Alimentação e cálcio: problemas e soluções Para algumas pessoas aumentar a quantidade de cálcio na alimentação pode, por motivos vários, ser considerado um problema. Mas para quase tudo existe uma solução! PROBLEMAO QUE SIGNIFICACOMO SE MANIFESTA COMO SE RESOLVEIntolerância à lactose (déficite de lactase) Dificuldade de digerir o açúcar (lactose) dos lacticínios por deficiência no enzima (lactase) que o digere Dores abdominais, diarréia, náuseas, meteorismo (gases) quando ingere leite Prefira os iogurtes e os queijos (a lactose já está digerida) Beba leite sem lactose Use leite de soja e seus derivados Hipercolesterolémia Colesterol aumentado Risco aumentado de doenças cardiovasculares Use produtos magros ou meio- gordos (a quantidade de cálcio é igual) Obstipação Prisão de ventre A prisão de ventre pode ser agravada pelo aumento do cálcio na dieta Beba mais água Coma mais frutas e vegetais Coma fibras Faça exercício Obesidade Use produtos magros Reduza o consumo de gorduras e hidratos de carbono Faça exercício Litíase renal Cálculos (pedras) renais Formação de cálculos é provocada por eliminar muito cálcio na urina (hipercalciúria) e não por ingerir cálcio a mais Beba mais água Evite comer muitos alimentos ricos em oxalatos (p.ex. vegetais verdes) Outros cuidados alimentares para prevenir a osteoporose : - Não consuma bebidas alcoólicas em excesso. O álcool é prejudicial para o fígado, para os ossos e favorece as quedas. - Consuma com moderação as bebidas ricas em cafeína (p.ex. café, refrigerantes de cola, bebidas energéticas). A cafeína em excesso aumenta a excreção de cálcio na urina. - Não consuma m ais proteínas (carn e, peixe, ovos e leguminosas) do que as recomendadas na pirâmide alimentar. Mas, se tem mais de 65 anos ou se teve uma fractura recente deve ingerir a dose máxima recomendada. - Reduza o sal da sua dieta. Para além de ser bom para os seus ossos será ainda melhor para o seu coração. - A vitamina D também é importante para ter ossos saudáveis. Parte da vitamina D de que necessitamos é fabricada pela nossa pele através da exposição solar e outra parte provêm da alimentação (p.ex. lacticínios). Se tem mais de 65 anos, se sai muito pouco de casa e não apanha sol (embora 30 minuto s por dia de exposição solar o seja suficiente) deve ter mais cuidado com a alimentação ou falar com o seu médico para saber se precisa de um suplemento de vitamina D, principalmente nos meses de Outono e Inverno.
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Para algumas pessoas aumentar a quantidade de cálcio na alimentação pode, por motivos vários, ser
considerado um problema. Mas para quase tudo existe uma solução!
PROBLEMA O QUE SIGNIFICA COMO SE MANIFESTA COMO SE
RESOLVE Intolerância à lactose
(déficite de lactase)
Dificuldade de digerir
o açúcar (lactose) dos
lacticínios por
deficiência no enzima
(lactase) que o digere
Dores abdominais, diarréia,
náuseas, meteorismo (gases)
quando ingere leite
Prefira os iogurtes
e os queijos (a
lactose já está
digerida)
Beba leite sem
lactose
Use leite de soja e
seus derivados
Hipercolesterolémia Colesterol aumentado Risco aumentado de
doenças cardiovasculares
Use produtos
magros ou meio-
gordos (a
quantidade de
cálcio é igual)
Obstipação Prisão de ventre A prisão de ventre pode seragravada pelo aumento do
cálcio na dieta
Beba mais águaComa mais frutas
e vegetais
Coma fibras
Faça exercício
Obesidade Use produtos
magros
Reduza o consumo
de gorduras e
hidratos de
carbono
Faça exercício
Litíase renal Cálculos (pedras)
renais
Formação de cálculos é
provocada por eliminarmuito cálcio na urina
(hipercalciúria) e não por
ingerir cálcio a mais
Beba mais água
Evite comermuitos alimentos
ricos em oxalatos
(p.ex. vegetais
verdes)
Outros cuidados alimentares para prevenir a osteoporose :
- Não consuma bebidas alcoólicas em excesso. O álcool é prejudicial para o fígado, para os ossos e favorece
as quedas.
- Consuma com moderação as bebidas ricas em cafeína (p.ex. café, refrigerantes de cola, bebidas
energéticas). A cafeína em excesso aumenta a excreção de cálcio na urina.- Não consuma mais proteínas (carne, peixe, ovos e leguminosas) do que as recomendadas na pirâmide
alimentar. Mas, se tem mais de 65 anos ou se teve uma fractura recente deve ingerir a dose máxima
recomendada.
- Reduza o sal da sua dieta. Para além de ser bom para os seus ossos será ainda melhor para o seu coração.
- A vitamina D também é importante para ter ossos saudáveis. Parte da vitamina D de que necessitamos é
fabricada pela nossa pele através da exposição solar e outra parte provêm da alimentação (p.ex.
lacticínios). Se tem mais de 65 anos, se sai muito pouco de casa e não apanha sol (embora 30 minutos por
dia de exposição solar o seja suficiente) deve ter mais cuidado com a alimentação ou falar com o seu
médico para saber se precisa de um suplemento de vitamina D, principalmente nos meses de Outono e
Alimentos ricos em cálcio, com indicação dequantidade (mg)
Alimento Quantidade Cálcio(mg)
LEITE - Magro 200 mg 248
- Meio Gordo 200 mg 243- Completo (gordo) 200 mg 237- Em Pó 15 g 64- De Soja 200 mg 25IOGURTE MAGRO - Simples 150 g 278- Fruta 150 g 230GELADO MAGRO - Semifrio (3% gordura) 100 g 185- Duro (4% gordura) 100 g 117QUEIJO - Parmesão 50 g 643
- Cruyère, Emmenthal(45% gordura) 50 g 590
- Flamengo 50 g 386- Ilha 50 g 370- Fundido 50 g 300- Serra (60% gordura) 50 g 278- Brie (50% gordura) 50 g 200- Camembert (45%gordura)
50 g 190
- Mozzarela 50 g 143- Fresco Magro (2 - 4%gordura)
50 g 37
- Creme (60% gordura) 50 g 17OMOLETA DE QUEIJO - 1 ovo + 25 g de queijoflamengo
80 224
PIZZA DE QUEIJO ETOMATE
100 g 189
QUEIJADA 50 g 130PUDIM DE OVOSCASEIROS
100 g 95
FLOCOS DE AVEIA (semleite)
50 g 66
PÃO 50 g 54FRUTOS SECOS
- Figos 50 g 139- Amêndoas 50 g 134- Nozes 50 g 90- Damascos 50 g 45- Amendoins 50 g 29CHOCOLATE DE LEITE 100 g 220SARDINHAS FRSCAS (com espinhas) - Em óleo, só o peixe 50 g 195- Em tomate, só o peixe 50 g 150CAMARÕES GRANDES 100 g 150LARANJA 1 grande 58VEGETAIS FRESCOS (cozidos e secos
Durante a maior parte do tempo a osteoporose não dá sintomas, mas quando já existem fracturas
vertebrais você pode começar a ter dores nas costas.
As dores nas costas provocadas pela osteoporose podem ser agudas ou crónicas e a maneira de lidar com
elas é diferente nos dois casos.
Dor aguda
A dor aguda nas costas é habitualmente provocada por uma fractura vertebral. Surge de forma súbita, é
muito intensa e incapacitante, mas dura pouco tempo, não mais de 2 ou 3 semanas. Para tratar esta dor é
necessário fazer analgésicos (medicamentos para as dores) e alguns dias de repouso, evitando as
actividades mais pesadas da vida diária
Dor crónica
A dor crónica resulta do esforço que é colocado nos músculos e ligamentos da coluna. Se já desenvolveu
uma corcundae tem menos altura, como consequência da osteoporose, isso é resultado de várias
pequenas fracturas, que muitas vezes podem até ter passado despercebidas. Estas alterações tornam maisdifícil manter a coluna vertebral direita, exigindo um maior esforço aos músculos e ligamentos. Este
esforço é a causa da dor crónica. A dor crónica pode durar meses. A sua intensidade pode até nem ser
muito grande, mas é muito incomodativa e pode dificultar as tarefas diárias. Nos períodos de agravamento
da dor deve fazer os analgésicos que o seu médico receitou. Não espere que a dor seja insuportável para
começar a fazer os medicamentos. Mais vale tomar regularmente um analgésico, evitando que a dor se
agrave.
Outras medidas simples como a aplicação de calor local, são úteis para aliviar as dores nas costas. A
mudança frequente de posição e a utilização de um bom suporte lombar (p.ex. uma almofada atrás das
costas quando está sentada) são outros exemplos de gestos simples que também podem ajudar.
A execução regular de exercícios que ajudam a fortalecer e a alongar os músculos das costas são muito
importantes para diminuir a dor crónica. Estes exercícios podem ser executados em casa, depois de serem
aprendidos com um terapeuta.
A execução das tarefas diárias de forma correcta é fundamental para evitar as dores nas costas e também
para evitar novas fracturas vertebrais.
Nos quadros seguintes pode ver alguns exemplos de como deve executar as suas tarefas e também de
alguns exercícios de fortalecimento e alongamento que pode executar em casa, depois de se aconselhar
com o seu médico.
- Espinafres 100 g 600- Rama de Nabo (folhas ecaules)
100 g 168
- Couve Verde 100 g 160Brócolos 100 g 91Feijão de Soja 100 g 87Feijão Seco 100 g 45
doenças de má absorção intestinal, hipercalciúria idiopática e artrite reumatoide. O risco de fraturas
também está associado a maior risco de quedas, principalmente em pacientes com déficit visual, de força
muscular no quadríceps e/ou cognitivo, alterações de marcha e disfunções neurológicas que afetem o
equilíbrio.
Uso crônico de drogas: a incidência de fraturas osteoporóticas em usuários de corticosteroides po r mais
de seis meses é de cerca de 30 a 50%. Mesmo doses pequenas de glicocorticoides, incluindo os inalatórios,podem causar perda óssea na maioria dos indivíduos. Outras drogas associadas à perda óssea são
ciclosporina, bloqueadores da secreção de gonado trofinas, heparina, anticonvulsivantes como hidantoína,
carbamazepina e fenobarbitúricos e os quimioterápicos. Drogas que provoquem hipotensão postural ou
alterações do equilíbrio, como anti-hipertensivos, barbitúricos, benzodiazepínicos e diuréticos, po dem
aumentar o risco de quedas.
emedicine.medscape.com
Introduction
Background
Osteoporosis is a systemic skeletal disorder characterized by decreased bone mass and deterioration of
bony microarchitecture. The result is fragile bones and an increased risk of fractures, even after minimal
trauma. Osteoporosis is a chronic condition of multifactorial etiology and is usually clinically silent until a
fracture occurs. Osteoporosis is a significant health problem in the United States and around the world.
Pathophysiology
Osteoporosis results from hereditary and environmental factors that affect both bone mass and bonequality. Traditionally, osteoporosis was described as type I (postmenopausal) or type II (senile).
Postmenopausal osteoporosis (PMO) is primarily due to estrogen deficiency; senile osteoporosis is
primarily due to an aging skeleton and calcium deficiency. However, it is increasingly recognized that
multiple pathogenetic mechanisms interact in the development of the osteoporotic state, regardless of
age.
Cortical and trabecular (cancellous) bone differ in architecture but are similar in molecular composition.
Bone consists of cells and an extracellular matrix with mineralized and nonmineralized components. The
composition and architecture of the extracellular matrix is what imparts mechanical properties to bone.
Bone strength is determined by collagenous proteins (tensile strength) and mineralized osteoid
(compressive strength).[1 ]The greater the concentration of calcium, the greater the compressive strength.
Adult bone undergoes constant remodeling to maintain bone strength. Osteocytes, which are terminally
differentiated osteoblasts embedded in mineralized bone, direct the timing and location of remodelin g.
Osteoblasts not only secrete and mineralize osteoid but also appear to control the bone resorption carried
out by osteoclasts; thus, bone formation and resorption are coupled. Osteoclasts require weeks to resorb
bone, whereas osteoblasts need months to produce new bone. Therefore, any process that increases the
rate of bone remodeling results in net bone loss over time.[2 ]
Furthermore, in periods of rapid remodeling(eg, after menopause), bone is at an increased risk for fracture because the newly produc ed bone is less
densely mineralized, the resorption sites are temporarily unfilled, and the isomerization and maturation of
collagen is impaired. [3 ]
Molecular biologists have begun to elucidate the mechanisms of bone remodeling. For example, it is now
understood that the receptor activator of nuclear factor-kappa B ligand (RANKL)/receptor activator of
nuclear factor-kappa B (RANK)/osteoprotegerin (OPG) system is the final common pathway for bone
resorption. Osteoblasts and activated T cells in the bone ma rrow produce the RANKL cytokine. RANKL
binds to the RANK receptor expressed by osteoclasts and osteoclast precursors to promote osteoclast
differentiation. Osteoprotegerin is a soluble decoy receptor that inhibits RANK -RANKL by binding and
sequestering RANKL.
Bone mass peaks by the third decade of life and slowly decreases afterward. The failure to attain optimal
bone strength by this point is one factor that contributes to osteoporosis. Therefore, nutrition and physical
activity are important during growth and development. Nevertheless, hereditary factors play the principal
role in determining an individuals peak bone strength. In fact, genetics account for up to 80% of the
variance in peak bone mass between individuals. [4 ]
Estrogen deficiency not only accelerates bone loss in postmenopausal women but also plays a role in bone
loss in men. Estrogen deficiency can lead to excessive bone resorption accompanied by inadequate bone
formation. Osteoblasts, osteocytes, and osteoclasts all express estrogen receptors. In addition, estrogen
affects bones indirectly through cytokines and local growth factors. The estrogen -replete state mayenhance osteoclast apoptosis via increased production of transforming growth factor (TGF) beta. In the
absence of estrogen, T cells promote osteoclast recruitment, differentiation, and prolonged survival via
interleukin [IL]1, IL-6, and tumor necrosis factor (TNF)alpha. T cells also inhibit osteoblast differentiation
and activity and cause premature apoptosis of osteoblasts through cytokines such as IL-7. Finally, estrogen
deficiency sensitizes bone to the effects of parathyroid hormone (PTH).
Calcium, vitamin D, and parathyroid hormone help maintain bone homeostasis. Insufficient dietary calcium
or impaired intestinal absorption o f calcium due to aging or disease can lead to secondary
hyperparathyroidism. Parathyroid hormone is secreted in response to low serum calcium levels.
Parathyroid hormone increases calcium resorption from bone, decreases renal calcium excretion, and
increases renal production of 1,25 -dihydroxyvitamin D (1,25[OH]2 D). It is this active hormonal form of
vitamin D that optimizes calcium and phosphorous absorption from the gut, inhibits parathyroid hormone
synthesis, and plays a minor role in bone resorption.
Vitamin D deficiency can result in secondary hyperparathyroidism via decreased intestinal calcium
absorption. Interestingly, the effects of parathyroid hormone and 1,25[OH] 2 D on bone are mediated via
binding to osteoblasts and stimulating the RANKL/RANK p athway. Osteoclasts do not have receptors for
Endocrinologic conditions or medications that lead to bone loss (eg, glucocorticoids) can cause
osteoporosis. Corticosteroids inhibit osteoblast function and enhance ost eoblast apoptosis.[5
]Polymorphisms of IL-1, IL-6 and TNF-alpha, as well as their receptors, have been found to influence bone
mass. Other factors implicated in the pathogenesis of osteoporosis include polymorphisms in the vitamin D
receptor; alterations in insulin-like growth factor-1, bone morphogenic protein, prostaglandin E 2, nitrous
oxide, and leukotrienes; collagen abnormalities; and leptin -related adrenergic signaling.[2 ]
Osteoporotic fractures represent the clinical significance of these derangements in bone. Fractures occur
when bones fall under excess stress. Nearly all hip fractures are related to falls. [6 ]The frequency and
direction of falls can influence the likelihood and severity of fractures. The risk of falling may be amplified
by neuromuscular impairment due to vitamin D deficiency with secondary hyperparathyroidism or
corticosteroids. Vertebral bodies are composed primarily of cancellous bone with interconnected
horizontal and vertical trabeculae. Osteoporosis not only reduces bone mass in vertebrae but also
decreases interconnectivity in their internal scaffolding. [1 ]Therefore, minor loads can lead to vertebral
compression fractures.
International
Osteoporosis is estimated to affect over 200 million people worldwide. [8 ]An estimated 75 million people in
Europe, the United States, and Japan have osteoporosis. [9 ]
One in 3 women older than 50 years will eventually experience osteoporotic fractures, as will 1 in 5 men. [10
]By 2050, the worldwide incidence of hip fracture is projected to in crease by 240% in women and 310% in
men.[11 ]
Mortality/Morbidity
Osteoporosis is the most common human bone disease. In 2005, over 2 million osteoporosis -relatedfractures occurred in the United States. [12 ]Hip and vertebral fractures, in particular, are associated with
increased morbidity and mortality.
Hip fractures
y Hip fractures increase the one-year risk of death by 10-20%.[13,14 ]
y Patients with hip fractures incur decreased independence and a diminished quality of life. Only one
third of patients return to their prefracture level of function. [15 ]
y Among women who sustain a hip fracture, 50% spend time in a nursing home while recovering. In
addition, 1 in 5 patients with hip fractures requires long -term nursing home care.[7 ]
y Persons with a hip fracture are twice as likely to experience another fracture as persons withoutfractures. [16 ]
Vertebral fractures
y Vertebral fractures increase the 5-year risk of mortality by 15%.[17 ]
y Only one third of people with radiographic vertebral fractures are diagnos ed clinically.[18 ]
y Symptoms of vertebral fracture may include back pain, height loss, and disabling kyphosis.
y Compression deformities can lead to restrictive lung disease, abdominal pain, and early satiety.
y One in 5 postmenopausal women with a new vertebral fracture incurs another vertebral fracture
Dual-energy x-ray absorptiometry (DXA) is the standard study used to establish or confirm a diagnosis of
osteoporosis, to predict future fracture risk, and to assess changes in bone mass over time. DXA is used to
calculate bone mineral density (BMD) at the hip and spine. Although measurement at any site can be used
to assess overall fracture risk, measurement at a particular site is the best predictor of fracture risk at that
site. Whenever possible, the same technologist should perform subseq uent measurements on the samepatient using the same machine. This method can be used in both adults and children. Factors that may
result in a falsely high bone density determination include spinal fractures, osteophytosis, and extraspinal
(eg, aortic) calcification.
The National Osteoporosis Foundation and the International Society for Clinical Densitometry (ISCD)
recommend that BMD be measured in the following patients:
y Women aged 65 years and older and men aged 70 years or older, regardless of clinical risk factors
y Younger postmenopausal women and men aged 50 -70 years with clinical risk factors for fracture
y Women in menopausal transition with a specific risk factor associated with increased risk for
fracture (ie, low body weight, prior low-trauma fracture, use of a high-risk medication)y Adults with fragility fractures
y Adults who have a condition (eg, rheumatoid arthritis) or who take a medication (eg,
glucocorticoids, 5 mg of prednisone daily for 3 mo) associated with low bone mass or bone loss
y Anyone being considered for pharmacologic therapy for osteoporosis
y Anyone being treated for osteoporosis (to monitor treatment effect)
y Anyone not receiving therapy in whom evidence of bone loss would lead to treatment
Bone density data from a DXA are reported as T-scores and Z-scores. T-scores represent the number of
standard deviations (SD) from the mean bone density values in healthy young adults, whereas Z -scores
represent the number of SD from the normal mean value for age - and sex-matched controls.
y Criteria by the World Health Organization (WHO) define a normal T -score value as within 1 SD of
the mean bone density value in a healthy young adult.
o T-score of -1 to -2.5 SD indicates osteopenia.
o T-score of less than -2.5 SD indicates osteoporosis.
o T-score of less than -2.5 SD with fragility fracture(s) indicates severe osteoporosis.
y For each SD reduction in BMD, the relative fracture risk is increased 1.5-3 times.
y The WHO BMD diagnostic classification should not be applied to premenopausal women, men
younger than 50 years, or children. Z -scores adjusted for ethnicity or race should be used, with Z-
scores of -2.0 or lower defined as "below the expected range for age" and those above -2.0 being
"within the expected range for age." The diagnosis of osteoporosis in these groups should not be
based on densitometric criteria alone.
WHO fracture risk algorithm[24 ]
This algorithm (www.shef.ac.uk/FRAX/) was developed to calculate the 10-year probability of a hip fracture
and the 10-year probability of any major osteoporotic fracture (defined as clinical spine, hip, forearm, or
humerus fracture) in a given patient. These calculations account for femoral neck BMD and other clinical
y Secondary osteoporosis (ie, coexistence of rheumatoid arthritis)
y Parental history of hip fracture
y Current smoking status
y Alcohol intake (3 or more drinks per day)
This algorithm is useful in identifying patients with low bone mass (having T-scores in the osteopenicrange) who are most likely to benefit from treatment. The National Osteoporosis Foundation recommends
osteoporosis treatment in patients with low bone mass in whom a US -adapted WHO 10-year probability of
a hip fracture is 3% or more or in whom the risk for a major osteoporosis -related fracture is 20% or more.[7
]
Vertebral fracture assessment
Densitometric spine imaging can be performed at the time of DXA scanning to detect vertebral fractures.
Vertebral fracture assessment (VFA) is not available with all DXA machines. When available, VFA should be
considered when the results may influence clinical management of the patient. [25 ]
Radiography
Obtain radiographs of the affected area in symptomatic patients. Lateral spine radiography can be
performed in asymptomatic patients in whom a vertebral fracture is suspected, in those with height loss in
the absence of other symptoms, or in those with pain in the thoracic or upper lumbar spine.
y Radiographs may show fractures or other conditions such as osteoarthritis, disc disease, or
spondylolisthesis.
y Plain radiography is not as accurate as BMD testing. Approximately 30 -80% of bone mineral must
be lost before radiographic lucency becomes apparent on radiographs. [26 ]
Additional imaging modalities
y Quantitative CT scanning: This is used to measure BMD as a true volume density in g/cm 3, which is
not influenced by bone size. This technique can be used in both adults and children but assesses
BMD only at the spine. Other limitations include significant radiation exposure, high cost, and
possible interference by osteophytes.
y Peripheral DXA: This is used to measure BMD at the wrist. Peripheral DXA may be most useful in
identifying patients at very low fracture risk who require no furthe r workup.
y Quantitative ultrasonography of the calcaneus: This is a low-cost portable screening tool. This
method does not involve radiation but is not as accurate as other methods and cannot be used tomonitor the response to treatment because of its lack of precision.
Procedures
Undecalcified iliac bone biopsy with double tetracycline labeling is rarely necessary but may be considered
when no cause for osteoporosis is apparent, therapy is not eliciting a response, or osteomalacia is
suspected. Tetracycline double labeling is a process used to calculate data on bone turnover. In this
procedure, patients are given tetracycline, which binds to newly formed bone. This appears on biopsy
samples as linear fluorescence. A second dose of tetracycline is given 11 -14 days after the first dose; this
Adequate calcium and vitamin D intake are important in persons of any age, particularly in childhood as
the bones are maturing. If dietary intake is inadequate, add supplements.
Calcium
y Premenopausal women and men younger than 50 years w ithout risk factors for osteoporosis
should receive a total of 1000 mg of calcium daily.y Postmenopausal women, men older than 50 years, and other persons at risk for osteoporosis
should receive a total of 1200-1500 mg of calcium daily.
y See the National Osteoporosis Foundation Web site for further calcium recommendations.
Vitamin D
y Adults younger than 50 years should receive 400 -800 IU of vitamin D 3 daily.
y All adults older than 50 years should receive 800 -1000 IU of vitamin D 3 daily.
y See the National Osteoporosis Foundation Web site for further vitamin D recommendations.
Activity
y Weight-bearing exercise has been shown to positively affect BMD. Regular exercise should be
encouraged in all patients, including children and adolescents (in order to strengt hen the skeleton
during the maturation process). Exercise also improves agility and balance, thereby reducing the
risk of falls.
y Physical therapists can assist in developing exercise regimens and instructing patients in proper
techniques.
Medication
Antiresorptive agents, including bisphosphonates, the selective estrogen-receptor modulator (SERM)raloxifene, calcitonin, denosumab, and one anabolic agent, teriparatide, are currently available for
osteoporosis treatment. All therapies should be given with cal cium and vitamin D supplementation. The
American College of Physicians reviewed the evidence and proposed guidelines for pharmacologic
treatments of osteoporosis. [27 ]
A combination of calcium and vitamin D supplementation can reduce fracture risk. [28 ]A meta-analysis was
performed to evaluate the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip
fractures among individuals older than 65 years. The meta -analysis included 12 double-blind, randomized,
controlled trials of nonvertebral fractures (n=42,279) and 8 randomized controlled trials of hip fractures
(n=40,886) and compared oral vitamin D (with or without calcium) with either calcium alone or placebo.
The results showed that nonvertebral fracture prevention with vitamin D is dos e-dependent, and a higher
dose reduced fractures by at least 20% in individuals aged 65 years or older. [29 ]
An additional meta-analysis (n=68,517) concluded that vitamin D alone is not effective in preventing
fractures, although, when administered with calcium, hip fractures and total fractures (and possibly
vertebral fractures) were reduced. The conclusions were based on 7 large studies that were randomized
with at least one intervention arm in which vitamin D was given and included analysis of fractures as an
outcome and at least 1000 participants. [30 ]
Bisphosphonates are the most commonly used agents for osteoporosis. Oral and intravenous options are
available. Trials have provided limited data about long-term treatment with bisphosphonates, and,
Treatment or prevention in postmenopausal osteoporosis:
Oral: 150 mg PO qmo or 2.5 mg PO qd
Intravenous: 3 mg IV q3mo
Pediatric
Not established
Interactions
Multivalent cations (eg, calcium, aluminum, magnesium, iron) decrease absorption, administer at least 1 h
prior to vitamin and mineral supplements; NSAIDs may aggravate GI irritation
Contraindications
Documented hypersensitivity; uncorrected hypocalcemia; inability to stand or sit upright for at least 60 minfollowing drug administration
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Upper GI disease; renal insufficiency (CrCl <30 mL/min); correct any preexisting hypocalcemia or other
mineral or bone disturbances prior to starting therapy; ensure adequate vitamin D and calcium intake;
discontinue if esophageal reaction (eg, dysphagia, odynophagia, retrosternal pain, worsening heartburn) or
severe musculoskeletal pain occurs; renal toxicity rarely reported with IV dose; not for use in breastfeeding
women
Zoledronic acid (Reclast)
Most potent bisphosphonate available. Increases BMD at spine by 4.3 -5.1% and hip by 3.1-3.5% compared
with placebo. Reduces the incidence of spine fractures by 70%, hip fractures by 41%, and non -vertebralfractures by 25% over 3 y. Approved for the treatment of postmenopausal osteoporosis.
Aminoglycosides may enhance hypocalcemic effect of zoledronic acid; NSAIDs may enhance GI adverse
events; thalidomide may enhance adverse effects
Contraindications
Documented hypersensitivity; hypocalcemia
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Aspirin-sensitive asthma; concomitant cancer/chemotherapy/steroids or dental procedure in patients with
cancer may increase risk of osteonecrosis of the jaw; caution in renal insufficiency (CrCl <30 mL/m in);
correct preexisting hypocalcemia or other mineral or bone disturbances prior to starting therapy; ensure
adequate vitamin D and calcium intake; not for use in breastfeeding women
Hormone, Parathyroid
Teriparatide is a biological product that contains a portion of human parathyroid hormone. When given
intermittently, it increases bone remodeling with the net effect of increased bone mass and improved
skeletal microarchitecture. (This is in contrast to continuous exposure to parathyroid hormone, whichincreases bone resorption with a net effect of decreased trabecular bone volume). Teriparatide is
approved in the United States for postmenopausal osteoporosis and primary or hypogonadal osteoporosis
in men.
T eriparatide (Forteo)
Anabolic agent increases BMD at lumbar spine by 9-13% and hip by 3-6% compared with placebo. Reduced
the risk of spine fractures by 65% and nonspinal fractures by 54% in patients after an average of 18 mo of
therapy.Approved for postmenopausal osteoporosis and male osteoporosis.
Documented hypersensitivity; increased risk for osteosarcoma (including those with Paget disease of bone
or unexplained elevations of alkaline phosphatase, open epiphyses, or prior radiation therapy involving
skeleton); children or growing adults; patients with bone metastases or history of skeletal malignanciesand those with metabolic bone diseases other than osteoporosis
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Monitor for hypercalcemia; may cause orthostatic hypotension (particularly following first several doses),
dizziness, or leg cramps; therapy limited to 2 y owing to osteogenic sarcomas in rat studies
Selective Estrogen Receptor Modulator
Selective estrogen receptor modulators (SERMs) act as weak estrogens in some organ systems, while
acting as estrogen antagonists in others. Raloxifene is approved for the prevention and treatment of
postmenopausal osteoporosis.
Raloxifene (Evista)
Increases BMD at spine and hip.Reduces the incidence of spine fractures by 30 -55% over 3 y.
Most suitable in women <70 y at moderate risk for osteoporosis who have infrequent vasomotor
symptoms of menopause (eg, hot flashes) and who are at moderate-to-high risk for breast cancer.
Dosing
Adult
60 mg PO qd
Pediatric
Not recommended
Interactions
May antagonize warfarin; avoid with anion exchange resins (eg, cholestyramine); caution with other drugs
that are highly protein bound (eg, diazepam, diazoxide, lidocaine)
X - Contraindicated; benefit does not outweigh risk
Precautions
Not for use in premenopausal women; not recommended for use with concomitant estrogen replacement
therapy; discontinue 72 h before prolonged immobilization or surgery associated with thromboembolism
and resume once fully ambulatory; hepatic dysfunction; not recommended for use in breastfeeding
women
Calcitonin
This agent is a peptide hormone used to t reat and prevent osteoporosis in patients in whombisphosphonates and estrogen are contraindicated or not tolerated. It also has some analgesic effects in
patients with fractures.
Calcitonin (Miacalcin, Calcimar, Cibacalcin)
Increases BMD at lumbar spine by 1-1.5%. Reduced incidence of spine fracture by 33% in group receiving
200 IU/d. Available in parenteral and intranasal forms; however, intranasal form is more convenient and
better tolerated. Diminution of benefit may occur after 20 mo with parenteral f orm.
Dosing
Adult
200 IU (1 puff) qd in alternating nostrils
100 IU IM/SC qod
Pediatric
Not established
Interactions
May potentiate oral anticoagulants and oxyphenbutazone; may alter insulin effects
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform periodic nasal examinations and discontinue if severe ulceration occurs with nasal spray use;monitor for hypocalcemic tetany initially and urine sediments over long term with injectable use;
hypocalcemia may occur (supplement with calcium and vitamin D); examine urine sediment during
prolonged therapy; caution in breastfeeding women
Estrogen Derivative
Estrogen is approved for the prevention of osteoporosis and relief of menopause -associated vasomotor
symptoms and vulvovaginal atrophy. The lowest effective dose at the shortest duration necessary should
be used. The FDA recommends that other approved nonestrogen treatments should be considered first for
osteoporosis prevention.
Estrogens (conjugated)
Contains a mixture of estrogens obtained exclusively from natural sources, occurring as the sodium salts of
water-soluble estrogen sulfates blended to represent the average composition of material derived from
pregnant mares' urine. Mixture of sodium estrone sulfate and sodium equilin sulfate.Contains, as
concomitant components, sodium sulfate conjugates, 17-alpha-dihydroequilenin, 17-alpha-estradiol, and
17-beta-dihydroequilenin.
Restores estrogen levels to concentrations that induce negative feedback at gonadotrophic regulatory
centers, which in turn reduces release of gonadotropins from pituitary.Increases synthesis of DNA, RNA,
and many proteins in target tissues.
Multiple aspects of menopause respond to estrogen replacement therapy, including vasomotor symptoms
and atrophic vaginitis. Also reduces bone resorption and may increase osteoblast activity.
Routinely prescribing conjugated estrogens to premenopausal women is not recommended. Use this
medication in postmenopausal women who are incontinent and who have had a hysterectomy. For
postmenopausal women with an intact uterus, cautiously recommend a short -term low-dose of Premarin,
with frequent monitoring.
Dosing
Adult
Prophylaxis: Initial, 0.3 mg PO qd given continuously or in cyclical regimens (25 d on, 5 d off); adjust to
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Hypocalcemia must be corrected before initiating; hypocalcemia may worsen, especially in patients with
CrCl <30 mL/min or on hemodialysis; serious adverse reactions include hypocalcemia, serious infections
(including cellulitis), and dermatologic reactions (eg, dermatitis, rashes, eczema); common adverse effectsinclude back and musculoskeletal pain, extremity pain, hypercholesterolemia, and cystitis; bone t urnover
suppression; may increase risk for osteonecrosis of the jaw; pancreatitis reported in clinical trials
Patient Education
y Educate patients about osteoporosis and encourage them to follow preventive measures, including
adequate calcium and vitamin D intake, exercise, cessation of smoking, and moderation of alcohol
consumption.
y For excellent patient education resources, visit eMedicine's Bone Health Center; Eating Disorders
Center; Esophagus, Stomach, and Intestine Center; and Women's Health Center.
y Also, see eMedicine's patient education articles Understanding Osteoporosis Medications, AnorexiaNervosa, Inflammatory Bowel Disease, Menopause, and Hormone Replacement and Osteoporosis.
Miscellaneous
Medicolegal Pitfalls
Osteoporosis is a preventable disease with potentially devastating consequences. Failure to identify at -risk
patients, to educate them, and to implement preventive measures may lead to tragic consequences.
Special Concerns
y Recognize the increased mortality and morbidity associated with osteoporotic fractures.
y Many patients have a coexisting cause of bone loss. This should be investigated and treated.
y WHO criteria for T-scores should not be applied to premenopausal women, men younger than 50
years old, and children. Z-scores should be used for these individuals, and, in these cases, a
diagnosis of osteoporosis should not be based on densitometric criteria alone.
Os dive ¡ s ¢ s sinais e sintomas que acompanham a menopausa (parada do fluxo menstrual), vemsendo estudadosdesde o século XV
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rios sintomas que estão sendo gradativamente decifrados e com isso diversas medidas j ¥ podem ser tomadas para melhorar a qualidade de vida das mulheres ¤
Os diversos sinais e sintomas que acompanham a menopausa(parada do fluxo menstrual), vemsendo estudados desde o século XV
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É um período com v ¥ rios sintomas que estão sendo gradativamente decifrados e com isso diversas
medidas j ¥ podem ser tomadas para melhorar a qualidade de vida das mulheres ¤
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t§
̈ io: é o inicio do período que compreende alguns anos antes da parada do fluxo até alguns anos após
O osso pode apresentar uma perda progressiva da massa óssea de + ou - 2 a 3% ao ano principalmente os
ossos da coluna e colo de femur, podendo levar ao quadro de osteoporos e.
O risco cardiáco pode estar aumentado com o aumento dos lípídes, hipertensão arterial. Perda damemória e maior relação com Alzeimer. Ressecamento vaginal com dor na atividade sexual e diminuição
da libido.
Existe tratamento?
- A menopausa é uma fase da vida e deve ser encarada como tal. Você não está e se você se cuidar bem,