UY BAN NHAN DAN CONG HOA XA HOI CHU NGHIA VIET NAM ‘THANH PHO HO CH{ MINH Doe Igp - Ty do - Hanh phic SOY TE ———— 86.962) /SYT-NVY Thanh phé Hé Chi Minh, ngaydbthang)2nsim 2020 VW gidi thigu cp nhat va tai ban BENH VIEN QUAN THU DUC Hudng din Chin dodn, Digu tr] va $6261 Dy phong Lofing xuong cia Hi BEN | otis as Quin lodng xuong Thanh phd, Lu VT Kinh giti: Bénh vign cong Ip va ngoai cing lép. 86 Y té nhan duge Vin ban cia Hi Lo&ing xuong Thanh phé vé viée xin cp nhat ‘va tai ban “Huéng din Chan dodn, Didu tr va Dy: phdng Loding xuong” (sau day goi tit la Hung din); sau khi xem xét nOi dung tai ligu theo hé so dinh kém, So Y té 6 ¥ kién hu sau - Ngay 01 thang 10 nam 2013, Sé Y 16 da ban hanh quyét dinh 1983/QD-SYT ve vigc ban hnh “Huéng din Chan dodn, Didu trj va Dy phdng Lofing xuong” dyra trén d2 xudt cia H6i Loang xuong Thanh phé dé gitp cdc don vj trén dja ban thinh ph6 trién khai cée phuong phép digu tri, dy phong bénh long xuong, la mOt bénh chia c6 huéng din phac dd didu trj ca BO Y té tai thoi diém 46, - Ngay 25 thing 01 nim 2014, BO trudng BO Y té ban hanh vé “Hudng din chin doan va didu tr} cée bénh co xuong khép”, trong 46 4% c6 phée dd digu tr} bénh lo&ing xuong. - Hign nay sau gin 7 nim duge cée don vj khém chita bénh trén dja bin thanh phd 4p dung va dura vao trong cée phée dé didu tr] ca bénh vign, Hudng din da c6 nhidu didu chinh, bé sung, cp nh§t thém thong tin diéu trj méi va da duge thong qua tai phién hop ngay 30/07/2019 cba Ban chap hanh Hi lofing xuong TP. HCM, la dai dign cdc chuyén gia trong chuyén nganh nay tai thanh phd H& Chi Minh, cing nhu cép nhét thém nhiéu ndi dung y hoo dya trén tai ligu y hoo ching cit theo cée nghién ciru trong nhing nim gin day. Trén co sd d6, Sb Y té gidi thigu dén cdc don vj khém chtia bénh trén dja ban thanh phé dé nghign céru, xem xét vige Ap dung tai ligu nay dé bd sung vao phéc db digu trj ca don vj dé mang lai cée phong phap didu trj higu qua cho ngudi bénh. Tran trong./, 9. (Dinh kém tai ligu cdp nhat) Nol nh@n: = Nhu trén; ~ Hoi loding xwong Thanh phd, = Ban gidm déc ( 48 bao cdo) Luu: VT, NVY NND, BNTLAY CONG HOA XA HOI CHU NGHIA VIETNAM Déc lip - Ty do — Hanh phite Tp. Hé Chi Minh, ngay 20 thang 8 ndm 2019 4-téi-ban Hudng din Chin doén, Diéu tri va Dye phong Loang xuong EN (02. -fy aw | TOTRINA 8. Newt RHMGs|rs Neuyén Th Binh, Gidm dée SY TE TP ICM Nam 2013, véi quyét dinh 1983/QD-SYT ngay 1/10/2013 eda So Y Té TP HCM vé vige bién soan va ban hanh Hudng din Chin dodn, Diéu tri va Dy phong Lodng xuong, huéng din nay 4a tré than 1A mét tai ligu chuyén mon cho cée BS & nhidu chuyén khoa khdc nhau tham khao va thyc han trén thue té didu tri. Dén nay, sau hon 5 nim sir dung, Huéng din nay cdn duge diéu chinh, bd sung va cp nhét thém mét s6 kién thite méi Thay mat Ban Chdp Hanh H6i Loting Xuong TP HCM, kinh 48 nghj GS TS Nguyén TAn Binh, Giém déc $6 Y Té TP HCM cho phép Héi Loang xvong TP HCM, duge didu chinh, bé sung va téi bin Huéng dén Chan dodn, Didu tr] va Dr phong Lofing xuong. H@i Loding xuong TP HCM sé c6 ging d6ng vién cdc nguén ‘Ai tro cho vige cp nhgt, in én va cung efp cho cdc tuyén y t8 co s6 thude dia bin TP HCM, théng qua Phong Nghiép vy Y cia Se Y té, TP HCM Xin tran trong cém on TM, BCH Héi ) HOI (AMANG XUONG PGS TS Lé Anh Thr Chi tich Hi Loting xuong TP HCM Phé Chi tich Hdi Thdp khép hoc Viét NamDANH SACH HOI DONG KHOA HOC CUA HOI LOANG XUONG TP HCM ‘Tham gia cp nhat, diéu chinh va bé sung Hudng dan Chan doén, Digu tri va Dy phong Lofing xuong 2019 PGS TS BS Lé Anh Thu PGS TS Nguyén Thj Bich Dao TS BS Pham Viét Thanh TS BS V6 Vin Si PGS TS Vii Dinh Hing, BS CK II Trdn Thanh My PGS TS Nguyén Dinh Khoa PGS TS Lé Chi Diing PGS TS V6 Van Nho PGS TS Pham Ngoc Hoa PGS TS Nguyén Van Tri BS CK Il Thai Thj Héng Anh TS BS Nguyén Hitu Toan TS BS Luong Dinh Lam BS CK I Nguyén Thai Thanh ‘TS BS Huynh Van Khoa TS BS Trin Ngoc Diing TS BS Nguyén Thj Thanh ThiyHh) Senet | HUONG DAN CHAN DOAN, DIEU TRI VA DU PHONG LOANG XUONG (Ban hinh kem theo Quyés dink sé 1983/QD-SYT, ngdyy 01/10/2013, Auge céip nhat va bd xung ngay 10/8/2019Loi giéi thigu ‘V6i sy gia tang tuéi tho nh hién nay, Loang xuong da tré thanh mt vin dé sire khoé mang tinh toan cdu vi anh hudng rét nhiéu t6i site khoé ngudi oé tudi, dic bigt 1a phy nf. Long xuong duoc xem 1a “ké thi gidu mat” hay “ké giét ngudi thim king” vi dign bién Am thim, ning din va phitc tap. Losing xuong dé Igi hau qua nghiém trong, khéng chi hanh hg co thé bing dau dén kéo dai, thay 46i hinh thé, gay tin phé, gidm cae chie nding va chét ung séng ma cdn ting nguy co mic ede bénh khéc va tng nguy co tik vong. Hau hét ede bénh nhan duge phat hign bénh tr, khi da cb bin ching giy xuong, nén vige digu tr] thudng kéo dai, tn kém va ft higu qua La m6t bénh thutmg gip va dién tién kéo dai, long xuong can duge tim soét, anh gia va chin dosn hop ly 48 e6 mot tr igu thich hop va higu qua, Digu nay hign cn 14 mt thach thite t6n véi hg théng chim séc stie khoé ciia nude ta La mot hiém hoa v6i ste khée phy nt va site khde cng dng, nhung loang xuong 6 thé phong nga duge, Phong ngita dé trénh bj bénh va tran cic bién cb gay xuong, hau qua ngng né cia bénh Tuy nhién, phing lofing xuong 1a mt qué trinh cin duge thye hign bén bi sudt cuge ddi, luén két hop chat ché gitta van déng va dinh dutng 8 cé khdi long xuong dinh cao nhét lic truéng than Néu kidi Iugng xwong dinh ting duge 10%, 8 gidm duge 50% nguy co gdy xuong do lodng xuong trong subt cuge dei. Lofing xuong la m6t bénh 06 thé tim sodt, dy phong va didu tri higu qua, it tén kém hon nhigu so véi hu qua cita né gy ra. Dé dip ting duoc tiéu chi trén, $6 Y té Thanh phd Hd Chi Minh ra quyét dinh thinh lgp Hoi dng chuyén mon théng qua “Fhuong dn chén dodn, dibu tri vi dy phong bénh lodng xuong” duge sogn thio béi cae chuyén gia hing dau vé xwong khép va chuyén hoa tai Thanh phd Hd Chi Minh, ofp nhét hing kién thite méi nhét lién quan dén bénh ly long xuong trén thé gidi cfing nhu khu vue Chau A. Ching t6i hy vong “Huéng déin chan dodn, didu trj va dy phong bénh loang wrong” s& cung clip cho cfc thy thuée Iam sing nhting théng tin b8 ich trong vige cham séc va didu tr] bénh nhan, ‘Trong qué trinh bién sogn khong trdnh khdi nhiing thiéu sét, mong nhfin duge cic 26p ¥ ti Quy dong nghiép, dé ln t4i ban sau hoin chinh hon. Xin chan thanh cam on, ‘Thanh phé H8 Chi Minh, théng 10 nim 2013 TM. Ban bién sogn PGS Hoang Quéc Hoa, Gidm dée bénh vidn Nhan din Gia Dinh PGS TS Lé Anh Thu, Bac si Cao cp, Bénh vign Ch Ray Chi tich H6i Loaing xuong,TP Hé Chi MinhBAN BIEN SOAN (Thanh ldp theo quyét dinh 1983/ OD SYT, ngay 01 thang 10 nim 2013) Chit nhigm: PGS TS Hoing Quéc Hoa Gidm Déc Bénh vign Nhan dan Gia Dinh PGS TS BS Cao cép Lé Anh Thu Chi tich H6i Lofing Xuong thanh phd Hé Chf Minh Thu ky: BS CKI Trin Huy Hoang Chuyén vién Phong Nghigp Vu Y - So ¥ t8 Tham gia bién soan: BS CKH Thdi Thi Hing Anh Truréng khoa Co Xuong Khép, Bénh vién Nguy&n Tri Phuong TS BS Nguyén Dinh Khoa Trudng khoa Co Xuong Khép, Bénh vién Chg Ray ThS BS Hé Pham Thue Lan Truéng khoa Co Xuong Khép, Bénh vién Nhin dan 115 TS BS Nguyén Thi Thu Théo ‘Truéng khoa N6i tiét, Bénh vign Nhén dan Gia Dinh BS CKIT Phan Quang Tri Phé Gidm Béc Bénh vién Chin thuong Chink hinhCAP NHAT VA DIEU CHINH (10/8/2019) HOQIDONG KHOA HQC CUA HOI LOANG XUONG TP HCM Chit tich H9i ddng PGS TS BS Lé Anh Thu, H6i Lodng xuong TP Hé Chi Minh Cfe thanh vién HOi ddng PGS TS Nguyén Thi Bich Dao, chuyén gia Noi tiét, Hi LX TP HCM TS BS Pham Viét Thanh, chuyén gia San Phu khoa, Hoi LX TP HCM TS BS Vo Vain Si, chuyén gia Cot séng, Hoi LX TP HCM PGS TS Vil Dinh Hing, chuyén gia Thdp khép hoc, Hoi LX TP HCM BS CKU Trén Thanh Mj, chuyén gia Chan thwong, Chinh hinh, Héi LX TP HCM. PGS TS Nguyén Dinh Khoa, chuyén gia Thdp khép hoc, Hoi LX TP HCM BS CK Il Thai Thj Héng Anh, chuyén gia Thdp khép hoc, Héi LX TP HCM PGS TS Lé Chi Ditng, chuyen gia Chdn thuong, Chink hinh, Hi LX TP HCM PGS TS V6 Vin Nho, chuyén gia C6t sdng va Ngoai than kinh, Hét LX TP HCM PGS TS Pham Ngoc Hoa, chuyén gia Chén dodn hinh anh, Héi LX TP HCM PGS TS Nguyén Vein Trl, chuyén gia Lito khoa, H6i LX TP HCM TS BS Nguyén Hitu Todn, chuyén gia Dinh dieing, Hoi LX TP HCM TS BS Luong Dinh Lam, chuyén gia Chdn thong, Chinh hinh, H6i LX'TP HCM TS BS Nguyén Thi Thanh Thity, chuyén gia vé Dau, Hoi LX TP HCM TS.BS Hujnh Vin Khoa, chuyén gia Thdp khép hoc, Hoi LX TP HCM BS CKI Nguyén Thai Thanh, chugyén gia Chan thaeong, Chinh hinh, HOiLX TP HCM TS BS Trén Ngoc Ding, chuyén gia N6i Téng quét, Hi LX TP HCM Thw ky Hi ddng: TS BS Huynh Van Khoa, H6i LX TP HCM. Ban e6 vin: GS Nguyén Van Tudn, PGS TS Truong Van ViétCAC CHU VIET TAT Chet viét tit Tiéng Anh ALT Alanine Transaminase AST Aspartate Transaminase BMD Bone Mineral Density BMI Body Mass Index COPD —_Chronic Obstructive Pulmonary Disease CRP C Reactive Protein DXA Dual-energy X-ray absorptiometry FRAX The Fracture Risk Assessment Tool FT3 Free T3 FT4 Free T4 GRE Glomerular Filtration Rate HbAIC Glycosylated Hemoglobin IcD International Classifi cation of Diseases MRI Magnetic Resonance Imaging PTH Parathyroid hormone RCT Randomised Controlled Trial SERM _ Selective Estrogen Receptor Modulators TSH Thyroid-stimulating hormone USFDA —_ US Food and Drug Administration WHO World Health Organization Tiéng Vigt Men gan Men gan Mat 46 xuong Chi sé khdi co thé ‘Bénh phéi tie nghén man tinh Protein C phan img Hap phy tia X ning long kép Céng cy Iuong gid nguy co gay xuong Mite Igc clu thn Dudng gin vao Hemoglobin cia hdng clu Phan loai bénh quéc té COng hudng tir Hormon tuyén fin giép ‘Thi nghiém ngdu nhién 06 a6i ching Chat digu hoa thy thé Estrogen chon loc Hormon kich thich gidp Co quan quan ly thudc va thye pham My Té chite ¥ 16 thé gigiHUONG DAN CHAN DOAN, DIEU TRI VA DY! PHONG LOANG XUONG (Ban hanh kém theo Quyét dinh sd 1983/QD-SYT, ngay 01/10/2013, duge edp nhdt va bé xung ngay 10/8/2019 DINH NGHIA VA CAC KHAINIEM CHUNG Lofing xuong 1a mét rdi loan chuyén hod cia bo xuong gay tn thuong stte manh cla xuong dura dén ting nguy co gly xuong. Site manh cia xuong bao gdm sir toan ven ca vé khdi hrong va chit twong cia xuong. Gay xwong la hé qua ofa loang xuong ma lodng xuong 1a hé qua cia tinh trang suy giim site manh cla xuong trong 46 khdi luyng xwong bj gidm sit va chit long xuong bj hu hai ~ Khdi wong xuong hay mét 46 khodng chit ctia xuong (Bone Mineral Density ~ BMD) 6 thé do ludng duge, hign dang doe sit dung dé chdn dodn Lodng xwong, — Chit rong xuong 1a t&ng hop nhiing yéu t6 lién quan dén cu tric cia xuong, qui trinh chu chuyén (bone remodeling) ciia chit khodng trong xuong, d6 khodng héa (degree of mineralization), dc diém chét nén va chat Khodng cia xuong (collagen/mineral matrix)... hién chia o6 bign phdp Khé thi ndo 6 thé do huang. Loding xuong thirong gip nhdt 14 thé loding xwong tign phat & phy nt sau man kinh va ngudi 16n tudi & cd nam va nt. Loaing xurong cfing c6 thé thir phat do nhigu bénh ly hoe do sit dung céc thude khée nhau, dc bigt 1a do sit dung glucocorticoid kéo dai. Lofing xuong voi hu qua giy xuong c6 thé gly dau dén, thay di hinh thé, tan phé, ‘thim chi tir vong 1 mOt génh nang Ién cho ngudi bénh va cho cd cong ding, — Gay xuong do lofing xuong 1a vin d& site khde cong dng quan trong trén thé gidi vi xudt 49 kha cao va gay tan phé, gidm chét lung séng, ting nguy co tit vong va ting déng ké chi phi y té, Tét ed cée gay xwong quan trong déu c6 Hién quan dén ting nguy co tik vong, nhdt a gay xuong ving héng va gay d&t séng (ké od o6 va Khong o6 trigu chiing lam sing). Trén 20% trudng hop gy xuong ving hong ti Vong trong nim dau tién, 20% edn duge chim s6c Iéu dai va 30% Khong thé tro {ai lim cOng vige trude Kkhi gay xuong. Sau gay xong, ngudi bénh luén ¢6 nguy co ti gly xuong néu khéng 06 cde bign phap digu tr tfch exe. ~ Xuit 46 cia long xurong, + Trong lita tubi tir 50 — 70: 19,6 % phy nit va 3,1 % nam giéi bj mic bénh Jong xuong (Ne = 5 lin Nam) + Cdn 6 tudi trén 70 tudi: 58,8 % phy nit va 19,6% nam gidi bi mic bénh Jofing xuong (Nt = 3 tn Nam), Nhu vay cang nhidu tudi ty 18 mc bénh & ‘Nam va Nit cang gin nhau + MOt sé nghién citu tai Viét Nam fing dura ra con sé tuong ty. + Use tinh, toan thé gi6i hign o6 t6i trén 200,000,000 ngudi bi loang xuong, 70% 1a phy nf va con s6 nay 6 Vigt Nam khodng 3.500.000 (2018)— Lofing xttong gy gin 9.000.000 trudng hop g”y xuong hang nim (mdi 3 gidy sé 6 mét case gly xong). Chi phi hing nim dinh cho didu tri gay xuong va cic di ching cia gay xuong & Hoa Ky hign nay Ia trén 20 ti USD, trong vong 50 nim t6i, chi phi nay s8 vugt qua con sé 240 USD. ~ Lofing xwong va hju qua giy xwong do loing xuong cling dang tré thanh ganh ning rit 16n cho site khde cng ding tai céc qudc gia chau A vi dan s6 dong (chiém 3/4 dan s6 thé giéi), thu nhgp, mite séng thdp, ti 1¢ dan sé gid gia ting va téc d6 46 thi hoa cting dang gia ting ~ Gly xarong ving héng (bao gdm giy ob xuong dui, gay lién méu chuyén, ety duéi méu chuyén) 14 hau qua nghiém trong nhét cia lofing xuong, do gay nén nhiéu bién chimg khéc nhur dau dén, tan phé va tir vong, Céc s6 ligu hign o6 cho thy tl 1¢ méi giy du trén xuong dti & cdc quéc gia Chiu A bling khoang mét nifa ti 1 méi gay ghi nhin duge 6 Hoa Ky hofe chu Ue. Ti 18 méi gay ting cao hit & cae ving d6 thj va 6 cde quéc gia chau A phat trién nh Hong Kong, Dai Loan, Singapore. Dy kién dén 2050, khoaing 51% céc trudng hgp gay xuong ving hGng trén toan thé gidi sé tp trung 6 Chau A ~ Gay xwong abt séng chim 70% cée gay xurong do lofing xwong nhung thudng, Khong c6 trigu chimg r6 rang nén thudng khong duge phat hign va didu tr kip thoi. M@t s6 nghién otru 6 chau A va Vigt Nam cho thiy ty 16 gay xuong dét sng cia phu nt chau A la 15 - 30%, cao hon cée quéc gia chau Au (12 - 25%) ‘Theo bang phn loai quéc té vé bénh tt ICD 10: ~ Loing xwong khéng c6 gay xuongo6 mi sé: M81 — Loing xwong cé gy xuong (hay loaing xuong nding) c6 ma s6 : M80 Tuy nhién, Loding xuong lai 1a bénh chwa durge quan tém ding mite vi dign tién am. thim, ngudi bénh thudng Khong 06 trigu ching co nang gi 16 ring nén khong biét minh bj bénh cho d&n khi bj gay xuong, dic biét gay xuong ddt séng. Dé vige chin Gan, didu tr] va dy phong loting xtong va gay xuong c6 higu qua trade hét di hoi ning cao nhgn thite v8 bénh long xuong cho céc thy thude im sting thuge nhiéu chuyén khoa khéc nhau, cing nhu edn thiét phai xay dung nhting huéng din va tiéu chi chung trong vigc chin dodn, diu tri, dy phong loaing xuong va gay xuong, quan ly gay xuong... cho tét cd nhting thay thude tham gia vio viéc cham séc didu trj cfc bénh nhin lofing xuong va 6 nguy co loting xurong,PHAN 1, CHAN DOAN VA TAM SOAT LOANG XUONG I. CAC NGUYEN TAC CHUNG 1. Tém soft ede yéu t8 nguy co trén lim sang qua théim khdm va hdi tién st, dic biét tién sit gay xuong cita ngudi bénh va gia dinh 2 Thim Khim d8 phét hign céo déu higu o6 thé e6 cia lofing xuong va cée nguyén nhin gay lodng xuong this phat, trong 46 nén bao gdm vige do chigu cao dinh ky 48 xée dinh sy thay di chidu cao va quan sat hinh dang bénh nhan 4 phat hign gi o6t sing. . Chi dinh mét s6 xét nghiém va thim do a8 chén dodn lo&ng xuong va phat hién ce yéu té nguyen nhdn gép phén gay mit xuomg: a. Do mét do khodng xwong (BMD), tt nhft la bing phurong phap DXA. b. Xem xét chi dinh mgt s6 xét nghiém co ban can thiét 4. Lurong gid nguy co gly xuong 10 nim d6i véi gay cb xwong dai va cde gy xuong {én khée dura vao m6 hinh tién don gay xuong FRAX cia WHO hofe m6 hinh cua vign GARVAN, Ue. . Chin dodn xée dinh loang xwong dia vio: a. Bo BMD (phuong phép DXA) tei vj trl trung tim (cOt séng thét tung va cd xuong di) va sir dung tiéu chudin cia WHO (2001) b. Trén lam séng, ¢6 thé chin dodn loang xwong khi bénh nin 6 céc yéu t6 neuy cg va of bing ching cia gy xvong sau chin thuong nhg (trong dé 6 gay lin dbt séng), két hop véi viee ‘ogi trit cdc bénh ly gay hily xuong hoke ‘ofing xong thit phét (nhur cudng edn gidp trang, dau tiy xuong, v.v.), IL DANH GIA CAC YEU T6 NGUY CO Loding xurong 1a mot bgnh ly chiu Anh hung cia rét nhigu yéu t6 vi vay tht A phy ni sau min kinh va nam giéi trén 50 tudi cn duoc dinh gid nguy co loang xwong, Céo yéu t6 nguy co kim sting dé luong gid kha nang gay xuong gm: |. Suy giim m§t 4 sawong 1a yéu 18 nguy oo quan trong nhét, Rét nhieu nghién citu & newdi Au chdu va A chau cho thay ctr mi d6 Iéch chudn (twong duong voi 0.12 s/em2) giém mét dO xuong 6 8 xuong dit lam ting nguy co Bly xuong gip 2 Hn, Lofing xuong duge dinh nghia tir sy suy gidm mat a9 xuong, Do 6, mot chin doin loang xwong cing chinh la yéu t8 nguy co quan trong nhat otia gly xuong, . Cao tudi: Phy nt sau man kinh va nam sau 50 tudi c6 nguy co géy xuong gia ting so ‘V6i nhting c4 nhiin duéi 50 tudi. Tudi cdng cao, nguy co gay xwong cing ting, Cir 10 tudi 1A tuong duong véi 2.2 tin tang nguy co gay xvong. Khodng 50% phy nt gay c& xuong dii c6 tudi 70 rd len, Gi6i tinh: ntt 06 nguy co gay xong cao hon nam. Khodng 2/3 ca gly xuong xy rao nit gidi, x4, Trong lugng co thé thép: nhéing cé nhén c6 chi s6 kh6i co thé (body mass index - BMI) < 18.5 kg/m? o6 nguy co gay xwong ting 1.8 Ian so voi nhiing ngudi cé BMI cao hon 18.5. 5. Ding glucocorticoid duéng uéng voi liu lugng > Smeg predisone/ngiy hoxe ché phim tong duong > 3 théng lA mot yéu 16 gay xuong, dic biét ld xurong dét séng. . Hat thude (tien sit hod hin tai) . Udng nhidu ragu, bia > 3 don vj rugu/ ngay (1 don vj regu = 40 mi rugu manh hode 150 ml rugu vang ho¥e 300 ~ 350 ml bia). . Té nga va yu co 1A mot trong nhting yéu t6 nguy eo gay xwong quan trong, Khoang 90% ca gay oé xurong di 14 do té nga, Nguoi throng bj té nga cing cé nguy co cao. Nghién citu & ngudi A chau cho thiy ngudi té ng 0 nguy co gay xwong cao gap 4 ln so véi ngudi khdng té ng. Khi khém lm sing, cln cht ¥ hdi dén céc yéu t6 8 gfy té nga nhu cdc bénh ly ching mic (Yéu co, dau khép, thi lye kém, bénh ly hé than kkinh (mét thing bing, parkinson...), ha huyét ap tur thé, ha dudng huyét...), thidu thié bj hd tro trong phong tim, san nha tron trot, khong di anh séng, chuong ngai vat trén sin, cita ra vao dé vip nga. . Titn sit gia dinh c6 cha me bj gdy xuong ving hong hoe ban thin bi giy xuong sau tudi 50 14 mét trong nhting yéu Af nguy co quan trong, vi ngudi cé tien sit gily xuong 6 nguy co gly xuong Lan thit hai rit cao (ting 2-3 lan so véi ngudi khéng cé tién sit), Bénh nhan c6 tién sit gay xwong cé thé c6 chi djnh cho digu tri dé giam nguy co gay xuong dn thir hai, ao 2 10, Thiéu canxi: Newdi c6 ligu Inong canxi cung edp tir the phim <400 mg/ngay 6 nguy co gdy xuong ting gip 3 lan so voi nhting ngudi ob Iuong canxi hép thu tir the phim trén 400 mg/ngay. HL Nhing nguyén nhén thé phét gay lotng xurong: — Céc bénh viém khép hé théng: viém c6t séng dinh khép, vigm khép dang thdp, lupus ban 46 hé théng ~ Thidu ning tuyén sinh dye 6 nam va nit khong duge didu trj ~ Bat dong kéo dai — Ghép tang — Cuong gidp — ai théo dung type 1 ~ Bénh thn man, suy thn — Bénh dudng tiéu héa dic biét hOi ching kém hp thu — Bénh gan man tinh ~ Béah phdi tie nghén man tinh (COPD)II DANH GIA LAM SANG Lofing xvong 1a mOt bénh tién trién thdm Hing, giai doan thiéu xuong thudng . khong c6 trigu chime, Bénh cénh lam sang du tién ca loding xuong thudng la gay xuong. Mun hon 6 thé ¢6 céc bién ching cia giy xuong nhu dau, bién dang xuong va cfc thay d8i dic higu do gay lin d6t sng nhu gidm chidu cao, gi, thay adi thé hinb; gidm suit cdc hoat dong thie thé, ting sy I¢ thud. Trong lo&ing xwong thit phat, bénh nhiin c6 thé ¢6 cde trigu chimg cita bénh ly nen. CAC VI TR GAY XUONG DO LOANG XUONG THUONG GAP lién méu chuyén, gay duéi mau chuyén...) gay 06 xurong dit, gay va gay du diéi xwong quay ~ Ty I§ tir vong 20% trong vong 1 nim dau tién ~ Lam ting nguy co gay xwong trong tuong lai lén 2,5 lain Cot sing, - Vj tri thurong gip nhat cia gy xwong do loling xwong ~ Co thé khéng 4 trigu ching cp tinh ~ 2/3 bénh nhin khong duge phiét hign trén lam sing Xurong ving hong (g6m |= Thudng xudt hign o tudi muon hon so voi ply cot ‘song Diu du6i xuong quay ~ Tubi thudng tré hon so véi gy o6t sng va cd xuong di ~ Thuong [a déu hign dau tién cba loang xuong Ul. VAI TRO CUA CAC THAM DO CAN LAM SANG 1, Cdn Jam mgt s6 xét nghiém co ban cho moi béah nhan loang xuong nhim dénh gi tinh trang bénh, phat hign cc nguyén nhin géy lofng xwong tht phét va gitip chdn dodn phan bigt. Tay bénh canh lam sing, xem xét lam mot sé trong cée xét nghiém sau day cho nhiing bénh nin long xwong chua duge lam xét nghiém trude dé. A. Cac xét nghiém, thim do cin lam thuing quy cho moi bénh nhan Mau | Céng thie méu ~~] Ggiy thiéu mau do kém hp thu, bénh Iy de tinh hoc bénh ly thy xwon, Calei mau (ion a8) a = Clin thigt khi bit dau ding cdc thube chng hy xuong hogc ting ding héa. ~ Logi triy tinh trang ting calci méu trong loing xuong thir phat nhu cudng cfn gidp, bénh de tinh ctia xuong. + Gidm: H6i ching kém hdp thu, thiéu vitamin D Glucose, HbAIC ~ Tim soat dai th4o dudng AST, ALT, albumin |- Chic ning gan Creatinin - Chite ning thin GER = Mite loc chu than that lung hoge digu tri. Do BMD | Phuong phép DXA: |- Xéc dinh chin dodn loang xtong C6 xuong di - Dinh gid nguy oo gay xwong vWihote oft sing |= Theo doi thay déi khéi Iugng xuong do bénh lyB. Cac thitm dd xem xét la im thém khi nghi ngo 06 loding xwong thie phit hoc dé chin dodn phan bigt Mau | Téc 4} mau ling, ]- Bénh ly viém hote bénh gamma don dong (Ga u CRP tly) Phosphatase kiém | "Pang cao: trong bAt dng ko dai, aly xurong mdi, bénh Paget, cfc bénh vé xwong khéic (K di cin) Bign di protein [= Nghingd bénh da u sty Phospho mau = Giim trong bénh nhuyén xuong 25-OH vitaminD ]- DE xéc dinh tinh trang thiéu vitamin D. ~ C6 thé thiéu do khdu phan in hoe bénh dudng tigu héa, gitip chin dodn bénh nhuyén xuong PTH = Tang trong cung cfn gidp tran Cortisol budi sang Estradiol = Dfmh gid chic ning tuyén thugng thin = Nghi ngd thigu ning sinh duc 6 nit Testosterone = Nghi ng thiéu ning sinh due énam ‘TSH, FT, FT4 | Nghingd cudng gidp Nude |Téng phiin tich |- Xét nghiém co ban dinh gid nguyen nhdn thr tidy phat ca lofing xuong Dign di protein |- Khinghi ngd da u tiy xuong_ Calei nigu 24h |= Xéc dinh tinh trang ting ealci nigu - Thdp: pei ¥ thiéu vitamin D, nhuyén xuong, hod kém hp thu do bénh ly ru6t non X quang | Cét sdng (ngye va + Teed gid tej dé wdc tinh mat do xwong. xwong | that lung) hofe vj_|- Chi dinh dé: Khing dinh hode loai trir gay dét tri khac thy thude sng, hodc cde gy xuong khéc; hote dé loai trir 1am sing bénh ly xuong khéc (nhur bénh Paget, K) Cong — | Cotsbng (ngye va | Cé gid tri 48 tinh mat 46 xuong, nhung gid thanh hwéng | thit lung) hoge vj_| cao va khOng ding thutng quy dé dénh gis BMD. tir {ti khée tay thug |- Khi cn, 6 thé chi dinh 42 logi trit cdc bénh ly (MRI) | lém sang khéc gay gay xwong hoje gay dét séng, dic biét 1 céo bénh Iy de tin ‘Sink Xuong + Hiém khi cin thiét thidét ~ C6 thé chi dinh khi nghi ng’ ben ly Ae tinh 2. Cée chi déu (marker) sinh héa eta chu chuyén xong: Cée marker thursng ding: marker hiy xwong (Phosphatase kiém dae higu xuong, N-telopeptide, Hydroxyprotine nigu, Pyridinoline nigu va huyét thanh...), marker tao xuong (Osteocalcin) ~ Vig xét nghiém cde marker chu chuyén xtrong e6 thé cung cdp thém thong tin ign quan dén nguy co gay xuong — Tuy nhién cho t6i hign tai, cha cd sy thing nhdt wong viée sit dung cde xét nghiém nay mét cdch thardng qui trong dénh gid lodng xicong txén thye hinh lam singIv. CAC CHi DINH DO MAT BO XUONG (BMD) © Phy ntr trén 65 tudi va nam gigi trén 70, bat ké c6 yéu t6 nguy co hay khéng * Phy nit sau man kinh va nam gidi tir $0-69 tudi néu c6 cée yéu 15 nguy co loing xuong trén im sing * Phy ntt thi ky tin man kinh néu o6 cée yéu 16 lam ting nguy co gay xuong nhur can ning thép, tién sir gay xuong do chén thuong nhe hoje ding thuéc gay mét xuong © Tit cd nhing ngudi lon cé gly xuong sau tudi 50 + Nhting ngudi truéng thinh c6 bénh If gdy mét xuong nhu viém khop dang thap (VKDT), viém c§t séng dinh khép (VCSDK), hoic ding thudc nhém glucocorticoid > 5 mg/ngay, kéo dai >3 thang * Do BMD dé theo doi két qua diéu trj cho nhting ngudi dang diéu trj lofing xuong V. CAC KY THUAT DO MAT DO XUONG * Khuyén céo do BMD bing phurong php DXA. Day 1A phuong phap t6t nhét dé chin don lofing xwong, tién doin nguy co gay xuong vi theo d0i dap ting digu tri. * Che vj tri do BMD: tét nhat Ia lly gid tri do 6.2 vi tri: ~ Cb xuong didi (bén khong thudn) thudng duge sir dung nhat trong chén don loing xuong ~ Ct séng thét lung (tir TL 1 dén TL 4) - Co thé ldy gid trj do & du dugi 2 xurong cd tay, néu cée vj tif trén khong do dug * Che ky thugt do mat 49 xuong kha nhw DXA ngoai bién (do 6 coding tay, xuong 861, ngén tay) hoje sigu dm dinh luong (do 4 xurong gét) o6 thé o6 gid tri trong sang loc hoe tién rong phin ndo nguy co gay xuong, song khOng e6 gid tri tong chin dodn lodug xwong va theo déi dip ting didu tri. VI. SU’ DUNG TIRU CHUAN CHAN DOAN LOANG XUONG * Tiéu chudin chan dofn lofing xuong theo khuyén céo ota t8 chite y t8 thé gigi (WHO, 1994) dyra vao két qui do BMD bing phuong phip DXA, sit dung chi s6 T-score; chit yu Sp dyng cho phy nit sau miin kinh va nam gi6i trén 50 tudi. Xuong binh thuong T-score > -1 SD Khéi lugng xwong thép (thiéu xuong) __| T-score tr -2.5 én Lofing xwong T-score <-2.5 “| Lofing xuong ning T-score < -2.5 Kem theo gay xwong do xuong yéu * BMD thdp tuong quan véi mite d6 ning cia loding xuong va nguy co gily xuong. BMD gidm 1 d6 léch chudn g. tuong duong vdi gid 10-12% mét 46 xuong, va nguy co gy xuong tng gap khodng 1,5 lan. © Métsé luu y khi dign gidi két qua do BMD:— Tiéu chudn dya trén BMD dua ra khung co ban cho chén dodn loging xuong, tuy nhién, khdng sit dung Jam cin oft duy nbét khi quyét dinh digu tr] ma phai ket hop véi céc yéu t8 lam sing, die bigt 1a danh gid cde nguy co gay xuong, ~ Cn than trong Kkhi so sdnh két qua do BMD 6 cée vj ti xuong khée nhau hoiie hi sit dung cdc ky thugt do BMD khée nhau, cée may do khée nhau, Nén cho bénh nhan do va kiém tra trén cing mét may hote mot loai may ~ Trong thye hanh lam sing, véi cée d6i tong 1a phy no tude man kinh, nam 8i6i <50 tudi va tré em, hod khi ép dung cfc ky thugt do BMD khée thi khong nén ding T-score ma nén sit dung gid trj Z-score. Z-score <-2.0 SD durge coi la giém ih lugng xuong dang ké so véi cing dO tudi va 06 thé durge coi 1a cb loaing xuong. VII. LUQNG GIA NGUY CO GAY XUONG 1, Mé hinh FRAX cia WHO Ce yéu 6 sit dung trong m6 hinh FRAX cita WHO (htp:/howw.shef.ac.ukX/FRAX/index.aspx) Tudi hign tai ‘Viém khép dang thip Giéi Loding xwrong tht phat Tién sit gay xuong do long xuong (bao |BMD cd xuong di (o6 thé ding gdm giy dét sng) két qua do & c6t séng thét hg) Tién sit cha me 66 ely xuong ving hong | Hat thudc lé wong hign tai BMI thip Uéng rugu > 3 don vi/ngay Using glucocorticoid 2 5 mg prednisolon (hol tuong duong)/ngay, > 3 thang 2, M6 hinh cia vign GARVAN Cée yéu t6 sit dung trong mé hinh eta vign GARVAN (hitp:W/garvan.org.au/promotions/bone fracture-risk/caleulator/) Tudi hign tai Gidi Tién sit gay xwong sau tudi 50 Tidn sir té nga trong vong 12 thang trude a} BMD hot gid tr] T-scorePHAN 2. HUONG DAN pIkU TRI I. CAC NGUYEN TAC CHUNG 1. Myce dich didu tr} 1. Gidm nguy co gay xuong 2. Gidm nguy co gay xuong tii dign (néu o6 tién sir gay xuong) 3. Gidm mét xttong 4. Gidim nguy co tit vong lién quan dén gay xuong 2. Quyét dink diéu tr] cln dya trén vige xem xét toan dign ting bénh nhfn cy thé, bao gdm nhting vén 48 chinh sau: a, Danh gid cée yéu t6 nguy co cia lofing xwong (BMD) va gay xuong (FRAX) b. Loi ich va nguy co cta vige didu tr) ©. Chi phi didu tr} d. Mong muén cing nhw sy chap nhan cia ngudi bénh 3. Chién luge didu trj theo myc tigu — Muc tiéu didu tr] s8 duge xéo lép IA chi sé T > - 2,5 (v6i bénh nhin da c6 gly xurong, chi s6 T duge khuyén cdo > ~ 1,5) vi nguy co glly xuong chung trong 10 nam < 10% ~ Vigo do Iuong dya vio do BMD bing phuong phép DXA trung tim (CSTL va xuong ving hong) va dah gid nguy co gy xwong tinh theo mé hinh FRAX. ~ Céc bign php didu tri 06 di bing ching bao gdm: cée bisphosphonates (dudng udng va dudng tinh mach), denosumab, teriparatide .. v6i thoi gian ign tr dit 48 dat duge cdc mye tigu (3 nam tké 1én) Xem xet thoi diém tam nghi thude (Drug holiday), néu c6 thé, tiy thude vao vige at muc tiéu va gidm nguy co gay xuong (néu trén) IL CAC BIEN PHAP pIkU TRI 1. Cac bign phap khéng ding thudc (ludn ludn duge két hop véi thuéc) a. Ché d6 dinh duéng: cung ep day dit canxi; vitamin D © Canxi —. Tat cd céc bénh nhdn loang xuong cin duge cung efp day dit canxi (it nhét 1000 p/n), qua ché 46 dinh dudng (tin dung t6i da ngudn canxi tir thye phém) va uéng thudc bd sung, néu cin ~ Nhu clu canxi t6i ma tay thuge vao lia tudi va gigi tinh, song nén dim bio i 1000-1200 mg/ngay. Khoing 1000 mg/ngay d6i véi nam gigi 50-70 tudi va khodng 1200 mg/ngay cho nam >70 tudi va nit >50 tudi, - Khdng nén bd sung qué 1500 mg méi ngay. Cé mot sé chting ott Boiy vite bé sung canxi qué mite cin thiét c6 thé Jam ting nguy co nhdi mau co tim, s6i than. Tuy nhién nhiing vin dé nay vin con gy tranh cai,* Vitamin D ~ Dénh gid tinh trang vitamin D dya trén ndng 6 25(OH)D huyét thanh. Cung cp 40 vitamin D 6 dat ndng 46 thich hop trong méu 14 30-60 ng/ml. — Ngudn cung cp vitamin D tir anh nding mat trdi, thie an va cée ché phim bd sung. Néu can b6 sung, o6 thé ding vitamin D2 hoa D3; riéng calcitriol (dain chat chuyén héa cia vitamin D) cht yéu duge sit dung cho bénh nhan bénh thén man hog suy than, NCT. ~ Khuyéa céo nhu clu vitamin D hing ngay trung binh cho ngudi lén > 50 tudi 1A 800-1000 TU/hang nga. Gidi han an toin cho ngudi lén n6i chung 14 2000 1U/hang ngay, — Negwdi lén thiéu vitamin D c6 thé duoc didu trj bing 50.000 TU vitamin D2 hole vitamin D3 méi tuin mot lin hoe liéu hang ngay twong dong (6.000 TU vitamin D2 hoc vitamin D3) trong 8-12 tuan cho t6i khi dat duge ndng 46 25(OF)D huyét thanh 30 ng/ml sau 46 duy tri 1500-2000 TU vitamin D hang ngay ~ Luu ¥ nhting ngudi ¢6 nguy co cao thiéu vitamin D: Hoi ching kém hip thu (bénh IY dudng rudt), benh than man, béo phi, ngudi gid yéu it tiép xiie V6i dnh ning, sit dung thudc anh huéng dén qué trinh chuyén héa vitamin D, lida cao hon ©6 thé cn thidt d8 dat durge n mg 49 25(OH)D 1a 30 ng/ml. b. Duy tri thurong xuyén hogt dng thé Iyc va céc bai tap lam ting ste co ~ Hoat dong thé ine thurong xuyén gitip ting sire khée, gitt cn bing t6t hon lam gidm nguy co té nga va gay xtong ~ Cfo hogt dng thé Iyc 06 ich nhur di b6, chay nhe, thai eye quyén, khiéu va, aerobic, yoga vA cée bai tp thé duc chju ti khée, thy thuge vio 46 tudi va tinh trang site khée. ~ Bénh nhén nén duy tri hoat dng thé tye ft nhét 30 phit/ngay va it nhdt 5 ngay/tuin, ¢. Khuyén céo ngudi bénh thay 481 16i séng: han ché rugu bia, ngung hat thude = Tw vin cho bénh nhan ngung hit thudc. Ngudi nghién thuée I c6 xu huéng ¢6 cin ning thdp hon, min kinh ty nhién sém hon, c6 thé lam giéng ‘h6a estrogen ngogi sinh nhanh hon lam ting nguy co gay xuong, ~ Khéng nén uéng qué 3 don vj regu m6i ngay (1 don vj‘rugu : rugu manh 40 49 = 40ml, rugu vang = 150 ml, bia = 300m!) The hanh céc bign php phong trénh té ng ~ Khuyén cfo bénh nan dim bio an toan noi 6, noi lam vige (sir dyng tay vin Idi di Iai, bdo dam Anh séng, nén nha khdng tron trugt, sit dung dung oy hé trg di Iai néu edn, ~ Cai thign thi lye, co lye, didu tr] e4e bguh Iy cing mic (thin kinh, xuong khép..), thdn trong khi ding cée thude gay ngi cho NCT. 2, Bign phép ding thude© bi twgng cn duge xem xét didn tr) Phy nt sau min kinh va nam gidi > 50 tubi: Khuyén cdo ding thude digu tr] lofing xuong khi c6 mét trong céc tinh trang sau day: ~ Gay dét séng hoge ob xuong bi (khong bit bude phai dim bio tigu chudn ve gid trj cla T-score) — T-score < -2.5 (do 06 xwong diti hoe ¢6t sng, sau khi loai trir cd nguyén han thir phat) ~ T-score trong khodng tit-1.0 dén > - 2.5, nhung c6 nguy co gly xuong cao (nguy co gy xwong trong 10 nim > 3% vai gay xwong viing hong hoc > 20% véi mét gay xuong quan trong, tinh theo m6 hinh FRAX) * Che thude digu tr] loing xwong va biing ching | MOT SO THUOC PHO BIEN CHO DIRU TRI LOANG XUONG \ Thube Mots6 tén | Nhém thade | Hiigu qua | Higuqua | Higa qua | thuong gidim mit | chéng gay | chéng gay mai xwong (a) | xwong e6t | xwong ngodi | séng (b) CS (b) ‘Alendronate Fosamax | Chéng hiiy xwong | +r A A | Risedronate ‘Actonel ‘Chong hy xuong H A A Tbandronate Boniva | Chong hiiy xwong | __+F A 0 Zoledronic acid | Aclasia, _[ ChSng hiy xuong | + x A Calcitonin Miacalcic, “[ Chénghily xwong | + B 0 Estrogen/Thay thé | Prempro, | Chong hiyy xwong + A A hormone Premphase Raloxifene Evista Ch&ng hiy xuong | ++ A 0 Denosumab Prolia Chong hiiy xwong ++ A A PTH Forteo Tang tq xuong as iN A Strontium ranelate | Protelos ‘Tiing tao xuong. + A A Ghi chit: Chat tong ching cit v8 hibu qua: ) + ting mt dp sarong 35% ++ 5-109, ++ > 10%; (B) A: nghitn ci lam sing ai ching {RCT én, B: chiing cit chia hod todn nhdt quin, 0: chuea cé ching cit a, Nhém Bisphosphonate (BP) ~ Diy la nhém thudc tre ché hay xwong va IA nhém thude thudng duge Iya chon dan tign trong didu tr] loing xuong. ~ Cée ché phim chinh duge chp thudn gdm: + Alendronate 70mg (don thudn hodc két hop véi vitamin D3 2800 hofe S600UI): Burge chdp thudn dé dy phong va digu tr) loaing xuong cho lo&ng xwong sau mén Kinh, loang xvong nam gi6i, loing xuong ngudi cao tudi (NCT), losing xuong do glucocorticoid, + Zoledronic acid: Buge chép thugn cho dy phong va digu trj long xurong sau man Kink, dieu tej loang xuong nam gi6i, loang xuong NCP, dye phong va diéu ‘tilong xtrong do sit dung glucocorticoid kéo dai. Lidu lugng: truyén TM Smg, méi nam mot lan, Thude cai thign sy tuan tha, higu qué cao, gidm nguy co tir vong + Ibandronate: vién 150 mg udng mbi thing hotic 3 mg tiém tinh mech m&i 3 théng. Duge chdp thufin sir dung cho dy phong va didu tr loaing xwong sau min kinh, Risedronate: Ung 35 mg méi tuan, hoje 75 mg hai ngay mi thing hote 150 mg mét lan m@i thing, Duge chap thudn sir dung cho dy phéng va diéu tri loang xuong sau mén kinh. ~ Cfch sit dung ede bisphosphonate dang udng: Using hic déi, vio budi sang véi mot ly nud¢ Ioe (khoding 250 ml). Sau khi udng bénh nhiin khéng duge nim, khong duge tin udng hay ding bat ky thude gi trong it nhat 30 phat. Tée dung phy cho yéu cia cée bisphosphonate dang udng: Ia kich tng dudng tiéu héa nhu viém thye quan, loét da day, nudt khé... ~ Cich sir dung zoledronic acid: Truyén tinh mach (Smg/100 ml), trong it nhét 15, phut. Cha ¥ bd sung day du nude, canxi va vitamin D truéec khi truyén. Co thé ding acetaminophen (paracetamol) dé lim giém céc phan ting phy sau truyén thude (nh dau khép, dau dau, dau co, sét). Dang tiém truyén TM céi thign duge tée dung phy dudng tigu hoa cita dang udng va ting kha ning tufn thi didu tr] - Cée the dung phy hiém gip khac cia nhém bisphosphonate: gdm hogi tit xuong him, gay xuong khéng dién hinh, r6i loan thi lye, rung nhi, tay nhién ty 16 rét thép ~ Chéng chi djnh: phy ntt cé thai va cho con bi, dudi 18 tubi, suy thén véi tie loc ~ + edu thin (GFR) <35 ml/phiit, Cé thé ding céng thite Cockcroft Gault 48 uéc dodn 49 thanh loc (BTL) creatinine tir creatinine huyét thanh. DTL creatinine (mi/ph) = __140 ~ tui x cén ning (kg) 72x creatinine huyét thanh (mg/dl) + b. Calcitonin ~ Calcitonin c& hdi 06 tée dung tte ché hiy xuong va giim dau trong gay xuong do loging xwong (do nhidu co ché tryc tip va gin tiép phdi hop) ~ Thude duge chi dinh ngiin ngay (2 - 4 twin) trong gay xwong (dét sng, xuong ving hong), dau cp, phai niim bat dong voi ligu ding 100-200 TU tiém duréi da m6i ngay ¢. Ligu phap Estrogen/Hormon thay thé ~ Buige chip thugn cho dy phong loang xuong vi didu tej cde tigu ehting ién quan én mmf Kinh (ohur r6i logn vén mach, ki teo &m dao). ~ Hign tai khéng khuyén céo sit dung kéo dai (, 2 nim) dé didu tr) losing xuong do lo ngai nguy co tée dung phy (dic biét 1a huyét kh6i tic mach, ung thu va) c6 thé lén hon so v6i Igi ich didu tri. 4. Chat didu hda thy thé estrogen (SERM): Raloxifene ~ Buge chdp thugn trong dy phong va didu trj loang xttong & phy nff sau man kinh~ Raloxifene lam gidm nguy co ung thu vd xm ln, tuy nhién khéng lim giém nguy co bénh mach vanh va cé thé lam ting nguy co huyét khéi finh mach sau tuong ty hur estrogen. — Liéu tugng: vién 60 mg, uéng 1 vién mbi ngay e. Strontium ranelate ~ Duge chip thudn 4é dieu trj loang xuong 6 mot s6 made chau Au, thuring ding thay Khi 06 chéng chi dinh ding BP, hoge sau khi két thite dot didu tr} véi_ nhém BP. Tuy nhién, thuge dt bj ngung tir 2016 - 2017 vi lam gia ting nguy co huyét khdi, anh huéng xdu t6i tim mach va 06 thé gay phan img dj ting nghiém trong, ~ Co ché tée dung chua 16 ring, duye cho la cé tée dung kép, vita kich thich tao xuong, vita ite ché hily xuong. — Liu lugng va céch ding: Strontium ranelate nén udng vao budi t6i lic da day tréng, t6t nbft la trurée khi di ng, mdi ngay 1 g6i (2g) pha véi nude. — Thudc khong con gidi thigu tai Vigt Nam £ PTH (1-34): Teriparatide ~ Diy 1a thude Kich thich tao xuong. Dugc chp thuan cho didu tri loaing xuong phy ‘tt sau man kinh; loding xuong nam giéi c6 nguy co gly xuong cao; va lofing xuong do glucocorticoid cé nguy co gay xuong cao. ~ Lidu thudng ding 20 j1g mBi ngay; thdi gian téi da 2 nam. Khong ding ding thi VGi bisphosphonate, tuy nhién sau khi ngung teriparatide c6 thé ding tiép bisphosphonate 48 duy tri hoc lam ting thém hiéu qua didu tr, ~ Trénh ding 6 nhting ngudi 6 nguy co ung ther xuong (tien cin K, ‘ting canxi mau, xq tr] trude 46), ~ Thude dang o6 ké hogch gidi thigu tai Viet Nam g- Denosumab (thudc tre ché RANKL) ~ Co ché téc dung thong qua sy the dong 1én hé théng RANK-RANKL-OPG, denosumab la m6t khang thé don dong (monoclonal antibody) tte ché RANKL, duy tri ti s6 t6i um gitta RANKL va OPG, agin cn sy bigt hoa clia té bao hiy xuong. ~ Duge chip thudn cho didu trj losing xwong & phy nft man Kinh, 6 bénh nhan VDT. c6 nguy co géy xuong cao, & bénh nhan loan; xuong 06 GFR <35 ml/phit (chéng chi dinh BP). Thude cfing duge chi dinh dé dién trj cho phy nd bi ung thw va, nam Bi6i dang ding thudc diéu trj ung thu tidn ligt tayén.. c6 nguy oo gay xong cao ~ Lidu ding: 60 mg, tiém dudi da mdi 6 thang, ~ Thude dang 06 ké hogch gisi thigu tai Vigt Nam h, Romosozumab (Khang thé khiing sclerostin) ~ Romosozamab 1 mét khéng thé don ding, khéng Iai sclerosin. Sclerostin Ia mét protein duge bai tiét bdi ofc té bao xuong, gin két voi thy thé LPRS trén mang té bio tao xuong, the ché hoat dng ctia té bao nay.~ Romosozumab kim ting BMD, osteocalcin trén phy nif man kinh, méi duge FDA chap thudn cho didu tri Joaing xuong & phy intr man kinh véi tie dung tang tao xurong Che thude khée: Vitamin K2, mudi fluor, tibolone, hoe m@t s6 bisphosphonate khéc (Ctidronate, pamidronate) cing cé thé durge chi dinh trong dy phong va diéu tr loting xuong trong m6t sé truéng hgp nhdt dink, tuy nhign hign chia duge khuyén cdo r6 ring, IIL. THO! GIAN DIEU TRE ~ Quan diém chung hign nay bénh nhén nén duge didu tr] bing efe bisphosphonate Tien tue tit 3-5 niim (5 nim v6i BP dung udng va 3 nim voi BP during truyén tah mach), sau 46 sé cin nhic trén timg cé nhfin, da vao vige dinh gid mét db xuong (BMD/T-score) va nguy co gly xuong (FRAX) dé quyét dinh s& ngung thude (ogung mot thoi gian nhét dinh hofe ngung hin) hog tip tue ding nhém BP hofe chuyén sang ligu phap didu trj khéc (thurng la Denosumab), ~ Khi xem xét ngung digu tej cdn dae bigt chi ¥ tian sit gly xuong, nguy co tai gay ‘xuong, bénh man tinh cling mic hot thudc sit dung, cing nh kiém tra chiéu cao, mft d) xuong, X quang cét sng lung, nguy co gay xuong... dinh ky hang nim, TV. THEO DOI DIEU TRE Cin khuyén khich bgnh nhén dang didn te loang xuong nén ding thuée thich hop va lién tue, cha ¥ tun thi didu trj 48 gidm nguy co gy xuong va gidm tdi gay xuong, Thuong xuyén dénh gid lai céc yéu t6 nguy co va dong vién bénh nhan bé sung diy di calcium, Vitamin D, thudng xuyén van déng, trénh té nga va thay ddi 16i séng. 1. Lam sing ~ Thim khém, dénh gid bénh nbén sau 3-6 thing didu tr), sau dé ft nhdt mi nim 1 Hn. C6 thé thaim khém throng xuyén hon tiy thuée vao bénh ly ni khoa di kom, Khi tdi khém can dénh gid Iai cde yéu 16 nguy co; do chiéu cao hang nim; néu gidm> 2cm, nén cho chyp Xquang c6t sing dé phat hi gily xuong dét séng m ~ Can chi ¥ dén viée tuan thi didu ‘rj (sy tudn tha didu tri cé thd chi dat khoan, 50% sau 1 nim), do 46 cin khuyén céo ngudi bénh ding thuéc thudng xuyén, 2, Dinh gid dap ding didu trj bing do BMD ~ Cdn do mét 49 xuong dink ky trong qué trinh diéu tr] loaing xuong. Véi da sé bnh nhan chi cn do 2 nam mét ln, Trong mot $6 tudng hop oy thé (khi nguy co mit xuong cao, sir dung glucocorticoid kéo dai} khoing-cact a c6 thd ngin hon (méi 6 thang d&n 1 nim), ~ MOt sd luwy khi dign giai sy thay déi BMD trong theo doi higu qua didu tr]: + Khé 06 thé so sénh két qua gitta cdc tan do néu ding céc ky thudt khée nhau hoje sir dung cfc may do khée nhau. + Do c6 sy sai s6 gitta 2 tin do, cho nén chi khi 6 thay 45i BMD trén 4 - 5% (Phuong phép DXA) méi duge coi li c6 ¥ nghia v8 mat lam sang+ Gidm BMD cé thé do bénh nhfn khéng tuan thi diéu tr} hote ding thudc Kh6ng ding céch (sy hdp thu BP kém néu ding trong hodc sau bita &n) + Gitim BMD 6 bénh nhan tuén thi didu trj cho thdy néu khéng didu tri nguy co mit xutong sé cdn cao hon 3. Vai tré ciia ede marker chu chuyén xnong ~ Cé thé lam céc xét nghiém marker chu chuyén xuong (nhu phosphatase kiém dic higu xuong, osteocalcin, telopeptide) nhim dénh gid s6m dap ting digu tr. Nhting thay di goi y sy gidm chu chuyén xuong c6 thé thay sau 3-6 thang didu tri. ~ Han ché: Kha ning cho két qué lip lai tuomg 6i thdp, khong ngung hode thay 46i digu tri chi dya don thudn vao nhiing thay d6i bét thong ctia cdc markers nay. PHAN 3, HUONG DAN PHONG BENH Lofing xuong ld hiém hoa véi stte khée cing déng, nhung ¢6 thé phong ngita duge. Phong ngita dé trénh bj bgnh va phong tranh cdc bign 6 gay xuong. Phong lofing xuong 1a mét qué trinh cAn duge thyc hién ban bi suét cude ddi, luén két hop chat che gitta van dng va dinh duéng dé 06 khéi Iuong xwong dinh cao nhét Iie truéng thanh, Néu kidi hngng xuong dink ting duoc 10%, s@ gidm dupe 50% neuy co gdy xwong do loting axuong trong subt cube déi, Mue dich cia dy phong lofing xwong JA phat trién va duy tri khdi Iugng xuong tdt nhat cho moi ngurdi, gidm nguy co lofing xuong va gly xuong bling cach can thi¢p vao cf yéu t5 nguy co gay mat xuong va gay xuong, 2. Ti wu héa site khée xuong la c6ng vige edn duge quan tim sudt cue ddi mBi ngudi 3. Khuyén efo cho moi bénh nbn trong cdc lan khéim bénh thudng ky: ~ Cf yéu té nguy co ciia loang xurong va cde bign php phong ngtra co ban ~ Do chiéu cao dinh ky déu din ~ Khém ghi nhén gi veo c6t séng néu ob Cc bign phap phong ngita tién phat 1A mot phan cia didu tr] loaing xtong 4. Gido due bénh nhin va nang cao nhdn thite vé béah lofing xuong b. Khuyén cdo cfc bign phap dyr phong Loting xuong thich hop cho ting lira tudi: . Ché do dinh dutmg: cung edp dy dit canxi, vitamin D theo nhu edu ciia tiing Ita tudi © Canxi s wo — Nhu cdu canxi t6i wu tay thude vao Ita tudi va gsi tinh, song nén dam bao di. 1000-1200 mg/ngay. Khodng 1000 mg/ngay 4éi vei nam gidi 50-70 tudi va Khoang 1200 me/ngay cho nam >70 tudi va no >30 tudi, — Ngudn canxi: thye phdm (cée thite n, 43 udng gidu canxi dic biét 1a sta va cdc sin phdm ché bién tir ste), duge phim chita canxi sé edn thiét néu ché 3 dinh dudng khéng cung cp day du (it nhét 1000 mg/ngay) * Vitamin D~ Ngudn cung cp vitamin D tir énh nding mit trdi Ja quan trong nhat, ngdai ra tite an va cde ché phém vitamin D 6 thé ding bd sung, ~ Khuyén céo nhu cAu trung binh vitamin D hang ngay cho ngudi 1én > 50 tudi 1a 800-1000 TU/hang ngay. Giéi han an toan cho ngudi lén néi chung 1a 2000 TU/hang ngay, ~ Lam ¥ nhting ngudi o6 nguy co cao thiéu vitamin D: Hi ching kém hdp thu (bénh 1y dudmg rugt), bénh thgn man, béo phi, ngwoi gia yéu it tip xtc voi anh ning, sit dung thudc anh hung dén qué trinh chuyén héa vitamin D, 1idu cao hon c6 thé cn thiét dé dat due ndng 46 25(OH)D 30 ng/ml, 6. Duy te thuromg xuyén hogt dng thé luc va cdc bai tap lam ting stte co ~ Hoat dng thé tye thong xuyén gitip ting site khde xurong khép va co, gitip gilt cin bang t6t hom lém giém nguy co té nga va gay xuong ~ Cée hoat déng thé yc 06 ich nhu di b6, chay ihe, théi eye quyén, khiéu vi, aerobic, yoga va cdc bai tfp thé dye chju tai khic, ty thude vao 46 tudi va tinh, trang site khde. ~ Moi ngudi nén duy tri hogt dng thé lye thudng xuyén, it nhdt 30 phiit/mdi ngay va it nhét 5 ngay/tuan. 7. Khuyén cio ngudi bénh thay 44i 16i sng: ngung hit thud, han ché rugu, bia ~ Tu vin cho moi ngudi ngung thude 1a. Neudi hit thude 14 thudng ¢6 can ning thép hon, man kinh ty nhién sém hon, cé thé lam gidng héa estrogen ngoai sinh nhanh hon lam ting nguy co gty xwong. — Khong uéng qué 3 don vj rugu mdi ngay 8. Thyc hanh cdc bign php phong trénh té nga ~ Khuyén efo bénh nhén dim bjo an todn noi 6, noi lam vige (sir dyng tay vin 16i di Iai, bao dam anh séng, nén nha khdng tron trot, str dung dung cy hé tro di Igi néu can, ~ Bidu tj ce bénh cing mie: benh hg xwong khdp, hg than kinh, bénh chuyén ‘6a, bénh nGi khoa... ~ Cai thign thj Ivo, co Ie, chite ning thin kinh — co, thn trong khi ding ede thude gay ngu cho NCT 9. Chit ¥ eée bién phép dyr phong sém va higu qui cho nhting bénh nhan 6 nguy co lofing xuong cao, nguy co gay xuong cao. ,V6i céc bénh nhan da bj gay xuong, cin duge digu tri, theo doi va quan ly mot edch]hé théng (theo m6 hinh Fracture Liaison Service di duge tridn khai va hogt dong hifu qué é nhidu quéc gia va Chau lye) 48 phong ngiva gay tai phét. HGi Loang xuong TP HCM sé lim ddu méi 48 sém trién Khai va xy dyng md hinh nay tai Viét Nam RD.REFERENCES 1 Black DM, Rosen CJ. Clinical practice. Postmenopausal osteoporosis. N Engl J Med. 2016;374:254-62. 2 Black DM, Kelly MP, Genant HK, et al,; Fracture Intervention Trial Steering Committee; HORIZON Pivotal Fracture Trial Steering Committee. Bisphosphonates and fractures of the subtrochanterie or diaphyseal femur. N Engl J Med. 2010;362:1761-71. 3 Compston J, Cooper A et all. The National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of ‘osteoporosis 2017 4 Cosman F, De Beur SJ, Le Boff MS et al. National Osteopososis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Whashington DC 2014 5 Chang Y, Huang C, Hwang J, Kuo J, Lin K, Huang H, et al. Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review. Osteoporos Int 2017 Dec 28. Ching-Lung Cheung, Seng Bin Ang. An updated hip fracture projection in Asia: The Asian Federation of Osteoporosis Societies study. Osteoporosis and Sarcopenia 4 (2018) 16-21 Kanis JA, Cooper C, Rizzoli R, Reginster JY. Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) and the Committees of Scientific Advisors and National Societies of the Intemational Osteoporosis Foundation (IF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women, Osteoporos Int, 2019 5an;30(1):3-44, doi: 10,1007/s00198-018-4704-5, Epub 2018 Oct 15. 8 Kolata G. Fearing rare side effects, millions take their chances with osteoporosis. New York Times [Intemet]. 2016 Jun 1 {cited 2016 Jun 22). 9 Kim SC, Kim DH, Mogun H, et al, Impact of the US. Food and Drug Administration’s safety-related announcements on the use of bisphosphonates after hip fracture. J Bone Miner Res. Forthcoming, Epub 2016 Mar 31. DOI: 10.1002/jbmr.2832, 10 Lan HP T, Nguyen DN, Pham NH et all. Reference ranges for bone mineral density and prevalence of osteoporosis in Vietnamese men and women, BMC musculoskeletal disordess 12, 182, 2011 11 Reid IR, Home A, Stewart A et al, Fracture Prevention with Zoledronate in Older ‘Woman with Osteopenia. N England J Med 201 8; 10: 1056 12 Swan Sim Yeap et al. The Asian Federation of Osteoporosis Societies call to action to improve the undertreatment of osteoporosis in Asia. Osteoporosis and Sarcopenia 2 (2017) 1-3 13 Walters $, Khan T, Ong T and Sahota O. Fracture liaison services: improving outcomes for patients with osteoporosis, Clin Interv Aging. 2017; 12: 117-127, oSuonx Av fq ep tou 47 wonb wa (Tora WoT ronSu ¥91q oep) ¥SU 91 NSU Sugyd “(oxi nfy omtp gxp wor oD) up nap otip amp de USANT “f ---qup meur qudq ofo in nerp “Suonx 163 Suony yu ognip ovo Yup} “eIg mons gYO Ue yuip yu doy Sugny gs yur Suon doy toyd ogoy fn NaIP ep ‘Samp gu 90 * sareuoydsoydsiq wou Sunp GD Suoyo soy Sun dep Sug% ontp ny Sandu :09 24098 1 > s7-: dep GN [- Zed00s J, : Sugmyp yg CW ‘Syu Suonmy upgo op (Ae) go uonx ‘mp it uonx 99 “[L$9) Swonx Avs go 19m (vxa dd) Suny 324) Bugs 399 ea (UENY? SuQHy Ueq) Mp Suonx o>. (CIA) Fa0nx Op gu og 09 Z 1988 wea ‘Yury UEM nes nu ya peu voy updngo A nyp dey ofa Upp SuONY Guy ("Ign 1OW ‘nerU dy “voy NON SY) YUN woME yUdd ‘(S'8I > We) dep gmp 00 Bubny Buo2], ~-Bugms $4 op weq sndnry ‘dow qusp Buos 160 war, ‘dem Sup dowy wor, :yun uéUx dowry suony yusq eo OE (Gaem ¢ Z keBu/suojosrupaig Sus < Suonp Suom) rep 094 eploonios Sunc (Buonx Sago] ugp uenb uay Suonx Avs) 19m Og nes Saonx Avs iq Sum Gonz wo fy Yue “dur eyo) UN IB Suonx Avs Ns ULL nes Suén wenb 09 AnBu gi ng z < 99 (tom ¢z <) YOR Suonn tom AU eA WEN 19M 09 < fore weu “yan] uew nes nu Aigg eeriis SNONX DNYOT TL NFIE VA NYOG NYHO LVL WOL OG 00Té sO Y TE THANH PHO HO CHi MINH HUONG DAN CHAN DOAN, DIEU TRI VA Dd PHONG BENH LOANG XUONG 2013 - Luu hanh ngi béUY BAN NHANDAN CONG HOA XA HOI CHU NGHIA VIET NAM. THANH PHO HO CHI MINH Doc lip - Ty do - Hanh phic soy Te Greece ereeae cere erPPaeeaeEE 86: 1983 igp-syT TP. H8 Chi Minh, ngdy Ol.théng fOncim 2013 QUYET DINH Vé vige Ban hank “Hwéng dan chin dodn, diéu tri va dw phong lodng ston”, GIAM DOC SG Y TE THANH PHO HO CHi MINH Can tt Quyét dinh sé 25/2009/QD-UBND ngay 27/3/2009 cia Uy ban nhan dan Thanh phé vé ban hanh Quy ché t8 chit va hoat d6ng ca Sd Y té Thanh phd; Can ctr Quyét dink sé 889/QD-SYT ngay 17/6/2013 cia Giém déc Sé ¥ 16 thanh phé H8 Chi Minh vé viée thanh lap H6i ding chuyén mén cia So Yt xem xét xdy dying phéc 4d chin dodn va diéu tri lofing xuong cla Nganh Y té thinh phb; Cin off két qua Bién ban hop H6i déng chuyén mén So ¥ té; Xét dé nghj cta Phong Nghigp vu Y- So ¥ 16. QUYET DINH itu 1; Nay Quyét dinh Ban hanh “Huéng din chin dodn, didu tri va dy phong « loting xttong” (Anh kém). Bidu 2. Tai ligu chuyén mOn “Hudng din chdn dodn, didu tri va dy phon long xuong” nay 4p dung cho céc co sé khém bénh, chita bénh thudc thanh phd 8 Chi Minh 06 4 diéu kign thyo hign theo quy dinh hign hanb, 1a clin cit phép ly cho vigo thye hign k¥ thu@t, phét trién chuyén m6n kj thugt, righién ctu khoa hoc, chuyén tuyén, thanh todn vign phf va bao hiém y té. Didu 3. Quyét dinh nay od higu lye ké tir ngay ky. C4c Ong, Ba: Chénh van phong Sé, Truéng/Phé céc phing chite ning thudc Sé, Chénh Thanh tra Sa, Giém déc cée co sé khém bénh, chtta bénh truc thuje Thanh ph6 chju trach nhigm thi hanh Quyét dink, may 9 Noi nhgn: Nhu didu 3; ~ Ban Giém abc $6; - Luu'Vin phang 86. “NHN, THH, 5b” Neguyén Tan BinhLOLTVA Loang xvong va hau qua cia nd 1a van dé lon trong y hoc hign nay, lofing xuong lién quan dén sur gia ting tudi tho trén thé gidi cting nhu 6 Viét Nam, dic biét ld phy nd sau man kioh, Trong thyc hanh lm sang, ching ta thudng phai 6i pho voi hau qua nang né cla loang xwong/giy xuong gay ra: \ ¢ Gay xuong do lo&ng xwong va cde bién chitng lién quan © Dau dén cita ngudi bénh © Tan phé va tang ti 1é tir vong. © Chi phi didu trj cao, ting ganh ning cho gia dinh va xf hi © Chat lugng cugc séng cia ngudi bénh gidm trim trong Loang xvong la mét bénh cé thé tim soat, dy phong va didu tri higu qua, it tn kém hon nhiéu so v6i hau qua cha né gay ra. Dé dap ting duoc tiéu chi trén, So Y té inh phé H6 Chi Minh ra quyét dinh than lap Hi ddng chuyén mén théng qua “Hung din chan doén, didu tr] va-dy phdng bénh lofing xuong” duge soan thio béi cdc chuyén gia hang ddu vé khép va lo’ing xuong tai Thanh phd Hé Chi Minh, cp nhét nhiing kién thite méi nhét lién quan dén bénh ly lofing xuong trén thé giéi cfing nhu khu vye Chau A. Ching tai hy vong “Huéng dan chan dodn, digu trj va dy phong bénh lofing xong” sé cung cp cho céc thay thuéc lim sing nhimg théng tin bd ich trong viée chim séc va ign trj benh nhan. ‘Trong qué trinh bién soan khéng tranh khoi nhiing thiéu s6t, mong nhan duge cée gop ¥ tir Quy déng nghiép, dé lan tai ban sau hoan chinh hon. Xin chan thanh cam on. Thanh phd Hé Ch{ Minh, thang 10 nim 2013 ‘TM. Ban bién soan _ Gua PGS. TS. Hoang Quéc Hoa Gidm Déc Ben vign Nhan dan Gla DinhBAN BIEN SOAN Chai nhigm: PGS.TS. Hoang Quéc Hoa Giam Déc Bénh vign Nhan dan Gia Dinh Ph6 Chi nhigm: PGS.TS. Lé Anh Thr Chi tich Hi Loding Xuong thanh phd Hé Chi Minh Thu ky: BS.CKI. Trin Huy Hoang Chuyén vién Phong Nghiép Vu Y- So ¥ 18 Tham gia bién sogn: BS. CKIL. Thai Thi H&ng Anh ‘Trténg khoa Co xuong khép - Bénh vién Neuyén Tri Phuong TS.BS. Nguyén Dinh Khoa ‘Trudéng khoa Co xuong khép — Bénh vién Cho Ray ‘ThS.BS. Hé Pham Thue Lan ‘Truéng khoa Xuong khép ~ Bénh vign Nbfn dan 115 TS.BS. Nguyén Thi Thu Thao ‘Truéng khoa NGi tiét — Bénh vign Nhéin dan Gia Dinh BS.CKI Phan Quang Tri Ph6 Giém Déc Bénh vién Chan thong Chinh hinhSé¥T8 Thanh phé Hé Chi Mink Chir viét tit Tiéng Anh ALT AST BMD BMI COPD CRP DXA FRAX FT3 FT4 GRE HbAIC IcD MRI PTH RCT SERM TSH US. FDA. WHO CAC CHU VIET TAT ‘Tiéng Vit Alanine Transaminase Aspartate Transaminase Bone Mineral Density Body Mass Index Chronic Obstructive Pulmonary Disease C Reactive Protein Dual-energy X-ray absorptiometry The Fracture Risk Assessment Toot Free T3 Free T4 Glomerular Filtration Rate Glycosylated Hemoglobin International Classification of Diseases Magnetic Resonance Imaging Parathyroid hormone Randomised Controlled Trial Selective Estrogen Receptor Modulators Thyroid-stimulating hormone US, Food and Drug Administration World Health Organization Mit d6 xuong Chi s6 khdi co thé Bénh phdi the nghén man tinh Hép phy tia X nang hrong kép (Céng oy lugng gid nguy oo gly xuong Téc 46 loc clu than Dudng gin vao Hemoglobin cia hong clu Phan loai bénh quéc té COng hurdng tir Héc-mén cn gid ‘Thir nghigm ngdu nhién o6 chimg Chat didu ha thy thé Estrogen chon Ige Héc-mén kich thich gidp Co quan quan ly thude va thyc phim Hoa Ky Té chite Y té thé gidi “Hing din chdn don, didu tri vi de phing buh Lofing KwongSOY TE Thinh pho HO Chi Mink MUCLUC Léi tya Ban bién soan Cée chit vide tit DINH NGHIA VA CAC KHAI NIEM CHUN PHAN 1, CHAN BOAN VA TAM SOAT LOANG XUONG. 1 I til, NM Vv. vi. Vil vill PHAN 2: HUONG DAN DIRU TRI .... IL, tt. N PHAN 3: HUONG DAN PHONG BENH. ‘TAL LICU THAM KBA¢ Céc nguyén tie chung sess Danh gid cdc yéu t6 nguy co. anh gid lam sing... ‘Vai tr ola cdc thm dd cfn lam siny Cie chi dink do mgt 46 xuong.. Clic ky thugt do mat d6 xuong... Sir dung tiéu chudn chin don long xutong..... Lugng gid nguy co gly xuong. 1. Mé hinh FRAX cia WHO. 2. M6 hinh cia vign GARVAN. Cc nguyén tie chung... 1, Myc dich didn tri. 2. Quyét dinh digu tri Cée bign phap diéu 1. Cae bign phép khéng ding thude. 2. Bign phap ding thuéc.. Thai gian dieu tr) 18 Theo doi didu tr. 18 1. Lam san 18 2. Banh gia dap img didu tr] bang do BMD.......0...« 3. Vai tr ola ec marker chu chuyén xuong...... Huéng dan chdn dodn, didu tri va dy phong bénh Loding XvongSOY TE Thin phd HB Chi Min HUONG DAN CHAN DOAN, DIEU TRI VA DU’ PHONG BENH LOANG XUONG (Ban hanh theo Quyét dink s6:1983/QD-SYT, ngdy 01/10/2013) DINH NGHIA VA CAC KHAI NIEM CHUNG Lofng xuong 14 mét réi loan chuyén héa cia bO xuong gay ton thuong ste manh cita xuong dura dén ting nguy co gay xuong. Site manh cia xvong bao gém su toan ven cd vé khdi lwong va chat hrong cia xuong. Gay xvong la hé qué ota long xong ma loding xuong la hé qué ca tinh trang suy giam strc manh cla xwong trong dé khéi long xuong bj gidm sut va chat long xuong bi hu hai. © Khéi hrong xuong hay mat 49 khodng chdt ctia xwong (Bone Mineral Density - BMD) cé thé do lung duge, hién dang dvoe sit dung dé chin dodn lodng xuong © Chat lugng xuong [a ting hop nhting yéu td lign quan dén céu tric cia xwong, qui trinh chu chuyén (bone remodeling) cia cht khodng trong xuong, 49 khodng hoa (degree of mineralization), dic diém chat nén va chat khodng cia xuong (collagen/ mineral matrix)... hién chica cd bién phép khd thi ndo c6 thé do luong. Loang xuong thirdng gap nhat la thé loding xuong tién phat & phy nit sau main kinh va ngudi 16n tudi 6 ca nam va nit, Lofing xuong cfing cé thé thir phat do nhidu bénh ly ho&e do sir dung cdc thuéc khde nhau, dae biét la do sir dung glucocorticoid kéo dai. Lofing xuong voi hau qua gay xvong cé thé gay dau dén, thay di hinh thé, tan phé, tham chi tir vong ld mt génh nang lén cho ngwdi bénh va cho ca céng déng. © Gay xuong do lofing xuong 1a vin dé site khde cng déng quan trong trén thé gidi vi xuft 46 khé cao va gay tan phé, gidm chit Iuong séng, ting nguy co ti vong va ting dang ké chi phi y té. TAt ca cdc gay xwong quan trong déu cé lién quan dén tang nguy co ty vong, nhét 1a gay xuong ving héng va gay dét séng (ké ca c6 va kh6ng c6 trigu ching lam séng). Trén 20% trudng hop gay xuong ving hong tit vong trong nim dau tién, 20% clin duge chim sc lau dai va 30% khéng thé tré lai lam cong vige trade khi gay xwong. Sau giy xwong, nguoi bénh fu6n c6 nguy co thi giy xvong néu khéng 06 cdc bién phép didu tri tich ove. © - Xult 6 ota loting xuong. + Trong lita tudi ti 50 - 70 : 19,6 % phy nit va 3,1 % nam gidi bi mac bénh -Hwéng dén chin déén, diéu tr] va dy phong bénh Lodng Xiong @96 T8 Thanh phd HO Chi Minh long xurong (Nt = 5 lin Nam) + Con 6 tudi trén 70 tudi : 58,8 % phy nit va 19,6% nam gidi bj mac bénh lofing xuong (Nit = 3 kin Nam). Nhu vay cang nhidu tudi ty 16 mae bénh & Nam va Nit cang gin nhau, + Mét s6 nghién citu tai Vigt Nam ciing dura ra con sé tuong tyr. ++ Usée tinh, nam 2010, toan thé gidi c6 t6i trén 200,000.00 ngudi bj joang xurong va con sé nay & Vigt Nam khodng 2,800,000 ngudi. © Chi phi hang nam danh cho digu tri gay xuong va céc di ching cia gay xuong & Hoa Ky hign nay 1a trén 20 ti d6 la Mf, trong ving 50 nam t6i, chi phi nay sé vugt qua con s6 240 ti dé la My. _Loding xwong va hau qua giy xuong do long xuong cling dang tré thanh génh nding rét lon cho site khoe cng dong tai cdc quéc gia chau A vi dan s6 déng (chiém 3/4 dan sé thé gidi), thu nhap, mic sng thap, ti 1¢ dan s6 gid gia ting va tée dO dé thj hoa cing dang gia ting . © Gy xwong ving hong (bao gdm gay cé xwong dui, gay lién mau chuyén, gay dudi méu chuyén) ty lau duge cOng nhén 1d hau qua nghiém trong nhat cla long xuong, do kéo theo nhid © Cac sé liga hign 6 cho thdy ti 1é mdi gay ddu trén xuong diti & cdc quéc gia Chau ién chitng khac nhur dau dén, tin phé va tir vong. A bing khoang mét nia ti 1¢ méi gay ghi nhan duge & Hoa Ky hoge chau Uc. Ti 1é méi gy ting cao nbAt & cdc ving d6 thj va & cdc quéc gia chau A phat trién nhu- Hong Kong, Dai Loan, Singapore. Dy kién dén 2050, khoang 51% cac truong hop gay xuong ving hng trén toan thé gidi sé tap trung & Chau A, Gay xwong dét sing chiém 70% cac gay xuong do lodng xuong nhung thuong kh6ng c6 trigu ching co nang 16 ring nén thwong khéng duge phat hign va diéu tr) kip thoi. Mot sé nghién ciu 6 chau A va Vigt Nam cho thy ty 16 gay xuong dét séng cia phy nit chau A 1 15 - 30%, cao hon cc quéc gia chau Au (12 - 25%). Theo bang phan loai quéc 16 vé bénh tat ICD 10: = Lofing xuong khOng cé giy xuong cé mii sé: M 81 — Lofing xuong ¢6 gay xuong (hay long xuong ngng) o6 ma sb: M 80 Tuy nhién, lofing xuong Igi 1 bénh chua durge quan tim ding mite vi dign tién m tham, ngudi bénh thudng khéng cé trigu ching co nang gi 1 ring nén khéng biét minh.bj bénh cho dén khi bi gy xuong, dic biét gay xwong dét sdng, Dé viée chin doan, diéu tr] va e Huréng ddn chan dodn, didu tr va dee phing bénh Lofing XizongSé¥ TE Thanh phd HB Chl Mink dy phong loaing xuong va gay xwong cé higu qua tude hét d0i héi nang cao nhén thite ve bénh loding xuong cho cdc thay thudc lim sang thuge nhiéu chuyén Khoa khéc nhau, cing nhu oan thidt phai xay dyng nbiing huéng din va tiéu chi chung trong viée chin dodn, didu tri va dy phong loaing xuong cho tat ca nhitng thay thudc tham gia vao vige chim séc diéu tri cdc bénh nhfin lofing xuong va cé nguy co lo&ing xuong, Ltwtng dn chin dotin, did tr va ce phng bénh Loang Xiong 6inh phd H6 Chi Minh PHAN 1. CHAN DOAN VA TAM SOAT LOANG XUONG 1. CACNGUYEN TAC CHUNG 1. Tam sodt cdc yéu t6 nguy co trén lam sang qua thim khém va héi tidn st, dic bigt tién sty gay xuong cla ngudi bénh va gia dinh. | 2. Thim khdm dé phat hign cic dau higu c6 thé c6 cita long xuong va cdc nguyén nhan gay loang xuong thir phat, trong 46 nén bao gém viée do chiéu cao dinh ky dé xéc dinh sy thay d4i chiéu cao va quan sat hinh ding bénh nban dé phat hign gi c6t sng. Chi dinh mét s6 xét nghiém va thim dé dé chdn dodn lofing xuong va phat hién céc yéu t6 nguyén nhan gop phan gay mét xuong: a, Do mit d} xvong (BMD), tét nbAt 1a bing phuong phap hdp phy tia X nding Iurgng kép (DXA). b. Xem xét chi din mét sé xét nghigm co ban can thiét s Lugng gié nguy co gay xuong 10 nam déi Si gay cb xuong dui va cdc gay xurong Ién khéc dya vio mé hinh tién don gay xuong FRAX cia té chite y té thé gidi (WHO) hoc m6 hinh cia vién GARVAN, Uc. . Chin doan xéc dinh lofing xuong dya vi a. Do mat 49 xuong (BMD) bing phuong php hdp phy tia X ning luong kép (DXA) va sit dung tiéu chudn cia té chise y té thé gidi (WHO). b. Trén lam sang, cé thé chan doan lofing xwong Khi bénh nhan cé cée yéu t6 nguy e co va o6 bing chimg cia gay xwong sau chén throng nhg (trong d6 c6 gay kin 46t séng), két hop voi viée loai trit cde bénh ly gay hy xuong hoc lofing xvong thir phdt (ahw cutng cfm gidp trang, da u tity xwong, v.v.). Il. DANH GIA CAC YEU TO NGUY CO Loang xuong la mét béah ly chju anh hwéng cita rét nhigu yéu t6 vi vay tit cd phy nir sau man kinh va nam gidi trén 50 tudi cdn duge dénh gid nguy co lo’ing xuong. Cae yéu t6 nguy co Him sang dé luong gid kha nang gay xwong: Gidm mit d6 xwong 1A yéu td nguy co quan trong nhAt cia Loaing xuong. Céc nghién ciru déu thng nhat khi mat d9 xuong 6 cd xuong dai gidm | 46 1éch chudn. e Huéng din chan doin, didu tr vd ave phng beh Loding Xieomg i | i i | | | | | | iSOY 74 Thank pho H6 Chi Mink (tong duong véi gidm 0.12 g/cm’) sé lim ting nguy ee gay xwong gép 2 Tan. nay tiéu chudn chan dodn long xuong cita td chite y té thé giéi WHO dang da vao yéu t6 nay. 2. Cao tud i: Phu ni sau man kinh va nam sau 50 tudi cé nguy co gay xuong gia tang so voi nhiing c& nhan duéi 50 tuéi. Tudi cang cao, nguy co gay xurong cdng tang Cir 10 tudi 1a trong duong véi 2.2 lan ting aguy co gay xuong. Khoang 50% phy nit gay cd xuong di cb tdi 70 te Len, 3. Gidi tinh: nif cé nguy co gay xong cao hon nam. Khoang 2/3 ca giy xuong xdy ra nit gidi. 4, Trong lugng co thé thdp: nhitng c4 nhan c6 chi sé khdi co thé (body mass index - BM) < 18.5 kg/m? c6 nguy co gay xuong ting 1.8 ln so vai nhiing ngudi cb BMI cao hon 18.5. 5. Ding glucocorticoid dudng uéng v6i ligu hrong > Smg predisone/ngiy hofic ché pham tuong duong > 3 thang la mt yéu t6 gay xuong, dc bigt la xuong dét song. 6. Dang hut thude 7. Udng nhiéu rugu, bia > 3 don vi rugu/ ngay (1 don vi rugu = 40 ml rugu manh ho§e 150 ml rugu vang ho&e 300 ~ 350 ml bia). eo . TE nga va yéu co 1 mdt trong nhiing yéu 16 nguy co gay xuong quan trong. Khoang 90% ca gay o8 xwong diii ld do té nga. Nguai thiréng bj t& ng& cang cé nguy co cao, Nghién ciru & ngudi A chau cho thy ngudi té nga c6 nguy co gay xuong cao gip 4 lan so véi ngudi khong té nga. Khi kham lm sang, cin chit y hoi dén cdc yéu t6 & gy té nga nhw thiéu thiét bj hd trg trong phong tim, sin nha tron trot, khéng dt nh sing, chung ngai vat trén sin, cita ra vao dé vap nga. 2° . Tién sir gia dinh c6 cha me bj giy xwong ving héng hoje ban than bj gay xuong sau tudi 50 1a mdt trong nhiing yéu 16 nguy co quan trong, vi ngudi cé tién sit giy xuong c6 nguy co géy xwong [dn thir hai rét cao (ting 2-3 lan so voi ngudi Kh6ng c6 tién sit). Bénh nhan cé tidn sir gay xwong cé thé c6 chi dinh cho didu tri dé gidm nguy co gay xwong lin thir hai. 10. Thiéu canxi: Ngudi cé liéu long canxi cung cp tir thyc phim <400 mg/ngay 06 nguy co gay xuong ting gap 3 lin so voi nhiing ngudi cd lugng canxi hap thu tir thuc phdm trén 400 mg/ngay. 11. Nhing nguyén nhan thir phat gay lofing xwong: Huéng din chén dodn, diéu tri vé dw phoing bénh Loding Xwomg 6S618 Thank phé Hé Chi Minh Vien khép: viém o6t s6ng dinh khép, viém khép dang thép, thodi héa khép © Thiéu nang tuyén sinh duc 6 nam va nit khdng duge didu tr © Bat ddng kéo dai © Ghép tang © Cudng gidp © Tigu dudng Type 1 | © Bénh thén min © Bénh durdng tiéu hoa © Bénh gan main Bénh phdi tic nghén man tinh (COPD) IIL. DANH GIA LAM SANG © Long xuong lA mt bénh tién trién thim King, giai doan thiéu xwong thudng khong £6 trigu ching. Bénh canh Jam sang dau tién ciia loding xvong thudng 18 gay xuong, © Muén hon o6 thé e6 cae bién chiing cia gay xuong nhu dau, bién dang xwong va che thay ddi dic higu do gay hin dét sing nhu gidm chidu cao, gi, thay déi thé hinh, giam sit cdc hoat dng thyc thé, ting sy hud © Trong loding xuong thit phat, bénh nhan c6 thé cé céc trigu chéing cia bénh IY nén. CAC VJ TRI GAY XUONG DO LOANG XUONG THUONG GAP Cot sing Vj tri thuéng gap nhat ciia gay xuong do long xuong C6 thé khéng cé trigu ching cp tinh 2/3 bénh nbn khéng durge phat hign trén lam sang pau trén xuong di | ‘Thurdng xudt bign ¢ tudi mugn hon so véi gay o6t sing va (gdm gay cd xuong | gay diu duéi xwong quay dui, gy lién mau ‘TY 1é th vong 20% trong vong 1 ndm dau tién chuyén, gy duéi Lam tang nguy co gay xuwong trong twong lai Ién 2,5 lin méu chuyén) Dau duéi xwong ‘Tudi thudng tré hon so voi gay cot song va cd xuong dai quay ‘Thudng 1a déu hign du tién cia loding xwong e ‘Huéng din ehdn dodn, didu tri va dy phing bénh Lodng Xicong UU UI LALLA ELL UU LLLSéY TE Thank phd H3 Chi Mink IV. VAI TRO CUA CAC THAM DO CAN LAM SANG 1. Che chi déu (marker) sinh héa eta chu chuyén xurong (vi dy: phosphatase kiém dc higu xuong, osteocalein, N-telopeptide): — Vigc xét nghigm cdc marker chu chuyén xuong cé thé cung cp thém théng tin lién quan dén nguy co gay xuong — Tuy nhién cho t6i hign tai, chwa c6 sy thang nhat trong vie sie dung cdc xét nghiém nay mot cécl lam sing. Hh thudng qui trong dénh gid lodng xieong trén thye hank 2. Cn lam mot sé xét nghiém co bn cho moi bénh nhan lofing xwong nham dénh gid tinh trang bénb, phat hign cfc nguyén nbn gay loting xuong thir phat va gitp chan doan phan bigt. Tay bénh cénh lam sing, xem xét lam mot s6 trong ede xét nghiém sau day cho nhing bénh nbén loing xuong chua duge lam xét nghigm trude dé. ‘A. CAC XET NGHIEM, THAM DO CAN LAM THUONG QUY CHO MOI Hee Preece BENE NHAN _ cH Méu Céng thitc mau | Goi ¥ thiéu méu do kém hip thu, bénh ly 4c tinh hoc tham nhiém tiy xuong Calei mau (jon Can thiét khi bat ddu ding cdc thudc chéng hay xuong do) ho¥e ting ddng héa. ‘Loai tri tinh trang ting calci mdu trong loang xuong, thir phat nhw curing cn gidp, bénh de tinh cla xxong. Giam: H6i chimg kém hap thu, thiéu vitamin D Glucose, HbAIC | Tam soat tiéu dudng AST, ALT, Chie nang gan albumin BUN, creatinin | Chite nang than Do Phuong phap Xéc dinh chn dogn lodng xuong mitd@ | hap phy tia X anh gid nguy co gly xong xuong | ning luong ‘Theo ddi thay di khdi lugng xwong do bénh ly ho&e (BMD) | kép (DXA): eb didu ti, xuong di va ho§e e6t sng that hing Huwing din chén dod, diée tri vi die phong beh Loding Xiong e$6 ¥ Té Thanh phd Hé Cid Mink B. CAC THAM DO XEM XET LAM THEM KHI NGHI NGO CO LOANG XUONG THU PHAT HOAC DE CHAN DOAN PHAN BIET Méu | Téc.4$ mau lang, | Bénh ly viém hod bénb gamma don ding (da u ty) CRP Phosphatase kiém | Tang trong bat dOng kéo dai, gay xuong méi, bénh : Paget, cdc bénh vé xwong khéc (ung thu di cn) Digndi protein | Nghi ngd dau tly i Phospho miu__| Gim trong béah nbuyén xvong 25-OH vitamin D | Dé xdc inh tinh trang thiéu vitamin D. Co thé thiéu do khdu phin an hode bénh dudng tiéu eee héa, gidip chin dodn bgnh ahuyén xwong PTH _| Tang trong cuéng cn gidp trang Cortisol budi sing | H6i chimg Cushing Estradiol Nghi ngo thién nang sin dye & nit Testosterone ‘Nghi ngé thiéu nang sinh TSH, FT3,FT4 | Nghi ngo cudng gidp Nuéc | Téngphantich | Xét nghiém co ban danh gia nguyén nbdn thir phat tigu d ctta loang xwong | ign diprotein | Khi nghi ngé da u ty xuong Calei nigu 24h | Xée dnb tinh trang tng calci nigu Thap: go ¥ thiéu vitamin D, nhuy€n-xuong, hoge E 7 ____| kém hap thu do bh rudt non X-quang | Cot sing (ngye va_| ft 06 gid tri dé ude tinh mat 49 xwong, xuong | that ling) ho%e vi_ | Cé thé chi dinh dé: Khiing dinh hod logi trix gy tun tri khdc thy thuge | ddt sng, hoke cde gay xuong khéc; hotic dé loai triy lam sing bénh ly xurong khéc (nhw bénh Paget, ung thu) Céng Cétséng (ngye va | Cé gid tri dé tinh mat d6 xuong tuy nhién gid thanh hung tir | tht lung) hoe vi | cao va khéng ding thuving quy dé dénh gid mat d6 (MRI) | tri khéc tiy thuge | xuong (BMD). lam sang Khi can, c6 thé chi dinh 46 logi try cde bénh ly khée gly giy xuong hoi gay d&t sOng, dic bigt ld cic ben ly de tinh Sinh | Xuong Hiém khi can thiét, song 06 thé xem xét chi Gin khi thiét nghi ngo bénh Iy de tinh V. CAC CHi DINH BO MAT BO XUONG (BMD) © Phy nit trén 65 tudi va nam gidi trén 70, bat ké 6 yéu t5 nguy co hay khong © Phu nif sau min kinh dudi 65 tudi va nam gidi tir 50-69 tdi néu cé cdc yéu tS nguy co loding xuong trén lam sing. 06 Hung din chan dodn, diéu tj va de phong béxh Lodng XieongS87 Phanh phé H Chi Mink © Phynir thai ky tién man kinh néu cé cae yéu td lam ting nguy co gay xuong nhu can ning thap, tin sir gay xwong do chn thuong nhg hoc ding thudc gay mat xuong. ¢ Tat ca nhiing ngudi lon c6 gay xuong sau tdi 50, ¢ Nhiing ngudi trudng thanh c6 bénh ly gay mat xuong nhw viém khép dang thap, viém o6t séng dinh khop, ho%e ding thuée nhém glucocorticoid > $ mg/ngay, kéo ' dai > 3 thang, \ | © Do mat d6 xwong (BMD) dé theo dai két qua digu tri cho nhimng ngudi dang diéu tri loaing xuong. VI. CAC KY THUAT BO MAT BO XUONG (BMD) © Khuyén cdo do mat d6 xuong (BMD) bing phuong phap hap phy tia X nang lwong kép (DXA). Day la phuong phap tét nhat dé chdn dodn loaing xuong, tién doan nguy co gy xuong va theo doi dap ting didu tri. © Cac vj tri do mat 46 xuong (BMD); tét nhdt la ly gid tr] do & 2 vi tri = Cé xtrong di (bén khéng thufn) thudmg duge sir dung nhat trong chan doan : long xuong. 7 = Cét séng that lung (tir TL 1 dén TL 4). (Co thé ly gid tri do 6 dau dudi 2 xuong cé tay, néu cdc vi tr trén khdng do duge. © Cac ky thudt do mét a6 xwong Kkhéo nhur hap phy tia X nding long kép (DXA) ngoai bién (do 6 cing tay, xuong got, ngon tay) hoc siéu dm dinh hrong (do 6 xuong got) 6 thé c6 gid tr] trong sang loc hoe tién lung phan nio nguy co gay xvtong, song . hi zt ime du th Vil. SU DUNG TIRU CHUAN CHAN DOAN LOANG XUONG ¢ Tiéu chudn chdn dodn lofing xuong theo khuyén céo ciia té chite y t8 thé gigi (WHO, 1994) dya vao két qua do mt 49 xwong (BMD) bing phuong phdp hAp phy tia | X ning lwgng kép (DXA), siz dung chi s6 T-score; chit yéu 4p dung cho phy nir sau man kinh vA nam gidi trén 50 tudi, Xuong binh thudng ‘T-score > -1 Kh6i lugng xuong thap (thiéu xuong) -1 > T-score > - 2.5 Loiing xuong T-score $- 2.5 Lofing xuong ning T-score $- 2.5 : _| Kem theo gay xuong do xuong yéu Heim din chin doin, didu iva dy phong buh Lodiug Xuong oeSY TE Thitnh phd Hd Chi Mink © Mat d9 xwong (PMD) thép tuong quan voi mite 49 nang ca lofing xuong va nguy co gy xuong. MAt d6 xuong (BMD) gidm 1 49 {éch chudn (SD), tong duong voi gidm 10-12% mat 46 xuong va nguy co gay xwong ting gap khodng 1,5 lan, © Métsé hry khi dign giai két qua do mét d6 xuong (BMD): ~ Tiéu chudn dia trén mat d6 xuong (BMD) chi yéu dua ra khung co ban cho chan dodn lo&ing xuong, khong nén sit dyng lam cin cir duy nhét 48 quyét dinbidiéu trj ma phai két hop v6i lam sang, dc bigt ld dénh gia céc nguy co lofing xvong va gly xuong. — Cn than trong khi so sdnh két qua do mit dO xwong (BMD) 6 cée vj tri xvong khée nhau hojc khi sir dung céc kf thudt do mét d$ xwong (BMD) khac nhau, céc my do khée nhau, Nén cho bénh nhan do va kiém tra trén cling mot may hoe mot loai may. — Trong thytc hanh lam sang, véi cdc 46i tong la phy not trude min kinh, nam giéi <50 tudi va tré em, hod khi Ap dung céc kf thudt do mat 46 xwong (BMD) khée thi khong nén ding T-score ma nén sir dung gia tri Z-score, Z-score <-2.0 SD duge coi 1a giim khdi lugng xuong dang ké so véi cing 46 tudi va cé thé duge coi la ¢6 lofing xutong. VII. LUQNG GIA NGUY CO GAY XUONG 1, M6 hinh FRAX cia WHO CAC YEU T6 SU DUNG TRONG MO HINH FRAX CUA WHO (hitp:/www.shef.ac.uk/FRAX/index.aspx) ‘Tudi hién tai ‘Viém khép dang thé _ Gibi Lofing xuong thir phét Tién sit gay xuong do long xuong Mat d9 xuong (BMD) cb xwong dai (cd (bao gdm gay lin dét song) thé > xem xét ding két qua do o thit hung) | ‘Tin sircha me cé gay xwong di | Hign dang hiit thude Chi s6 kh6i co thé (BMI) thap Uéng ruigu > 3 don vi/ngty Ung glucocorticoid > 5 mg prednisolon (hofe twong duong)/ngay, > 3 thang es T @ Hudng din chdn dodn, diéu tj vd dw phong bénh Lodng XicongSOY Té Thanh phd H8 Chi Minh 2. M@ hinh cita vign GARVAN CAC YEU TO SU DUNG TRONG MO HINH CUA VIEN GARVAN (http://garvan.org.aw/promotions/bone-fracture-risW/calculator/) Tudi hign tai Gidi ‘Tién str gay xuong sau tdi 50 Tidn sir té nga trong vong 12 thang truée 46 “Mat d6 xuong (BMD) hodc gid tri T-score Hiring dan chin dodn, dia ti vi de phing bénh Loaing Xiong eoSéY 78 Thanh phd Hé Chi Minh PHAN 2. HUONG DAN DIEU TRI 1. CAC NGUYEN TAC CHUNG 1. Mye dich diéu tri Giam nguy co giy xuong, \ Giam nguy co gly xwong tai din (néu cé tidn sir gay xirong), Giam mét xuong, idm nguy co tir vong lign quan dén gay xuong. 2. Quyét djnh didu tri cin dya trén viée xem xét toan dign ting bénh nhan cy thé, bao gém nbiing van dé chinh sau: a. Dénh gid cdc yéu t6 nguy co cita lo’ing xuong va gay xuong, trong 6 cé mat do xwong (BMD). b, Loi ich va nguy co cia vide diéu tri. c. Chi phi diéu tri. d. Mong muén cing nhu sy chdp nhan cita ngudi bénh, u, CAC BIEN PHAP DIEU TRI 1, Céc bign phap khéng ding thudc a, Ché d6 dinh duéng : cung cfp day di canxi, vitamin D © Canxi ~ Tétcd cde bénh nhén loaing xwong c&n duge cung cdp day di canxi (it nhdt 1000 mg/ngay), qua ché 46 dinh dudng va uéng thudc bé sung, néu c&n. ~ Nhucdu canxi t6i uu thy thudc vao Kira tudi va gidi tinh, song nén dim bio th 1000-1200 mg/ngay. Khoang 1000 mg/ngay déi véi nam giéi 50-70 tudi va khoang 1200 mg/ngay cho nam >70 tudi va nti >50 tudi. — Khéng nén bd sung qué 1500 mg mBi ngay. Cd mot sé ching cit ggi ¥ vie bd sung canxi qua mite cn thiét cé thé Lim ting nguy co nhdi mau co tim, sdi than. Tuy nhién nhiing vin dé nay van con gay tranh cfii. © Vitamin D — Pénh gid tinh trang vitamin D dya trén néng 46 25(OH)D huyét thanh, Cung cdp du vitamin D dé dat néng 46.thich hop trong mau 1a 30-60 ng/ml. oe Huéng ddn chin dodn, did tri va de phang bénh Loaing Xiong