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JCEM:“抵消”糖皮质激素骨折副作用的尝试成功了？

2018-02-05 石岩 环球医学

骨折糖皮质激素
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糖皮质激素作为一种广泛用于多种疾病的“万能药”，可谓让人又喜又忧。喜的是其具有强大的抗炎和免疫抑制作用，忧的是它被认为会引起继发性骨质疏松症。这使得医生对骨折高危人群使用糖皮质激素变得更加小心翼翼，那么有没有一种方法能够让大家不必担心骨折风险而放心大胆地使用糖皮质激素呢？

糖皮质激素作为一种广泛用于多种疾病的“万能药”，可谓让人又喜又忧。喜的是其具有强大的抗炎和免疫抑制作用，忧的是它被认为会引起继发性骨质疏松症。这使得医生对骨折高危人群使用糖皮质激素变得更加小心翼翼，那么有没有一种方法能够让大家不必担心骨折风险而放心大胆地使用糖皮质激素呢？

秉着“对症治疗”的原则，科学家们猜想通过联合抗骨质疏松药物或许能抵消糖皮质激素的副作用。考虑到目前没有临床试验能够证明这一点，2018年1月，瑞典科学家在《Journal of Clinical Endocrinology & Metabolism》上发表了一篇回顾性队列研究，旨在考察阿仑膦酸钠对口服糖皮质激素的老年人非椎体骨折风险的影响。

研究人员使用了瑞典国家登记处的回顾性队列研究，确定了2006~2011年开始口服糖皮质激素治疗（强的松≥2.5mg/d或≥91天的同等剂量）的≥50岁的患者（n=3347959）。最后的分析纳入了16890名阿仑膦酸钠服用者和16890名阿仑膦酸钠未服用者，研究人员采用随时间依赖的倾向性得分进行匹配。

该研究的主要结局为未预先设定的非椎体骨折。

在中位随访14.5个月期间，在阿仑膦酸钠服用者中非椎体骨折的发生率为每2例/100人年，在阿仑膦酸钠未服用者中为2.4例/100人年。这种差异表明在阿仑膦酸钠服用者中风险降低了16%（风险比为0.84）。

特异性地针对髋部骨折，阿仑膦酸钠服用者比未服用者的髋部骨折发生率要低34%（风险比为0.66）。在接受高剂量糖皮质激素治疗的患者中服用阿仑膦酸钠与较低的非椎体骨折风险之间的相关性最为明显。

由此可见，服用阿仑膦酸钠与非椎体骨折（包括髋部骨折）的风险降低相关。在临床试验的meta分析中也有类似相关性的报道，但缺少统计学意义。

由于这是一项观察性研究，所报告的相关性不一定是因果关系。但是，既往关于双膦酸盐临床试验的两个荟萃分析显示非椎骨骨折风险降低。而该项广泛的观察研究似乎合理估计了阿仑膦酸钠“抵消”糖皮质激素副作用效果的大小。

必须要说明的是，尽管这种方法避免了基线特征的差异，但骨折风险降低有一部分可能与治疗无关。除此之外，研究可能导致对阿仑膦酸钠的效果期望过高，实际上它的影响应当是渐进式的。

在这项研究中，接受糖皮质激素治疗数月后再服用阿仑膦酸钠的患者骨折风险并未降低。与此相反，之前有研究表明，不管之前的糖皮质激素治疗持续多久，阿仑膦酸钠对骨密度都有好处。这可能是由于研究中的混淆因素造成的，但也因此，更建议将阿仑膦酸钠作为预防性治疗。

相信在不久的将来会找到更好的方法来驾驭糖皮质激素这一双刃剑。

原始出处：

Jonathan Bergman, Anna Nordstrm, Peter Nordstrm. Alendronate Use and the Risk of Nonvertebral Fracture During Glucocorticoid Therapy： A Retrospective Cohort Study. The Journal of Clinical Endocrinology & Metabolism， Volume 103， Issue 1， 1 January 2018， Pages 306–313， https：//doi.org/10.1210/jc.2017-01912.

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    2018-11-01 showtest

    #副作用#

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    2018-04-07 smallant2015

    #JCEM#

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    2018-05-22 Tommy1959

    #糖皮质#

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    2018-10-31 achengzhao

    #JCE#

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    2018-02-07 bbwznl

    #皮质激素#

    0

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本研究旨在评价胸部钝器伤行全身CT检查肋软骨（CC）骨折的发病率及CC骨折分布、合并伤、损伤机制、报告准确性及其对30天死亡率的影响，研究人员将结果发表在Radiology上。本研究共查阅了36个月来胸部钝器伤行全身CT的患者资料，并由另一位阅片者对胸部创伤CT进行分析。在1461例行全身CT检查的患者中，39% (574 / 1461)具有胸部损伤（男性为74.0% [425 / 574]，平均

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该患者接受阿奇霉素治疗，并接受手术治疗修复发生骨折的肋骨和胸壁的相关疝。该患者完全康复出院。医务人员对其家庭接触者以及几名曾与患者密切接触的医务人员采用阿奇霉素进行暴露后预防。