RationalTherapeuticsinDiabetesMellitus糖尿病患者的合理治疗.pptVIP

Slide * of 10 From TT Brown, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide * of 10 From TT Brown, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide * of 10 IAS–USA Todd T. Brown, MD, PhDAssociate Professor of Medicineand EpidemiologyThe Johns Hopkins UniversitySchool of MedicineAtlanta, GA Challenges in the Management of Osteoporosis and Vitamin D Deficiency in the HIV-Infected Patient From TT Brown, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Pathophysiology and Risk Factors HIV Disease Factors Inflammation and Viral Proteins ↑ bone resorption ↓ bone formation Medication Factors Tenofovir Certain PIs (ATV/r) ART initiation (↓ 2-6% over 96 weeks) Pathophysiology and Risk Factors Patient-Related Factors Low Body Weight Smoking Alcohol Use Opiate Use Hepatitis C Co-infection Physical Inactivity Hypogonadism Low Vitamin D CID, October 2010 “we recommend a DXA scan for all HIV-infected post-menopausal women and men 50 years” Definitions Functional Definition (DXA)- WHO Definition Osteoporosis: T-score -2.5 Osteopenia: T-score= -1.0 to -2.5 Normal: T-score -1.0 ↑ Risk of fracture by 1.5-3.0 x for each SD decrease Caveats: Z-score (-2.0) used in men 50 years and premenopausal women BMD explains only about 50% of fracture risk 2008 US NOF Guidelines: Who to Treat* Those with hip or vertebral fractures Those with BMD T-scores ≤ -2.5 at the femoral neck, total hip, or spine by DXA Those with T-score b/t -1 and -2.5 (osteopenia) at above sites AND 10-year hip fracture probability ≥ 3% or 10-year all major osteoporosis-related fracture ≥ 20% based on FRAX model *applies to post-menopausal women and men ≥ 50 years Secondary Causes of Low BMD Vitamin D deficiency? 25 OH Vit D Hyperparathyroidism? PTH, Ca++ Subclinical Hyperthyroidism? TSH Hypogonadism? Males: Free Testosterone Phosphate wasting? Fractional Excretion of Phosphate Idiopathic Hypercalciuria? 24 hr Urinary Calcium Celiac Sprue? Tissue Transglutaminase Multiple Myel