problendoПроблемы ЭндокринологииProblems of Endocrinology0375-96602308-1430Endocrinology Research Centre10.14341/probl2017636392-426problendo-8757Research ArticleОбзорыReviewsФедеральные клинические рекомендации по диагностике, лечению и профилактике остеопорозаRussian federal clinical guidelines on the diagnostics, treatment, and prevention of osteoporosishttps://orcid.org/0000-0002-5634-7877МельниченкоГалина АфанасьевнаMel'nichenkoGalina A.

Академик РАН, д.м.н., профессор, директор Института клинической эндокринологии, заместитель директора ФГБУ ЭНЦ по науке

MD, PhD, Professor, Academician of the RAS

teofrast2000@mail.ruhttps://orcid.org/0000-0002-6674-6441БелаяЖанна ЕвгеньевнаBelayaZhanna E.

Д.м.н., заведующая отделением нейроэндокринологии и остеопатий, Институт клинической эндокринологии

MD, PhD

jannabelaya@gmail.comhttps://orcid.org/0000-0001-7041-0732РожинскаяЛюдмила ЯковлевнаRozhinskayaLyudmila Ya.

Д.м.н., профессор, главный научный сотрудник отделения нейроэндокринологии и остеопатий

MD, PhD, Professor

rozh@endocrincentr.ruhttps://orcid.org/0000-0003-4739-4302ТоропцоваНаталья ВладимировнаToroptsovaNatalia V.

Д.м.н., заведующая лабораторией остеопороза, отдел метаболических заболеваний костей и суставов с центром профилактики остеопороза Минздрава России

MD, PhD

toroptsovan@mail.ruhttps://orcid.org/0000-0002-8931-4991АлексееваЛюдмила ИвановнаAlekseevaLyudmila I.

Д.м.н., заведующая отделом метаболических заболеваний костей и суставов с центром профилактики остеопороза МЗ РФ, заведующая лабораторией остеоартроза

MD, PhD

Alekseeva@irramn.ruhttps://orcid.org/0000-0001-9007-4123БирюковаЕлена ВалерьевнаBiryukovaElena V.

Д.м.н., профессор, кафедра эндокринологии и диабетологии

MD, PhD, Professor

lena@obsudim.ruhttps://orcid.org/0000-0003-1413-1549ГребенниковаТатьяна АлексеевнаGrebennikovaTatiana A.

Научный сотрудник отделения нейроэндокринологии и остеопатий

MD

grebennikova@hotmail.comhttps://orcid.org/0000-0002-0327-4619ДзерановаЛариса КонстантиновнаDzeranovaLarisa K.

д.м.н., главный научный сотрудник отделения нейроэндокринологии и остеопатий

MD, PhD

dzeranovalk@yandex.ruhttps://orcid.org/0000-0002-3135-9003ДревальАлександр ВасильевичDrevalAleksandr V.

д.м.н., профессор, заведующий отделением терапевтической эндокринологии, заведующий кафедрой эндокринологии факультета усовершенствования врачей, главный эндокринолог Московской области

MD, PhD, Professor

dreval@diabet.ruhttps://orcid.org/0000-0002-6736-9772ЗагороднийНиколай ВасильевичZagorodniyNikolay V.

Д.м.н, профессор, руководитель Клиники эндопротезирования на базе ЦИТО им. Н.Н. Приорова, заведующий кафедрой травматологии и ортопедии РУДН, заведующий кафедрой травматологии и ортопедии ФФМ МГУ, главный ортопед-травматолог г. Москвы

MD, PhD, Professor

Zagorodniy51@mail.ruhttps://orcid.org/0000-0002-3259-4443ИльинАлександр ВикторовичIl'yinAleksandr V.

Заведующий лабораторией клинической биохимии

MD

alexilin2005@yandex.ruhttps://orcid.org/0000-0002-7876-5105КрюковаИрина ВикторовнаKryukovaIrina V.

К.м.н., ассистент кафедры эндокринологии факультета усовершенствования врачей

MD, PhD, Assistant Professor

kiv200877@yandex.ruhttps://orcid.org/0000-0002-0143-0614ЛеснякОльга МихайловнаLesnyakOl’ga M.

Д.м.н., профессор кафедры семейной медицины, Президент Российской Ассоциации по остеопорозу

MD, PhD, Professor

olga.m.lesnyak@yandex.ruhttps://orcid.org/0000-0002-9783-3599МамедоваЕлизавета ОктаевнаMamedovaElizaveta O.

Научный сотрудник отделения нейроэндокринологии и остеопатий

MD

lilybet@mail.ruhttps://orcid.org/0000-0001-6759-8367НикитинскаяОксана АнатольевнаNikitinskayaOksana A.

К.м.н., старший научный сотрудник лаборатории остеопороза, отдел метаболических заболеваний костей и суставов с центром профилактики остеопороза Минздрава России

MD, PhD

nikitinskayaox@ya.ruhttps://orcid.org/0000-0001-6539-466XПигароваЕкатерина АлександровнаPigarovaEkaterina A.

К.м.н., ведущий научный сотрудник отделения нейроэндокринологии и остеопатий

MD, PhD

kpigarova@gmail.comhttps://orcid.org/0000-0002-2726-8758РодионоваСветлана СеменовнаRodionovaSvetlana S.

Д.м.н., профессор, руководитель научно-клинического центра остеопороза

MD, PhD, Professor

rod06@inbox.ruhttps://orcid.org/0000-0002-1763-0725СкрипниковаИрина АнатольевнаSkripnikovaIrina A.

Д.м.н, руководитель отдела профилактики остеопороза, профессор кафедры клинической и социальной гериатрии ФПКМР РУДН

MD, PhD, Professor

ISkripnikova@gnicpm.ruhttps://orcid.org/0000-0001-7965-9454ТарбаеваНаталья ВикторовнаTarbaevaNatalia V.

К.м.н., научный сотрудник консультативно-диагностического отделения, врач-рентгенолог

MD, PhD

ntarbaeva@inbox.ruhttps://orcid.org/0000-0002-8694-3880ФарбаЛеонид ЯковлевичFarbaLeonid Ya.

Врач-хирург травматологического отделения

MD

farbasurg@mail.ruhttps://orcid.org/0000-0001-9074-2291ЦориевТимур ТамерлановичTsorievTimur T.

Аспирант отделения нейроэндокринологии и остеопатий

MD

timur.tsoriev@gmail.comhttps://orcid.org/0000-0003-1966-0159ЧерноваТатьяна ОлеговнаChernovaTatiana O.

К.м.н., ведущий научный сотрудник отделения рентгенодиагностики и рентгеновской компьютерной томографии

MD, PhD

tatcher2@ya.ruhttps://orcid.org/0000-0003-2864-066XЮреневаСветлана ВладимировнаYurenevaSvetlana V.

Д.м.н., ведущий научный сотрудник отделения гинекологической эндокринологии

MD, PhD

syureneva@gmail.comhttps://orcid.org/0000-0002-7430-1207ЯкушевскаяОксана ВладимировнаYakushevskayaOksana V.

К.м.н., научный сотрудник отделения гинекологической эндокринологии

MD, PhD

Ykushox83@mail.ruhttps://orcid.org/0000-0002-8175-7886ДедовИван ИвановичDedovIvan I.

Академик РАН, д.м.н., профессор, директор ФГБУ «Национальный медицинский исследовательский центр эндокринологии» Минздрава России

MD, PhD, Professor, Academician of the RAS

dedov@endocrincentr.ru<p>ФГБУ &laquo;Национальный медицинский исследовательский центр эндокринологии&raquo; Минздрава России</p>Россия<p>Endocrinology Research Centre</p>Russian Federation<p>ФГБУ &laquo;Национальный медицинский исследовательский центр эндокринологии&raquo; Минздрава России</p>Россия<p>Endocrinology Research Centre</p> <p>&nbsp;</p> <p>&nbsp;</p>Russian Federation<p>ФГБНУ &laquo;Научно-исследовательский институт ревматологии им. В.А. Насоновой&raquo;</p>Россия<p>Research Institute of Rheumatology named after V.A. Nasonova</p>Russian Federation<p>ФГБОУ ВО &laquo;Московский государственный медико-стоматологический университет им. А.И. Евдокимова&raquo;</p>Россия<p>Moscow State University of Medicine and Dentistry named after A.I. Evdokimov</p>Russian Federation<p>ГБУЗ МО &laquo;Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского&raquo;</p>Россия<p>Moscows regional research clinical institute named after M.F. Vladimirskiy</p>Russian Federation<p>ФГБУ &laquo;Центральный научно-исследовательский институт травматологии и ортопедии им. Н.Н. Приорова&raquo;;&nbsp;ФГАОУ ВО &laquo;Российский университет дружбы народов&raquo;</p>Россия<p>Central Research Institute of Traumatology and Orthopedics named after N.N. Priorova; Peoples Friendship University of Russia</p>Russian Federation<p>ГБОУ ВПО &laquo;Северо-Западный государственный медицинский университет им. И.И. Мечникова&raquo; Минздрава России</p>Россия<p>North-Western State Medical University named after I.I. Mechnikov</p>Russian Federation<p>ФГБУ &laquo;Центральный научно-исследовательский институт травматологии и ортопедии им. Н.Н. Приорова&raquo; Минздрава России</p>Россия<p>Central Research Institute of Traumatology and Orthopedics named after N.N. Priorova</p>Russian Federation<p>ФГБУ &laquo;Государственный научно-исследовательский центр профилактической медицины&raquo; Минздрава России</p>Россия<p>National Research Center for Preventive Medicine; Peoples Friendship University of Russia</p>Russian Federation<p>ГБУЗ &laquo;Городская клиническая больница №13&raquo; Департамента здравоохранения Москвы</p>Россия<p>Municipal Clinical Hospital №13</p>Russian Federation<p>ФГБУ &laquo;Научный центр акушерства, гинекологии и перинатологии им. В.И. Кулакова&raquo; Минздрава России</p>Россия<p>Research Center for Obstetrics, Gynecology and Perinatology</p>Russian Federation201711022018636392426Copyright &#x00A9; Мельниченко Г.А., Белая Ж.Е., Рожинская Л.Я., Торопцова Н.В., Алексеева Л.И., Бирюкова Е.В., Гребенникова Т.А., Дзеранова Л.К., Древаль А.В., Загородний Н.В., Ильин А.В., Крюкова И.В., Лесняк О.М., Мамедова Е.О., Никитинская О.А., Пигарова Е.А., Родионова С.С., Скрипникова И.А., Тарбаева Н.В., Фарба Л.Я., Цориев Т.Т., Чернова Т.О., Юренева С.В., Якушевская О.В., Дедов И.И., 20172017Мельниченко Г.А., Белая Ж.Е., Рожинская Л.Я., Торопцова Н.В., Алексеева Л.И., Бирюкова Е.В., Гребенникова Т.А., Дзеранова Л.К., Древаль А.В., Загородний Н.В., Ильин А.В., Крюкова И.В., Лесняк О.М., Мамедова Е.О., Никитинская О.А., Пигарова Е.А., Родионова С.С., Скрипникова И.А., Тарбаева Н.В., Фарба Л.Я., Цориев Т.Т., Чернова Т.О., Юренева С.В., Якушевская О.В., Дедов И.И.Mel'nichenko G.A., Belaya Z.E., Rozhinskaya L.Y., Toroptsova N.V., Alekseeva L.I., Biryukova E.V., Grebennikova T.A., Dzeranova L.K., Dreval A.V., Zagorodniy N.V., Il'yin A.V., Kryukova I.V., Lesnyak O.M., Mamedova E.O., Nikitinskaya O.A., Pigarova E.A., Rodionova S.S., Skripnikova I.A., Tarbaeva N.V., Farba L.Y., Tsoriev T.T., Chernova T.O., Yureneva S.V., Yakushevskaya O.V., Dedov I.I.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.probl-endojournals.ru/jour/article/view/8757

Скрининг для выявления групп с высокой вероятностью переломов рекомендован с использованием алгоритма FRAX среди всех женщин в постменопаузе и мужчин старше 50 лет (A1). Рекомендуется устанавливать диагноз и назначать терапию остеопороза лицам с низкотравматическим переломом крупных костей скелета, и/или с высокой индивидуальной вероятностью основных низкотравматических переломов (FRAX), и/или при выявленном снижении МПК до –2,5 SD по Т-критерию в шейке бедра и/или поясничных позвонках (А1). Пациентам с болевым синдромом в спине, снижением роста на 4 см в течение жизни или на 2 см при регулярном медицинском контроле, принимающим глюкокортикоиды, больным с длительно некомпенсированным сахарным диабетом 2-го типа или на инсулинотерапии, а также c диагностированными переломами другой локализации рекомендовано проведение стандартного рентгенологического исследования позвоночника (Th4—L5) в боковой проекции для выявления компрессионных переломов тел позвонков (B1).

Проведение двухэнергетической рентгеновской денситометрии (DXA) рекомендовано лицам с индивидуальной 10-летней вероятностью переломов (FRAX) в интервале между низкой и высокой вероятностью переломов (B1). Результат трабекулярного костного индекса (ТКИ), полученный в ходе стандартной рентгеновской денситометрии, рекомендуется включать в алгоритм FRAX с целью повышения чувствительности метода (B1).

Лабораторные методы исследований рекомендуется проводить всем пациентам с впервые установленным диагнозом остеопороза, а также при неэффективности ранее назначенной терапии с целью дифференциальной диагностики с другими причинами повышенной хрупкости скелета (B1).

Для предупреждения низкотравматических переломов и повышения МПК у пациентов с остеопорозом в равной степени рекомендованы бисфосфонаты (БФ), или антитела к лиганду рецептора-активатора ядерного фактора каппа-бета (деносумаб), или аналоги паратгормона (терипаратид) (A1). Деносумаб также рекомендован для предупреждения потери костной массы и переломов при отсутствии костных метастазов у женщин, получающих терапию ингибиторами ароматазы по поводу рака молочной железы, и у мужчин с раком предстательной железы, получающих гормон-депривационную терапию (A1). Ввиду анаболического эффекта терипаратида рекомендуется его использовать в качестве первой линии терапии у пациентов с тяжелым остеопорозом, с уже имеющимися переломами тел позвонков в анамнезе, у лиц с крайне высоким риском низкотравматических переломов, пациентов с неэффективностью предшествующей терапии, а также непереносимостью альтернативного лечения (B1). Все препараты для лечения остеопороза рекомендуется назначать в сочетании с препаратами кальция и витамина D (A1).

Screening using the Fracture Risk Assessment Tool (FRAX) is recommended in all postmenopausal woman and mеn over 50 (A1) in order to identify individuals with high probability of fractures. It is recommended to diagnose osteoporosis and start treatment in patients with fragility fracture of large bones of the skeleton and/or high individual probability of major fragility fractures (FRAX) and/or detected decrease in bone mineral density (BMD) up to –2.5 T-score as assessed by DXA in the femoral neck and/or lumbar vertebrae (A1). Patients with back pain, lifetime height loss of 4 cm or height loss of 2 cm since a previous medical examination, those who receive glucocorticoids, patients with long lasting decompensated type 2 diabetes mellitus, or those receiving insulin therapy, as well as patients who were previously diagnosed with fragility fractures at the other sites are advised to underwent standard lateral X-ray imaging of the spine (Th4—L5) in order to verify the presence of compression vertebral fractures (B1).

Dual-energy X-ray absorptiometry (DXA) is recommended for individuals whose 10-year probability of major osteoporotic fracture (FRAX) falls within the medium risk group (B1). It is recommended to include the trabecular bone score (TBS) the FRAX algorithm in order to improve the sensitivity of this method (B1).

Laboratory testing is recommended for the differential diagnosis with other causes of increased skeletal fragility in all patients with newly diagnosed osteoporosis and when previously prescribed antiosteoporostic treatment was ineffective (B1).

Bisphosphonates (BPs), antibodies to receptor activator of nuclear factor kappa-beta ligand (RANKL) (denosumab), or parathyroid hormone analogue (teriparatide) are equally recommended to prevent fragility fractures and increase BMD in patients with osteoporosis (A1). Denosumab is also recommended to prevent BMD loss and fractures in females receiving aromatase inhibitors therapy for breast cancer and males with prostate cancer receiving hormone-deprivation therapy and having no bone metastases (A1). Since teriparatide has the anabolic effect, it is recommended as the first line treatment in patients with severe osteoporosis having history of vertebral fractures, in the individuals with very high risk of fragility fractures, or in the cases when antiresorptive treatment was ineffective (B1). All medications for treatment of osteoporosis are recommended in combination with calcium and vitamin D supplements (A1).

остеопорознизкотравматический переломминимальная травматяжелый остеопорозosteoporosisfragility fractureminimal traumasevere osteoporosisReferencesKanis JA, on behalf of the who scientific group. Assessment of osteoporosis at the primary health-care level. Technical Report. Sheffield (UK): University of Sheffield (UK), Who Collaboraiting Centre; 2007 [Cited 2017 Jun 29]. Available From: https://www.sheffield.ac.uk/FRAX/pdfs/WHO_Technical Report. pdfKanis JA, on behalf of the who scientific group. Assessment of osteoporosis at the primary health-care level. Technical Report. Sheffield (UK): University of Sheffield (UK), Who Collaboraiting Centre; 2007 [Cited 2017 Jun 29]. Available From: https://www.sheffield.ac.uk/FRAX/pdfs/WHO_Technical Report. pdfRaman-Wilms L. Guidelines for preclinical evaluation and clinical trials in osteoporosis. (Book Review). Ann Pharmacother. 1999;33(12):1377-1378. doi: 10.1177/106002809903301207Raman-Wilms L. Guidelines for preclinical evaluation and clinical trials in osteoporosis. (Book Review). Ann Pharmacother. 1999;33(12):1377-1378. doi: 10.1177/106002809903301207AAOS.org [Internet]. Rosemont (Il): American Association of orthopaedic surgeons; orthopaedic care of patients with fragility fractures. American Association of orthopaedic surgeon position statement, Doc. No. 1159, December 2009 [Revised 2016 Sep; Cited 2017 Jun 29]. Available From: https://www.aaos.org/uploadedFiles/1159%20)rthopaedic%20Care%20of%20Patients%20with%20Fragility%20Fractures.pdfAAOS.org [Internet]. Rosemont (Il): American Association of orthopaedic surgeons; orthopaedic care of patients with fragility fractures. American Association of orthopaedic surgeon position statement, Doc. No. 1159, December 2009 [Revised 2016 Sep; Cited 2017 Jun 29]. 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The authors declare that there are no conflicts of interest present.