强直性脊柱炎继发骨质疏松症诊断与治疗临床实践指南

浙江省医师协会骨质疏松与骨矿盐疾病专业委员会; 中国老年学和老年医学学会骨质疏松和骨内科分会

doi:10.16766/j.cnki.issn.1674-4152.003825

强直性脊柱炎继发骨质疏松症诊断与治疗临床实践指南

doi: 10.16766/j.cnki.issn.1674-4152.003825

基金项目:

国家中医药管理局-浙江省中医药管理局共建重点项目 GZY-ZJ-KJ-23047

详细信息

通信作者: 李涯松，E-mail：lysong2@163.com

中图分类号: R593.23 R681
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出版历程
- 收稿日期: 2024-11-16

Clinical practice guidelines for the diagnosis and treatment of osteoporosis secondary to ankylosing spondylitis

摘要

摘要: 强直性脊柱炎(AS)是一种以脊柱、骶髂关节等中轴关节受累为主的慢性炎症性疾病，AS可以并发多系统病变，其中继发性骨质疏松常见，目前国内外尚无相关诊治共识或指南。本指南由浙江省医师协会骨质疏松与骨矿盐疾病专业委员会、兰州大学循证医学中心、中国老年学和老年医学学会骨质疏松和骨内科分会联合牵头发起，采用英国牛津分级体系和国际实践指南报告标准(RIGHT)，就我国一线风湿免疫科、骨科医师关注的11个临床问题，给出了较为详细的循证推荐，旨在提高AS继发骨质疏松诊疗的科学性，提高以患者为中心的医疗服务质量。
- 强直性脊柱炎 /
- 骨质疏松 /
- 指南 /
- 证据质量与推荐强度分级
Abstract: Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton, including the spine and sacroiliac joints. AS can lead to multi-system complications, with secondary osteoporosis being common. Currently, there are no relevant consensus or guidelines on diagnosis and treatment domestically or internationally. This guideline was jointly initiated by the Zhejiang Medical Association Osteoporosis and Bone Mineral Disease Committee, the Evidence-Based Medicine Center of Lanzhou University, and the Osteoporosis Society of China Association of Gerontology and Geriatrics. It follows the Oxford grading system and the Reporting Items for Practice Guidelines in Healthcare (RIGHT), providing detailed, evidence-based recommendations on eleven clinical questions concerned by frontline rheumatologists and orthopedists in our country. The guidelines aim to strengthen the scientific basis for diagnosing and treating osteoporosis secondary to AS while improving the quality of patient-centered healthcare.
- Ankylosing spondylitis /
- Osteoporosis /
- Guidelines /
- Evidence Quality and Recommendation Strength Grading
证据组成员(按姓名拼音排序)： 黄跃(浙江中医药大学)，钱璐辛(浙江中医药大学)，施晓慧(桐乡市第一人民医院风湿免疫科)，王丽娟(浙江省人民医院风湿免疫科)，王天乐(浙江省人民医院风湿免疫科)，谢炫晓(浙江省人民医院风湿免疫科)，徐聪颖(浙江中医药大学)，许卓(浙江中医药大学)，钟扬(乐清市人民医院)。

首席专家： 李涯松(浙江省人民医院)，陈耀龙(兰州大学健康数据科学研究院)，王亮(中国人民解放军总医院第八医学中心)。

专家组成员(按姓名拼音排序)： 杜红卫(金华市中心医院风湿免疫科)，何岚(西安交通大学附属医院风湿免疫科)，洪盾(浙江省台州医院骨科)，黄萍(浙江省人民医院药学部)，李涯松(浙江省人民医院风湿免疫科)，李毅中(福建医科大学附属第二医院骨科)，厉小梅(安徽省立医院风湿免疫科)，寿张轩(浙江中医药大学附属第二医院药剂科)，童培建(浙江中医药大学附属第一医院骨科)，王宏智(嘉兴市第一医院风湿免疫科)，王亮(中国人民解放军总医院第八医学中心老年医学科)，吴华香(浙江大学医学院附属第二医院风湿免疫科)，徐三中(浙江大学医学院附属第一医院骨科)，应奇峰(浙江省人民医院骨质疏松中心)，袁义(宁波市第二医院骨科)，张学武(北京大学人民医院风湿免疫科)，张振春(临沂市人民医院风湿免疫科)，赵东宝(上海长海医院风湿免疫科)，朱剑(中国人民解放军总医院第一医学中心风湿免疫科)，朱小春(温州医科大学附属第一医院风湿免疫科)；卢亚新(患者代表)，黄海军(患者代表)。

方法学组成员： 李哲玮(兰州大学公共卫生学院)，李昊东(兰州大学公共卫生学院)，任亚轩(成都中医药大学智能医学学院)，王冰怡(兰州大学基础医学院)，张洁(兰州大学基础医学院)。

外审专家(按姓名拼音排序)： 黄烽(中国人民解放军总医院第一医学中心风湿免疫科)，田金徽(兰州大学循证医学中心)，徐卫东(上海长海医院骨科)，章振林(上海交通大学医学院附属第六人民医院骨质疏松科)。

秘书组成员： 李哲玮(兰州大学公共卫生学院)，王丽娟(浙江省人民医院风湿免疫科)，王涵(浙江省人民医院风湿免疫科)。

指南制订组成员

利益冲突 无

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图 1 AS-OP的诊断流程

Figure 1. Diagnostic Process for AS-OP

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表 1 英国牛津大学循证医学中心证据分级和推荐标准(2009版)

Table 1. Evidence grading and recommendation standards (2009) from the center for evidence-based medicine, University of Oxford

推荐意见	证据级别	描述
A	1a	同质随机对照试验的系统评价
	1b	单个随机对照试验(可信区间窄)
	1c	“全或无”的病例系列研究
B	2a	同质队列研究的系统评价
	2b	单个队列研究(包括低质量随机对照试验，如随访率 < 80%)
	2c	结果研究或生态学研究
	3a	同质病例-对照研究的系统评价
	3b	单个病例-对照研究
C	4	病例系列研究(包括低质量队列或病例-对照研究)
D	5	基于经验未经严格论证的专家意见或评论或基础实验

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表 2 AS分类诊断标准(1984年修订的纽约标准)

Table 2. AS classification diagnostic criteria (revised New York criteria, 1984)

临床标准		放射学标准
(1)下腰痛持续至少3个月，活动(而非休息)后可缓解		0级: 正常骶髂关节
(2)腰椎在垂直面和水平面的活动受限		Ⅰ级: 可疑或极轻微的骶髂关节炎
(3)胸廓活动度较同年龄、同性别的正常人减少		Ⅱ级: 轻度骶髂关节炎(关节边缘模糊，近关节区域硬化)
		Ⅲ级: 中度骶髂关节炎(关节边缘明显模糊，近关节区域硬化，关节间隙变窄，骨质破坏明显)
		Ⅳ级: 骶髂关节融合或完全强直，伴或不伴硬化
注：具备放射学标准单侧Ⅲ~Ⅳ级，或双侧Ⅱ~Ⅳ级骶髂关节炎，加上临床标准3条中至少1条可诊断AS。

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表 3 基于DXA测定BMD和/或脆性骨折的OP诊断标准

Table 3. Diagnostic criteria for OP based on DXA-measured BMD and/or fragility fractures

DXA测定BMD的分类标准(股骨颈、全髋、腰椎L_1~4)		脆性骨折诊断需具备以下3条
(1)对于绝经后女性、50岁及以上男性，T值诊断如下：正常BMD：T值≥-1.0 SD；骨质减少：-2.5 SD < T值< -1 SD；骨质疏松症：T值≤-2.5 SD；严重骨质疏松：T-值≤-2.5 SD+脆性骨折。		(1)无明确暴力损伤史或具有低能量损伤史(如从人站立或更低的高度跌倒为低能量损伤)。 (2)骨折影像学检查证据，包括X线平片、CT、MRI等。 (3)需要鉴别诊断，排除其他原因造成的骨折(如：骨肿瘤、内分泌代谢疾病等)。
(2)对于儿童、绝经前女性和50岁以前的男性，其BMD水平的判断建议用同种族的Z值(Z-score)表示。Z值≤-2.0 SD仅视为“低于同年龄段预期范围”或低骨量。BMD Z值越低提示发生病理性骨折的风险越高。

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