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The Effects of Combined Treatment of Alendronate Plus Active or Plain Vitamin D on the Vitamin D Metabolism and Bone Turnover Marker in Patients with Osteoporosis

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The Effects of Combined Treatment of Alendronate Plus Active or Plain Vitamin D on the Vitamin D Metabolism and Bone Turnover Marker in Patients with Osteoporosis

(Endocrinol Metab 25:305-309, 2010, Jee-Hoon Koo et al.)

장상아

가톨릭대학교 의과대학 내분비내과

Sang-Ah Chang

Department of Internal Medicine, The Cathollic University of Korea, Seoul, Korea Endocrinol Metab 26(1):106-107, March 2011

DOI: 10.3803/EnM.2011.26.1.106

LETTER

골다공증은폐경기여성이나노인에있어서만성질환중의하나 로노인인구의증가와함께유병률이급격히늘어나는질환입니다. 특히노인에있어서골다공성골절이나질환은개인생활의질을현 격히떨어드리고일상생활의자율성을위협하기에더욱그렇습니다. 이러한골다공증을치료하고그에따른골절을예방하기위하여 여러다른기전을가진골다공증약물들이사용되고있는데, 보통 은작용기전이다르더라도 환자에따라 한가지 종류의골다공증 약제를사용하고있습니다. 다른만성질환, 즉고혈압, 당뇨병, 악성 종양등이여러기전의약제를병합하여사용하는것에비해, 골다 공증에서는각각 다른기전의 골다공증약제를병합하여사용할 때더좋은효과를나타낸다는만족할만한임상연구가많지않기 때문이기도할것입니다.

최근몇년동안 vitamin D에대한새로운작용이많이밝혀지면

서, vitamin D가칼슘과인대사에관여하는것뿐만아니라, 근육의

힘과기능에작용하고, 뼈에도골형성을촉진하는등신경근육계 에대한여러작용을하는것이대두되었습니다[1,2]. 즉 vitamin D 의보충은단순히칼슘흡수를위한영양학적인보충뿐만이아니라, 골대사에좋은영향을주는것으로확인되었습니다[2]. 따라서골흡 수억제제에 vitamin D를병합하여사용할때, 골다공증치료에더 이익이되리라는것을추정할수있습니다.

그런데 vitamin D 제재에있어, 비활성형인 cholecaclferol보다는 활성형인 calcitriol이나 alfacalcidol 제재가생리적효과가더크다는 보고가있습니다. 즉활성형 vitamin D는근육이나뼈의 vitamin D

수용체에붙어서바로작용을일으키나, 비활성형 vitamin D는활성

화되는데있어서신장기능의영향을받고, 칼슘농도나 vitamin D 농도등에의한 negative feedback mechanism의적용을받으므로 활성화되는데제한점이있다는것입니다[3].

대한내분비학회지 25권 4호에 Koo 등의연구는골흡수억제제인

alendronate와활성형 vitamin D인 calcitriol 복합제인 Maxmarvil® 과 alendronate와 plain vitamin D 2800 U를포함한복합제 Fosa- maxPlus®를사용한군에서 vitamin D의 metabolism 및 bone turn- over marker를 1년동안관찰함으로써, 실제임상적치료에서 vita- min D 대사와 bone turnover marker에어떠한변화가있는가를본 의미있는연구라고할수있습니다. 그러나후향적연구라서여러 가지자료제시에한계가있는것같아아쉬운점이있습니다. 본연 구에대해몇가지궁금한것을여쭈어보려고합니다.

먼저두군에서 bone turnover marker나 vitamin D level 이외에 골밀도검사의변화라든가골절여부, 넘어짐의빈도등에대해보 셨는지알고싶습니다. 두약제의효과를비교해보시지는않으셨는 지요? 국외의연구에서도보여준바와같이활성형비타민인 alfacal- cidol을 alendronate에병합요법으로사용하였을때하루에 1000 uint의 plain vitamin D를병합하여사용한군보다골밀도증가및 골절의감소, 넘어지는빈도(falling event)가적었던것을보고하고 있어서[4] 이두약제의차이점이있었는지궁금합니다.

또한 Maxmavil®군에서는 25(OH) D는증가하지않으나 parathy- roid hormone (PTH) level이감소하였고, Fosamaxplus®군에서는 25(OH) D는증가하였으나 PTH level은변화가없었던것이 bone turnover marker의감소정도에영향을주었다고보시는지, 즉 Max- mavil®군에서 osteocalcin 수치가더감소한것으로나타나는것이 의미가있는것인지궁금합니다. 또이두군에있어서칼슘의보충 은어떻게하셨는지도궁금합니다.

마지막으로 Maxmavil®군과 FosamaxPlus®군에서기저연령에차

이가나면서, Maxmavil® 투여군의나이가더젊은것으로나타나고

있습니다. 흔히활성형 vitamin D의보충은신장기능이나, 근육기능 이나이가들수록감소하므로높은연령에더적합한것으로되어 있는데, 실제임상에서활성형 vitamin D 제재와 plain vitamin D 제

(2)

Combined Treatment of Alendronate Plus Vitamin D

DOI: 10.3803/EnM.2011.26.1.106

107

http://www.enm-kes.org 재를선택하는데있어서고려할만한좋은기준이있다면알려주시

면좋겠습니다.

각골다공증약제의임상적효과에대해좋은연구를수행하여 발표하여주신저자들께깊은감사드립니다.

참고문헌

1. Boland R: Role of vitamin D in skeletal muscle function. Endocr Rev 7:434-448, 1986

2. Cranney A, Horsley T, O’Donnell S, Weiler H, Puil L, Ooi D, Atkinson S,

Ward L, Moher D, Hanley D, Fang M, Yazdi F, Garritty C, Sampson M, Barrowman N, Tsertsvadze A, Mamaladze V: Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep):1-235, 2007

3. Ringe JD, Schacht E: Potential of alfacalcidol for reducing increased risk of falls and fractures. Rheumatol Int 29:1177-1185, 2009

4. Ringe JD, Farahmand P, Schacht E, Rozehnal A: Superiority of a com- bined treatment of Alendronate and Alfacalcidol compared to the combi- nation of Alendronate and plain vitamin D or Alfacalcidol alone in estab- lished postmenopausal or male osteoporosis (AAC-Trial). Rheumatol Int 27:425-434, 2007

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