골다공증 치료의 최신 지견: 누구를, 무엇으로, 얼마 동안 치료할 것인가?
Management of Osteoporosis: Who to Treat, What to Use, and for How Long?
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과거에 비해 우리는 골다공증의 치료의 영역에서 효능이 입증된 다양한 무기를 확보할 수 있게 되었다. 따라서 골절 위험이 높은 대상을 찾아내어 골절의 위험으로부터 보호하고자 하는 노력이 절실히 요구되고 있다. 골다공증의 치료의 중심이 되고 있는 비스포스포네이트는 골에 특이적이며 매우 짧은 반감기를 갖고 있어 타장기에 영향을 주지 않는 장점이 있으나 장기간 사용으로 인한 부작용들이 보고되고 있다. 지금 사용 중인 다양한 골다공증 치료제를 얼마 동안 사용할 것인가 하는 문제는 아직까지 결론이 없으나 현재까지의 임상 연구들의 증거를 바탕으로 칼시토닌을 제외한 골흡수 억제제의 경우 3-5년간 사용하는 것은 근거가 있으며 안전성에도 큰 무리가 없어 보인다. 5년 이상 alendronate를 투여한 연구에서 임상적 척추 골절 예방 등의 효과를 얻을 수 있는 고위험군을 찾아내려는 노력이 일부에서 있었으나 아직까지 비스포스포네이트 전체로 일반화하기는 어렵다. Denosumab은 현재까지 골량 증가 효과와 안전성이 우수하여 촉망받고 있다. 현재 개발 중인 cathepsin K 억제제, sclerostin 항체 등이 지금 사용 중인 약제보다 훨씬 우수한 효과와 안전성을 가진 약물로서 임상에 빨리 사용될 수 있기를 기대한다.
Abstract
Osteoporosis is a huge global problem both socially and economically- in the South Korea alone, in 2011 66 million dollar was spent on treatment and social care of the 773,000 osteoporotic patients- and therefore variable preventative and therapeutic approaches are keys to managing this problem within the aging population of today. This review discusses the main issues- who should be treated, what pharmacological agents should be used, and how long they should be administered- surrounding current osteoporosis management. Identifying patients at risk is challenging before they develop a fracture. Probability of fracture based on the Korea-adapted WHO algorithm should be used in making decision of treatment. Though bisphosphonates are the most commonly used drugs for the treatment of osteoporosis, the majority of data on fracture effect is from studies of 3 or 4 years. The long-term treatment should balance fracture efficacy against the risk of adverse events. Although evidence is limited regarding the risk of fracture with the continuation of bisphosphonate therapy, it might be useful to continue treat osteoporosis up to 10 years, to prevent vertebral fractures in the high risk elderly. There are currently no data to guide clinicians in determining who should continue treatment after 5 years. The duration of treatment and the agent selected should be based on individual assessment of risks and benefits and on patient preference.
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