGL 0.09 0.09 0.56* 0.42*
NPP 0.31 -038 -0.19 0.06
Given the established significant relationship between the enzyme activity of leukocytes and the severity of postmenopausal osteopsia, we decided to find out what effect hormonal drugs used to treat postmenopausal osteoporosis have on the activity of leukocyte enzymes. We believed that the study of the enzymatic status of leukocytes during treatment would reveal new aspects of the impact of various types of hormonal therapy on bone metabolism in postmenopausal osteoporosis.
The results of a cytochemical study showed that therapy with hormonal drugs that affect the metabolism of bone tissue causes specific changes in the enzymatic profile of leukocytes (Table 6).
Taking into account the presence of a significant negative correlation between the activity of ALP and SDGL, on the one hand, and BMD, on the other hand, the observed dynamics of the activity of these enzymes during therapy with alfacalcidol (Table 6) may indicate the phase nature of changes in BMD during treatment, i.e. on the phase nature of the effect of small doses of alfacalcidol on bone density.
Apparently, alfacalcidol at a dose of 0.5 µg has the maximum effect on BMD in the first 3 months of therapy, which confirms the trend towards a decrease in ALP activity (p = 0.06) and the stability of SDHL levels. With a duration of treatment of more than three months, the activity of the studied leukocyte enzymes increases (p<0,05), что, вероятно, свидетельствует об усилении резорбции костной ткани и замедлении прироста МПКТ.
In bone tissue, the main target cells for the action of the drug are osteoblasts [Dambacher M.A., Shakht E., 1996]. The weakening of the activity of small doses of alfacalcidol after 3 months of therapy, obviously, leads to a decrease in the function of osteoblasts and a decrease in the intensity of bone formation, which can be
indicate a decrease in the level of alkaline phosphatase in the blood plasma (Table 4). A decrease in plasma calcium levels in the last 3 months of observation (Table 4), indicating a decrease in active transport of calcium through the intestinal wall, may also indicate a weakening of the effectiveness of therapy during this period.
Table 6. Activity of leukocyte enzymes in patients receiving various types of hormonal therapy.
Types of therapy Stages of research
HRT (n=11) Before treatment 1 month. therapy 3 months. therapy 6 months. therapy 43.2±6.96 47.2*10.78 46.4±10.73 42.4±10.49 21.4*1.82 18.3±1.10 20.7*1.06 21.8±1.20 151.4±8.52 133.0*1.78* 127.8*6.74 143.0*8.14 199.7±9.12 212^±8.78 207 .8±14.77 199.0±8.52
HRT + PEM (n=11) Before treatment with PEM - 2 weeks ZGG + PEM - 1 month. HRT + PEM-3 months HRT + PEM-6 months. 30.6±6.80 32.7±4.67 38.&±11.62 35.5*10.74 60.5±12.25*Y# 19.1±1.24 20.6±0 .91 21D±0.51 23.0*1.21* 22.1±1.23 139.0*6.31 147.2*10.89 133.3*7.72 139.6±8.79 136.0±6.32 195.6±11.27 209.7±7.93 184.1±7.81U 197.3±9.61 176.4±8.04U
Alfacalcidol (n=14) Before treatment 1 month. therapy 3 months. therapy 6 months. therapy 29.1±6.47 22.3±6.47 17.3±5.83 33.4±7.02# 17.3±0.97 19.9±0.98 21.7*1, 31* 23.5±1D5* 1263*7.87 147.8*8.46 142.8*9.39 146.4*5.90 178.0±14.31 201.6±6.85 196, 1±4.04 196.9±5.14
Kalydatonin + alfacalcidol (n=12) Before treatment 1 month. therapy 3 months. therapy 6 months. therapy 41.8±11.71 23.9*6.22 24.9*8.79 36.5±8.09# 21.0*1.85 19.4*1.27 21.2*1, 39 22.5±1.56 133.2*8.11 144.5*7.49 139.0±8.97 148.3±9.77 188.2*12.46 203.1±11.30 201D±8.69 200.3±6.53
Reliability of indicator change (p<0,05):
* - in relation to enzyme activity before treatment
# - in relation to enzyme activity after 3 months of therapy
V - but in relation to enzyme activity after 2 weeks of taking PEM
Thus, despite the significant clinical effect of alfacalcidol at a dose of 0.5 mcg in bone pain and psycho-emotional disorders, after about 3 months, the positive effect of small doses of the drug on BMD is likely to be exhausted. Therefore, in postmenopausal osteoporosis, the appointment of alfacalcidol at a dose of 0.5 μg seems to be indicated for a period of not more than 3 months, and then it is advisable to increase the dose to 0.75-1.0 μg per day.
An increase in ALP activity in the last 3 months of treatment in patients who received a combination of calcitonin with alfacalcidol (Table 6) probably also indicates a slowdown in the increase in BMD after discontinuation of calcitonin therapy against the background of a gradual weakening of the effect of alfacalcidol.
In patients who received only HRT, the activity of SDGL and alkaline phosphatase did not change significantly during treatment (Table b), therefore, the clinical efficacy of HRT, apparently, remained equally high throughout the entire study period. In addition, during the first month of HRT, there was a decrease in the activity of SSORL, which, like SLGL, characterizes the functional state of mitochondria [Komissarova I.A., Narcissov Ya.R., Burbenskaya N.M., 1996]. A decrease in the activity of the second enzyme indicates a decrease in the intensity of biochemical reactions in mitochondria, i.e. about the decrease in the severity of cellular hypoxia during the first month of estrogen treatment.
PEM increase the activity of most leukocyte enzymes, in particular SDGL and alkaline phosphatase [Narcissov R.P., 1997], therefore, an increase in the activity of these enzymes in patients receiving a combination of HRT and PEM (Table 6) was most likely due to the direct effect of glycine and lemontar on the functional state of leukocytes. However, given that against the background of combined therapy with HRT and PEM, there is a weakening of the bone formation process, a negative calcium balance, as well as a weaker increase in bone mass compared to HRT, an increase in the activity of ALP and SDGL may indicate a weakening of the effect of estrogens on BMD under the influence of PEM.
Since no dependence of MPP activity on the severity of osteopenia was found, the changes in the activity of this enzyme detected during the combined therapy of HRT and PEM (Table 6) were obviously associated not with changes in bone tissue, but with the direct effect of citric and succinic acids on functional state of neutrophils [Narcissov R.P., 1997].
Thus, as a result of the study, a significant relationship was established between a decrease in BMD in postmenopausal women and an increase in the activity of HCFP and SDGL, therefore, these enzymes, apparently, can be considered as metabolic markers of postmenopausal osteopenia. The found correlation between the enzymatic activity of leukocytes and BMD of certain areas of the skeleton suggests that the results of a cytochemical study of ALP and LDHL can probably indicate an increased activity of the process in certain areas of the skeleton, and also allow us to evaluate the effectiveness and prognosis of therapy for postmenopausal osteoporosis at the cellular biochemical level.
Combination of hormone replacement therapy and preparations of natural metabolites glycine and limontar in the treatment of menopausal syndrome
The results of the study demonstrated the effectiveness of HRT for all types of menopausal disorders - neurovegetative, psycho-emotional, urogenital. Neurovegetative syndrome in patients receiving only HRT decreases on average during the first month of treatment (Table 7), and psycho-emotional (Table 8) and urogenital disorders - after 3 months.
PEM did not have any effect on the course of neurovegetative syndrome, either as monotherapy in the first two weeks of treatment, or in combination with HRT, although they had an independent therapeutic effect for headaches (Table 7).
The positive effect of PEM on the intensity of headaches is obviously associated with the adrenergic properties of glycine [Komissarova I.A., 1996], as well as with the improvement of microcirculation in the vessels of the brain due to the anticoagulant effect of citric acid, which is part of limontar.
An independent effect of the combination of glycine and limontar was revealed in astheno-neurotic syndrome in general and in individual psycho-emotional symptoms - irritability, mood lability, sleep disturbance (Table 8). In addition, in the presence of general weakness in patients, PEM accelerate the onset of the clinical effect of HRT, and with a decrease in mood and libido, they expand the range of positive effects of HRT.
The effectiveness of PEM in psycho-emotional menopausal disorders is probably due to the combination of the anti-stress action of citric and succinic acids, which are part of the lemontar [Narcissov R.P., 1997], with a sedative effect
glycine, which, due to interaction with glycinergic receptors of the brain, activates the processes of inhibition [Komissarova IA, 1996].
Table 7. Dynamics of neurovegetative disorders in patients receiving HRT
Study Stage 3IT (n=11) Combination 31 "G and PEM (n=11)
before treatment 1.3±0.29 1.4±0.4
Neurovegetative PEM - 2 weeks - 1.2±0.36
syndrome, HRT scores -1 month 0.5±0.22* 0.1±0.1*
HRT - 3 months 0.0±0.00" 0.0±0.00*
HRT - 6 months 0.0±0.00" 0.0±0.00*
Neurovegetative symptoms
before treatment 9.0±2.42 10.9±4.62
The average number of PEM - 2 weeks - 10.2±4.26
hot flashes per day HRT -1 month 2.1±1D7* 1.4±1.00*
HRT - 3 months 0.0±0.00* 0.0±0.00*
HRT - 6 months 0.0±0.00* 0.0±0.00*
before treatment 0.9±0.31 o.b±odb
Arterial PEM height - 2 weeks - 0.6±0.26
hypertension, HRT scores - 1 month 0.6±0.27 0.6±0.26
HRT - 3 months 0.7±0D6 0.4±0.13
HRT - 6 months 0.7±0.27 0.4±0.13
before treatment 1.4±0.27 0.9±0.31
The frequency of changes in blood pressure, PEM - 2 weeks - 0.910 ^ 1
HRT scores - 1 month 0.9±0.29 0.8±0D7
HRT - 3 months 1.1±0.27 0.7±ODZ
HRT - 6 months 0.8±0DZ* 0.3±0.13*
before treatment 1.7±0.26 1.6±031
PEM - 2 weeks - 1.2±0DZ*
Headaches, HRT scores -1 month 1.4±0.34 0.8±0.25*
HRT - 3 months 1.1±0.28*# 0.3±0.15*#
HRT - 6 months 1.0±0.26"# 0.3±0.15*#
Before treatment 1.2±0.36 0.8±0.31
PEM - 2 weeks - 0.8±0.31
Dizziness, HRT scores - 1 month 0.9±0.38 0.5±0.7
HRT - 3 months 0.6±0.34* 0.2±ODO*
HRT - 6 months 0.5±0.27* 0D±0.20*
* - R<0,05 но отношению к уровню до лечения;
# - # - R<0,05 между выраженностью симптома на соответствующем этапе исследования
Glycine and limontar accelerate the onset of the clinical effect of HRT in atrophic changes in the genitourinary system caused by estrogen deficiency. With combination therapy, a significant decrease in urogenital symptoms was noted 1 month after the appointment of HRT (from 0.9±0.31 to 0.20±0.21 points, p<0,05), в то время как у больных, получавших только ЗГТ, урогениталъные нарушения уменьшились только через 3 месяца лечения (с 0,9±0,28 и 0,10±0,10 балла, р<0,05).
The combination of glycine, citric and succinic acids, apparently, improves the trophism of the tissues of the lower parts of the urogenital tract [Korneev A.A., Komissarova I.A., 1994; Narcissov R.P., 1997], which, in combination with pathogenetic estrogen therapy, contributes to the rapid relief of urogenital symptoms.
Table 8. Dynamics of psychoemotional symptoms in patients receiving HRT
Stage of research MHG (n=11) Combination of MHG and PEM (n=11)
before treatment 1.1±0.18 1.1±0.10
Astheno-neurotic PEM - 2 weeks - 0.7±0.15*
syndrome, HRT scores-1 month 0.7±0.22 0D±0.13*
HRT - 3 months 0.1±0.10" 0D±0.13*
HRT - 6 months 0.1±0.10* 0.2±0.13*
Psychoemotional symptoms, points
before treatment 1.2±0D9 0.9±0.28
PEM - 2 weeks - 0.5±0D2
General weakness of HRT -1 month 0.8±0.33# 0.0±0.00*#
HRT - 3 months 0.2±0.20* 0.1±0.10*
HRT - 6 months 0.2±0.20* 0.0±0.00*
before treatment 1.6±0.34 1.5±0.34
PEM - 2 weeks - 0.8±0.29*
Irritability HRT - 1 month 0.7±0.26* 0.6±0.27*
HRT - 3 months 0.6±0D2* 0.5±0.27*
HRT - 6 months 0.6±0.22* 0.5±0D7*
before treatment 1.1±0.38 1.3±0.21
PEM lability - 2 weeks - 0.7±0.21*
mood HRT -1 month 0.8±0.36 0.1±0.10*
HRT - 3 months 0.3±0.21* 0.1±0.10*
HRT - 6 months 0.2±0.13* 0.0±0.00*
before treatment 0.9±0.34 1.2±036
1HEM - 2 weeks - 0.6±0.31
Decreased mood HRT - 1 month 0.710.21 0.2±0D0*
HRT - 3 months 0.6±0.18 0.1±0.10*
HRT - 6 months 0.6±0.18 0.1±0.10*
before treatment 1.2±0.33 1.7±0.37
PEM - 2 weeks - 0.9±0^8*
Sleep disturbance HRT - 1 month 0.6±0.30 0.4±0D2*
HRT - 3 months 0.5±0.31* 0.2±0.13*
HRT - 6 months 0.7±0.34* 0.2±0.13*
before treatment 1.3±0.30 1.0±0.26
I1EM - 2 weeks - 1.0±0D6
HRT memory loss -1 month 0.2*0.29 1.0±0.26
HRT - 3 months 1.1±0.28 0.8±0.17
HRT - 6 months 0.8±0DZ* 0.5±0.17*
Before treatment 2D±0.39 2.5±0.31
PEM - 2 weeks - 2.5±0.31
Violation of libido HRT -1 month 2D ± 0.39 2.1 ± 0.41
HRT - 3 months 2.2±0.39 1.6±0.40*
HRT - 6 months 2.2±0.39 1.6±0.40*
* - R<0,05 но отношению к уровню до лечения;
#- # - R<0,05 между выраженностью симптома на соответствующем этапе исследования
The obtained data on the effect of PEM on the course of various menopausal disorders suggest that the combination of glycine and limontar in combination with HRT in the absence of osteopenia can be widely used to treat psycho-emotional and urogenital menopausal disorders. In addition, if the climacteric syndrome is represented mainly by astheno-neurotic symptoms, effectively prescribe only glycine and limontar, without HRT.
1. The results of a densitometric examination of a random sample of 64 women 4570 years old showed that the frequency of detection of ossiporosis in different areas of the skeleton varies significantly: the highest is observed in the spine and Ward's area (in 32% and 26% of cases, respectively), and the lowest is in the greater trochanter ( in 8% of cases). Osteopenia, i.e. a high risk of developing osteoporosis was found in every second woman in all parts of the skeleton, with the exception of the greater trochanter, where the majority of those examined were diagnosed with normal bone density.
2. Dual-energy x-ray absorptiometry of the lumbar spine accurately assesses only the risk of lumbar vertebral fractures, but does not give an objective idea of the risk of compression fractures in the thoracic spine. Dual-energy X-ray absorptiometry of the distal forearm does not give an idea of the state of the density of the bone tissue of the spine and proximal femur, however, the presence of osporosis in the distal forearm indirectly indicates the development of severe osteoporosis in the spine, complicated by compression deformities of the vertebral bodies.
3. Hormone replacement therapy, due to its antiresorptive action, slows down the loss of bone mass in the greater trochanter of the femur and contributes to an increase in bone density in all other areas of the skeleton, most intensively in the distal forearm, trunk and pelvic bones. Hormone replacement therapy is also effective in climacteric disorders - neurovegetative, psycho-emotional, urogenital.
4. Therapy with alfacalcidol at a dose of 0.5 μg reduces pain during the first month of treatment, and psychoemotional disorders - after 3 months, increases bone density in the Ward area of the femur and pelvic bones, slows down bone loss in the spine, femoral neck, lower extremities, torso and does not have any effect on the density of the bones of the hands and, in particular, the distal forearm. Against the background of therapy with alfacalcidol, the intensity of bone remodeling decreases, the level of calcium in the blood plasma and the excretion of calcium in the urine increase.
5. In patients with severe postmenopausal osteoporosis, the combination of calcitonin and alfacalcidol reduces bone pain and psycho-emotional disturbances during the first month of treatment. The combination of alfacalcidol with calcitonin favorably affects the state of calcium-phosphorus metabolism and bone remodeling processes, improves the mineral saturation of trabecular bone tissue, bones of the extremities and pelvis, slows down bone loss in the femoral neck and does not have any effect on the bone density of the trunk and distal forearm.
6. The combination of glycine with limontar is effective for astheno-neurotic syndrome in general and for individual psycho-emotional symptoms in menopause - irritability, mood lability, sleep disturbance. In addition, if patients have general weakness and urogenital disorders due to estrogen deficiency, glycine and limontar accelerate the onset of the clinical effect of hormone replacement therapy, and with a decrease in mood and libido, they expand the range of its positive effect. The positive effect of the combination of glycine and limontar in postmenopausal osteoporosis was not revealed.
7. As a result of the study, a significant relationship was established between a decrease in bone density in postmenopausal women and an increase in the activity of alkaline phosphatase in neutrophils and succinate dehydrogenase in
lymphocytes; these enzymes can probably be considered as metabolic markers of postmenopausal osteopenia.
1. In postmenopausal women, it is necessary to conduct a simultaneous densitometric study of all “critical” zones for fractures, primarily the spine and Ward region of the femur, where the risk of developing osteoporosis is highest.
2. With densitometrically detected osteopenia of the lumbar vertebrae, an X-ray examination of the thoracic spine is necessary.
3. Dual-energy x-ray absorptiometry of the distal forearm can be used not only to assess the risk of fracture of the radius in a typical location, but also to roughly assess the risk of vertebral compression fractures.
4. The appointment of hormone replacement therapy is effective in postmenopausal osteopenia of all areas of the skeleton, as well as in all types of menopausal disorders: neurovegetative, psycho-emotional, urogenital.
5. Despite the effectiveness of alfacalcidol at a dose of 0.5 μg for pain and astheno-neurotic syndrome, in postmenopausal osteoporosis, the appointment of alfacalcidol at this dosage is probably advisable for a period of no more than 3 months, and then it is necessary to increase the dose to 0.75- 1.0 mcg per day. The appointment of alfacalcidol is not indicated for a tendency to hypercalcemia or hypercalciuria.
6. The combination of alfacalcidol with calcitonum is indicated for severe osteoporosis with severe pain and astheno-neurotic disorders, with high activity of bone resorption and with a predominance of osteopenia in trabecular bone structures, limbs and pelvic bones.
7. The combination of glycine and limontar in combination with hormone replacement therapy in the absence of osteopenia can be widely used for the treatment of psycho-emotional and urogenital menopausal disorders. If the climacteric syndrome is represented mainly by astheno-neurotic symptoms, only glycine and limontar are effective, without hormone replacement therapy.
8. An increase in postmenopausal activity of alkaline phosphatase in neutrophils and succinate dehydrogenase in lymphocytes can serve as an indirect criterion for the presence of osteopenia or osteoporosis. The results of a cytochemical study of the enzyme activity of leukocytes of the moth, apparently, help to identify women with an increased risk of postmenopausal osteoporosis, as well as to assess the effectiveness and prognosis of therapy for this disease at the cellular biochemical level.
1. Problems of involutional osteoporosis // Proceedings of the scientific-practical conference "Common endocrinopathies". Iushchino-1997. pp.79-82. / Co-authors A. V. Dreval, G. A. Onoprienko, O. P. Kuznetsova.
2. Selective effect of combination therapy with myacalcic and low doses of alfacalcidol on bone mineral density of various skeletal segments in severe postmenopausal osteoporosis // Osteoporosis and osteopathy, 1998. No. 3. pp.39-41. / Co-authors A.V.Dreval, R.S.Tishsnina, B.I.Minchenko, N.M.Mylov, G.A.Onoprienko, V.I.Shumsky.
3. Postmenopausal osteoporosis: new approaches to diagnosis and treatment // Almanac of Clinical Medicine, vol. 1. M.-1998. P. 145-153. I. Shumsky, O.P. Kuznetsova.
4. Using changes in the activity of redox and hydrolytic enzymes in peripheral blood leukocytes to assess the effectiveness of osteoporosis therapy // Abstracts of the 5th Russian National Congress "Man and Medicine". M.-1998. P.150. / Co-authors Ya.R.Narcissov, T.D.Soldatenkova, T.T.Kondrasheva, Yu.V.Gudkova, I.A.Komissarova, O.P.Kuznetsova, A.V.Dreval.
5. Leykocytc redox and hydrolytic enzymes activity in postmenopausal osteoporosis. // Osteoporosis Int. 1998. V.8 (suppl. 3). P.87. / With O.P.Kuznetsova, A.V.Dreval, I.A.Komissarova, Ya.R. Nartsissov.
6. Clinical significance of redox enzymes of leukocytes in postmenopausal osteopenia // Problems of Endocrinology, 1999. No. 2. S. / Co-authors. A.V.Dreval, O.P.Kuznetsova, G.A.Onoprienko, V.I.Shumsky, I.A.Komissarova, Ya.R.Narcissov, R.S.Tishenina, Yu.V.Gudkova, T. T. Kondrasheva, T. D. Soldatenkova.
7. Combination of hormone replacement therapy with preparations of natural metabolites (glycine and limontar) in the treatment of menonasal syndrome // Problems of Endocrinology, 1999. No. 3. / Co-authors A.V.Dreval, R.S.Tishenina, B.I.Minchenko, G.A.Onoprienko, V.I.Shumsky, I.A.Komissarova, Ya.R.Narcissov.
8. Comparative informativeness of densitometry of the axial and peripheral skeleton and radiography in the diagnosis of postmenopausal osteoporosis // Osteoporosis and osteopathy, 1999. No. 1. pp.25-28. / Co-authors A.V.Dreval, N.M.Mylov, I.A.Novoseltsva, G.A.Onoprienko, V.I.Shumsky.
9. The effectiveness of myacalcic therapy in severe postmenoiausal osteoporosis // Abstracts of the 6th Russian National Congress "Man and Medicine" / Co-authors. A.V. Dreval, N.M. Mylov.
10. Osteoporosis: current state of the problem (literature review) // Russian Medical Journal (in print).
11. Diagnostic efficacy of X-ray densitometry of the skeleton and radiography in postmenopausal osteoporosis // Almanac of Clinical Medicine, vol. 2 (in press) / Co-authors. A.V.Dreval, N.M.Mylov, I.A.Novoseltseva, G.A.Onoprienko, V.I.Shumsky.
USED ABBREVIATIONS
BP - blood pressure
DRA - dual energy X-ray absorptiometry
HRT - hormone replacement therapy
MPN - myeloperoxidase in neutrophils
BMD - bone mineral density
PEM - preparations of natural metabolites
PTH - parathyroid hormone
SDGL - succinate dehydrogenase in lymphocytes
SSORL - succinate: cytochrome-C-oxedoreductase in lymphocytes
ALP - alkaline phosphatase in neutrophils
L.J L^Lj,L4 - first - fourth lumbar vertebrae
SD - standard deviation
The congress "Actual issues of cardioendocrinology of the Central Federal District" was held
"Cardioendocrinology 2016"
Organizer: RUSSIAN SCIENTIFIC MEDICAL SOCIETY OF THERAPISTS
Organizing Committee:
Martynov Anatoly Ivanovich-President of the Russian Scientific Medical Society of Therapists, Academician of the Russian Academy of Sciences, doctor of the highest category in the specialties of therapy and cardiology, academician of the International Academy of Information Processes and Technologies, Doctor of Medical Sciences, Professor
Mkrtumyan Ashot Musayelovich– Head of the Department of Endocrinology and Diabetology, Moscow State Medical University named after A.I. A.I. Evdokimova, Member of the Scientific Council of the Russian Academy of Sciences, expert of the Higher Attestation Commission, Doctor of Medical Sciences, Professor
Struk Raisa Ivanovna- Head of the Department of Internal Medicine, MGMSU named after A.I. A. I. Evdokimova, Doctor of Medical Sciences, Professor
Main scientific directions:
Metabolic syndrome: clinical factors and risks
Obesity, arterial hypertension, diabetes mellitus, dyslipidemia, IHD, CHF
Osteoporosis in diabetes mellitus - an unnoticed complication
Diabetic Nephropathy: Problems and Solutions
Impaired kidney function in patients with type 2 diabetes
Diabetic polyneuropathy
Hyperprolactinemia - a multifactorial treatment strategy
Impaired glucose tolerance and CVD risks
Interactive discussion "Type 2 diabetes mellitus and non-alcoholic fatty liver disease: the view of an endocrinologist and hepatologist"
Combination therapy for diabetes
diabetic heart
Heart in diseases of the thyroid gland and neuroendocrine system
Cardiovascular disease and osteoporosis
Complications of diabetes mellitus: an interdisciplinary approach
CONGRESS PROGRAM
10.00-10.10 Grand opening of the congress
10.10-10.55 Forsiga - the first SGLT2 inhibitor in Russia: data from real clinical practice
Mkrtumyan Ashot Musayelovich- Head of the Department of Endocrinology and Diabetology, Moscow State Medical University named after A.I. A.I. Evdokimova, MD, Professor
10.55-11.25 Metformin: new opportunities. Modern view in the therapy of metabolic disorders
Zilov Alexey Vadimovich, Associate Professor, Department of Endocrinology, First Moscow State Medical University named after I.M. Sechenova, member of the Presidium of the Russian Association of Endocrinologists, member of the European Endocrinological Association for the Study of Diabetes Mellitus (EASD), Ph.D.
11.25-11.45 Modern approaches to the treatment of arterial hypertension. New fixed combinations
Evdokimova Anna Grigorievna- Professor of the Department of Hospital Therapy No. 2 of the Moscow State Medical University. A.I. Evdokimova, MD
11.45-12.15 Correction of arterial hypertension in pregnant women with metabolic syndrome
Struk Raisa Ivanovna- Head of the Department of Internal Medicine, MGMSU named after A.I. A.I. Evdokimova, Doctor of Medical Sciences, Professor
12.15-12.45 Hypoglycemic therapy in patients with type 2 diabetes mellitus and coronary heart disease. Efficacy and safety
Smirnova Olga Mikhailovna, Chief Researcher of the Federal State Budgetary Institution "Endocrinological Research Center" of the Ministry of Health of Russia, Professor of the Department of Endocrinology and Diabetology, Faculty of Pediatrics, First Moscow State Medical University. THEM. Sechenov, d.m.s.
12.45-13.00 New approaches to the use of statins in diabetes mellitus
Martynov Anatoly Ivanovich- Academician of the Russian Academy of Sciences, Professor of the Department of Hospital Therapy No. 1 of the Faculty of Medicine, Doctor of Medical Sciences
13.00-13.30 BREAK
13.30-14.00 Diabetic foot syndrome. Modern principles of prevention and treatment
Guryeva Irina Vladimirovna- Professor of the Department of Endocrinology and Diabetology of the Therapeutic Faculty of the Russian Medical Academy of Postgraduate Education, Head of the Moscow Center "Diabetic Foot" of the Federal Center for Expertise and Rehabilitation of the Disabled, MD.
14.00-14.20 Shock wave therapy - a new direction in the treatment of diabetic foot
Vasyuk Yuri Alexandrovich- Head of the Department of Clinical Functional Diagnostics of the Medical Faculty of the Moscow State Medical University. A.I. Evdokimova, Doctor of Medical Sciences, Professor
Shkolnik Evgeny Leonidovich - Professor of the Department of Clinical Functional Diagnostics of the Medical Faculty of the Moscow State Medical University named after. A.I. Evdokimova, MD
Ivanova Svetlana Vladimirovna Associate Professor of the Department of Clinical Functional Diagnostics of the Faculty of Medicine of the Moscow State Medical University. A.I. Evdokimova, PhD
14.20- 14.40 Modern approaches to the treatment of diabetic polyneuropathy
Mkrtumyan Ashot Musayelovich
14.40-15.10 Subclinical hypothyroidism in the practice of a district therapist
Martynov Anatoly Ivanovich- Academician of the Russian Academy of Sciences, Professor of the Department of Hospital Therapy No. 1 of the Faculty of Medicine, Doctor of Medical Sciences
15.10-15.30 Endothelial dysfunction as a common pathogenetic mechanism of cardiovascular diseases and type 2 diabetes mellitus and ways of its correction
Sviridova Maria Ivanovna- Endocrinologist at the Polyclinic of the Ministry of Economic Development of the Russian Federation
15.30-15.50 Complex preparations of calcium and vitamin D as the basis for the prevention and treatment of osteoporosis
Marchenkova Larisa Alexandrovna- Head of the Department of Active Longevity and Endocrinology, Head of the Department of Rehabilitation of Patients with Somatic Diseases of the Federal State Budgetary Institution RRC MRiK of the Ministry of Health of Russia, Ph.D.
15.50-16.10 Osteoporosis is a life-threatening complication of diabetes mellitus. Prevention and treatment
Mkrtumyan Ashot Musayelovich- Head of the Department of Endocrinology and Diabetology, MGMSU named after A.I. A.I. Evdokimova, Doctor of Medical Sciences, Professor
16.10-16.30 Principles and modern possibilities of medical rehabilitation of patients with osteoporosis
Marchenkova Larisa Alexandrovna- Head of the Department of Active Longevity and Endocrinology, Head of the Department of Rehabilitation of Patients with Somatic Diseases of the Federal State Budgetary Institution RRC MRiK of the Ministry of Health of Russia, Ph.D.
Closing of the congress
Within the framework of the congress, a thematic exhibition exposition of manufacturers and distributors of medicines, medical equipment, preventive and therapeutic products, specialized literature was organized.
The congress was attended by cardiologists, endocrinologists, neurologists, therapists, rheumatologists, traumatologists, general practitioners and other specialties.
On October 20, 2015, in Domodedovo, Moscow Region, a large-scale action dedicated to the World Osteoporosis Day was held under the motto: “Healthy nutrition for healthy bones!”.
The events were held in the city palace of culture and sports "Mir".
Action organizers: Moscow Regional Center for Medical Prevention (branch for medical prevention of GAUZMO KTsVMiR), Moscow Regional Center for Osteoporosis on the basis of the Department of Therapeutic Endocrinology, GBUZ MO MONIKI named after. M.F. Vladimirsky, Department for the Coordination of the Activities of Medical and Pharmaceutical Organizations No. 12 of the Ministry of Health of the Moscow Region, administration of the city of Domodedovo.
For the residents of Domodedovo was read lecture on the topic "What you need to know about osteoporosis and its prevention" head Department of Endocrinology of the Federal State Budgetary Institution “Russian Scientific Center for Medical Rehabilitation and Balneology” of the Ministry of Health of Russia, member of the Presidium of the Russian Association of Osteoporosis, Ph.D. Larisa Alexandrovna Marchenkova.
Chief Physician of GBUZ MO "Stupino Center for Medical Prevention" Zinaida Vladimirovna Kositsyna spent master class in Nordic walking as a way to prevent osteoporosis and clearly showed the benefits of this method of physical activity.
In continuation of the event, specialists from the Domodedovo Health Center conducted a screening program for everyone, including the measurement of blood pressure, heart rate, blood glucose and cholesterol levels, and a heart examination on a cardiovisor. All participants of the action were able to taste dairy products of domestic producers. Everyone left satisfied with a milk gift. More than 250 people took part in the action.
One of the significant events of the day was the District Scientific and Practical Conference for medical workers, which was attended by therapists, endocrinologists, and traumatologists.
With a welcome word The assembled participants of the conference were addressed by: Deputy Chief Physician of the Moscow Regional Center for Medical Prevention Yuri Dmitrievich Shalyagin, Head of the Department for Analysis and Monitoring of the Activities of the Department for the Coordination of the Activities of Medical and Pharmaceutical Organizations No. 12 of the Ministry of Health of the Moscow Region Natalya Sergeevna Malneva, Chief Physician of the Domodedovo Central City Hospital Andrey Anatolievich Osipov.
Presentations were made by:
- - head. Department of Endocrinology, Federal State Budgetary Institution “Russian Scientific Center for Medical Rehabilitation and Balneology”, member of the Presidium of the Russian Association of Osteoporosis, Ph.D.
“Problems of osteoporosis for the practitioner. Topical Issues in Diagnosis and Treatment”
2. Kryukova Irina Viktorovna- Assistant of the Department of Therapeutic Endocrinology, GBUZ MO "MONIKI them. M.F. Vladimirsky, Ph.D.
Larisa Alexandrovna Marchenkova- Researcher at the Department of Endocrinology of MONIKI
Moscow Regional Scientific Research Clinical Institute (MONIKI) (Director Corresponding Member of the Russian Academy of Medical Sciences, Professor G.A. Onoprienko), Endocrinology Department of MONIKI (Head Prof. Drewal A.V.)
Osteoporosis: current state of the problem. Larisa Aleksandrovna Marchenkova Researcher of the Department of Endocrinology of MONIKI. Moscow Regional Scientific Research Clinical Institute (MONIKI) (Director Corresponding Member of the Russian Academy of Medical Sciences, Professor G.A. Onoprienko) Endocrinology Department of MONIKI (Head Prof. Dreval AV)
- the most common metabolic disease of the skeletal system, which is characterized by a decrease in bone mass per unit volume and a violation of the microarchitectonics of bone tissue, leading to increased bone fragility and an increased risk of fractures.
Osteoporosis affects approximately 30% of women and almost 50% of women have low bone mass of the femoral neck, spine or bones of the distal forearm, that is, a high risk of developing the disease. Osteoporosis causes 1.3 million fractures in the United States each year, including 500,000 vertebral fractures and 247,000 hip fractures.
Due to the high incidence of fractures and the severity of complications, the economic losses associated with osteoporosis are truly enormous and are increasing every year. In the United States in 1985, the "cost of osteoporosis" was estimated at 5-6 billion dollars, and now - more than 12 billion dollars a year. In particular, the "price" of a hip fracture in a woman aged 50-65 is 19.5 thousand US dollars per year, and in a patient older than 65 years - 21.9 thousand dollars. Given the general trend towards an aging population, a significant increase in the incidence of osteoporosis is expected, and hence the economic costs of treatment and rehabilitation of patients with fractures. According to the forecast of a number of epidemiologists, by 2040 the frequency of hip fractures, and, accordingly, the material losses associated with them, will increase threefold.
Risk Factors for Osteoporosis
The development of osteoporosis is directly related to a decrease in bone mass and, accordingly, bone mineral density (BMD), which determines the strength of the bone and its resistance to excessive physical impact. Bone mass increases up to about 25 years in proportion to the growth of the whole organism and after the completion of growth in mature people remains practically unchanged. In the period of aging, resorption begins to prevail over bone synthesis, which leads to a decrease in bone mass.
It is now believed that the level of bone mass in old age, and, consequently, the risk of developing osteoporosis, equally depends on two factors - the mass of bone formed during childhood and adolescence (the so-called peak bone mass), and the speed of its loss during aging. Peak bone mass is affected by genetic status, physical activity level, and dietary habits, primarily the adequacy of calcium, vitamin D, and protein intake. The rate of bone mass loss is potentiated by a lack of sex hormones (menopause, oophrectomy, amenorrhea, hypogonadism) and age-related changes - a decrease in physical activity and a weakening of calcium absorption in the gastrointestinal tract due to a decrease in the synthesis of vitamin D. In addition, osteopenia can be a consequence of chronic diseases ( endocrine, rheumatic, hematological, gastroenterological, nephrological, alcoholism, etc.) or drug therapy, primarily glucocorticoid.
The likelihood of fracture in individuals with low bone mass is largely determined by the presence of risk factors for fractures, which are also well defined. In particular, the risk of hip fracture increases the female gender as such, white or Asian race, older age, low bone density, the presence of other fractures in the past, underweight, smoking, family history (cases of hip fracture in blood relatives), taking sedatives, decreased vision and increased susceptibility to falls. Risk factors for other fractures are low bone mass, advanced age, a history of fractures, and, for all fractures except vertebral compression deformities, an increased tendency to fall.
Naturally, the causes leading to the formation of a low peak bone mass or a high rate of its loss also predispose to fractures. On the contrary, regular exercise, a balanced diet and moderate consumption of alcoholic beverages, which increase bone mass, reduce the likelihood of fractures.
The ratio of risk factors determines the level of bone mass by only 20-40%, which somewhat limits their value for the diagnosis of osteoporosis in clinical practice. However, assessment of risk factors for fractures identifies women at high risk of bone injury and those in need of preventive measures or treatment.
Consequences of osteoporosis
Low bone mass itself has no clinical manifestations, so the clinical picture and complications of osteoporosis are associated exclusively with fractures. Typical for osteoporosis are traditionally considered a fracture of the proximal femur (primarily the femoral neck), compression deformities of the vertebral bodies and a fracture of the bones of the distal forearm (the so-called fracture of the beam in a typical place, or Colles fracture). However, due to a generalized decrease in bone mass in the entire skeleton, absolutely all types of fractures can occur in osteoporosis, for example, the distal third of the thigh, ribs, humerus, fingers, pelvic bones, etc.
A significant part of fractures has an uncomplicated course and ends with a complete recovery of the patient. However, in many cases, fractures cause pain, bone deformities, limited range of motion, the need for constant medical care, psychological and other problems leading to a significant decrease in the quality of life, disability and often death.
The most dangerous complications are a hip fracture, which requires hospitalization in 50% of cases, and in 10% of cases - constant home care for the patient during the year. 11% of patients after a hip fracture permanently lose the ability to walk independently and only 30-50% of patients fully restore their physical level.
Compression fractures of the vertebral bodies are found in approximately 36% of older women. About 24% of patients with one or more compression fractures suffer from persistent back pain, and 5% eventually become disabled. Compression deformities of the vertebrae in a significant proportion of patients are the cause of limited physical activity, spinal deformities with the development of thoracic hyperkyphosis (the so-called "widow's hump"), a significant decrease in growth and emotional problems associated with changes in appearance.
Colles' fracture is not as dangerous as the fractures described above, however, even after it, no more than half of the patients fully recover functionally within the first six months. From 29% to 44% of such patients experience severe pain, 36 - 40% complain of weakness and stiffness in the hand, and 27% have at least one of the symptoms of algodystrophy.
Naturally, constant debilitating pain, immobility and the associated change in the habitual lifestyle of patients with fractures leads to the development of psycho-emotional disorders, the most common of which is depression. In addition, quite often in patients with osteoporosis there is a fear of falling and new fractures, a decrease in mood, and anger.
Severe depression and other astheno-neurotic disorders adversely affect the speed and quality of recovery of patients with fractures. The severity of the consequences of a fracture is also significantly affected by the status of the patient before the moment of injury - age, state of health, degree of social activity, as well as factors independent of the patient, such as the location of the fracture or the presence of postoperative complications.
Sufficiently high mortality, characteristic of osteoporosis, is associated primarily with a fracture of the femoral neck - 5-20% of patients die within the first year after the fracture. In most cases, death occurs due to associated comorbidities, however, hip fracture itself reduces life expectancy by 12-20%.
Diagnosis of osteoporosis
According to modern concepts, the main goal of diagnostic measures in osteoporosis is to decide on the need to prescribe therapy to prevent fractures or to decide on the nature of therapy if its choice will affect the outcome of the disease. At the same time, the benefits of the study should cover the inconvenience, possible risks and material costs associated with its conduct. Diagnostic measures are considered inappropriate if their results do not affect the choice of therapy or the outcome of the disease. Obviously, the patient does not need any diagnostic tests if it is known in advance that the treatment is not indicated for him.
Modern methods for diagnosing osteoporosis are based on a quantitative study of BMD - osteodensitometry, which can be carried out using one of the following methods: monophoton or diphoton absorptiometry, monoenergetic or dual energy X-ray absorptiometry (XRA), quantitative computed tomography or radiographic absorptiometry. An analysis of the latest literature shows that all these technologies are non-invasive and safe for the patient, but they differ significantly in the accuracy and reproducibility of measurements, in their significance for clinical and scientific practice, and also in their general availability.
Of the above methods of densitometry, DXA is preferred all over the world, which, with minimal radiation exposure to the patient, allows scanning the bone with high accuracy and high speed and, importantly, is a relatively inexpensive method. With the help of DXA, it is possible to examine the BMD of any part of the skeleton and, therefore, assess the risk of fractures of any localization, including the vertebrae and the femoral neck.
The possibilities of measuring BMD in dynamics depend on the measurement reproducibility error associated with the rate of metabolic processes in bone tissue in each specific part of the skeleton. Therefore, having a minimum reproducibility error of 1-1.5%, DXA is the best method compared to other methods for monitoring the dynamics of BMD in order to identify individuals who are rapidly losing bone mass and evaluate the effectiveness of therapy.
In the past few years, peripheral DXA - densitometers - have become widely used in practice. These devices are designed to measure BMD of the distal forearm only, however, they are much smaller in size, cost, and scanning time compared to complete DXA. According to the results of recent studies, there is no significant correlation between BMD of the forearm and BMD of the spine and hip. However, there is evidence that the presence of osteoporosis in the bones of the distal forearm is an indirect sign of severe osteoporosis of the spine, complicated by at least one vertebral compression fracture.
Diphoton absorptiometry has similar characteristics to DXA, however, is more expensive and requires a long bone scan time - from 20 to 60 minutes, depending on the area of study. In this regard, the use of diphoton absorptiometry in everyday clinical practice is considered inappropriate.
The methods of monophoton and monoenergetic X-ray absorptiometry have a fairly high measurement accuracy - 2-5%, a relatively low reproduction error - 1-2%, minimal radiation exposure to the patient, high throughput due to the short scanning time and, importantly, the lowest in comparison with other cost research methods. The disadvantage of both methods is their suitability for studying only the peripheral parts of the skeleton, that is, the inability to assess the density of the spine or hip. In addition, the area to be examined, the forearm or foot, must be placed in a liquid medium, since the accuracy of the result is affected by the thickness of the soft tissues. Monoenergetic X-ray absorptiometry is a newer and more modern technology and therefore is gradually replacing monophotonic.
Unlike other methods, quantitative computed tomography makes it possible to evaluate not only the BMD of any part of the skeleton as a whole, but also the density of the spongy or cortical substance in isolation. The error of the method is quite large (5-10%), which is due to the influence of the thickness of the visceral fat layer on the result of the study. The disadvantages of the method are also the high cost of the study and a rather large radiation exposure, which does not allow the use of quantitative computed tomography for the diagnosis of osteoporosis widely enough.
Radiographic absorptiometry can only examine the peripheral skeleton, such as the arm, whose BMD is measured in relation to the density of a standard aluminum sample. However, BMD of the phalanges of the fingers correlates strongly enough with the density of other parts of the skeleton, which allows us to consider radiographic absorptiometry as a fairly informative screening method for diagnosing osteopenia and the risk of fractures.
Currently, densitometry is recommended:
- to determine the risk of fractures and decide on the appointment of therapy over the age of 50 years, if there is not one of the main risk factors that obviously require treatment - the presence of at least one of the osteoporotic fractures of the vertebrae, wrist or hip, osteoporotic fractures in blood relatives, mass body below 57.8 kilograms or prolonged smoking;
- for monitoring BMD to identify individuals who are rapidly losing bone mass;
- for an adequate choice of a therapeutic drug;
- to monitor the effectiveness of therapy.
In Russia, densitometry has not yet become widely used due to the high cost of such equipment; therefore, the most common and generally accepted method for topical diagnosis of osteoporosis is still visual assessment of skeletal radiographs. Classical radiography makes it possible to quite reliably recognize osteoporosis and evaluate its severity in the diaphysis of tubular bones based on such an objective symptom as thinning of the cortical layer. However, it is somewhat more difficult to detect a spongy substance lesion, changes in which dominate in osteoporosis, on standard radiographs. In particular, osteoporosis of the spine can be reliably diagnosed only at the stage of compression of the vertebral bodies.
Despite the fact that standard radiography has been used to diagnose osteoporosis for a long time, there is still no consensus on the information content of this method for diagnosing the disease. On the one hand, standard radiography is an inaccurate method and therefore does not allow for reliable diagnosis of pathology at the preclinical stage. On the other hand, some studies show that spinal radiography is a more specific method for diagnosing severe osteoporosis of the spine than densitometry.
A number of works are devoted to the possibility of assessing the state of bone tissue by the intensity of attenuation and the speed of passage of an ultrasonic wave through the bone. Ultrasound bone scan data correlate extremely weakly with BMD, however, there are facts proving that the ultrasound method provides a more complete picture of the properties and strength of bone tissue than BMD measurement. There is also an opinion that bone ultrasound has approximately the same capabilities for detecting microstructural damage as monophoton absorptiometry, and can be used to assess the risk of fractures of various locations.
Some authors believe that a fairly informative method for diagnosing osteoporosis is a direct assessment of bone microarchitectonics, since according to some publications, the risk of hip fracture depends more on the bone geometry of this area than on its BMD level.
Recently, much attention has also been paid to the study of biochemical markers of bone remodeling. It is believed that biochemical assessment of bone metabolism patterns can predict the risk of fractures regardless of the level of bone density, although some studies refute this point of view. The risk of fractures is closely related to the rate of bone remodeling and, probably, the combination of studying the intensity of bone metabolism by biochemical methods with densitometry is the optimal diagnostic complex.
There is evidence that the state of bone tissue can be assessed using a cytochemical study of the activity of leukocyte enzymes. In particular, it was found that in patients with postmenopausal osteoporosis, the activity of alkaline phosphatase in neutrophils and succinate dehydrogenase in lymphocytes is significantly increased compared with healthy postmenopausal women and significantly negatively correlates with the level of BMD of the spine and hip. Apparently, a cytochemical study, not being an alternative to densitometry, can complement the examination of osteoporosis risk groups, and can also be used to assess the effectiveness of disease therapy at the cellular biochemical level.
Prevention and treatment of osteoporosis
Primary prevention of osteoporosis is indicated for children and adolescents to achieve optimal peak bone mass. Secondary prevention is essential for all postmenopausal women, older and older people, and those on medications or with chronic conditions that cause bone loss. Prevention of osteoporosis should be comprehensive and include a balanced diet, exercise, elimination of risk factors, primarily smoking cessation, intake of calcium and vitamin D supplements.
Currently, indications for the appointment of specific therapy are: 1) the presence of at least one osteoporotic fracture in history - vertebrae, wrist or hip, 2) osteopenia, 3) the presence of osteoporotic fractures in blood relatives, 4) low body weight - less than 57.8 kilogram, 5) prolonged smoking. Such persons, in addition to the above general measures, need treatment with drugs that affect the processes of bone remodeling. An important condition for the success of the treatment of patients with fractures is also symptomatic therapy, physiotherapy and complex rehabilitation measures.
When choosing a treatment method, there must be firm confidence in its effectiveness in terms of preventing fractures and their consequences. The expected result should significantly cover the potential danger of therapy associated with possible side effects, as well as the material costs associated with the treatment.
Considering that an increase in BMD indirectly indicates a decrease in the likelihood of fractures, and a decrease in BMD indicates an increase in this probability, the main method for assessing the adequacy of therapy in a particular patient is monitoring densitometry. The effect of the drug on the "quality" of bone tissue is also important, since the susceptibility of bone to fractures depends not only on its density, but also on qualitative characteristics - a decrease in the elasticity of the bone matrix, the accumulation of "chronic bone fatigue" due to multiple microstructural defects, and an increase in the fragility of the hypermineralized " old bone. In addition, the improvement of the general condition of the patient is of great importance - the reduction of pain and psycho-emotional disorders, the expansion of motor activity, the maximum recovery of working capacity and habitual lifestyle, as well as the effect of therapy on calcium-phosphorus metabolism and bone remodeling processes.
The treatment of choice for postmenopausal osteoporosis is hormone replacement therapy (HRT). Long-term treatment with estrogens, for 10 years or more, in general, reduces the risk of fractures by 75%, including compression fractures by 50% within 10 years, and the femoral neck by approximately 25% within 5 years. The best result is achieved if treatment is started in the first 5 years of menopause, however, there is evidence that HRT increases BMD by 5-10% within 3 years, even in women who started taking estrogens 10 years after the end of menarche. Combined therapy with estrogen-progestin drugs, both in cyclic and continuous regimens, does not differ in clinical effect from estrogen monotherapy. However, some progestins, derivatives of nortestosterone, have an independent effect on the level of bone mass, although not as pronounced as compared to estrogens.
After the end of estrogen, bone loss resumes, so theoretically HRT should never stop. However, the breadth and duration of the use of HRT is significantly limited by a large range of contraindications and a high risk associated with this type of therapy associated with the proliferative effect of estrogens in relation to estrogen-dependent organs. The combination of estrogens with progestins does not fully eliminate the potential risk of endometrial cancer, and, in addition, taking HRT for more than 10 years increases the risk of breast cancer. Given the high risk associated with this type of treatment, the question of the appointment and duration of HRT should be decided strictly on an individual basis.
Recently, much attention has been paid to a new promising group of drugs - selective estrogen receptor modulators - as an alternative to HRT in the treatment and prevention of postmenopausal osteoporosis. Their feature is agonism in relation to estrogen receptors of the liver and bone tissue and antagonism in relation to the uterus and mammary glands. As a result, selective estrogen receptor modulators have a positive effect on the blood lipid spectrum and bone mass, according to some reports, comparable in strength to the effect of HRT. However, these drugs, unlike estrogens, do not cause proliferation of endometrial tissue and mammary glands.
Calcitonin, whose main biological effect is to reduce bone resorption by suppressing osteoclast activity, has been used for the prevention and treatment of osteoporosis for more than 30 years. Regular use of calcitonin for 3 years reduces the incidence of new bone fractures in general by 37-50%, and most studies show a positive effect of calcitonin on the incidence of compression deformities of the vertebral bodies - a decrease of 75% over 2 years of treatment. According to the results of separate publications, treatment with calcitonin also reduces the risk of hip fracture by an average of 24%, but the severity of the effect of the drug is directly proportional to the dosage. The strength of the effect of calcitonin on BMD of the spine and hip also depends on the dose.
Calcitonins are the only group of antiresorptive drugs that have a direct analgesic effect, so calcitonin drugs are the therapy of choice for osteoporosis with severe pain. The complexity of the use of calcitonin is associated with resistance, which develops to it in 50% of patients. In this regard, long-term treatment is effective only with intermittent administration with two to three-month breaks.
Bisphosphonates are a modern generation of drugs that are the most powerful inhibitors of osteoclastic bone resorption. The effect exerted by bisphosphonates on the level of BMD is achieved even after a short period of treatment - after 3 years, an increase in BMD in the spine averages 6-8%, in the hip - 4%. Data on the effect of bisphosphonates on the incidence of fractures are contradictory, but in general it can be considered that the risk of all types of fractures with this type of therapy is reduced by 30%, and fractures of the vertebrae and femoral neck - by 50%. There is evidence that due to the accumulation of bisphosphonates in bone tissue, an increase in BMD in the spine continues for some time even after stopping treatment, but the long-term effects of this type of therapy have not yet been studied. Strict adherence to the rules for taking bisphosphonates by patients is necessary due to their poor absorption in the intestine and a fairly wide range of possible adverse reactions.
Of the drugs that stimulate bone formation, fluorides are most widely used. Studies show that fluorides have an ambiguous effect on the level of BMD: they significantly increase bone mineralization in the axial skeleton (by 4-8% per year), but do not change or even reduce it in the peripheral skeleton. The effect of fluorides on the incidence of fractures is also ambiguous and depends not so much on the dynamics of BMD, but on the dosage of the drug. Most studies have not found a positive effect of fluoride on fracture statistics, however, there is evidence of a decrease in the incidence of fractures by about a third when prescribing fluoride in low doses. In addition, treatment with high doses of fluoride in 10% - 40% of patients causes a variety of side effects (joint pain, gastrointestinal symptoms, tendency to microfractures), so only low doses are currently recommended.
Despite the fact that calcium preparations have a certain antiresorptive potential and in large doses have a significant, albeit very weak effect on BMD and fracture rate, most authors note that the independent role of calcium preparations in the treatment and prevention of osteoporosis is very modest. The appointment of calcium supplements is indicated in the treatment of most antiresorptive drugs that have a hypocalcemic effect (calcitonins, bisphosphonates), as well as to prevent possible violations of bone mineralization during therapy with fluorides or some bisphosphonates. For prophylactic purposes, it is advisable to combine calcium preparations with vitamin D for better absorption and effectiveness.
Treatment with native vitamin D preparations in combination with calcium preparations, according to the results of some studies, reduces the risk of hip fracture by an average of 25%, and other fractures, in particular, vertebrae and distal forearm - by 15%. However, most authors note the absence of a significant effect of vitamin D preparations on BMD and fracture rate, therefore, in some countries, such as the United States, their administration is recommended only for prophylactic purposes.
Treatment with the active metabolite of vitamin D - calcitriol and its synthetic analogue - alfacalcidol reduces the incidence of osteoporotic fractures by 10-50% according to various sources, and also contributes to an increase in bone mass, although more moderately compared to antiresorptive drugs. In addition, alfacalcidol and calcitriol positively affect the quality of bone tissue, therefore, in osteoporosis, their appointment as monotherapy or in combination with antiresorptive drugs is fully justified.
Currently, the search for new methods of drug therapy for osteoporosis continues. In particular, a positive effect on the level of BMD preparations of synthetic parathyroid hormone, ipriflavon and somatotropic hormone was noted. However, there are no reliable data on the beneficial effect of these pharmaceuticals on the statistics of fractures, so their exact place in the daily practice of treating patients with osteoporosis has not yet been determined.
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