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Aktuelle Rheumatologie 2001; 26(3): 129-137
DOI: 10.1055/s-2001-16316
MEDIKAMENTÖSE THERAPIE
© Georg Thieme Verlag Stuttgart · New York

Spezielle medikamentöse Therapie der Osteoporose bei chronisch-entzündlichen Erkrankungen des Bewegungsapparates

Specific drug therapy for osteoporosis in chronic inflammatory diseases of the musculoskeletal systemT. Eidner, G. E. Hein
  • Rheumatologie & Osteologie, Klinik für Innere Medizin IV, Friedrich-Schiller-Universität Jena
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Publication History

Publication Date:
31 December 2001 (online)

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Zusammenfassung

Die systemische Osteoporose mit erhöhtem Frakturrisiko ist eine häufige Begleiterscheinung chronischer entzündlich-rheumatischer Erkrankungen. Pathogenetisch spielen sowohl systemisch wirksame Entzündungsmediatoren als auch therapeutisch eingesetzte Glukokortikoide durch direkte Wirkung am Knochen und Beeinflussung des Kalzium-Metabolismus eine entscheidende Rolle. Zur medikamentösen Osteoporose-Prophylaxe ist bei chronischer systemischer Entzündung und/oder notwendiger Glukokortikoid-Langzeittherapie eine Kalzium- und Vitamin-D-Substitution zu empfehlen. Bei hoher entzündlicher Aktivität oder nachgewiesenem 1,25-Dihydroxy-Vitamin-D3-Mangel kommen auch aktive Vitamin-D-Metabolite (Calcitriol, Alfacalcidol) in Frage. Bei manifester Osteoporose sind Bisphosphonate Mittel der ersten Wahl, wobei derzeit die besten Studiendaten mit signifikanter Senkung der Frakturrate bereits nach einem Jahr Therapie für Risedronat vorliegen. Bei postmenopausalen Frauen mit Rheumatoider Arthritis sollte eine Hormonersatztherapie erwogen werden. Neben den antiresorptiven Strategien stehen alternativ osteoanabol wirksame Fluoride zur Verfügung, ohne dass deren Effekt auf die Frakturrate bisher zweifelsfrei belegt ist. Weniger zur Dauertherapie als vielmehr passager, etwa bei frischen Frakturen - empfehlen sich Calcitonin-Injektionen. Nur als Reservemedikamente sind in Anbetracht der derzeitigen Studienlage sowie unter Kosten-Nutzen-Abwägung Calcitonin-Nasenspray und Anabolika zu betrachten. Raloxifen, ein selektiver Estrogen-Rezeptor-Modulator, könnte demnächst das therapeutische Spektrum erweitern, ebenso wie Kombinationsstrategien der genannten Substanzen. Als neues osteoanaboles Therapieprinzip liegen erste klinische Erfahrungen für Parathormon bzw. dessen Analoga bei Glukokortikoid induzierter Osteoporose vor.

Specific drug therapy for osteoporosis in chronic inflammatory diseases of the musculoskeletal system

Systemic osteoporosis with an increased risk of fracture is a frequent concomitant complication of chronic inflammatory rheumatic diseases. From a pathogenetic point of view, systemically acting inflammatory mediators as well as therapeutically applied glucocorticoids play an important role by their direct action on bone and influence on calcium metabolism. Chronic systemic inflammation and/or necessary long-term glucocorticoid therapy are indications for a preventive strategy with substitution of calcium and vitamin-D. In case of high inflammatory activity or 1,25-dihydroxy-vitamin-D3-deficiency, active vitamin-D-metabolites (calcitriol, alfacalcidol) may be considered as well. Bisphosphonates are agents of first choice in established osteoporosis. At present, the most reliable data are available from controlled studies of risedronate already showing a significant reduction of fracture rate after one year of therapy. Hormone replacement therapy is appropriate in postmenopausal women with rheumatoid arthritis. Besides antiresorptive strategies, osteoanabolic fluorides can be used, but with their effect on fracture rate not being established yet. Injections of calcitonin can be recommended for temporary treatment, especially in case of acute fracture, rather than for long-term therapy. Considering current study data and the expected cost-benefit ratio, calcitonin nasal spray or anabolics should be considered as reserve drugs only. Raloxifene, a selective estrogen-receptor-modulator, as well as combination strategies of the mentioned drugs, could extend our therapeutic possibilities in future. First clinical experience is available for the treatment of glucocorticoid-induced osteoporosis with the parathyroid hormone and its analogues representing a new osteoanabolic principle.

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Prof. Dr. G. E. Hein

Leiter Rheumatologie & Osteologie
Klinik für Innere Medizin IV der FSU

Erlanger Allee 101
07740 Jena


Phone: +49-3641-939628

Fax: +49-3641-939269

Email: gert.hein@med.uni-jena.de

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