1

ivane javaxiSvilis saxelobis Tbilisis saxelmwifo universiteti

xelnaweris uflebiT

nana xaCiZe

adiuvanturi (hormonaluri) Terapiis gavlena Zvlis

mineralur simkvriveze sarZeve jirkvlis kibos mqone

postmenopauzalur qalebSi

disertacia

doqtoris akademiuri xarisxis mosapoveblad medicinaSi

samecniero xelmZRvaneli - medicinis mecnierebaTa doqtori, profesori

elene giorgaZe

Tbilisi 2017 w.

ავტორის სტილი დაცულია

2

sarCevi

pirobiTi aRniSvnebi da Semoklebebi ----------------------------------------- 4

Sesavali ------------------------------------------------------------------------------ 5

kvlevis amocanebi ------------------------------------------------------------------------------ 7

naSromis mecnieruli da praqtikuli Rirebuleba ----------------------- 9

publikaciebi -------------------------------------------------------------------------------------- 9

disertaciis moculoba --------------------------------------------------------------------- 10

Tavi 1. literaturis mimoxilva.

1.1 osteoporozi: definicia da misi etio-paTogenezi------------------------ 11

1.2 osteoporozis klasifikacia --------------------------------------------------------- 18

1.3 osteoporozis klinikuri niSnebi --------------------------------------------------- 22

1.4Oosteoporozis diagnostikuri kriteriumi da riskis Sefaseba ------- 23

1.5. osteoporozis kvlevis meTodebi ----------------------------------------------------- 30

1.6. osteoporozis prevencia -------------------------------------------------------------------- 31

1.7. osteoporozis mkurnaloba ------------------------------------------------------------------- 34

1.8 osteoporozis gavrceleba onkologiur pacientebSi ---------------------- 39

1.9 sarZeve jirkvlis agebuleba da funqcionirebisaTvis

aucilebeli hormonebi--------------------------------------------------------------------------------------41

1.10 sarZeve jirkvlis kibos klasifikacia -------------------------------------------------- 47

1.11 sarZeve jirkvlis kibos gavrceleba ------------------------------------------------------- 50

1.12 sarZeve jirkvlis gamomwvevi risk-faqtorebi ----------------------------------------- 53

1.13 sarZeve jirkvlis kibos mkurnalobis meTodebi

ავტორის სტილი დაცულია

3

(da maTi ZiriTadi garTulebebi) ------------------------------------------------------ 57

Tavi 2 kvleva

2.1 Kkvlevis masala da meTodebi --------------------------------------------------------- 64

2.2Kkvlevis eTikuri aspeqtebi --------------------------------------------------------------- 65

2.3 miRebuli Sedegebi --------------------------------------------------------------------------- 65

2.3.1 Zms-is cvlileba pacientebSi sakvlevi jgufebis mixedviT

hormonaluri (adiuvanturi) mkurnalobis dawyebamde,

mkurnalobidan 1; 2 da 5 welSi ----------------------------------------------------------- 66

Tavi 3 miRebuli Sedegebis ganxilva -------------------------------------------------- 74

daskvna ---------------------------------------------------------------------------------------------------------- 78

kvlevis mokle SinaarSi inglisurad ------------------------------------------------------ 79

bibliografia --------------------------------------------------------------------------------------------- 83

ავტორის სტილი დაცულია

4

pirobiTi aRniSvnebi da Semoklebebi

sj - sarZeve jirkvali

Zms – Zvlis mineraluri simkvrive

bmp- bolo menstruaciis periodi

jmo- jandacvis msoflio organizacia

rad – rentgenologiuri absorbciuli densitometria

op – osteoporozi

ChT- CanacvlebiTi hormonaluri Terapiis

DXA_ ormagenergetikuli rentgenuli absorbciometria

SERMs _seleqtiuri estrogenis receptoris modulatorebi

AIs – aromatazas inhibitorebi

BMP- Zvlovani morfogenuli cilebi

ER - estrogenuli receptori

FRAX - motexilobis 10 wliani riskis gansazRvris algoriTmi

IGF- insulinis msgavs zrdis faqtors

OPG - osteoprotegerini

RANK - osteoklastebis birTvuli faqtori kappa B-s (NF-kB) receptoruli

aqtivatori

RANKL – RANK -is ligandi

SOS - ultrabgeris gavlis siCqare

TNF - simsivnis nekrozis faqtori

ავტორის სტილი დაცულია

5

Sesavali

Temis aqtualoba:

osteoporozi dRes erT-erT yvelaze aqtualur problemadaa miCneuli da

Tavis mniSvnelobiT meoTxe adgili ukavia gul-sisxlZarRvTa sistemis,

diabetis da onkologiuri daavadebis Semdeg (1,2,5).

Zvlovani sistebis es metaboluri daavadeba dabali Zvlovani masiT, Zvlis

arqiteqtonikis rRveviT, simyifis zrdiT da motexilobebis sixSiriT

xasiaTdeba. (6)

am daavadebis mimarT didi interesi im mxrivadac SeiZleba aixsnas, rom

osteoporozis fonze Zvlebis motexilobebis mkurnaloba did danaxarjebs

moiTxovs. mas agreTve Tan axlavs Sromis unarianobis dakargva, cxovrebis

xarisxis gauareseba da letalobis zrda (7,16).

osteoporoziT gamowveuli motexilobebi ufro xSiria vidre infarqti da

ZuZus kibo. 3 dan 1 qals da 5 dan 1 mamakacs aReniSneba osteoporozuli

motexilobis albaToba sicocxlis ganmavlobaSi (8-10).

osteoporoziT daavadebulia 200 milionze meti qali msoflioSi (3,4,

11,12,13,14). evropaSi, aSS-Si da iaponiaSi osteoporoziT daavadebulTa ricxvi

75 milions Seadgens (15). NHNHNES -is monacemebis mixedviT, aSS mosaxleobis

10 milions aqvs osteoporozi, xolo 34 milionze mets aReniSneba Zvlis

dabali masa, ris gamoc imyofeba osteoporozisa da osteoporozuli

motexilobis ganviTarebis riskis qveS. aqedan 80% qalia, umetesad,

postmenopauzuri asakis. dadgenilia, rom kavkasoiduri rasis yoveli meore

qali da mexuTe mamakaci ganicdis osteoporozul motexilobas sicocxlis

manZilze (N NOF, 2013). sicocxlis xangrZlivobis zrdasTan da mosaxleobis

daberebasTan erTad, prognozirebulia osteoporoziT daavadebulTa

ricxvis zrda.

ავტორის სტილი დაცულია

6

2000 wels, evropaSi 50 welze ufrosi asakis qalebsa da mamakacebSi

daregistrirda barZayis Zvlis motexilobis 620,000, winamxris _ 574,000, mxris

Zvlis proqsimaluri nawilis _ 250,000 da xerxemlis malebis _ 620,000 axali

SemTxveva. am motexilobebma Seadgines mTeli msoflios motexilobebis 34,8%.

garda aRniSnulisa, SesaZloa ganviTardes sxva midamoebis – menjis Zvlebis,

neknebis, barZayis Zvlis distaluri nawilis da wvivis Zvlis

osteoporozuli motexilobebic (7).

ukanasknel periodSi klinicistebisTvis Zalzed mniSvnelovani gaxda

meoradi osteoporozi. igi mravali faqtorebiT SeiZleba iyos gamowveuli.

onkologiuri daavadebis struqturaSi wamyvani poziciis gamo, rogorc

msoflioSi, aseve saqarTveloSi, ZuZus kibos problema aqtualuria misi

yvela aspeqtiT.

1) mas pirveli adgili uWiravs onkologiur daavadebaTa Soris, rogorc

msoflios umravles qveyanaSi, aseve saqarTveloSi.

2) dinamikaSi misi moculoba yovelwliurad izrdeba. 1995 wels yovel 100.000

qalze Cvens respublikaSi ZuZus kiboTi 44,4 avaddeboda.

3) uaxlesi monacemebiT 2005 wlisaTvis yovel 100.000-dan daavadebam miaRwia

48.8. jandacvis msoflio organizaciis bolo monacemebiT, mTel msoflioSi

kiboTi avaddeba 10.000.000 da iRupeba 6.000.000 avadmyofi, yovelwliurad ZuZus

kibos 540.000 axali SemTxveva vlindeba jandacvis msoflio eqspertTa

monacemebiT, ZuZus kibos yovelwliurma matebam 2005 wlisaTvis Seadgina

1.000.000-mde axali SemTxveva. TiTqmis yvela, ekonomikurad ganviTarebul

qveynebSi, ZuZus kibos pirveli adgili uWiravs avadobis maCveneblis

mixedviT.

Aadiuvanturi Terapia (qimioTerapia da hormonaluri), romelic farTod

gamoiyeneba am daavadebis marTvaSi uaryofiTad moqmedebs Zvlis mineralur

simkvriveze, rasac mivyavarT mis gamofitvamde da osteoporozamde. (17)

ავტორის სტილი დაცულია

7

preklinikuri kvlevebiT dadasturebulia ciklofosfamidis,

doqsorubicinis da metotreqsatis negatiuri gavleba Zvalze. qimioTerapiis

es preparatebi farTod gamoiyeneba sarZeve jirkvlis kibos mkurnalobaSi,

iwvveven sakvercxeebis disfunqcias da zrdian Zvlis masis danakargs

premenopauzalur qalebSi. qimioTerapiis dros premenopauzaSi myofi qalebis

70%- s uviTardebaT amenorea da naadrevi menopauza, romelic zrdis

osteoporozis da Zvlis motexilobebis risks.

mravali kvleva mimdinareobs agreTve ukanasknel periodSi postmeopauzaSi

myof qalebSi Zms-is Seswavlaze, romelTac utardebaT adiuvanturi -

hormonaluri Terapia. Sualedurma kvlevebma aCvenes, rom postmenopauzaSi

myofi qalebSi adiuvanturi (hormonaluri) Terapiis sxvadasxva medikamenti

gansxvavebulad moqmedeben Zms-ze.

aRniSnuli kvlevebis umravlesoba kvlavac mimdinarea da uaxloes periodSi

gamoqveyndeba Sedegebi.

Kkvlevis amocanebi

Cveni kvlevis mizania sarZeve jirklvis kibos dros adiuvanturi

(hormonaluri) mkurnalobis da Zvlis mineralur simkvrives Soris

urTierTkavSiris dadgena, osteoporozis da osteopeniis gavrcelebis

Seswavla postmenopauzaSi myof qalebSi, adiuvanturi (hormonaluri)

mkurnalobis dros postmenopauzis xangrZlivobis da medikamentebis

zegavlenis Sefaseba Zms-ze.

am miznis gansaxorcieleblad dasaxuli iqna Semdegi amocanebi:

1) Zvlis mineraluri simkvirivis cvlilebis Seswavla sarZeve jirkvlis

kibos mqone postmenopauzaSi myof qalebSi

2) Zvlis mineraluri simkvrivis cvlilebis Sefaseba sarZeve jirkvlis

kibos mkurnalobis (adiuvanturi, hormonaluri) dawyebamde, 1; 2 da 5 welSi.

ავტორის სტილი დაცულია

8

3) Zvlis mineraluri simkvrivis cvlilebis Sefaseba menopauzis

xangrZlivobis mixedviT adiuvantur (hormonalur) mkurnalobaze myof

pacientebSi.

4) korelaciuri kavSirebis dadgena welis malebsa da proqsimaluri

barZayis Zms-sa da menopauzis xangrZlivobasa da medikamentis saxeobas Soris

naSromis mecnieruli Rirebuleba

Cveni kvlevis SedegebiT gamovlenil iqna Zvlis mineraluri simkvrivis

daqveiTeba aromatazas inhibitorebiT mkurnalobis dros da agreTve

dadasturda Zms-s mateba postmenopauzalur asakSi tamoqsifeniT

mkurnalobisas.

warmodgenili naSromi saqarTveloSi pirveli mcdelobaa, dadgindes:

• osteopeniis da osteoporozis gavrcelebis sixSire sarZeve

jirkvlis kibos mkurnalobis dros;

• pirvelad iqna Seswavlili Zvlis mineraluri simkvrivis

maCveneblebis ormagenergetikuli rentgenuli absorbciometriis

meSveobiT adiuvanturi (hormonaluri) Terapiis dawyebamde,

mkurnalobis 1, me-2 da me-5 wels.

• pirvelad iqna dadgenili Zvlis mineraluri simkvrivis

gansxvavebuli raodenobrivi cvlileba kortikalur da

trabekulur ZvalSi adiuvanturi hormonaluri Terapiis dros.

maCveneblebis araerTgvarovneba ConCxis sxvadasxva fragmentSi

• pirvelad iqna dadgenili Zvlis mineraluri simkvrivis

gansxvavebuli raodenobrivi cvlileba kortikalur da

trabekulur ZvalSi menopauzis xangrZlivobis mixedviT

ავტორის სტილი დაცულია

9

naSromis praqtikuli Rirebuleba

ZuZus kibos mqone pacientebSi, romelTac utardebaT adiuvanturi

hormonaluri Terapia rekomendebulia Zms-s bazisuri maCveneblebis Seswavla

hormondeprivaciul Terapiamde da yovel momdevno wels, raTa im kontigents

romelTac aReniSnebaT Zms-s daqveiTeba osteopeniis tipiT daeniSnoT

antirezorbciuli mkurnaloba Semdgomi monitorirebi.

Ppublikaciebi

Khachidze N., GiorgadzeE., Tsagareli M., Adjuvant (hormonal) therapy as a reason of bone loss in

patients with breast cancer (review of literatute). Georgian Medical News No 1 (262) 2017

http://www.geomednews.org/

Nana Khachidze, Elene Giorgadze, Marina Tsagareli, Nino Dolidze, Tea Sulikashvvili. Effect of

Adjuvant (Hormonal) Therapy on Bone Mineral Density in Caucasian Women with Breast Cancer.

European Scientific Journal July 2017 edition Vol.13, No.18

URL:http://dx.doi.org/10.19044/esj.2017.v13n18p1

Khachidze N., Giorgadze E., Tsagareli M., Dolidze N. - Drug induced osteoporosis - review of

literature. Translational and Clinical Medicine – Georgian Medical Journal. Vol 2, Issue 2 (2017)

http://www.tcm.tsu.ge/index.php/TCM-GMJ/article/view/53

ავტორის სტილი დაცულია

10

disertaciis moculoba da struqtura

• disertacia warmodgenilia qarTul enaze, 102 gverdze; Sedgeba 3

Tavisagan; Seicavs daskvnebs da praqtikul rekomendaciebs.

• disertacia Seicavs gamoyenebuli literaturis sias (218

literaturuli wyaro), 13 cxrils, 2 diagramas, 3 suraTs.

ავტორის სტილი დაცულია

11

Tavi 1. literaturis mimoxilva.

1.1 osteoporozi- definicia da misi etio-paTogenezi

janmrTelobis msoflio organizaciis (janmo) ganmartebiT osteoporozi

daavadebaa, romelic Zvlovani masis SemcirebiTa da Zvlis qsovilis

mikroarqiteqtonikis gauaresebiT xasiaTdeba, rac zrdis Zvlis simyifesa da

motexilobis risks (18). (sur 1)

sur 1. Nnormaluri da osteoporozuli Zvlis agebuleba

osteoporozi, misi mZime klinikuri gamosavlebisa da masTan dakavSirebuli

mkurnalobis xarjebis gamo sazogadoebrivi jandacvis udides problemadaa

miCneuli.

janmo-s monacemebiT, aqtualurobis mixedviT osteoporozi meoTxe

adgilezea, iseTi daavadebebis Semdeg rogoricaa gulis iSemiuri daavadeba,

onkologia da Saqriani diabeti (Sd).

ავტორის სტილი დაცულია

12

asakis matebasTan erTad osteoporoziT avadoba izrdeba. osteoporozi

msoflioSi 200 milionze met adamians aReniSneba. osteoporozis evropuli

fondis monacemebiT evropaSi 75 milioni adamiania daavadebuli

osteoporoziT, xolo postmenopauzuri asakis qalTa 40-50% osteoporozuli

motexilobebis maRali riski gaaCniaT. aSS osteoporoziT daavadebulia 10

milioni adamiani da kidev 18 milions aReniSneba Zvlis dabali masa

xandazmuli mosaxleobis matebasTan erTad mosalodnelia osteoporozis

prevalirebis Semdgomi eskalacia. aSS-sa da evropis qveynebSi osteoporozi

menopauzis Semdgom periodSi qalebis 30%-s aReniSneba. maT 40%-s darCenili

sicocxlis manZilze, sul mcire, erTi motexiloba mainc uviTardeba.

evropaSi 2000 wels osteoporoziT gamowveuli motexilobebis mkurnalobis

pirdapiri xarji 32 miliard evros Seadgenda. mosaxleobis daberebis

tendenciis, osteoporozis prevalirebisa da motexilobis riskis zrdasTan

erTad 2050 wlisTvis am xarjebis orjer gazrdaa mosalodneli (19).

osteoporozis garTulebebTan dakavSirebuli mZime ekonomikuri da

socialuri tvirTi kidev erTxel adasturebs osteoporozis prevenciis,

adreuli diagnostikisa da mkurnalobis mniSvnelobas.

osteoporozi Zvlis remodelirebisa da rezorbciis fazebs Soris

balansis darRvevis Sedegia.

Zvali xrtilovan qsovilTan erTad qmnis ConCxovan sistemas. Zvlovani

qsovili organizmSi asrulebs sam ZiriTad funqcias _ meqanikur (qmnis

sayrden-mamoZravebel aparats), damcvelobiT (warmoadgens karkass

sasicocxlo mniSvnelobis organoebisaTvis, maT Soris Zvlis tvinisaTvis)

da metabolur (warmoadgens kalciumisa da fosforis depos da monawileobs

mTliani organizmis homeostazis SenarCunebaSi) funqciebs.

Zvlovani qsovili warmoadgens dinamiur sistemas, romelSic mTeli

sicocxlis ganmavlobaSi mimdinareobs remodelirebis procesi _ Zveli

qsovilis rRveva da axlis warmoSoba.

ავტორის სტილი დაცულია

13

Zvlis remodelirebis procesSi osteoblastebi, osteoklastebi (20) da

maTi winamorbedebi erTmaneTs sxvadasxva sasignalo molekulebis

saSualebiT ukavSirdebian. rezorbciaze pasuxs ageben osteoklastebi,

romlebic Tavis mxriv osteoblastebis mier sekretirebuli citokinebis

saSualebiT aqtiurdebian. osteoblastebi gamoimuSaveben da gamoyofen

rogorc RANKL-s, aseve osteoprotegerins (OPG) (32-33). RANKL aris

nuklearuli faqtori-kappa B-s (NF-kB) receptoruli aqtivatoris, RANK-is

ligandi hemopoetur ujredebSi da misi funqciaa osteoklastebis

diferenciaciis gaaqtiureba (23-26). osteoprotegerini ki aris aRniSnuli

receptoris konkurentuli inhibitori da xels uSlis RANK/RANKL

urTierTqmedebas, aqedan gamomdinare, aferxebs osteoklastebis

diferenciaciasa da cxovelmyofelobas. RANKL/OPG Soris balansis darRveva

ganapirobebs osteoporozis ganviTarebas. Zvlis rezorbciis

stimulatorebi zrdian RANKL-is eqspresias osteoblastebSi, zogierTi

amcirebs OPG-s eqspresiasac. RANK-RANKL urTierTkavSiri warmoadgens

osteoporozis nebismieri paTogenezuri faqtoris saboloo meqanizms (21-36).

RANKL-is inhibitorebi warmoadgenen osteoporozis samkurnalo saSualebaTa

uaxles klass (34).

Zvlis struqturis yovel calkeul erTeulSi remodelireba mimdinareobs

drois konkretul monakveTSi. bavSvobisa da mozardobis periodebSi Zvali

ganicdis masiur remodelirebas _ am dros Zvlis warmoqmnis procesi

sWarbobs rRvevas (rezorbcias). remodelirebis tempi asakis matebasTan

erTad sagrZnoblad iklebs. 25 wlis asakisaTvis Zvlovani masa piks aRwevs.

Zvlovani qsovilis dabali pikuri masis Camoyalibebaze mniSvnelovan

zegavlenas axdens menstrualuri funqciis darRveva da araswori kveba. 25-

dan 35 wlamde myardeba rezorbciisa da formirebis procesebs Soris

garkveuli balansi da Semdeg iwyeba Zvlovani masis kargvis periodi. ̂ Tavidan

es kargva umniSvneloa da weliwadSi udris 0,3-0,5% -s. qalebSi menopauzis

dadgomis dros es procesi Cqardeba da kargva aRwevs 2-3% -s weliwadSi. ase

grZeldeba 65-70 wlamde, ris Semdegac Zvlis masis kargvis procesi isev

ავტორის სტილი დაცულია

14

neldeba 0,3-0,5%-mde. mTlianobaSi icvleba Zvlis agebuleba da asakTan

dakavSirebuli moxucebulobiTi atrofiis Sedegad igi xdeba ufro myife.

remodelirebis procesSi aqtiur monawileobas Rebuloben sistemuri

hormonebi, romelTa moqmedebis meqanizmi moyvanilia cxrilSi №1.

Zvlovani remodelirebis sistemuri regulacia

cxrili №1

რეზორბცია ფორმირება ძვლის შენიშვნა

პარათირეოიდული ინარჩუნებს Ca-ჰომეოსტაზს რეზორბციის

ჰორმონი (პჰ) ↑ ↑(↓)

აქტივაციით. ოსტეობლასტები მალის

კოლაგენის სინთეზს აფერხებს

1,25(OH)2D3 ინარჩუნებს Ca-ჰომეოსტაზს და ძვლოვან

↑ ↑(↓)

ქსოვილს. მაღალ კონცენტრაციებში ძვლებში

კოლაგენის სინთეზს აფერხებს

კალციტონინი ოსტეოკლასტების აქტივობის ინჰიბიტორი

↓

ესტროგენები ანელებს ძვლის რემოდელირების პროცესს,

↓ (↓)

უპირატესად რეზორბციას

ანდროგენები ანაბოლურ ზეგავლენას ახდენს ძვლებზე.

↑

ტესტოსტერონის დეფიციტის დროს მამაკაცებში

ვითარდება ოპ

ზრდის ჰორმონი მოზრდილებში იწვევს ძვლის ცვლის

↑ ↑

დაჩქარებას, ბავშვებში და მოზარდებში ძვლის

ავტორის სტილი დაცულია

15

ზრდას უწყობს ხელს

თირეოიდული აჩქარებს ძვლის ცვლას. მათი სიჭარბე ძვლოვან

ჰორმონები ↑ ↑

დანაკარგებს იწვევს

გლუკოკორტიკო- ასტიმულირებს რეზორბციას, ამცირებს Ca

სტეროიდები (გკ) ↑ ↓

შეწოვას ნაწლავებში; აძლიერებს ძვლოვანი

უჯრედების მგრძნობელობას პჰ-მიმართ:

თრგუნავს ოსტეობლასტების აქტივობას

osteoporozi Zvlovani qsovilis generalizebul dazianebas iwvevs, ris

Sedegadac motexilobis aRmoceneba nebismier ubanSia mosalodneli.

daavadebis klasikuri mimdinareobisas gansakuTrebiT xSiria xerxemlis

gulmkerdisa da welis malebis, sxivis Zvlis distaluri da barZayis

proqsimaluri nawilis motexilobebi.

Zvlovani masis Semcireba da simyifis momateba SesaZloa ganviTardes,

Tu a) ver miiRweva optimaluri Zvlis pikuri masa da simtkice zrdis

periodSi; b) gaZlierebulia Zvlis rezorbcia, rac iwvevs Zvlovani masis

Semcirebas da mikroarqiteqturis darRvevas; g) araadeqvaturia formirebis

faza, ris gamoc ver xerxdeba dakarguli Zvlis adeqvaturi aRdgena.

estrogenebis deficiti kritikul rols asrulebs osteoporozis

paTogenezSi, rasac adasturebs faqti, rom postmenopauzur qalebs yvelaze

xSirad uviTardebaT osteoporozi (35,36). morfologiurma kvlevebma da

Zvlis metabolizmis bioqimiuri markerebis gansazRvram gviCvena, rom

menopauzis periodSi Cqardeba Zvlis remodelireba, imatebs rogorc

rezorbciis, ise formirebis markerebis done, Tumca estrogenis deficitis

pirobebSi wamyvan rols asrulebs rezorbciis gazrda. estrogenebis

deficiti monawileobs Zvlis kargvaSi qalebSi 70-80 wlis asakSic, rasac

ავტორის სტილი დაცულია

16

adasturebs faqti, rom estrogenebiT mkurnaloba swrafad amcirebs Zvlis

kargvas aseT pacientebSi. motexilobis riski ukuproporciul kavSirSia

estrogenis SemcvelobasTan postmenopauzuri asakis qalebSi (28).

estrogeni kritikul rols TamaSobs pubertatul periodSi, orive

sqesis mozardebis epifizebis daxurvaSi da aregulirebs Zvlis cvlas

rogorc qalebSi, ise mamakacebSi. estrogeni ufro metad ganapirobebs Zvlis

rezorbciis Seferxebas mamakacebSi, vidre androgeni, Tumca savaraudod

androgenic TamaSobs garkveul rols. estrogeni aseve aucilebelia Zvlis

pikuri masis miRwevisTvis mamakacebSi. ufro metic, hipoestrogenemia

mamakacebSi dakavSirebulia osteoporozTan.

estrogeni moqmedebs ori receptoris saSualebiT, esenia: estrogenuli

receptori alfa (ERα) da estrogenuli receptori beta (ERβ). dadgenilia,

rom ERα aris estrogenebis moqmedebis ZiriTadi mediatori Zvalze (31).

garda pirdapiri zemoqmedebisa Zvlis ujredebze, estrogenebi

moqmedeben sxvadasxva citokinebze, romlebic Tavis mxriv aregulireben

osteoklastebis warmoqmnas da funqcionirebas. estrogenebis deficitis

dros izrdeba monocitebis mier simsivnis nekrozis faqtoris (TNF)

produqcia da osteoblasturi rigis ujredebi ufro mgrZnobiare xdeba

interleikin-1-is (IL-1) zemoqmedebis mimarT (37,38). IL-1 da TNF astimulireben

stromul ujredebs da pre-osteoblastebs, yvela es faqtori astimulirebs

osteoklastebis warmoqmnas da amcirebs maTY apoptozs. estrogenebis

deficiti aseve uaryofiTad moqmedebs osteoprotegerinze (32).

asakobriv Zvlis kargvaSi monawileoben sxva hormonebic.

paraTireoiduli hormonis (PTH) done izrdeba asakTan erTad, rac

savaraudod dakavSirebulia kalciumis da D vitaminis miRebis deficitsa da

daqveiTebul kuW-nawlavismier absorbciasTan. meoradi hiperparaTireozi da

D vitaminis deficiti ara mxolod aCqarebs Zvlis kargvas, aramed arRvevs

ავტორის სტილი დაცულია

17

nerv-kunTovan funqciebsac, rac zrdis davardnis da Sesabamisad,

motexilobis risks.

klinikurma kvlevebma, romlebSic CarTuli iyo kalciumis da D

vitaminis deficitis riskis mqone xandazmuli pacientebi, gviCvena, rom

orives Canacvlebas mohyva meoradi hiperparaTireozis ukuganviTareba, Zvlis

rezorbciis Semcireba, Zvlovani masis gazrda, motexilobebis ricxvis

Semcireba, da davardnis sixSiris Semcirebac ki. (39-42)

genetikuri faqtorebi ganapirobeben rogorc Zvlis pikur masas, ise

Zvlis asakobriv kargvas. dadasturebulia tipi 1 kolagenis, estrogenis

receptoris, D vitaminis receptoris da osteoprotegerinis makodirebeli

genebis roli am procesSi. bolo periodSi aRmoCnda, rom dabali simkvrivis

lipoproteinis receptorTan SekavSirebuli cila-5-is (LRP-5) genis

gamaaqtivebelma mutaciam SesaZloa gamoiwvios Zvlis simkvrivis gazrda,

xolo LRP-5 genis delecia iwvevs mZime osteoporozul sindroms (31).

garda sistemuri hormonebisa, Zvlis cvlaSi monawileoben lokaluri

faqtorebi anu citokinebi. insulinis msgavs zrdis faqtors (IGF) da simsivnis

zrdis faqtors (TGF-β) SeuZlia Secvalos Zvlis formireba. IGF-1-is

lokaluri produqciis Seferxeba aris glukokortikoidebiT gamowveuli

osteoporozis mniSvnelovani faqtori.

prostaglandini E2 (PGE2) aris Zvlis mier gamomuSavebuli ZiriTadi

prostaglandini, romelic astimulirebs rogorc rezorbcias, ise

formirebas. Zvlis mineralur simkvriveze aseve gavlenas axdenen citokinebi:

IL-1, IL-6, TNFa da maTi receptorebis polimorfizmi. epidemiologiuri

kvlevebiT gamovlinda Zms-is mcire zrda da motexilobis riskis Semcireba

pacientebSi, vinc mkurnalobdnen arasteroiduli anTebis sawinaaRmdego

saSualebebiT.

ავტორის სტილი დაცულია

18

Zvlis remodelirebaSi monawileoben aseve Zvlovani morfogenuli

cilebi (BMP), romlebic ainducireben Zvlis warmoqmnas. BMP-s receptorebi

aRmoCenilia osteoblastebis winamorbedi ujredebis zedapirze.

1.2Oosteoporozis klasifikacia

etiologiis mixedviT ganasxvaveben pirvelad da meorad osteoporozs.

gamoiyofa pirveladi osteoporozis oTxi tipi:

1. iuveniluri osteoporozi-SesaZloa ganviTardes prepubertatul

periodSi orive sqesis pirebSi;

2. idiopaTuri osteoporozi-diagnostirdeba axalgazrdebSi,

rodesac osteoporozis gamomwvevi meoradi mizezis identificireba ver

xerxdeba;

3. postmenopauzis asakis osteoporozi-aRiniSneba qalebSi

klimaqteriuli periodis dawyebidan 15-20 wlis ganmavlobaSi;

4. seniluri osteoporozi-aRiniSneba xandazmulebSi.

meoradi osteoporozi dakavSirebuli sxvadasxva daavadebebsa da

paTologiur mdgomareobebTan, agreTve zogierTi medikamentis moqmedebasTan

(43-52) .

meoradi osteoporozis mizezebi naCvenebia cxrilSi #2

ავტორის სტილი დაცულია

19

cxrili #2

meoradi osteoporozis mizezebi

revmatiuli da autoimunuri

daavadebebi

maankilozebeli spondiliti,

wiTeli mglura, revmatoiduli

arTriti

endokrinuli darRvevebi hiperparaTireozi,

hiperkorticizmi, hipogonadizmi,

Tireotoqsikozi, Saqriani diabeti

tipi 1 da sxv.

Tirkmlis daavadebebi Tirkmlis qronikuli ukmarisoba,

milakovani acidozi da sxv

medikamentebi glukokortikoidebi, heparini,

varfarini, antikonvulsantebi,

metotreqsati, liTiumi, aluminis

Semcveli antacidebi, aromatazas

inhibitorebi da sxv

sisxlmbadi sistemis darRvevebi leikemiebi da limfomebi,

namglisebrujredovani anemia,

Talasemia da sxv

hipogonaduri mdgomareobebi anoreqsia nevroza,

hiperprolaqtinemia,

panhipopituitarizmi, naadrevi

klimaqsi, terneris da

klainfelteris sindromi da sxv.

genetikuri daavadebebi,

SemaerTebelqsovilovani

daavadebebi

cisturi fibrozi, elers-danlosis

daavadeba, glikogenis dagrovebis

daavadebebi,

marfanis sindromi, arasruli

osteogenezi da sxv.

ავტორის სტილი დაცულია

20

cnobilia osteoporozis klasifikaciis ramdenime varianti. janmo

osteoporozis klasifikacias Zvlis mineraluri simkvrivis safuZvelze

axdens.

Zvlis mineraluri simkvrive Zvlis skanirebuli zedapiris erT kvadratul

santimetrze gramebSi mineralebis absoluturi odenobiT gamoixateba

(g/sm2). Zvlis mineraluri simkvrivis SefasebisTvis or sazoms iyeneben:

1. Z-maCvenebeli-asaxavs gansxvavebas konkretuli asakisa da sqesis

pacientebis mosalodnel, normalur maCvenebelsa da faqtiur maCvenebels

Soris;

2. T-maCvenebeli-asaxavs gansxvavebas imave sqesis axalgazrda pacientis

normalur da faqtiur maCveneblebs Soris.

es gansxvaveba saSualo maCveneblidan standartuli gadaxdiT (deviaciiT)

izomeba. Cveulebriv, 1 standartuli gadaxra Zvlis mineraluri simkvrivis

10%-dan 15%-mde meryeobs.

axalgazrda asakSi Zvlis mineraluri simkvrivis saSualo maCveneblisagan

standartuli deviaciis Sefasebis safuZvelze gamoiyofa normis,

osteopeniisa da osteoporozis mdgomareoba. Zvlebis mineraluri

simkvrivis daqveiTeba mozrdili asakis adreuli periodidan iwyeba.

menopauzis asakis qalebSi procesi gansakuTrebiT intensiur xasiaTs iRebs

da orive sqesis pirebSi menopauzis Semdgom, xandazmulobis periodSic

grZeldeba. Zvlis mineraluri simkvrivis Sefasebisas normasTan SedarebiT

gansxvavebis zrdasTan erTad motexilobis riski izrdeba

ავტორის სტილი დაცულია

21

ცხრილი 3. ოსტეოპოროზის კლასიფიკაცია ძვლის მინერალური სიმკვრივის საფუძველზე

ნორმა

ძვლის მინერალური სიმკვრივე ახალგაზრდა ასაკის საშუალო მაჩვენებელთან შედარებით მხოლოდ 1 სტანდარტული გადახრით (სტანდარტული დევიაციით)

T score ≥-1.

ოსტეოპენია

ძვლის მინერალური სიმკვრივე ახალგაზრდა ასაკის საშუალო მაჩვენებლისაგან განსხვავებით 1-დან 2.5 სტანდარტულ გადახრამდე მერყეობს

T score -1-სა და -2.5 შორისაა

ოსტეოპოროზი

ძვლის მინერალური სიმკვრივე ახალგაზრდა ასაკის საშუალო მაჩვენებელთან შედარებით 2.5 სტანდარტული გადახრით (სტანდარტული დევიაციით)

T score ≤-2.5.

მძიმე ოსტეოპოროზი ერთი ან რამდენიმე მოტეხილობის ანამნეზით.

ოსტეოპოროზი

aRsaniSnavia is garemoeba, rom riskis amgvari stratifikacia marTebulia

mxolod qalebisTvis. rac Seexeba mamakacebs, uaxlesi periodis kvlevebiT

vlindeba, rom SesaZlebelia mamrobiTi sqesis normebTan am meTodis

adaptireba. Tumca sayovelTao SeTanxmeba am sakiTxze jerjerobiT ar

arsebobs.

ავტორის სტილი დაცულია

22

1.3 osteoporozis klinikuri niSnebi

osteoporozi xSirad usimptomod an xerxemlis yru tkiviliT mimdinareobs

da mxolod pirveli motexilobis Semdeg iqcevs pacientisa da samedicino

personalis yuradRebas. paTologiuri motexilobebi osteoporozis

yvelaze TvalsaCino klinikuri niSania (53). ziandeba xerxemali da barZayi.

SedarebiT iSviaTia neknebis, winamxrisa da wvivis Zvlebis dazianeba.

osteoporozis adreuli simptomi xSirad zurgis mwvave tkivilis epizodia,

romelic Cveuli fizikuri datvirTvis Sesrulebisas viTardeba (mag. win

daxra, fanjris gaReba, adgoma, umniSvnelo simZimis aweva da a.S.) da

xerxemlis malebis kompresiuli motexilobiTaa ganpirobebuli (54).

pacienti zustad asaxelebs tkivilis dawyebis moments. Tumca uWirs

tkivilis lokalizaciis konkretulad miTiTeba. xerxemlis motexilobis

Sedegad izRudeba Tavisufali moZraobis unari. tkivili mjdomare an fexze

mdgom mdgomareobaSi Zlierdeba, xolo horizontalur poziciaSi

sustdeba. pacienti cdilobs nela iaros, Tumca siarulis sxva saxis

darRvevebi ar aRiniSneba.

malis mwvave motexilobis gamo adgili aqvs paravertebraluri kunTebis

spazms, ris Sedegadac SesaZlebeli xdeba maTi vizualizacia da palpacia.

motexilobebs Soris periodSi pacientebs Civilebi, Cveulebriv, ar

aReniSnebaT. Tumca zogierTi maTgani mudmivad uCivis welis yru tkivils,

gansakuTrebiT fexze xangrZlivi dgomis Semdeg.

xerxemlis kompresiul motexilobas, rogorc wesi, Tan ar axlavs

nevrologiuri simptomkompleqsi. nevrologiuri simptomebis

manifestirebisas aucilebelia iseTi paTologiebis gamoricxva, rogoricaa

Zvlis metastazuri an pirveladi kibo, mieloma, pejetis daavadeba an

limfoma.

ავტორის სტილი დაცულია

23

malebis kompresiuli motexilobis fonze mosalodnelia gulmkerdis

kifozisa da welis lordozis Camoyalibeba.

rig SemTxvevebSi, osteoporozi aravertebraluri motexilobebiT

manifestirdeba. es motexilobebi, Cveulebriv, mcire travmiTaa gamowveuli.

asakis matebasTan erTad barZayis yelis osteoporozuli motexilobebis

insidentoba izrdeba.

motexiloba osteoporozis yvelaze xSiri da saxifaTo garTulebaa.

darCenili sicocxlis manZilze osteoporozuli motexiloba 50 wlis

zemoT yovel meore qalsa da rvidan erT mamakacSia mosalodneli.

osteoporoziTaa ganpirobebuli xandazmulebSi barZayisa da xerxemlis

motexilobebis 90%.

Zalian maRalia barZayis motexilobasTan dakavSirebuli daavadebianobisa

da sikvdilobis finansuri, socialuri da moraluri tvirTi. aRsaniSnavia,

rom barZayis yelis motexilobis Semdeg momdevno erTi wlis manZilze

sikvdilobis maCvenebeli 20-24%-s Seadgens. aranakleb sayuradReboa

xerxemlis motexilobis gamosavlebi, rac xSirad tkivilis gamo Sromis

unaris mniSvnelovani daqveiTebisa da uunarobis mizezi xdeba.

1.4Oosteoporozis diagnostikuri kriteriumi da riskis Sefaseba

osteoporozis diagnozi anamnezs, risk-faqtorebis identificirebas,

fizikalur gasinjvasa da Zvlis mineraluri simkvrivis gansazRvras

emyareba. osteoporozTan asocirebuli riskis Sefaseba klinikuri

simptomkompleqsis safuZvelze rekomendebulia postmenopauzis asakis

qalebsa da 50 wlis zemoT mamakacebSi. Zvlis densitometriis aucilebloba

winaswari klinikuri Sefasebis Sedegad dgindeba.

ავტორის სტილი დაცულია

24

prevenciuli praqtikis warmatebuli ganxorcielebisTvis aucilebelia

erTis mxriv osteoporozis, xolo meores mxriv osteoporozuli

motexilobebis riskis Sefaseba.

osteoporozis prevenciasa da droul mkurnalobas arTulebs misi

asimptomuri mimdinareoba, ris gamoc daavadebis diagnostireba xSirad

mxolod pirveli motexilobis Semdeg xdeba. osteoporozis Tavidan

acilebisa da drouli mkurnalobisaTvis saWiroa im faqtorebis

gaTvaliswineba, romelic xels uwyobs mis ganviTarebas (cxrili 3).

osteoporozis aramodificirebadi risk-faqtorebi

a) asaki

daberebis procesSi Zvlis mineraluri masa mcirdeba da, Sesabamisad,

osteoporozis riski matulobs. 60 wlis Semdeg yovel momdevno dekadaSi

osteoporozis riski mniSvnelovnad izrdeba. amerikis SeerTebuli

Statebis janmrTelobisa da kvebis erovnuli kvlevis mesame fazis

SedegebiT gamovlinda, rom osteoporozi 50-59 wlis TeTrkaniani qalebis

27%-s, 60-69 wlis asakSi 32%-s, xolo 70 wlis zemoT qalebis 41%-s

aReniSneba.

b) sqesi

qalebSi Zvlis masa bunebrivad mcirea. amas emateba menopauzis periodSi

Zvlis mineraluri simkvrivis swrafi daqveiTeba, rac ganapirobebs qalebSi,

mamakacebTan SedarebiT osteoporozis maRal risks. mamrobiTi sqesis

pirebSi Zvlovani masis klebis intensivoba gacilebiT dabalia, Tumca es

ar amcirebs am jgufSi osteoporozis prevenciis mniSvnelobas. magaliTad,

fremingemis osteoporozis kvlevaSi qalebSi Zvlovani masis klebis

intensivoba 0.86-1.21% iyo, xolo mamakacebSi 0.04-0.9%-s ar aRemateboda.

ავტორის სტილი დაცულია

25

mamakacebSi SedarebiT xSiria meoradi osteoporozi, rac SemTxvevaTa

40%-s Seadgens.

g) reproduqciuli faqtorebi

mecnieruli monacemebiT dasturdeba, rom adreuli menopauzis SemTxvevaSi

Zvlis mineraluri simkvrive gacilebiT swrafad iklebs. amis gamo, qalebi

adreuli menopauzis anamneziT osteoporozis maRali riskis jgufs

miekuTvnebian.

monacemebi Zvlis mineraluri masis moculobasa da sxva reproduqciul

funqciebs (mag. Svilosnoba, abortebis raodenoba, ZuZuTi kveba) Soris

kavSirze naklebad damajerebelia da specifikuri rekomendaciebis

Camoyalibebis saSualebas ar iZleva.

qalebSi estrogen-CanacvlebiTi Terapiis fonze, imave asakis sxva qalebTan

SedarebiT, Zvlis mineraluri simkvrive maRalia, rac osteoporozis

SedarebiT dabal riskze miuTiTebs.

d) osteoporozis ojaxuri anamnezi

osteoporozis ojaxuri anamnezi gulisxmobs pirveli rigis naTesavebSi

osteoporozis, kifozis da 50 wlis Semdeg umniSvnelo travmiT gamowveuli

motexilobebis anamnezs. zogadad, osteoporozis ojaxuri anamnezi ufro

sensitiuri maCvenebelia, vidre cal-calke dedis an mamis anamnezi (55-58).

ავტორის სტილი დაცულია

26

osteoporozis modificirebadi risk-faqtorebi

a) wona

wonis mkveTri dakleba da sxeulis masis indeqsis dabali

maCvenebeli Zvlis mineraluri simkvrivis klebas miuTiTebs.

osteoporozis riski gansakuTrebiT maRalia postmenopauzis asakis

qalebSi sxeulis masis indeqsis dabali maCvenebliT (59-63).

b) Tambaqos moweva

osteoporozisa da motexilobis riskze nikotinis mavne zemoqmedebis

Semswavleli kvlevebis meta-analiziT gamovlinda, rom menopauzis Semdgom

periodSi mwevelebSi, aramwevelebTan SedarebiT, Zvlis mineraluri

simkvrive yovel aTwleulSi 2%-iT naklebia. 80 wlis asakSi es gansxvaveba

6%-s aRwevs (64-67).

mwevel qalebSi barZayis motexilobis riski Tambaqos mowevis intensivobis

Sesabamisad izrdeba. mowevis SewyvetasTan erTad osteoporozis riski

mcirdeba, Tumca mniSvnelovani Sedegi mxolod aTi wlis Semdeg aRiniSneba.

g) alkoholi

alkoholsa da osteoporozis riskis Taobaze Catarebuli kvlevebis

Sedegebi urTierTsapirispiro da naklebad sarwmunoa. unda aRiniSnos, rom

am kvlevebSi alkoholis Warbad momxmarebeli pirebi ar monawileobdnen

(68-69).

d) varjiSi

kanadasa da italiaSi axalgazrda (18-35 weli) da Suaxnis asakis qalebSi

Catarebuli kvlevebiT dadginda, rom regularuli fizikuri datvirTva

pozitiur korelaciaSia Zvlis mineralur simkvrivesTan. postmenopauzis

ავტორის სტილი დაცულია

27

asakis inglisel qalebSi dadasturda, rom varjiSi xels uwyobs Zvlis

mineraluri simkvrivis SenarCunebas. 50-75 wlis norvegiel qalebSi

regularuli fizikuri aqtivobis fonze aRiniSna motexilobebis dabali

maCvenebeli, im qalebTan SedarebiT, vinc varjiSis reJims ar icavda.

avstraliaSi Catarebuli kvleviT monacemTa sawyisi analizis Sedegad

varjiSsa da Zvlis mineralur simkvrives Soris pozitiuri damokidebuleba

gamovlinda. Tumca asaki, sxeulis masis indeqsisa da kalciumis moxmarebis

gaTvaliswinebis Semdeg Sedegebi statistikurad mniSvnelovani ar

aRmoCnda.

e) dieta

menopauzis asakamde rZiT mdidari dieta pozitiur korelaciaSia Zvlis

mineralur simkvrivesTan (45-49). stokholmSi 80 wels gadacilebul

arainstitucionizebul xandazmul qalebSi Zvlis mineraluri simkvrive

dadebiT korelaciaSi aRmoCnda D vitaminis miRebasTan. mniSvnelovani

urTierTkavSiri sxva dietur faqtorebsa da Zvlis mineralur simkvrives

Soris dadgenili ar aris.

v) dacemis riski

ramdenadac osteoporoziT gamowveuli motexilobebis didi nawili

dacemis Sedegia, mniSvnelovania dacemis riskis Sefaseba (cxrili 4). maT

Soris yvelaze sayuradReboa dacemis anamnezi, kunTovani sisuste,

wonasworobis darRveviT mimdinare daavadebebi da mxedvelobis daqveiTeba.

ავტორის სტილი დაცულია

28

cxrili 4 dacemis risk-faqtorebi

გარემო პირობები ზოგადი სამედიცინო რისკ-ფაქტორები

საყრდენი ხარიხების/მოწყობილობის არ არსებობა ასაკი

ცუდი განათება შფოთვა და აჟიტირებული მდგომარეობა

ფეხის დაცურების საშიშროება არითმია

ავეჯის ისეთი განლაგება, რაც აფერხებს თავისუფალ დეჰიდრატაცია

გადაადგილებას

ნევროლოგიური და ძვალ-კუნთოვანი რისკ- დეპრესია

ფაქტორები

კიფოზი მდედრობითი სქესი

წონასწორობის დარღვევა მოძრაობის უნარის შეზღუდვა

პერიფერიული მგრძნობელობის დაქვეითება კვებითი დეფიციტი

კუნთების სისუსტე სედაციის გამომწვევი მედიკამენტები (ნარკოტიკული

ანალგეზიური, კრუნჩხვის საწინააღმდეგო და

ფსიქოტროპული პრეპარატები)

სხვა რისკ ფაქტორები ორთოსტატიკული ჰიპოტენზია

დაცემის შიში მხედველობის გაუარესება

წარსულში დაცემის შემთხვევები

ცნობიერების გაუარესება

zemoaRniSnulidan yvelaze kritikuli risk-faqtorebi gamoyenebulia

janmos-s motexilobis 10-wliani riskis Sefasebis modelSi. am faqtorebis

arseboba, Zvlis mineraluri simkvrivis maCveneblis miuxedavad,

motexilobis maRal riskze miuTiTebs, amdenad maTi gaTvaliswineba

pacientis klinikuri mdgomareobis Sefasebisas gansakuTrebiT

mniSvnelovania (cxrili 5).

ავტორის სტილი დაცულია

29

cxrili 5. janmos motexilobis 10-wliani riskis Sefasebis modelSi

gaTvaliswinebuli risk-faqtorebi (janmos teqnikuri angariSi)

riskis xarisxis Sefaseba

osteoporozis prevenciuli praqtikis ganxorcielebisTvis saWiroa

erTmaneTisagan gavmijnoT osteoporozisa da dacemis da motexilobis riski.

osteoporozi dacemiT gamowveuli motexilobis erT-erTi risk-faqtoria.

amdenad, pacientebi dacemis maRali riskiTa da warsulSi motexilobis

anamneziT pirvel rigSi saWiroeben osteoporozis prevenciis mizniT

rekomendebul RonisZiebebs. aranakleb sayuradReboa pacientebi

osteoporozis sxva risk faqtorebiTa da daavadebebiT, romlebic

astimulireben osteoporozis process. aseTi pacientebi maRali riskis

jgufs miekuTvnebian da osteoporozis Tavidan acilebisTvis intensiur

mkurnalobas saWiroeben.

ავტორის სტილი დაცულია

30

1.5. Oosteoporozis kvlevis meTodebi

osteoporozisa da masTan dakavSirebuli motexilobebis riskis Sefaseba

osteoporozis diagnostirebis pirveli da yvelaze informatiuli etapia.

klinikuri Sefasebisas mniSvnelovania gamovlindes yvela faqtori, ramac

SesaZloa xeli Seuwyos osteoporozis ganviTarebas. marTalia,

osteoporozis klinikuri diagnozi xSirad riskis profilis Sefasebas

emyareba, rig SemTxvevebSi mniSvnelovania laboratoriul-instrumentuli

gamokvlevebi. barZayisa da xerxemlis ormag-energetikuli rentgenuli

absorbciometria (DXA) osteoporozis diagnostirebis „oqros

standartadaa“ miCneuli. DDXA seriuli gazomvebi osteoporozis

diagnostirebis, motexilobis riskis Sefasebisa da pacientis mdgomareobis

monitoritebis saSualebas iZleva.

Zvlis densitometria naCvenebia pacientebSi motexilobebis maRali riskiT

mxolod im SemTxvevaSi, Tu gamokvleva aucilebelia medikamenturi

mkurnalobis Taobaze gadawyvetilebis misaRebad.

Zvlis densitometria naCvenebia:

• 65 wlis zemoT qalebsa da 70 wlis zemoT mamakacebSi, klinikuri risk-

faqtorebis profilis miuxedavad;

• 65 wlamde postmenopauzis asakis qalebSi da 50-69 wlis mamakacebSi

osteoporozis mravlobiTi risk-faqtorebiT;

• qalebSi menopauzis gardamaval periodSi specifikuri risk-

faqtorebiT, rac zrdis motexilobis risks, mag. sigamxdre, anamnezSi

umniSvnelo travmis fonze aRmocenebuli motexilobebi an osteoporozis

gamomwvevi medikamentebis moxmareba;

• pacientebSi, 50 wlis zemoT asakSi motexilobebis anamneziT;

ავტორის სტილი დაცულია

31

• pacientebSi osteoporozis meoradi mizezebiT

• nebismier SemTxvevaSi osteoporozis sawinaaRmdego medikamenturi

mkurnalobis daniSvnamde;

• pacientebSi, romelebic itareben osteoporozis sawinaaRmdego

medikamentur mkurnalobas;

• postmenopauzis asakis qalebSi, romlebic raime mizeziT wyveten

estrogenebis miRebas.

1.6. osteoporozis prevencia

kalciumisa da D vitaminis adekvaturi dieturi moxmareba, regularuli

varjiSi, Tambaqosa da alkoholis moxmarebis SezRudva xels uwyobs Zvlis

jansaRi Senebis SenarCunebas da, amdenad, rekomendebulia yvelasaTvis.

osteoporozis progresirebis Seferxebisa da amasTan dakavSirebuli

motexilobebis Tavidan acilebisTvis arsebiTi mniSneloba aqvs meoradi

prevenciis ganxorcielebas. meoradi prevenciis strategia iTvaliswinebs,

rogorc cxovrebis jansaRi wesis damkvirdebasa da dietur rekomendaciebs,

aseve specifikur medikamentur mkurnalobas (70-73).

araerTi mecnieruli kvleviT dasturdeba, rom regularuli fizikuri

datvirTva amcirebs xandazmulebSi dacemis risks. TemSi mcxovrebi

xandazmulebisTvis gansakuTrebiT efeqtiani aRmoCnda sayrdeni xarixebis

gamoyeneba da wonasworobis dacvaze orientirebuli varjiSis programebi.

ramdenime sistemurma mimoxilvam da kvlevebis meta-analizma uCvena, rom

dabali zemoqmedebis wonis SemanarCunebeli datvirTva da Zalismieri

intensiuri varjiSebi mamakacebsa da postmenopauzis asakis qalebSi Zvlis

mineraluri simkvrivis SenarCunebis saSualebas iZleva. wonis

SemanarCunebeli varjiSisas mniSvnelovania barZayisa da xerxemlis kunTebis

ავტორის სტილი დაცულია

32

datvirTva. sasurveli Sedegis misaRwevad saWiroa datvirTvis intensivobis

etapobrivi mateba. varjiSis programa pacientisTvis komfortuli zomieri

datvirviT unda daiwyos.

aseve aRsaniSnavia, rom kalciumisa da D vitaminis adekvaturi raodenobiT

miReba motexilobis riskis Semcirebis usafrTxo da iafi gzaa. samecniero

literaturis sistemuri mimoxilva miuTiTebs, rom postmenopauzis asakis

TeTrkanian qalebSi kalciumiT mdidari dieta iseve efeqtiania, rogorc

kalciumis preparatebis miReba. dRiur racionSi 1000 mg kalciumis moxmareba

24%-iT amcirebs barZayis motexilobis risks (74-78).

dRis ganmavlobaSi 2500mg-ze meti kalciumis miReba pacientebSi, romlebsac

Tirkmlis paTologia ar aReniSnebaT, usafrTxoa da hiperkalcemiisa an

kenWebis formirebas ar iwvevs. pacientebSi Tirkmlis funqciebis gauaresebiT

dRiur racionSi 2500 mg-ze meti odenobis kalciumis miReba rekomendebuli

ar aris. Tirkmlis qronikuli paTologiebis dros kalciumiT mdidari

dietis SerCeva gansakuTrebuli sifrTxiliT unda moxdes (79-83).

dieturi kalciumis sasurveli dozis misaRwevad rekomendebulia dRis

ganmavlobaSi 3-4-ulufa romelime qvemoT CamoTvlili sakvebis moxmareba:

• 200 ml rZe

• 1 iogurti

• 30 grami myari yveli

• 200 ml soios rZe kalciumis danamatiT

• 60 gr sardini

• 4 naWeri TeTri puri

• 1 ulufa kalciumiT mdidari burRuli rZiT

ავტორის სტილი დაცულია

33

im pacientebs, romlebic raime mizezis gamo uars amboben kalciumiT mdidar

sakvebze, kalciumis danamatebis miReba unda SevTavazoT. 1000 mg an meti

doziT kalciumis danamatebis miReba iseTive warmatebiT amcirebs

motexilobis risks, rogorc kalciumiT mdidari dieta (84-88).

unda aRiniSnos, rom 65 wlis zemoT D vitaminis rekomendebuli dRiuri

dozis (400 IU) uzrunvelyofa xSirad mxolod danamatebis miRebis gziTaa

SesaZlebeli. saxls mijaWvul pacientebSi, rodesac D vitaminis deficitis

albaToba maRalia, vitaminis rekomendebuli doza 2-jer metia da 800 IU-

Seadgens.

sasmel wyalSi ftoris Semcvelobasa da motexilobis sixSires Soris

kavSiris Semswavleli kvlevebiT ftoris roli osteoporozis prevenciisa

da Zvlis mineraluri simkvrivis SenarCunebaSi ar dadasturda. Tumca unda

aRiniSnos, rom am kvlevebis manZilze xanmokle dakvirveba amgvari kavSiris

dadgenisTvis SesaZloa sakmarisi ar yofiliyo.

osteoporozis prevenciisTvis sxvadasxva avtorebi aRniSnaven bunebrivi

progesteronis, magniumis da homeopaTiuri saSualebebis mniSvnelobas. Tumca

mecnieruli mtkicebulebebi maTi efeqtianobis Taobaze mcirea da klinikuri

praqtikis gaumjobesebis Taobaze rekomendaciebis gakeTebis saSualebas ar

iZleva.

literaturaSi garkveuli yuradReba eTmoba ipriflavonis rols

osteoporozis prevenciaSi. ipriflavoni flavinoidebis jgufs miekuTvneba

da didi raodenobiTaa soias produqtebSi. marTalia, ori randomizebuli

kontrolirebuli kvleviT gamovlinda ori wlis manZilze ipriflavonis

zemoqmedebiT sxivis Zvlisa da malebis motexilobis ramdenadme Semcireba,

momdevno kvlevebma es efeqti ar daadastura.

xSirad aRiniSneba, rom karbonatebiT, alkoholiTa da kofeiniT mdidari

sasmeli azianebs Zvlovan qsovils. mecnieruli monacemebi Zvlis mineralur

ავტორის სტილი დაცულია

34

simkvriveze am nivTierebebis zegavlenis Taobaze mcirea da konkretuli

daskvnis gamotanis saSualebas ar iZleva.

osteoporozis meoradi prevenciisa da masTan dakavSirebuli motexilobis

riskis Semcirebis mizniT xSirad mimarTaven medikamentur mkurnalobas.

medikamenturi mkurnalobis mizania motexilobebis insidentobis Semcireba;

motexilobiT gamowveuli simptomebis Semsubuqeba; da momdevno

motexilobebis prevencia.

osteoporozuli motexilobebis prevenciis mizniT rekomendebuli

medikamentebi pirobiTad or did jgufad SeiZleba gaiyos (1) medikamentebi,

romlebic gansakuTrebiT efeqtiania vertebraluri motexilobebis

prevenciisTvis; (2) medikamentebi, romlebic gansakuTrebiT efeqtiania

aravertebraluri motexilobebis prevenciisTvis. zogadad, pirveli SerCevis

medikamentad iTvleba is preparati, romelic Tanabrad efeqtiania rogorc

vertebraluri, ise aravertebraluri motexilobebis prevenciisTvis.

1.7. osteoporozis mkurnaloba

medikamenturi mkurnaloba rekomendebulia pacientebSi, romelTac

gansakuTrebiT maRali aqvT motexilobebis riski. motexilobis maRal riskze

miuTiTebs Zvlis mineraluri simkvrivis dabali maCvenebeli, asaki,

motexilobis anamnezi da dacemis momatebuli albaToba. 60 wlis zemoT

asakis qalebSi osteoporoziTa da osteoporozuli motexilobebis

anamneziT Zalian maRalia vertebraluri da aravertebraluri

motexilobebis riski. SemTxvevaTa umravlesobaSi medikamenturi

mkurnalobis dawyeba Zvlis mineraluri simkvrivis Sefasebis safuZvelze

xdeba (aqsialuri DXA gamokvleviT). motexilobis riskis Semcirebis mizniT

ავტორის სტილი დაცულია

35

medikamenturi mkurnalobis dawyeba Zvlis mineraluri simkvrivis gazomvis

gareSe gaumarTlebelia da dasaSvebia mxolod gamonaklis SemTxvevebSi.

amgvar gamonakliss miekuTvneba pacientebi anamnezSi, sul mcire, ori

vertebraluri motexilobiT, romelTac ar aReniSnebaT metastazuri kibo,

mieloma an sxva destruqciuli daavadeba.

postmenopauzis asakis qalebSi motexilobis prevenciis mizniT medikamenturi

reJimis efeqtianobis Semswavleli kvlevebis Sedegebi warmodgenilia #6

cxrilSi.

medikamenturi mkurnaloba dawyebis Semdeg xangrZlivad, wlebis manZilze

unda gagrZeldes.

cxrili №6. postmenopauzis qalebSi motexilobis prevenciis mizniT

medikamenturi reJimis efeqtianobis Semswavleli kvlevebis Sedegebi

მკურნალობის სქემა

მოტეხილობის ფარდობითი რისკის შემცირების

მაჩვენებელი

ხერხემალი ბარძაყის ძვალი სხვა

ჰორმონჩანაცვლებითი თერაპია 33% 34% 23%

კალციტონინი (PROOF) 36% (5 წელი) _ _

სტრონციუმის რანელატი (SOTI, 41%-49% (3 წელი) 36% 15%

TROPOS) (I) 33% (4 წელი)

ალენდრონატი (FIT, FLEX, 55% 51% (3 წელი) 47% (1 წელი)

FOSIT) 56 %(4 წელი)

იბანდრონატი (BONE, MOBILE, 62% (3 წელი) _ _

DIVA)

ზოლენდრონატი (HORIZON) 60% (1 წელი) 41% (3 წელი) 25% (3 წელი)

70% (3 წელი)

cxrilSi moyvanili medikamentebi saqarTveloSi daregistrirebulia,

rogorc antiporozuli efeqtis mqone preparatebi. maTi efeqtianobis

ავტორის სტილი დაცულია

36

Sesafaseblad gamoyenebulia motexilobebis fardobiTi riskis Semcirebis

maCveneblebi, rac praqtikuli TvalsazrisiT ufro metad mniSvnelovania,

vidre Zvlis mineraluri simkvrivisa da metabolizmis markerebis dinamika.

kalcitonini _ Zvlis rezorbciis Zlieri inhibitoria. is Trgunavs rogorc

osteoklastebis momwifebis process, aseve zrdasruli osteoklastebis

aqtivobas, riTac amcirebs maT raodenobas remodelirebis ubanSi (89-94).

garda rezorbciis daTrgunvisa, kalcitonini xels uwyobs Zvlis formirebis

process anaboluri Tvisebebis arsebobis gamo. moqmedebs ra uSualod

centraluri nervuli sistemis specifiur receptorebze, is ukanasknel

wlebSi warmatebiT gamoiyeneba rogorc Zlieri analgetiki Zvlovani

osteoporozuli motexilobebis dros, saxsrovani tkivilebis dros

revmatologiur klinikaSi (95-101).

stronciumis ranelats aqvs ormagi moqmedeba: rogorc antirezorbciuli,

aseve Zvilis formirebis mastimulirebeli (102-109). miiReba 2 gr. fxvnili

dReSi erTxel, saRamos, Wamidan sul mcire 2 saaTis Semdeg. SOTI kvleviT

postmenopauzur qalebSi amcirebs xerxemlis motexilobis fardobiT risks

1 wlis ganmavlobaSi 49%-iT, 3 weli - 41%-iT, 4 weli - 33%-iT. TROPOS kvleviT

aravertebrul motexilobaTa fardobiTi ricxvi mcirdeba 16 %-iT 3 wlis

ganmavlobaSi (15%-5 weli). yvelaze xSiri motexilobebis fardobiTi riski

mcirdeba 19%-iT. barZayis yelis motexilobebi Zvlis dabali simkvriviT T-

score≤-3 36%-iT. am kvleviT xerxemlisTvis miRebuli iqna Semdegi monacemebi:

45%-1 w., 39%-3w., 35%-5w. gverdiTi efeqtebi saSualo simZimisaa da

tranzitulia, yvelaze xSiria gulisreva, diarea, rac mkurnalobis me-3 Tveze

gadis.

bisfosfonatebi antirezorbciuli preparatebis jgufs miekuTvneba,

xelmisawvdomia oraluri da intravenuri formiT (110-115). oraluri

bisfosfonatebis miReba rekomendebulia diliT uzmoze (sakvebis miRebamde

30-60 wuTiT adre), didi raodenobiT wyalTan erTad (sxva siTxeebis miReba

bifosfonatebTan erTad dauSvebelia) wamlis miRebidan 30-60 wuTis manZilze

ავტორის სტილი დაცულია

37

pacienti unda imyofebodes vertikalur (mjdomare an fexze mdgom)

mdgomareobaSi saylapavze adheziis da dawylulebis profilaqtikisTvis.

bisfosfonatebiT mkurnalobis dawyebamde da mkurnalobis periodSi unda

xdebodes sisxlSi kalciumis da kreatininis monitoringi. bisfosfonatebTan

erTad unda iniSnebodes kalciumi da D3 vitamini.

alendronis mJava (alendronati) 70 mg, rekomendebulia 1 abi kviraSi erTxel.

FIT, FLEX da FOSIT kvlevebiT dgindeba, rom SedarebiTi riskis Semcireba

mravlobiTi vertebruli motexilobebisTvis aris 47% (3 weli); klinikuri

vertebruli motexilobebisTvis 55%; barZayis motexilobisTvis 51% (3 weli)

da 56% (4 weli); sxva motexilobebisTvis - 47% (1 weli). mamakacTa

populaciaSi Catarebuli kvlevebiT alendronatisTvis naCvenebi iqna igive

efeqtianoba.

ibandronis mJava (ibandronati) rekomendebulia oraluri formiT 150 mg-iani

preparati yovelTviurad an intravenuri 3 mg yovelkvartlurad an 2 mg or

TveSi erTxel. BONE 3 wliani kvlevis Tanaxmad ibandronati (2,5 mg

yoveldRiuri doza) amcirebs vertebrul motexilobaTa fardobiT risks

62%-iT. MOBILE kvlevam aCvena yoveldRiuri 2,5 mg da yovelTviuri 150 mg

ibandronatis moqmedebis identuroba. DIVA kvlevam aCvena intravenurad 3 mg

yovelkvartlurad efeqturoba. aravertebruli motexilobebisaTvis

sarwmuno monacemebi ar aris, Tumca qvejgufSi barZayis yelis Zvlis

mineraluri simkvriviT T-score≤-3 motexilobis riskis reduqcia iyo 69%

(yoveldRiuri 2,5 mg).

zolendronis mJava (zolendronati), rogorc antiporozuli preparati

saqarTveloSi daregistrirebulia 5 mg formiT (100ml flakonSi

intravenurad 15 wT-is ganmavlobaSi, weliwadSi erTxel). HORIZON kvleviT

dasturdeba, rom 3 wlis manZilze zolendronatiT mkurnalobisas

vertebruli motexilobebis riski mcirdeba 70%-iT, barZayis yelis

motexilobebis - 41%, xolo sxva motexilobebis - 25%-iT.

ავტორის სტილი დაცულია

38

bisfosfonatebis gverdiTi movlenebi moicavs oraluri formebisTvis

ylapvis gaZnelebas, ezofagits, saylapavsa da kuWis wylulis riskis

momatebas. intravenuri gamoyenebisas SesaZlebelia temperaturis momateba,

mialgia, arTralgia, cefalgia, rac advilad emorCileba paracetamoliT da

arasteroiduli anTebis sawinaaRmdego medikamentebiT mkurnalobas. es

movlenebi yovel Semdgom weliwads TandaTan mcirdeba. literaturaSi

aRwerilia bisfosfonatebis fonze ybis saxsris osteonekrozisa

(gansakuTrebiT venuri administrirebisas kiboTi daavadebul pacientebSi) da

mxedvelobis moSlis SemTxvevebi.

saxls mijaWvul xandazmul pacientebSi medikamenturi mkurnalobisas

aucilebelia D vitaminis deficitis maRali riskis gaTvaliswineba.

mecnieruli monacemebiT dasturdeba, rom am pacientebSi, winaswari

laboratoriul-instrumentuli gamokvlevebis gareSe, D vitaminis daniSvna

35%-iT amcirebs barZayis, xolo 26%-iT aravertebraluri motexilobebis

insidentobas.

denosumabi. osteoporozis samkurnalo yvelaze Tanamedrove saSualeba aris

nuklearuli faqtori-kappa B-s (NF-kB) receptoruli aqtivatoris, RANK-is

ligandis inhibitori, denosumabi. is amcirebs vertebruli da aravertebruli

motexilobebis risks rogorc postmenopauzuri asakis qalebSi, ise

mamakacebSi (116-123).

osteoporozis pirveladi prevenciis mizniT 45 wlis asakidan yvela qals da

50 wlis asakidan yvela mamakacs unda mieces detaluri rCeva-darigeba

regularuli fizikuri datvirTvisa da kalciumiT mdidari dietis Taobaze.

osteoporozis meoradi prevenciis mizniT rekomendebulia, rogorc jansaRi

cxovrebis wesis Sesaxeb pacientebis konsultireba, aseve medikamentebis

gamoyeneba. jansaRi cxovrebis wesis Taobaze rCevebi moicavs fizikuri

varjiSis waxalisebas, dRiur racionSi sakvebis an danamatebis saxiT, sul

mcire, 1000 mg kalciumisa da 400 IU D vitaminis miRebas.

ავტორის სტილი დაცულია

39

medikamenturi mkurnaloba rekomendebulia pacientebSi, romelTac

gansakuTrebiT maRali aqvT motexilobebis riski. motexilobis maRali

riskze miuTiTebs Zvlis mineraluri simkvrivis dabali maCvenebeli, asaki,

motexilobis anamnezi da dacemis momatebuli albaToba.

osteoporozuli motexilobebis Tavidan acilebis mizniT SerCevis

pirveli rigis medikamentebs miekuTvneba bisfosfonatebi, kalcitonini,

estrogenebis agonist/antagonistebi.

postmenopauzis asakis qalebSi, sul mcire, ori vertebraluri

motexilobis anamneziT (dadasturebulia rentgenologiurad) medikamenturi

mkurnalobis dawyeba dasaSvebia Zvlis densitometriis gareSe.

1.8 osteoporozis gavrceleba onkologiur paciantebSi

osteopenia da osteporozi qalebSi Zalian gavrcelebuli daavadebaa.

sarZeve jirkvlis kibos standartuli Terapia, rogoricaa adiuvanturi

(qimio an hormonaluri Terapia), zrdis Zvlis masis danakargs, rac Tavis

mxriv zrdis osteoporozis ganviTarebis risks. premenopauzaSi myof qalebi,

standartuli adiuvanturi Terapia xSirad iwvevs sakvercxeebis dazianebaს

an adreul menopauzas. sakvercxeebis dazianeba asocirebulia Zvlis masis

dakargvasTan.

postmenopauzaSi tamoqsifeni icavs Zvals gamofitvisgan, maSin roca

premenopauzaSi tamoqsifeni iwvevs Zvlis mineraluri simkvrivis daqveiTebas.

anastrozoli (aromatazas inhibitori) romelic postpenopauzaSi myof

pacientebSi damtkicebulia rogorc adreuli stadiis kibos (estrogen

receptor pozitiuri kibos) mkurnalobis meTodi, 5 an naklebi wlis ganm-Si

mkurnalobis dros zrdis motexilobebis risks vidre tamoqsifeniT

mkurnaloba.

ავტორის სტილი დაცულია

40

qimioTerapia. klinikamdelma kvlevebma gviCvena, rom ciklofosfamidi,

doqsorubicini da metotreqsati negatiur gavlenas axdens Zvlovan

matriqsze (qsovilze). premenopauzaSi myof qalebSi msgavsi tipis

qimioTerapia iwvevs sakvercxeebis disfunqcias da Zvlovani qsovilis

Semcirebas. qimioTerapiaze myof qalebis daaxloebiT 70 %-s uviTardebaT

amenorea da naadrevi menopauza. naadrevi menopauza Tavis mxriv zrdis

osteoporozis da motexilobis ganviTarebis risks.

qimioTerapia ara mxolod premenopauzalur qalebSi azianebs Zvlovan

qsovils, aramed postmenopauzaSic. prospeqtiulma kvlevebma aCvena rom

pospenopauzaSi myof qalebSi qimioTerapiis Semdgom yovelwliurad

Zvlovani qsovilis danakargi 10 % -s Seadgens.

hormonaluri (endokrinuli Terapia) postmenopauzaSi tamoqsifens Zvalze

dadebiTi efeqti gaaCnia. 1990 wlebSi Catarebuli kvlevebiT tamoqsifenis

jgufSi myof pacientebSi aRiniSna Zvlis mineraluri simkviris momateba

barZayis yelsa da xerxemalSi yovelwliurad 0.5-1.0 %-iT, xolo placebo

jgufSi Zms-s daqveiTeba. premenopauzaSi, tamoqsifens SesaZloa hqondes

negatiuri gavlena Zvalze, rac kvlevebiTac dadasturda (aRiniSna Zms-s

daqveiTeba) (124,125).

aromatazas inhibitorebi: orive tipis steroiduli (eqsemastini) da

arasteroiduli (letrozoli, anastrozoli) aromatazas inhibitorebi

negatiur gavlenas axdens Zvlis mineralur simkvriveze da zrdian

motexilobis risks (126,127).

ავტორის სტილი დაცულია

41

1.9 sarZeve jirkvlis agebuleba da funqcionirebisaTvis aucilebeli

hormonebi

sarZeve jirkvali warmoadgens wyvil organos, romelsac

milakovan_alveoluri agebuleba aqvs. igi Sedgeba erTmaneTTan

filogenetikurad da anatomo-fiziologiurad mWidrod dakavSirebuli ori

komponentis _ parenqimisa da stromisagan. parenqima warmoadgens jirkvlovan

qsovils, romelSic ganTavsebulia sxvadasxva diametris sadinarebi (sur 2).

stroma SemaerTebeli qsovilia, romelic jirkvals yofs wilebad da

wilakebad. stroma da parenqima cximovani qsoviliT aris garemoculi.

sarZeve jirkvlis ukana zedapirs faravs fasciis firfita. am firfitasa da

mkerdis did kunTs Soris arsebuli sivrce amovsebulia faSari ujreduli

masiT, romelic ganapirobebs sarZeve jirkvlis Zvradobas (128).

sur. 2. sarZeve jirkvlis agebuleba

ავტორის სტილი დაცულია

42

cnobilia, rom sarZeve jirkvlis Canasaxi formirebas iwyebs embrionaluri

ganviTarebis me-10 kviridan. postembrionuli ganviTarebis pirveli 3-5 dRis

ganmavlobaSi sarZeve jirkvali umniSvnelod izrdeba dedisgan miRebuli

placentaruli hormonebis gavleniT. sqesobriv momwifebamde sarZeve

jirkvali imyofeba funqciurad mosvenebul mdgomareobaSi (129) . sqesobrivi

momwifebis periodSi 12-16 wlis asakSi iwyeba sarZeve jirkvlis intensiuri

ganviTareba. am periodSi aRiniSneba Tirkmelzeda jirkvlis qerqisa da

sasqeso jirkvlebis funqciuri aqtivobis zrdac. jirkvalSi adgili aqvs

cximis Calagebas, SeimCneva sarZeve jirkvlis sadinarebis dagrZeleba, maT

daboloebebze ki warmoiqmneba acinozuri gafarToebebi. es ukanasknelni

jirkvlis wilakebis Canasaxs warmoadgenen (131-134) .

cnobilia, rom sarZeve jirkvlis zrdis da ganviTarebis procesSi adgili

aqvs 4 tipis wilakis Camoyalibebas :

• pirveli tipis wilakebi xasiaTdebian naklebi diferencirebiT da

warmoadgenen sarZeve jirkvals menarqemde.

• meore tipis wilakebSi warmodgenilia ufro kompleqsuri

morfologiuri suraTi, gazrdilia sadinarebis ricxvi TiToeul wilakze.

• mesame tipis wilakebSi sadinarebis ricxvi kidev ufro gazrdilia.

aRniSnuli wilakebi hormonalur stimulacias orsulobis periodSi

ganicdian.

• meoTxe tipis wilakebis ganviTareba uSualod dakavSirebulia

laqtaciasTan.

cnobilia, rom calkeuli wilaki garSemotymulia mkrivi

SemaerTebelqsovilovani feniT, Signidan ki amovsebulia faSari

SemaerTebeli qsoviliT, romelic mdidaria limfocitebiT, plazmuri

ujredebiT da axalgazrda fibroblastebiT.

ავტორის სტილი დაცულია

43

pre- da postmenopauzur periodSi adgili aqvs sarZeve jirkvlis regresul

cvlilebebs (wilakebis, aseve wvrili da saSualo zomis sadinarebis

atrofia, gaqroba da maTi Canacvleba fibrozuli da cximovani qsoviliT) .

cnobilia, rom reproduqciul periodSi sarZeve jirkvlis zrdasTan da

ganviTarebasTan dakavSirebuli yvela procesi hormonalur regulacias

eqvemdebareba (130). qsovilovani homeostazi ki ganpirobebulia

proliferacias, diferencirebasa da apoptozs Soris arsebuli

wonasworobiT .

sarZeve jirkvlis ganviTarebaSi erT-erT mTavar rols asruleben

umTavresad sasqeso gonadebSi sinTezirebuli steroiduli hormonebi:

estrogenebi _ estroni da estradioli, aseve progesteroni. sarZeve

jirkvlis ganviTarebaze pubertatuli (sqesobrivi momwifebis) periodis

pirvel fazaSi (10-13weli), menarqemde (menstruaciuli ciklis dawyebamde)

ZiriTadad estrogenebis zegavlena aRiniSneba. meore fazaSi (sqesobrivi

momwifebis periodSi, 13-15w) estrogenebi da progesteroni kompleqsurad

moqmedeben.

cnobilia, rom estrogenebi pasuxs ageben sarZeve jirkvlis sadinarebisa da

SemaerTebeli qsovilis ganviTarebaze (estradioli stimulacias uwevs

jirkvlis sadinarebis epiTeliumis proliferacias, diferencirebasa da

ganviTarebas, aZlierebs epiTeliumis mitozur aqtivobas, inducirebs

acinusis formirebas, agreTve astimulirebs vaskularizacias da zrdis

SemaerTebeli qsovilis hidratacias) xolo progesteroni jirkvlovani

qsovilis zrdasa da ganviTarebaze. progesteroni sadinarebis epiTeliumSi

Trgunavs proliferacias da iwvevs diferencirebas wilakebad da

alveolebad, aferxebs sarZeve jirkvlis sadinarebis epiTeliumis mitozur

aqtivobas, xels uSlis estrogenebiT ganpirobebul kapilarebis

ganvladobis zrdas .

ავტორის სტილი დაცულია

44

sarZeve jirkvlis ganviTareba aseve damokidebulia mTeli rigi hormonebis

(gonadotropin-rilizing hormoni, maluTeinizirebeli hormoni,

folikulomastimulirebeli hormoni, prolaqtini, somatotropini, insulini,

zrdis faqtorebi, kortizoli, aldosteroni, Tiroqsini da triiodTironini)

koordinirebul moqmedebazec (135-137) .

aucilebelia aRiniSnos, rom pubertatis dawyeba uSualod dakavSirebulia

hipoTalamusTan. hipoTalamusSi sinTezirebuli gonadotropin-rilizing

hormonis impulsuri gamoyofa aregulirebs adenohipofizis mier

gonadotropinebis (maluTeinizirebeli hormoni da

folikulomastimulirebeli hormoni) gamoyofis process .

gonadotropinebi uSualod zemoqmedeben sakvercxeebis mier steroiduli

hormonebis sinTezis procesze. sakuTriv steroiduli hormonebis

Semcveloba ki ukukavSiris principiT axorcielebs zemoqmedebas sistemaze

hipoTalamusi- hipofizi .

cnobilia, rom adenohipofizSi xorcieldeba agreTve somatotropinisa da

prolaqtinis sinTezic. somatotropinis ZiriTad funqcias zrdis stimulacia

warmoadgens. aRniSnul stimulacias somatotropini axorcielebs

insulinismsgavs faqtor I-Tan (IGF-I) da II-Tan (IGF-II) (somatomedinebi)

kombinaciaSi. aqve unda aRiniSnos, rom hepatocitebSi IGF-I da IGF-II-is

sekreciis stimulators sakuTriv somatotropini warmoadgens.

aRniSnuli hormonebis moqmedeba morfo-genetikuri da anaboluri

procesebis gaZlierebaSi mdgomareobs da gamoixateba nukleinis mJavebis

sinTezSi da ujredebis dayofaSi. cnobilia, rom somatotropini agreTve

ganapirobebs adenohipofizis kidev erTi hormonis _ prolaqtinis sinTezis

stimulacias .

prolaqtinis ZiriTadi funqcia laqtocitebiT rZis sekreciis stimulaciaa.

prolaqtiniT warimarTeba estrogenuli receptorebis ricxvis matebac. aseve

cnobilia, rom progesteronTan erTad prolaqtini aaqtivebs epiTeluri

ავტორის სტილი დაცულია

45

ujredebis zrdas . aqve unda aRiniSnos, rom Tavis mxriv estrogenebic

mniSvnelovan gavlenas axdenen prolaqtinis sinTezze, rogorc

hipoTalamusze zemoqmedebiT, aseve uSualo gavleniTac . cnobilia isic, rom

estrogenebi sarZeve jirkvlis qsovilze aseve zrdis faqtorebis saSualebiT

moqmedeben (EGF, TGF, IGF-I, IGF-II) da iwveven ujredebis transformacias .

rogorc zemoT avRniSneT, steroiduli hormonebis biosinTezi ZiriTadad

sasqeso gonadebSi mimdinareobs (estrogenebi, androgenebi, progesteroni)

Tumca maTi sinTezi Tirkmelzeda jirkvlis qerqSic warimarTeba . sarZeve

jirkvlis qsovilze aRiniSneba aseve Tirkmelzeda jirkvlis qerqSi

sinTezirebuli sxva kortikosteroidebis (aldosteroni da kortizoli)

zemoqmedebac, Tumca maTi roli SedarebiT umniSvneloa . cnobilia, rom

kortizoli gavlenas axdens sarZeve jirkvlis qsovilSi prolaqtinis

receptorebis ganviTarebaze da prolaqtinTan erTad xels uwyobs

epiTeluri ujredebis zrdas .

aseve cnobilia, rom insulini kortikosteroidebTan erTad xels uwyobs

jirkvlovani qsovilis zrdas, maSin, rodesac insulini, Tireoiduli

hormoni, glukokortikoidebi da mineralokortikoidebi erToblivad

moqmedeben jirkvlovani ujredebis metabolizmze da nivTierebaTa cvlis

saerTo procesebze .

farisebri jirkvlis hormonebi (Tiroqsini da triiodTironini)

mniSvnelovan rols asruleben sarZeve jirkvlis epiTeluri ujredebis

morfogenezSi da funqciur diferencirebaSi. maTi zemoqmedeba sarZeve

jirkvlis qsovilze xorcieldeba rogorc uSualod, aseve mTeli rigi

Sualeduri hormonebis moqmedebiT, maT Soris prolaqtinis (138-141) .

amgvarad sarZeve jirkvlis srulyofili diferencirebisa da

funqcionirebisaTvis sasqeso gonadebTan erTad aucilebelia hipoTalamusis,

adenohipofizis, farisebri jirkvlis, Tirkmelzeda jirkvlis qerqis,

kuWqveSa jirkvlisa da RviZlis hormonebis erToblivi moqmedeba.

ავტორის სტილი დაცულია

46

rogorc cnobilia steroiduli hormonebi qolesterolis warmoebulebs

warmoadgenen . steroiduli hormonebi, iseve rogorc qolesteroli Seicaven

ciklopentanperhidro-fenantrenis birTvs gansxvavebuli gverdiTi jaWvebiT

da jgufebiT, romlebic am ukanasknelebs specifiurobas aniWeben. cnobilia

isic, rom qolesteroli endokrinul ujredebSi sinTezirdeba acetatisagan

an gadadis sisxlidan, lipoproteinebis SemadgenlobaSi (upiratesad) .

amgvarad, moxvdeba ra/an sinTezirdeba qolesteroli endokrinul ujredebSi

(sakvercxeebis teka qsovilSi) , pirvel etapzeve adgili aqvs

qolesterolisagan pregnenolonis warmoqmnas, romelic Semdgom

gardaiqmneba progesteronad (pirobiTad I gza).

sinTezirebuli progesteroni srulyofil hormons warmoadgens, romelsac

sarZeve jirkvalze damoukideblad zemoqmedebis unari gaaCnia (142).

garda amisa progesteronisagan miiReba androgenebi _ androstendioni,

romelic SesaZloa gardaiqmnas testosteronad. rac Seexeba pirobiTad II

gzas, aRniSnul SemTxvevaSi pregnenolonidan miiReba

dehidroepiandrosteroni, romelic Semdgom gardaiqmneba testosteronad.

rac Seexeba Tirkmelzeda jirkvlis qerqSi gamomuSavebul

steroidul hormonebs, aRniSnul jirkvalSi adgili aqvs rogorc sasqeso

steroiduli hormonebis (progesteroni, estrogenebi, androgenebi)

sinTezs, aseve kortikosteroidebis warmoqmnasac (kortizoli,

aldosteroni) . literaturidan cnobilia, rom androgenebis estrogenebad

gardaqmna cximovan qsovilSic mimdinareobs. es ukanaskneli ki Tirkmelzeda

jirkvlis qerqTan erTad warmoadgens qalebisTvis estrogenebis ZiriTad

wyaros postmenopauzur periodSi.

amrigad sarZeve jirkvlis srulyofili diferencireba da funqcionireba

ZiriTadad hormonaluri zemoqmedebiTaa ganpirobebuli, xolo hormonaluri

disbalansi SesaZloa sarZeve jirkvlis paTologiebis ganviTarebis mizezi

gaxdes.

ავტორის სტილი დაცულია

47

1.10 sarZeve jirkvlis simsivneebis klasifikacia

sarZeve jirkvlis simsivnuri transformaciebi moicavs rogorc

keTilTvisebian, aseve avTvisebian simsivneebs (143,144).

mastopaTia warmoadgens hormonaluri disbalansiT ganpirobebul

keTilTvisebian hiperplaziur process sarZeve jirkvalSi. misTvis

damaxasiaTebelia epiTeluri da SemaerTebelqsovilovani komponentebis

Tanafardobis cvlileba. cnobilia keTilTvisebiani simsivneebis anu

mastopaTiebis Semdegi klasifikacia.

• fibrozo-kistozuri mastopaTiis difuzuri forma :

- difuzuri mastopaTia kistozuri komponentebis siWarbiT, romelic

xasiaTdeba elastiuri konsistenciis mravalricxovani kistozuri

warmonaqmnebiT.

- difuzuri mastopaTia fibrozuli komponentebis siWarbiT, romelic

xasiaTdeba wilakTSorisi SemaerTebeli qsovilisa da

sadinarebSida qsovilis proliferaciis zrdiT, rac jirkvlis

sanaTuris Seviwroebas da srul obliteracias iwvevs. aRniSnuli

saxis mastopaTia xSirad viTardeba hiperandrogeniis dros.

- difuzuri mastopaTia jirklovani komponentebis siWarbiT, anu

adenozi, romelic xasiaTdeba jirkvlis wilakebis

maRaldiferencirebuli hiperplaziiT. aRniSnuli saxis

mastopaTiebs iwvevs androgenebis matebisa da saSvilosnos tanis

hiperplaziebis erToblivi Tanaarseboba.

- difuzuri mastopaTiis Sereuli forma, xasiaTdeba wilakebis

hiperplaziiT, Sidawilakuri da wilakTSorisi SemaerTebeli

qsovilis skleroziT, sadinarebis gafarToebiTa da alveolebis

kistozur warmonaqmnebSi gardaqmniT.

ავტორის სტილი დაცულია

48

• fibrozo-kistozuri mastopaTiis kvanZovani forma (fibroadenoma)

xasiaTdeba sxva mastopaTiebis SemTxvevebSi aRwerili cvlilebebiT. im

gansxvavebiT, rom aRniSnul cvlilebebs lokaluri xasiaTi aqvT.

warmodgenilia erTi an ramdenime kvanZis saxiT.

cnobilia, rom glukokortikoidebis gaZlierebuli gamoyofis fonze adgili

aqvs mastopaTiis Tirkmelzeda jirkvlovan formas. aRniSnuli daavadeba

xasiaTdeba glukokortikoidebis siWarbiT, rac iwvevs hiperglikemias,

hiperlipidemiasa da arteriul hipertenzias, mastopaTiis aRniSnuli

formisaTvis damaxasiaTebelia simsuqne, diabeti, aTerosklerozi da

hipertonuli daavadebebi .

rac Seexeba sarZeve jirkvlis avTvisebian simsivnes _ kibos, klinikuri

mimdinareobis mixedviT gamoyofen 4 stadias (sur3) .

- pirveli stadia _ sarZeve jirkvalSi isinjeba 0.8-2 sm diametris

patara mkvrivi umtkivneulo kvanZi, misi sazRvrebi mkafiod ar

aRiniSneba, simsivne odnav xorkliani da moZravia .

- meore stadia _ simsivne SedarebiT didi zomisaa (2-5 sm diametrSi).

kanTan an kanqveSa qsovilTan Sezrdilia, Tumca regionaluri

metastazebi ar isinjeba; meore stadiaze dasaSvebia agreTve

metastazebi regionalur limfur kvanZebSi.

- mesame stadia _ simsivne 5 sm-ze meti zomisaa, kanTan Sezrdilia,

mfaravi kani dawylulebulia, ar isinjeba regionaluri metastazebi.

igive stadiisaTvis damaxasiaTebelia agreTve metastazebi iRliis,

laviwqveSa da laviwzeda limfur kvanZebSi (III b stadia).

- meoTxe stadia _ simsivnes TiTqmis mTeli sarZeve jirkvali ukavia.

simsivnis areSi aRiniSneba wyluli gamonadeniT. gulmkerdis wina

zedapirze mravlobiTi kankveSa kvanZebia ganviTarebuli. simsivne

ავტორის სტილი დაცულია

49

umoZraod aris fiqsirebuli gulmkerdze. aRiniSneba gadidebuli,

mkvrivi da umoZrao limfuri kvanZebi.

sur. 3. sarZeve jirkvlis avTvisebiani simsivnis stadiebi

ავტორის სტილი დაცულია

50

cnobilia sarZeve jirkvlis simsivnis pre- da postmenupauzuri formebi.

daavadebis premenopauzuri (ovariuli) da postmenopauzuri (Tirkmelzeda an

hipoTalamuri) variantebi gamoirCevian ara mxolod mTeli rigi klinikuri

maCveneblebiT, aramed hormonalur-metaboluri darRvevebis farTo speqtriT.

1.11 sarZeve jirkvlis kibos gavrceleba

sarZeve jirkvlis kibo yvelaze xSirad saSualo da xandazmuli asaki

qalebSi aris gavrcelebuli da sxva simsivneebTan SedarebiT sarZeve

jirkvlis kibo sakmaod gavrcelebul daavadebad iTvleba (145,146).

2009-2013 wlebis monacemebiT mTels msoflioSi:

• qalebSi ZuZu kibos axali SemTxvevebi 100.000 qalidan 125-Si

dafiqsirda.

• sikvdilianobis maCvenebeli (ricxvi) 100.000 qalidan 21.5-Si.

kibos ganviTarebis riski: 2010-2012 wlebis monacemebiT qalebis daaxloebiT

12.3 procentSi iyo diagnostirebuli sarZeve jirkvlis kibo maTi sicocxlis

ganmavlobaSi (147,148).

msoflioSi:

• 2012 wels sarZeve jirkvlis kibos daaxloebiT 1,7 milioni axali

SemTxveva dafiqsirda.

• 2012 wels warmoadgenda yvela saxis axali simsivneebis 12 %-s da 25 %-

qalebSi yvela saxis simsivneebSi.

• 184 qveynidan 140 qveyanaSi sarZeve jirkvlis kibo qalebSi yvelaze

xSirad diagnostirebul kibos warmoadgens.

ავტორის სტილი დაცულია

51

• mTels msoflioSi yvela saxis simsivneebSi qalebSi 4 dan 1 aris

sarZeve jirkvlis kibo

• 2008 wlidan sarZeve jirkvlis kibos sixSire gaizarda 20 procentiT,

sikvdilianoba 14 %-iT

kibos msoflio kvlevis saerTaSoriso fondis monacemebze dayrdnobiT

me-7 cxrilSi mocemulia 20 qveyana sadac 20012 wels dafiqsirda sarZeve

jirkvlis kibos yvelaze maRali sixSire

cxrili 7.

ქვეყანა

ასაკით სტანდარტიზებული

სიხშირე 100.00 მოსახლეზე

(მსოფლიოში)

1 ბელგია 111.9

2 დანია 105

3 საფრანგეთი 104.5

4 ნიდერლანდები 99

5 ბაჰამა 98.9

6 ისლანდია 96.3

7 გაერთიანებული სამეფო 95

8 ბარბადოსი 94.7

9 ამერიკის შეერთებული შტატები 92.9

10 ირლანდია 92.3

11 საფრანგეთის პოლინეზია 92.2

12 გერმანია 91.6

13 იტალია 91.3

14 ფინეთი 89.4

15 ლუქსემბურგი 89.1

16 ახალი კალედონია 87.6

17 ავსტრალია 86

18 მალტა 85.9

19 ახალი ზელანდია 85

20 შვეიცარია 83.1

ავტორის სტილი დაცულია

52

sarZeve jirkvlis kibos prevalentoba aSS-Si 2013 wels daaxloebiT 3,053,450

-s miaRwia.

aSS-Si kanis kibos Semdeg sarZeve jirkvlis kibo yvelaze gavrcelebuli

onkologiuri daavadebaa. xolo filtvis kibos Semdgom sarZeve jirkvlis

sikvdilianobis maCvenebeli meore adgilzea (149-151).

Ddiagrama 1 - ze mocemulia 2017 wels sarZeve jirkvlis simsivnis

mosalodneli Sedegebi, 1992-2014 wlebSi axali SemTxvevebis da

sikvdilianobis grafiki, agreTve 2007-2013 wels 5 wliani procentuli

gadarCenis maCveneblebi.

diagrama. 1.

mosalodnelia rom 2018 wels msoflioSi dafiqsirdeba:

• 246,660 invaziuri sarZeve jirkvlis kibos axali SemTxveva

• 61,000 arainvaziuri karcinoma in situ

• sarZeve jirkvlis sikvdilianoba qalebSi Seadgens 40,450

ავტორის სტილი დაცულია

53

1.12 sarZeve jirkvlis kibos gamomwvevi risk-faqtorebi

risk faqtorebi SeiZleba daiyos or kategoriad:

1) modificirebadi risk faqtorebi

da

2) aramodificirebadi risk faqtorebi

mdedrobiTi sqesi: sarZeve jirkvlis kibos ganviTarebaSi udides risk

faqtors warmoadgens mdedrobiTi sqesi.

asaki: asakis matebasTan erTad izrdeba sarZeve jirkvlis kibos ganviTarebis

riski. sarZeve jirkvlis invaziuri kibos 3 -dan 2 SemTxveva aRmoCenilia 55

wlis da meti asakis qalebSi (152,153).

ojaxuri anamnezi: daavadebis ganviTarebis maRali riski aqvT qalebs,

romelTa axlo naTesavebs diagnostirebuli hqondaT sarZeve jirkvlis kibo.

riski ormagdeba Tu pirveli xazis naTesavi (da, deda, qaliSvili)

diagnostirebuli zemoTaRniSnuli daavadebiT.

genetika (memkvidreoba): sarZeve jirkvlis kibos SemTxvevebis daaxloebiT 5

dan 10%-mde iTvleba memkvidreobiTad, gamowveuli anomaluri genis

gadacemiT mSoblidan Svilze (154).

sarZeve jirklvis kibos piradi anamnezi: warsulSi sarZeve jirkvlis kibos

diagnostirebis SemTxvevaSi, jirkvlis sxva adgilas an meore sarZeve

jirkvalSi kibos ganviTarebis riski imatebs 3 - 4 -jer.

gulmkerdis an saxis radiacia 30 wlamde: radiaciuli (sxivuri) Terapiis

Catarebis SemTxvevaSi sxva simsivnis gamo, rogoricaa hojkinis daavadeba, an

ara hojkinis limfoma, sarZeve jirkvlis kibos ganviTarebis didi riski

arsebobs. mozardobis periodSi aknes gamo radiaciuli mkurnalobs

Catarebis SemTxvevSic maRalia riski mogvianebiT sarjeve jirkvlis kibos

ganviTarebis.

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54

diagnostirebuli sarZeve jirkvlis garkveuli keTilTvisebiani

mdgomareobebisas (sadinrovani hipeplazia-atipiis gareSe; kompleqsuri

fibroadenoma, papiloma an papilomatozi.), sarZeve jirkvlis kibos

ganviTarebis riski agreTve maRalia.

rasa/eTnikuroba: zogadad TeTrkanian qalebSi sarZeve jirkvlis kibos

ganviTarebis Sansi ufro metia vidre afro -amerikelebSi, espanel da aziel

qalebSi. Tumca axalgazrda asakSi diagnostirebuli sarZeve jirkvlis kibo

afro amerikelebSi ufro metad agresiulad mimdinareobas

Warbi wona: Warbi wona da simsuqne warmoadgens maRal risk faqtors sarZeve

jirkvlis kibos ganviTarebis, normaluri wonis qalebTan SedarebiT,

gansakuTrebiT menopauzis Semdgom. Warbi wona SesaZlebelia gaxdes

recidivis ganviTarebis mizezi qalebSi romelTac anamnezSi hqondaT

zemoTaRniSnuli daavadeba (155-158).

orsuloba: kibos ganviTarebis riski izrdeba qalebSi, romelTac hqondaT

arasruli orsuloba an pirveli mSobiaroba 30 wlis Semdgom, im qalebTan

SedarebiT romlebmac imSobiares 30 wlamde.

laqtacia: ZuZuTi kveba (laqtacia) amcirebs sarZeve jirkvlis kibos

ganviTarebis risks, gansakuTrebiT Tu laqtacia 1 welze meti mimdinareobs.

menstrualuri cikli: qalebi, romelTac menarxe hqondaT 12 welze adreul

asakSi da menopauza 55 wlis asakis zeviT imyofebian sarZeve jirkvlis kibos

ganviTarebis riskis qveS.

CanacvlebiTi hormonaluri Terapiis (ChT) gamoyeneba: warsulSi an mimdinare

CanacvlebiTi hormonaluri Terapiis gamoyeneba zrdis sarZeve jirkvlis

kibos ganviTarebis risks. 2002 wlidan, rodesac gamokvlevebiT dadasturda

ChT-is kavSiri s/j-is kibos ganviTarebasTan, mkveTrad Semcirda CanacvlebiTi

hormonaluri Terapiis gamoyeneba qalebSi (159-162).

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55

alkoholis moxmareba: gamokvlevebi cxadyobs, rom alkoholuri sasmelebi-

ludi, Rvino da spirtiani sasmelebi iwvevs estrogen receptor pozitiuri

sarZeve jirkvlis kibos ganviTarebis riskis matebas (163).

mkvrivi mkerdi: mkvrivi mkerdis arseboba 6- jer ufro metad zrdis s/j-is

kibos ganviTarebas da mamologebisTvis arTulebs kibos diagnostirebas.

moweva: axalgazrda da premenopauzalur asakSi moweva zrdis s/j-is kibos

ganviTarebis risks. gamokvlevebma agreTve uCvena rom pasiur mwevelebSi s/j-

is kibos ganviTarebis riski izrdeba postmenopauzalur asakSi.

simsivnuri daavadebebis 10% ganviTarebulia memkvidruli winaswarganwyobiT,

anu mutaciiT genebSi, romlebic arian pasuxismgebeli ujreduli ciklis

swor mimdinareobaze (mag. mutacia BRCA1/2 ). genetikuri analizi mutaciaze

rekomendebulia Tuki pacients aqvs piradi an ojaxuri anamnezi, romelic

metyvelebs simsivnuri daavadebis SesaZlo memkvidrul ganwyobaze.

magaliTisTvis, BRCA1 da BRCA2 is genetikuri analizi tardeba im

SemTxvevaSi Tuki pacients aqvs sakvercxis da/an sarZeve jirkvlis

avTvisebiani simsivnis ojaxuri anamnezi (pirveli da meore rigis naTesavi),

Tuki ojaxis wevrebi arian BRCA1 da BRCA2 mutaciis mtareblebi, simsivnis

diagnostirebis axalgazrda asaki.

risk -faqtorebis gaTvaliswinebiT SesaZlebelia adamianTa mikuTvneba

maRali, saSualo da dabali risk jgufebisaTvis. maTi dayofis arsi, zogierT

SemTxvevaSi, skriningis sxvadasxva meTodis damatebiT gamoyenebasa da

intensivobis cvlilebas ganapirobebs. magaliTisTvis, Tu qalbatoni BRCA1

da BRCA2 genis mutaciis mtarebelia, maSin sarZeve jirkvlis skrining

meTods, sarZeve jirkvlis magnito-rezonansruli (MRI) gamokvlevac emateba.

ZuZus kibos skrining meTodebs miekuTvneba:

• TviTgasinjva

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56

• klinikuri gasinjva

• mamografia

• sarZeve jirkvlis ultrasonografia

• sarZeve jirkvlis magnitur-rezonansuli gamokvleva.

sarZeve jirkvlis skriningi 40 wlis asakidan iwyeba, magram Tu qalbatons

aqvs sarZeve jirkvlis da /an sakvercxis avTvisebiani simsivnis ojaxuri

anamnezi aseT SemTxvevaSi skriningi iwyeba 10 wliT adre, vidre ojaxis

wevris diagnostirebis asakia. sarZeve jirkvlis simsivnis skriningi

gulisxmobs yovelwliurad gamokvlevebis Catarebas da miRebuli SedegebiT

onkologis konsultacias.

sarZeve jirkvlis MRI ar warmoadgens skriningis rutinul tests. am

gamokvlevis Catarebis Cvenebaa: qalbatoni, romelsac aqvs BRCA1 da BRCA2

mutacia; romelTa ojaxis wevri aris amave mutaciis mtarebeli, magram

TviTon jer ar aqvs Catarebuli testi mutaciaze; qalbatonebi, romlebsac

10-30 wlis asakSi Catarebuli aqvT sxivuri Terapia sarZeve jirkvlis areSi;

ავტორის სტილი დაცულია

57

1.13 sarZeve jirkvlis kibos mkurnalobis meTodebi (da maTi ZiriTadi

garTulebebi)

sarZeve jirkvlis kibos mkurnalobis mravali meTodi arsebobs, romelic

damokidebulia daavadebis tipsa da stadiaze.

lokaluri (adgilobrivi) mkurnaloba: aris mkurnalobis meTodi, romelic

mxolod simsivneze moqmedebs da sxeulis sxva nawilebze ar axdens gavlenas

(164-167).

lokaluri mkurnalobis tipebia:

• qirurgia

• radiaciuli (sxivuri) Terapia

aseTi tipis mkurnalobis meTodebi upiratesad gamoiyeneba kibos adreul

stadiaze (nakleb ganviTarebuli), Tumca maTi gamoyeneba SesaZlebelia sxva

SemTxvevebSic.

sistemuri mkurnaloba: sarZeve jirkvlis kibos samkurnalo preparatebi

SesaZlebelia pacients mieces peroralurad, kanqveS an intravenurad.

sistemuri tipis mkurnalobis dros medikamenti sxeulis nebismier nawilSi

arsebul kibos ujredebze moqmedebs.

imis mixedviT Tu ra tipisaa kibos ujredebi, SesaZlebelia Catardes:

• qimioTerapia

• hormonaluri (endokrinuli) Terapia

• miznobrivi Terapia

mravali pacients SesaZlebelia mkurnalobis erTze meti meTodi Cautardes.

s/j-is adreuli kibos qirurgiuli mkurnalobis Semdgomi safexurs

warmoadgens misi marTva: recidivis riskis Semcireba da darCenili kibos

ავტორის სტილი დაცულია

58

ujredebis mocileba. es ujredebi uxilavia, Tumca dadgenilia rom maT aqvT

kibos ganviTarebis adgilobrivi da Soreuli recidivis ganviTarebis unari.

qirurgiuli mkurnalobis Semdgom Terapias adiuvanturi Terapia ewodeba.

adiuvanturi Terapia moicavs: radiaciul (sxivur) Terapias, qimioTerapias,

miznobriv da/an hormonaluri Terapias. Tu romeli tipis adiuvanturi

Terapiis Catarebaa aucilebeli, damokidebulia kibos ujredebis tipze.

miuxedavad imisa rom adiuvanturi Terapia amcirebs recidivis ganviTarebis

risks, is srulad ar aRmofxvris mis risks.

hormonaluri Terapia

hormonaluri (anu endokrinuli) Terapia efeqturia adreuli stadiis da

metastazirebuli sarZeve jirkvlis kibos- estrogen da progesteron

receptor pozitiur ujredebze. hormonebis blokirebiT xdeba recidivis

prevencia (168-169).

tamoqsifeni:

tamoqsifens (seleqtiuri estrogen receptoris modulatori SERMM) gaaCnia

sxvadasxva qsovilebSi estrogenis antagonistis da agonistis kompleqsuri

farmakologiuri efeqti. simsivnur qsovilSi sarZeve jirkvlis kibos mqone

pacientebze tamoqsifeni ZiriTadad antiestrogenul efeqts axdebs, xels

uSlis estrogenis estrogenis receptorebTan dakavSirebas, aqedan

gamomdinare adgili aqvs estrogendamokidebul qsovilebSi ujreduli

proliferaciis Semcirebas (170-172).

tamoqsifeni peroralurad misaRebi medikamentia.

zogadi gverdiTi reaqciebidan aRsaniSnavia: alebi, vaginaluri simSrale,

saSvilosnodan gamonadeni an sisxldena, iSviaTad kataraqta,

hiperkoagulacia. tamoqsifenma SesaZlebelia dadebiTad imoqmedos Zvalze

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59

da qolesterinis doneze. medikamenti efeqturad gamoiyeneba orive: pre da

postmenopauzaSi.

aromatazas inhibitorebi:

postmenopauzis periodSi, rodesac sakvercxeebis mier estrogenebis sekrecia

Sewyvetilia, ferment aromatazas mier etrogenebis warmoqmna xdeba

androgenebidan. aromatazas inhibitori aris medikamenti romelic blokavs

ferment aromatazas (173). es medikamentebia: anastrozoli (arimideqsi),

letrozoli (femara) da eqsemestani (aromazini) (174-179). yvela tipis

aromatazas inhibitoebi peroralurad misaRebi medikamentia. recidivis

riskis ganviTarebis mxriv postmenopauzaSi zemoTaRniSnuli jgufis

preparatiT calke an tamoqsifenTan kombinaciaSi mkurnaloba bevrad

efeqturia vidre mxolod tamoqsifeniT mkurnaloba. aromatazas inhibitorebi

efeqturia agreTve estrogen pozititiuri metastazirebuli s.j-is kibos

dros (180-186).

gverdiTi efeqtebidan aRsaniSnavia: kunTovani da saxsrovani tkivili, alebi,

vaginaluri simSrale, osteoporozis ganviTarebis riski, motexiloba,

qolesterinis mateba sisxlSi. qalebi romlebic ar imyofეbian menopauzaSi

aromatazas inhibitoris miReba dauSvebelia, radgan preparati ver blokavs

(Trgunavs) sakvercxeebis mier gamomuavebul esrogenebs. aromatazas

inhibitoris daniSvnamde rekomendebulia sisxlSi estrogenebis donis

Semowmeba, raTa dadasturdes sakvercxeebis mier estrogenebis produqciis

arseboba (187-188).

arsebobs mkurnalobis ramdenime varianti qalebisTvis, romlebic

menopauzaSi imyofebian:

• mkurnalobis dawyeba aromatazas inhibitorebiT romelic 5 wlamde

grZeldeba

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60

• mkurnalobis dawyeba tamoqsifeniT 2-3 wlis ganmavlobaSi da Semdgom

aromatazas inhibitorebze gadasvla romelic aseve 2-3 wlamde gagrZeldeba.

• an tamoqsifeni 5 wlis ganm-Si da Semdgom 5 weli aromatazas

inhibitorebi.

mimdinare kvlevebma aCvena, rom adreuli stadiis s/j-is kibos dros 10

wliani tamoqsifeniT mkurnalobam SesaZlebelia mkveTrad Seamciros

recidivis riski, Tumca medikamentiT gamowveuli gverdiTi efeqtebis

gamovlenis Sansebic izrdeba.

hormonaluri Terapia premenopauzaSi myof qalebSi

rogorc zemoT iyo aRniSnuli, premenopauzaSi myofi qalebisTvis aromatazas

inhibitorebis daniSvna uefeqtoa.

adiuvanturi hormonaluri Terapiis variantebi romlebic gamoyenebul

SeiZleba iqnas premenopauzaSi:

• 5 an 5-ze meti wlis ganm-Si tamoqsifeni, menopauzis dadgomis Semdgom

aromatazas inhibitorebis (ai) CarTva mkurnalobis sqemaSi.

• sakvercxeebis funqciis supresiis Semdgom tamoqsifeni an /da

tamoqsifeni ai -ebTan kombinaciaSi.

yvelaze Zveli hormonaluri Terapiis meTodi hormon receptor pozitiuri

s/j-is kibos dros aris sakvercxeebis supresia, raTa daiTrgunos

sakvercxeebis mier estrogenebis sekrecia (189).

sakvercxeebis supresiisTvis gamoiyeneba gonadotropin rilizing an

maluTeinizirebeli hormonis analogebi (iwveven droebiT menopauzas).

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gozerelini (zoladeqsi) da leuprolidi (luproni) -medikamentebi romlebic

TveSi erTxel an 3 TveSi erTxel kanqveSa ineqciis gziT gamoiyeneba, qalebSi

blokaven sakvercxeebis mier estrogenebis sekrecias 1 an 3 Tvis ganm-Si (190).

am jgufis medikamentebi ufro xSirad miecema tamoqsifenTan da ai-ebTan

erTad, iSviaTad monoTerapiis saxiT.

sakvercxeebis mTlianad gaTiSvis mizniT garkveul SemTxvevebSi mimarTaven

ovarieqtomias. sakvercxeebis supresia an ablaciac (tamoqsifenTan

kombinaciaSi) gamoiyeneba premenopauzaSi myof qalebSi.

hormonaluri Terapia metastazuri sarZeve jirkvlis kibos dros

hormonaluri Terapia agreTve sakmad efeqturia metastazirebuli s/j-is

kibos dros:

• tamoqsifeni

• sakvercxis supresia

• aromatazas inhibitorebi

• fulvestanti (faslodeqsi) aris seleqtiuri estrogen receptoris

donis dawevis regulatori (SERD). sxva hormonaluri Terapiisgan

gansxvavebiT fulvestranti keTdeba intramuskuarulad TveSi erTxel.

xSirad miecema Semdegi sqemiT: 2 kviraSi erTxel - 2 ineqcia (ganmeordes 3 -

jer), Semdeg grZeldeba TveSi erjeradi ineqciiT. rekomendebulia

fulvestratis kombinacia palbociklib-Tan (ibransi) an ai-ebTan.

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sarZeve jirkvlis mkurnalobis Semdgomi garTulebebi

sarZeve jirkvlis mkurnalobam SesaZlebelia gamoiwvios garTulebebi da

gverdiTi efeqtebi, romelic damokidebulia mkurnalobis tipsa da

medikamentze (191-209).

qimioTerapiis yvelaze xSir garTulebebia: saerTo sisuste, gulisreva,

Rebineba , Tavbruxveva, Tmis cvena,sisxlis da limfuri sistemis mxriv : anemia,

leikopenia, Trombocitopenia. adgilobrivi sisxlCaqcevebi (silurje),

infeqciebisadmi midrekileba, xasiaTis cvlilebebi : depresia, SiSebi,

uxasiaToba(210-212).

menopauzaSi myof qalebSi qimioTerapia iwvevs sakvercxeebis funqciis

gaTiSvas da estrogenebis sekreciis daTrgunvas, rac osteoporozis

ganviTarebis erT-erT risk faqtors warmoadgens. menopauzisTvis

damaxasiaTebel vaginalur simSrales da alebs .

radiaciuli (sxivuri) Terapiis garTulebebia: SeSupeba da simZimis SemrZneba

sarZeve jirkvlis areSi, kanis cvlilebebi damiznebul areSi, advilad

daRla

zogjer SesaZlebelia gamoiwvios: braqialuri pleqsopaTia, tkivili da

sisuste zemo kiduris areSi.

• sxivuri Terapiis Semdgom xSiria laqtaciis problemebi.

• iRliis areSi dasxivebam agreTve SesaZloa gamoiwvios limfedema,

tkivili da SeSupeba xelsa da gulmkerdis areSi; neknebis simyife da

motexiloba, warsulSi xSirad ziandeboda filtvis da gulis nawili

gulmkerdis areSi sxivuri Terapiis gamo, Tumca ukanaskneli Tanamedrove

aRWurvilobis meSveobiT msgavsi problebi aRar gvxvdeba.

• sxivuri Terapiis uiSviaTes garTulebas warmoadgens sxva tipis kibos-

angiosarkomis warmoqmna, romelic swrafad mzardi da gavrcelebadi

daavadebaa.

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Qqirurgiuli mkurnalobis masteqtomiis Semdgomi garTulebebia:

• s/j-is areSi SeSupeba, tkivili, simZimis SegrZneba nawiburis areSi

• infeqcia an sisxldena

• limfedeba (limfuri kvanZebis amokveTis gamo)

hormonaluri Terapiis garTulebebi

tamoqsifenis gverdiT efeqtebs miekuTvneba: alebi; vaginaluri gamonadeni,

mentrualuri ciklis darRveva, Tmis cvena, kanis cvlileba, fertilobis

darRveva, mexsierebis darRveva, advilad daRla, saxsrovani tkivili, Tavis

tkivili, Zilis darRvevebi, Warboflianoba, gulisreva, wonis cvlileba,

xasiaTis cvlileba (213).

aromatazas inhibitorebis gverdiTi efeqtebi- yvelaze xSir gverdiT efeqts

warmoadgens menopauzis simptomebi, rogoricaa alebi, oflianobis mateba da

vaginaluri simSrale. am jgufis preparatebisTvis damaxasiaTebelia

kunTovani da saxsrovani tkivilebi. tamoqsifenis da raloqsifenisgan

gansxvavebiT iwveven Zvlis gamofitvas, rac SemdgomSi iwvevs osteoporozi

ganviTarebas da Zvlebis motexilobas (214-218).

sakvercxeebis supresiis gverdiTi efeqtebi: menopauzis simptomebi, alebi,

wonaSi mateba da Zvlebis tkivili.

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Tavi 2 kvleva

2.1 Kkvlevis masala da meTodebi

Cvens mier Catarebul kvlevaSi gamokvleul iqna 156 postmenopauzaSi myofi

qali, romelic davyaviT 3 ZiriTad jgufad.

I sakvlev jgufSi gaerTianda 60 pacienti hormon pozitiuri sarZeve jirkvlis

kibos diagnoziT, romlebic iRebdnen aromatazas inhibitors – anastrozols

an letrozols (am mkurnalobamde pacientebs sxva deprivaciuli an

qimioTerapiuli agenti ar miecemodaT).

II sakvlev jgufSi myofi 58 pacienti hormon pozitiuri sarZeve jirkvlis

kibos diagnoziT iRebda seleqtiur estrogen receptoris modulators-

tamoqsifens (am mkurnalobamde pacientebs sxva deprivaciuli an

qimioTerapiuli agenti ar miecemodaT).

I da II jgufis pacientebs hormonaluri adiuvanturi Terapiis dawyvebamde

Catarebuli hqondaT masteqtomia.

III sakontrolo jgufi warmodgenili iyo 38 pacientiT. sarZeve jirkvlis

kibos diagnozis mqone pacientebi, romlTac masteqtomiis Semdgom ar

utardebodaT adiuvanturi Terapia, radgan simsivnuri qsovilis

imunohistoqimiurma kvlevam ar daadastura simsivnis hormondamokidebuleba.

Ggamoricxvis kriteriums warmoadgenda mkurnalobis dawyebamde

osteoporozis arseboba (T-score < -2.5) .

TiToeuli jgufi Tavis mxriv daiyo or qve-jgufad:

• Ppacientebi, romelTac bolo menstrualuri periodi aReniSnebodaT 3

welze meti xangrZlivobiT

Dda

• Ppacientebi, romelTac bolo menstrualuri periodi aReniSnebodaT 3

welze naklebi xangrZlivobiT

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aRsaniSnavia isic rom, kvlevaSi CarTuli arcerTi pacienti ar iRebda

antirezorbciul mkurnalobas. zogierT maTgans miecemodaT kalciumis

karbonati araTanabari komplaentobiT, rac gulisxmobda imas, rom kvebiTi

danamatis saxiT saSualod iRebdnen elementuri kalciumis 400-500 mg-s.Y

yvela jgufSi welis malebis da barZayis yelis Zvlis mineraluri simkvrive

Sefasda hormonaluri mkurnalobis dawyebamde, mkurnalobidan 1; 2 da 5

welSi ormagenergetikuli rentenuli absorbciometriis saSualebiT.

2.2Kkvlevis eTikuri aspeqtebi

kvlevis Catarebaze Tanxmoba mogvca “endokrinologiis erovnul institut “-

Tan arsebulma eTikurma komisiam, gaiTvaliswina ra kvlevis dizainis

Sesabamisoba medicinaSi klinikuri kvlevebis eTikuri standartebis Sesaxeb

helsinikis deklaraciasTan (1977) mimarTebaSi.

2.3 miRebuli Sedegebi

pacientebis saSualo asaki iyo 56 weli.

Mmkurnalobamde I sakvlevi jgufis (aromatazas inhibitorze myofi

pacientebi) pacientebis 58% -s da II sakvlevi jgufis (tamoqsifenze myofi

pacientebi) 22%-s@ aReniSna osteopenia welis malebSi (P<0.0001) Zms-s

daqveiTeba osteopeniis tipiT aseve dafiqsirda barZayis yelSi - I sakvlev

jgufSi 28% da II sakvlev jgufSi 10% (P <0.0001).

III sakontrolo (medikamentis gareSe myofi paceintebi) jgufis pacientebSi

mkurnalobamde ar aReniSnaT daqveiTebuli Zms-s maCveneblebi (P <0.0001).

ავტორის სტილი დაცულია

66

2.3.1 Zms-is cvlileba sakvlevi jgufebis mixedviT hormonaluri

(adiuvanturi) mkurnalobis dawyebamde, mkurnalobidan 1; 2 da 5 welSi

I sakvlev jgufSi CaerTo 49 wlidan 74 wlamde asakis postmenopauzaSi myofi

60 qali (saSualo asaki 61 weli).

Yyvela pacienti qirurgiuli mkurnalobis Semdgom iRebda aromatazas

inhibitors (anastrozols an letrozols) 5 wlis ganmavlobaSi.

I sakvlevi jgufi Tavis mxriv daiyo 2 qvejgufad:

1. Ppacientebi, 3 welze meti bolo menstruaciis periodiT, romelTa

raodenobamac Seadgina sakvlevi jgufis 77% (46 pacienti)

2. Ppacientebi, 3 welze naklebi bolo menstruaciis periodiT, romelTa

raodenobamac Seadgina sakvlevi jgufis 23% (14 pacienti)

I საკვლევი ჯგუფი

მენოპაუზის ხანგრძლივობის

მიხედვით

რაოდენობა პროცენტი

3 წელზე მეტი 46 77%

3 წელზე ნაკლები 14 23%

ჯამი 60 100%

DXA Catarda hormonaluri (adiuvanturi) mkurnalobis dawyebamde, 1 ; 2 da 5

wlis Semdeg.

miRebuli Sedegebi:

L1-L4 malebSi Zms-s cvlileba :

• Mmkurnalobis dawyebamde 60 pacientidan 25 pacients (41,7 %) aReniSna

normaluri Zms da 35 pacients (58,3 %) Zms-s daqveiTeba osteopeniis

tipiTLwelis malebSi (L1-L4).

ავტორის სტილი დაცულია

67

• Mmkurnalobis dawyebidan 1 welSi normaluri Zms-s maCvenebli kvlav

dafiqsirda 25 pacientSi, xolo 35 osteopeniis mqone pacientidan 1

pacients aReniSna Zms-s daqveiTeba osteoporozis tipiT

• Mmkurnalobis dawyebidan 2 welSi Sedegebi kvlav igive darCa rogorc

1 welSi dafiqsirda.

• xolo mkurnalobis dawyebidan me-5 wels 35 osteopeniis mqone 2

pacients daufiqsirda jamSi osteoporozis diagnozi. Nnormaluri Zms-

s maCvenebeli kvlav 25 pacientSi SenarCunda (cxrili 8)

cxrili 8

L1-L4

მკურნალობის პერიოდი

მკურნალობამდე მკურნალობის

დაწყებიდან 1 წელში

მკურნალობის

დაწყებიდან 2 წელში

მკურნალობის

დაწყებიდან 5 წელში

ძმს-ს მაჩვენებელი პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

Tscore - 1 მდე 25 41.7 25 41.7 25 41.7 25 41.7

Tscore -1 დან -2.5 35 58.3 34 56.7 34 56.7 33 55.0

Tscore < -2.5 0 0 1 1.7 1 1.7 2 3.3

ჯამი 60 100 60 100 60 100 60 100

Zms-s cvlileba barZayis yelSi:

• Mmkurnalobis dawyebamde 60 pacientidan 43 pacients (71,7 %) aReniSna

normaluri Zms da 17 pacients (28.3 %) Zms-s daqveiTeba osteopeniis

tipiT barZayis yelSi.

• Mmkurnalobis dawyebidan 1; 2 da 5 welSi normaluri Zms-s maCvenebli

kvlav dafiqsirda 43 pacientSi, xolo 17 pacients aReniSna Zms-s

daqveiTeba kvlav osteopeniis tipiT (cxrili 9).

ავტორის სტილი დაცულია

68

cxrili 9

II sakvlev jgufSi CaerTo 46 wlidan 60 wlamde asakis postmenopauzaSi myofi

58 qali (saSualo asaki 53).

Yyvela pacienti qirurgiuli mkurnalobis Semdgom iRebda seleqtiuri

estogenis receptoris modulators -tamoqsifens

II sakvlevi jgufi Tavis mxriv daiyo 2 qvejgufad:

1. Ppacientebi, 3 welze meti bolo menstruaciis periodiT, romelTa

raodenobamac Seadgina sakvlevi jgufis 27.6 % (16 pacienti)

2. Ppacientebi, 3 welze naklebi bolo menstruaciis periodiT, romelTa

raodenobamac Seadgina sakvlevi jgufis 72.4 % (42 pacienti)

II საკვლევი ჯგუფი

მანოპაუზის ხანგრძლივობის

მიხედვით

რაოდენობა პროცენტი

3 წელზე მეტი 16 27.6

3 წელზე ნაკლები 42 72.4

ჯამი 58 100

Total Hip

მკურნალობის პერიოდი

მკურნალობამდე მკურნალობის

დაწყებიდან 1 წელში

მკურნალობის

დაწყებიდან 2 წელში

მკურნალობის

დაწყებიდან 5 წელში

ძმს-ს მაჩვენებელი პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

Tscore - 1 მდე 43 71.7 43 71.7 43 71.7 43 71.7

Tscore -1 დან -2.5 17 28.3 17 28.3 17 28.3 17 28.3

Tscore < -2.5 0 0 0 0 0 0 0 0

ჯამი 60 100 60 100 60 100 60 100

ავტორის სტილი დაცულია

69

L1-L4 malebSi Zms-s cvlileba :

• Mmkurnalobis dawyebamde 58 pacientidan 45 pacients (77,6 %) aReniSna

normaluri Zms da 13 pacients (22.4 %) Zms-s daqveiTeba osteopeniis

tipiTLwelis malebSi (L1-L4 )

• Mmkurnalobis dawyebidan 1 ; 2 da 5 wlebSi normaluri Zms-s maCvenebli

kvlav dafiqsirda imave raodenobis pacientSi (45) da osteopeniis tipiT

Zms-s daqveiTeba igive raodenobis anu 13 pacientSi (cxrili 10).

cxrili 10

L1-L4

მკურნალობის პერიოდი

მკურნალობამდე მკურნალობის

დაწყებიდან 1 წელში

მკურნალობის

დაწყებიდან 2 წელში

მკურნალობის

დაწყებიდან 5 წელში

ძმს-ს მაჩვენებელი პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

Tscore - 1 მდე 45 77.6 45 77.6 45 77.6 45 77.6

Tscore -1 დან -2.5 13 22.4 13 22.4 13 22.4 13 22.4

Tscore < -2.5 0 0 0 0 0 0 0 0

ჯამი 58 100 58 100 58 100 58 100

barZayis yelSi Zms-s cvlileba:

• Mmkurnalobis dawyebamde 58 pacientidan 52 pacients (89.7 %) aReniSna

normaluri Zms da 6 pacients (10.3 %) Zms-s daqveiTeba osteopeniis

tipiTLbarZayis yelis doneze

• Mmkurnalobis dawyebidan 1 ; 2 da 5 wlebSi normaluri Zms-s maCvenebli

kvlav dafiqsirda imave raodenobis pacientSi (52), da osteopeniis

tipiT Zms-s daqveiTeba igive raodenobis anu 6 pacientSi (cxrili 11).

ავტორის სტილი დაცულია

70

cxrili 11

III sakontrolo jgufSi CaerTo 49 wlidan 62 wlაmde asakis postmenopauzaSi

myofi 38 qali (saSualo asaki 54). (romelTac sarZeve jirkvlis

hormonpozitiuri kibos diagnozi ar daudasturdaT).

Ypacientebis es jgufi qirurgiuli mkurnalobis Semdgom ar iRebda

medikamentozur mkurnalobas da imyofebodnen perioduli meTvalyureobis

qveS (mamografia, eqoskopia, onko markerebis da onkologis konsultacia)

sakontrolo jgufi Tavis mxriv daiyo 2 qvejgufad:

1. Ppacientebi, 3 welze meti bolo menstruaciis periodiT, romelTa

raodenobama Seadgina sakvlevi jgufis 27.6 % (16 pacienti)

2. pacientebi, 3 welze naklebi bolo menstruaciis periodiT, romelTa

raodenobama Seadgina sakvlevi jgufis 72.4 % (42 pacienti)

III საკონტროლო ჯგუფი

მანოპაუზის ხანგრძლივობის

მიხედვით

რაოდენობა პროცენტი

3 წელზე მეტი 16 42.1

3 წელზე ნაკლები 22 57.9

ჯამი 38 100.0

DXA gamokvleviT sakontrolo jgufSi myof yvela pacients qirurgiuli

mkurnalobis Semdgom aReniSnebodaT normaluri Zms-is maCvenebeli welis

malebsa da barZayis yelSi.

Total Hip

მკურნალობის პერიოდი

მკურნალობამდე მკურნალობის

დაწყებიდან 1 წელში

მკურნალობის

დაწყებიდან 2 წელში

მკურნალობის

დაწყებიდან 5 წელში

ძმს-ს მაჩვენებელი პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

პაციენტების

რაოდენობა პროცენტი

Tscore - 1 მდე 52 89.7 52 89.7 52 89.7 52 89.7

Tscore -1 დან -2.5 6 10.3 6 10.3 6 10.3 6 10.3

Tscore < -2.5 0 0 0 0 0 0 0 0

ჯამი 58 100 58 100 58 100 58 100

ავტორის სტილი დაცულია

71

Zms-isNnormaluri MmaCvenebeli SenarCunda agreTve dakvirvebis periodis 1;

2 da 5 welzec.

Zms-s procentuli cvlileba sakvlevi jgufebis mixedviT mkurnalobamde, 1

; 2 da 5 welSi menopauzis xangrZlivobis mixedviT

I sakvlev jgufSi A(aromatazas inhibitoris - anastrozolis an letrozolis

jgufi) mkurnalobis dawyebidan 5 wlis Semdeg aRiniSna Zms-s daqveiTeba

welis malebSi (3 welze meti bolo menstruaciis periodis mqone pacientebSi

– 5.22%-iT (P =0.01) da 3 welze naklebi bolo menstruaciis periodis mqone

pacientebSi – 10.08%-iT- (P =0.01) da barZayis yelSi (3 welze meti bolo

menstruaciis periodis mqone pacientebSi – 6.52 %-iT (P =0.03) da 3 welze

naklebi bolo menstruaciis periodis mqone pacientebSi – 6.10 %-iT (P =0.05)

tamoqsifenis jgufTan SedarebiT.

Mmeore sakvlev jgufSi (tamoqsifenis jgufi) mkurnalobis dawyebidan 5 wlis

Semdeg aRiniSna Zms-s mateba welis malebSi (3 welze meti bolo menstruaciis

periodis mqone pacientebSi +2.62%-iT (P =0.03) da 3 welze naklebi bolo

menstruaciis periodis mqone pacientebSi +3.54%-iT (P =0.01) da barZayis yelSi

(3 welze meti bolo menstruaciis periodis mqone pacientebSi +0.03%-iT

(P =0.05) da 3 welze naklebi bolo menstruaciis periodis mqone pacientebSi

+2.03%-iT (P =0.01).

Mmesame (anu sakontrolo) jgufSi mkurnalobis dawyebidan 5 wlis Semdeg

aRiniSna Zms-s mateba welis malebSi (3 welze meti bolo menstruaciis

periodis mqone pacientebSi +1.29%-iT (P =0.05) da 3 welze naklebi bolo

menstruaciis periodis mqone pacientebSi +1.14%-iT) (P =0.05) da barZayis

yelSi (3 welze meti bolo menstruaciis periodis mqone pacientebSi +2.31%-

iT (P =0.05) da 3 welze naklebi bolo menstruaciis periodis mqone

pacientebSi +0.90%-iT (P =0.05) . (cxrili 12; diagrama 2)

ავტორის სტილი დაცულია

72

arcerT pacients, romelsac mkurnalobamde aReniSnaT Zvlis mineraluri

simkvrivis normaluri maCvenebeli, 5 wliani hormonaluri Terapiis fonze

ar daufiqsirdaT osteoporozi.

cxrili 12

წელის მალებსა და ბარძაყის ყელში პროცენტული ცვლილება ბოლო მენსტრუაციის პერიოდის

ხანგრძლივობის მიხედვით

საკვლევი ჯგუფი

პაციენტების

რაოდენობა

% ცვლილება მკურნალობის

დაწყებიდან

1 წელი 2 წელი 5 წელი

წელ

ის

მალ

ები

არომატაზას ინჰიბიტორის ჯგუფი (>3 წელი

ბოლო მენსტრუაციის პერიოდიდან) 46 -1,61% -3,02% -5,22%

არომატაზას ინჰიბიტორის ჯგუფი (<3 წელი

ბოლო მენსტრუაციის პერიოდიდან) 14 -5,01% -6,32% -10,08%

ტამოქსიფენის ჯგუფი (>3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 16 +0,87% +2,03% +2,62%

ტამოქსიფენის ჯგუფი (< 3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 42 +2,01% +2,87% +3,54%

საკონტროლო ჯგუფი (>3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 16 -0,88% +0,09% +1,29%

საკონტროლო ჯგუფი (<3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 22 -0.96% +0,04% +1,14%

ბარ

ძაყი

ს ყ

ელი

არომატაზას ინჰიბიტორის ჯგუფი (>3 წელი

ბოლო მენსტრუაციის პერიოდიდან) 46 -1,25% -3,27% -6,52%

არომატაზას ინჰიბიტორის ჯგუფი (<3 წელი

ბოლო მენსტრუაციის პერიოდიდან) 14 -2,20% -3,27% -6,10%

ტამოქსიფენის ჯგუფი (>3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 16 +0,71% +1,03% +0,03%

ტამოქსიფენის ჯგუფი (< 3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 42 +0,72% +1,69% +2,03%

საკონტროლო ჯგუფი (>3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 16 +0,27% +0,68% +2,31%

საკონტროლო ჯგუფი (<3 წელი ბოლო

მენსტრუაციის პერიოდიდან) 22 +0,14% +0,02% +0,90%

*sakontrolo jgufSi myofi pacientebi qirurgiuli mkurnalobis Semdgom medikamentozur

mkurnalobas ar iRebdnen

ავტორის სტილი დაცულია

73

diagrama 2 Zvlis mineraluri simkvrivis procentuli cvlileba 1, 2 da 5 welSi A. welis malebSi cvlileba wlebis mixedviT B. barZayis yelSi cvlileba wlebis mixedviT

ავტორის სტილი დაცულია

74

Tavi 3 . miRebuli Sedegebis ganxilva

Cvens mier Catarebuli kvlevis dasrulebisas dafiqsirda Zms-s mniSvnelovani

daqveiTeba aromatazas inhibitoriT mkurnalobis mqone pacientebSi,

seleqtiuri estrogenis receptoris modulatoriT namkurnalev pacientebTan

SedarebiT. Zms-s mkveTri daqveiTeba aRiniSna welis malebSi hormonaluri

mkurnalobis dawyebidan 2 welSi, vidre 2 dan 5 wlamde (upiratesad

trabekulur ZvalSi vidre kortikalurSi).

cnobilia rom Zvlis danakargi mkveTradaa gamoxatuli gviani perimenopauzis

da postmenopauzis pirvel wlebSi.

Catarebuli kvlevis Sedegad aRmovaCineT rom, Zms -s daqveiTeba ufro mkafio

iyo aromatazas inhibitoris jgufSi 1, 2 da 5 welze welis malebSi im

pacientebSi, romelTac aReniSnebodaT 3 welze naklebi bolo menstrualuri

periodidad (vidre pacientebSi 3 welze meti bolo menstrualuri periodiT).

sarZeve jirkvlis kibos mqone pacientebi, romelTac utardebodaT

hormonaluri mkurnaloba tamoqsifeniT daufiqsirdaT Zms-s e.w.

“damcvelobiTi efeqti”, rogorc moxseniebulia literaturaSi.

Aam jgufis pacientebSi Zms-s mateba ufro metad gamoxatuli iyo <3 weli

bmp-is qalebSi. sakontrolo jgufSi myof pacientebSi aRiniSna Zms-s

umniSvnelo cvlileba welis malebsa da barZayis yelSi.

Kkvlevis miRebulma Sedegebma aCvena rom, samive jgufis pacientebi romelTac

mkurnalobis dawyebamde hqondaT normaluri Zms ar AaReniSnaT Zms-s

daqveiTeba osteoporozis tipiT mkurnalobis me-5 welze. Sedegebis mixedviT

SegviZlia gavakeToT daskvna, rom osteoporozis ganviTarebis riski 5 wliani

hormonaluri Terapiis dros gamovlindeba im pacientebSi romelTac Tscore

mkurnalobamde hqondaT -1,5 da naklebi.

Aaqedan gamomdinare SegviZlia davaskvnaT, rom hormonaluri mkurnalobis

dawyebamde osteopeniis ar arsebobis SemTxvevaSi ar aris aucilebeli

antiosteoporozuli mkurnalobis dawyeba adiuvanturi mkurnalobis

ავტორის სტილი დაცულია

75

dawyebisTanave , xolo osteopeniis mqone pacientebs (risk-faqtorebis: asakis,

ojaxuri anamnezis, Tambaqos moxmarebis da Tanmxlebi medikamentebis, mag:

kortikosteroidebis arsebobis SemTxvevaSi), romelTac daeniSnebaT

aromatazas inhibitoris medikamenti, saWiroeben Zms-s regularul

monitorings da Zvlis damcvelobiTi strategiis SerCevas.

Kmravali klinikuri kvlevis SedegebiT dadasturda, rom intravenuri da

peroraluri bisfosfonatebis daniSvna efeqturia im pacientebSi romelTac

utardebaT adiuvanturi (horonaluri) Terapia, raTa SenarCundes Zvlis

mineraluri simkvrivis normaluri maCveneblebi.

gasaTvaliswinebelia is faqtic rom, aromatazas inhibitorebi amcireben

estrogenebis dones 90%-iT, rac Tavis mxriv iwvevs Zvlovan danakargs da

motexilobebis riskis maRal maCvenebels.

saerTo jamSi, kvlevis Sedegebidan irkveva rom sarZeve jirkvlis kibos mqone

pacientebi, romlebic imyofebian adiuvantur (hormonalur) Terapiaze da

iReben anastrolozols an letrozols, imyofebian Zms-s daqveiTebis

ganviTarebis risk jgufSi.

Bbevri kvleva adasturebs, rom antirezorbciuli mkurnaloba naCvenebia

mxolod im pacientebSi, romelTac hormonalur Terapiis daniSvnamde

aReniSnaT Zms-s daqveiTeba osteoporozis tipiT. Tumca sxva kvlevebis

rekomendaciiT Zvlovani danakargis kontroli xorcieldeba DXA kvleviT da

bisfosfonatebis daniSvniT saWiroebis SemTxvevaSi.

Mme-13 cxrilSi mocemulia U.S. Food and Drug Administration (FDA) -is mier

damtkicebuli medikamentebis sia, romlebic gamoiyeneba postmenopauzalur

asakSi osteoporozis prevenciisa da/an mkurnalobisTvis.

oTx agents (alendronati, rizendronati, zolendronismJava da denosumabi)

gaaCnia damtkicebuli “farTo speqtris” efeqturoba da unda CaiTvalos

osteoporozis mkurnalobis dawyebis Tavdapirvel variantebad.

ავტორის სტილი დაცულია

76

Ddabali da saSualo motexilobis riskis mqone pacientebisTvis (mag:

naadrevi postmenopauzalur qalebSi anamnezSi motexilobis gareSe da

saSualod dabali Tscore -iT) rekomendebulia peroraluri agentebi. saineqcio

agentebi, rogoricaa teriparatidi, denosumabi an zolendronis mJava

mizanSewonilia motexilobis maRali riskis mqone pacientebisTvis (mag:

qalebs, romelTac anamnezSi aReniSnaT mravlobiTi vertebruli

motexilobebi an barZayis yelis motexiloba, an Zalian dabali T-score), aseve

pacientebisTvis romelTac aReniSnebaT gastro-intestinaluri problemebi

da oraluri agentis intolerabeluroba. welis malebis motexilobis

maRali riskis mqone pacientebisTvis (romeltac ar aqvT aravertebruli da

barZayis yelis momtexilobis riski) metad rekomendebulia ibandronati da

raloqsifeni, da aseve aRsaniSnavia rom raloqsifens aqvs “gverdiTi

benefiti” rac gamovlindeba sarZeve jirkvlis kibos riskis SemcirebaSi.

Tirkmlis ukmarisobis mqone pacientebisTvis denosumabi arCevis preparats

warmoadgens, Tumca dializze myof pacientebSi Tirkmlis ukmarisobis me-5

stadiis dros hipokalcemiis ganviTarebis maRali riskis gamo am agentis

daniSvna rekomendebuli ar aris.

ავტორის სტილი დაცულია

77

cxrili 13

U.S. Food and Drug Administration (FDA) -is mier damtkicebuli medikamentebis sia, romlebic gamoiyeneba postmenopazur asakSi

osteoporozis prevenciisa da/an mkurnalobisTvis

Ppostmenopauzuri osteoporozi

medikamenti prevencia mkurnaloba

Aalendronis mJava (fozamaqsi)

5 mg peroralurad dReSi erTxel 35 mg peroralurad kviraSi erTxel

10 mg peroralurad dReSi

erTxel 70 mg peroralurad kviraSi erTxel 70 mg + D3 vitamini

kalcitonini (miakalciki) — 200 IU intranazalurad dReSi erTxel, an 100 IU kanqveS yovel meore dRes

denosumabi (prolia) — 60 mg kanqveS 6 TveSi erTxel

estrogeni sxvadasxva reJimiT —

ibandronis mJava (bonviva, generikuli formebi)

2.5 mg peroralurad dReSi erTxel 150 mg peroralurad TveSi erTxel

2.5 mg peroralurad dReSi

erTxel

150 mg peroralurad TveSi erTxel

3 mg intravenurad 3 TveSi erTxel

raloqsifeni (evista) 60 mg peroralurad dReSi erTxel

60 mg peroralurad dReSi erTxel

rizendronis mJava (aqtoneli, atelvia, generikuli formebi)

5 mg peroralurad dReSi erTxel

35 mg peroralurad kviraSi erTxel

150 mg peroralurad TveSi erTxel

5 peroralurad dReSi erTxel

35 mg peroralurad kviraSi erTxel

150 mg peroralurad TveSi erTxel

teriparatidi (forteo) — 20 μg kanqveS dReSi erTxel

zolendronis mJava (aklasta, generikuli formebi)

5 mg intravenurad yovel meore wels

5 mg intravenurad weliwadSi erTxel

ავტორის სტილი დაცულია

78

daskvna

1) adiuvanturi hormonaluri Terapiis erT-erTi jgufi – aromatazas

inhibitori warmoadgens Zvlis mineraluri simkvrivis daqveiTebisa da

danakargis progresirebis risk faqtors postmenopauzaSi myof

qalebSi

2) Zvlis mineraluri simkvrive ufro mkveTrad qveiTdeba pacientebSi,

romlebsac aReniSnebaT 3 welze naklebi bolo menstrualuri

periodi da iReben aromatazas inhibitorebs 5 wlis ganmavlobaSi.

3) Zms-s daqveiTeba aromatazas jgufis miRebisas ufro mkveTrad

gamoxatulia welis malebSi (anu trabekulur ZvalSi) vidre barZayis

yelSi (anu kortikalur ZvalSi).

4) Aaromatazas inhibitorebis jgufisgan gansxvavebiT homonaluri

Terapiis erT-erTi jgufis – seleqtiuri estrogen receptoris

modulatoris (tamoqsifenis) efeqti Zms-ze postmenopauzaSi myof

qalebSi miuxedavad menopauzis xangrZlivobisa aris dadebiTi.

5) 5 wliani tamoqsifeniT mkurnalobis dros Zms welis malebSi imatebs

+ 3.54%-iT (pacientebSi, romelTac aReniSnaT 3 welze naklebi bolo

menstruaciis periodidan).

6) G5 wliani aromatazas inhibitoris mkurnalobis dros Zms welis

malebSi iklebs - 10,08 %-iT (pacientebSi, romelTac aReniSnaT 3

welze naklebi bolo menstruaciis periodidan).

7) გamovlenil iqna sarwmuno korelaciuri urTierTkavSiri hormonalur

Terapiasa da bolo menstrualuri periodis xangrZlivobas Soris.

ავტორის სტილი დაცულია

79

English summary

Estrogens play an important role in female bone homeostasis; in the estrogen deficient state, bone

resorption is increased. As a result of these predictable postmenopausal findings, estrogens have been

extensively used as the main therapy to prevent bone loss in postmenopausal women. Estrogens

reduce bone turnover rate and, as an antiresorptive, clearly improve bone density.

In the 10 years following the menopause, there is a reduction in BMD averaging 2% per annum,

and osteoporosis is a major cause of morbidity in postmenopausal women.

Tamoxifen is a synthetic antiestrogen that, since its introduction for the treatment of patients with

breast cancer in the early 1970s, has come to have a major role in the management of all stages of the

disease. More recently, tamoxifen has been proved to have a favorable effect on disease-free and

overall survival when given as adjuvant therapy after primary treatment for invasive breast cancer.

Aromatase inhibitors (AIs): Anastrozole and Letrozole -nonsteroidal aromatase inhibitors are

hormone therapy drugs that can slow or stop the growth of hormone receptor-positive tumors. They

lower estrogen levels in the body by blocking aromatase, an enzyme that converts other hormones

into estrogen. This prevents the cancer cells from getting the hormones they need to grow.

Aromatase inhibitors cause a loss of bone density, which leads to higher rates of osteoporosis and

bone fractures compared to tamoxifen.

Tamoxifen is not a pure antiestrogen; it has some estrogen-agonist properties, such as the ability to

decrease the serum concentrations of cholesterol and increase those of sex-hormone-binding

globulin.

The beneficial effects of tamoxifen on BMD are most apparent at sites of trabecular bone, such

as the lumbar spine; such protective effects are associated with decreased bone resorption and

formation.

In our study, we report the 5-years results of adjuvant (hormonal) therapy on bone mineral density in

Caucasia women with breast cancer.

156 Caucasian postmenopausal women (between 46-74 years) were enrolled in this study at the

National Institute of Endocrinology, Metabolic Disorders in Georgia. The study was approved by the

ethical committee of the National Institute of Endocrinology according to the declaration of Helsinki.

ავტორის სტილი დაცულია

80

60 patients were receiving Aromatase inhibitors (AIs) - Anastrozole or Letrozole, 58 patients -

selective estrogen receptor modulators (SERMs) Tamoxifen. We have measured Lumbar Spine (LS)

and Total Hip (TH) BMDs, values were obtained using Dual Energy X-ray absorptiometry.

38 postmenopausal women with invasive breast cancer were also enrolled in the study as control

group. These patients were not receiving any treatment after primary surgery.

T-score > -2.5 was exclusion criteria, so patients with osteoporosis were not enrolled in our study.

Lumbar spine and Total hip BMD assessments were done at baseline, after 1, 2, and 5 years of

therapy by dual energy x-ray absorptiometry (DXA).

For the lumbar spine, DXA measurement was derived by taking an average of the L1, L2, L3,

and L4 values. Total hip BMD was calculated from the ratio of the total bone mineral content and

bone area from the trochanteric, intertrochanteric, and femoral neck regions of the hip.

60 postmenopausal Caucasian women received AI and 58 Tamoxifen. 38 postmenopausal women

(as control group) with invasive breast cancer not receiving any treatment after primary surgery. They

all had a baseline DXA.

The mean age at entry was 56 years. At baseline, approximately 58% patients from anastrozole

or letrozole group, 22% patients from tamoxifen group and 29 % of the control group had osteopenia

of the lumbar spine. Both treatment groups had osteopenia also in total hip (28% in AI group; 10 %

in Tamoxifen group).

Most of the patients in the tamoxifen and the control group were within 3 years of menopause

compared with the anastrozole and letrozole group.

Among Aromatase inhibitors treated patients, there was a decrease in median BMD from baseline

to 5 years in lumbar spine (patients with > 3 years of LMP -5,22% and patients with < 3 years of

LMP - 10,08%) and total hip (patients with > 3 years of LMP -6,52% and patients with < 3 years of

LMP - 6,10 % compared with the Tamoxifen group (lumbar spine : patients with > 3 years of LMP

+2,62 % and patients with < 3 years of LMP +3,54 %; total hip: patients with > 3 years of LMP

+0,03 % and patients with < 3 years of LMP +2,03 %). No patients with normal BMD at baseline

became osteoporotic at 5 years.

ავტორის სტილი დაცულია

81

The control group showed changes in median BMD over the 5-year period (lumbar spine +1,29%;

total hip +2,31%).

Patients with normal BMD at baseline, who received treatment (anastrozole or letrozole - n 60; or

tamoxifen- n 58), none had become osteoporotic (T-score <-2.5) at 5 years. Only 2 women with

osteopenia at baseline developed osteoporosis on AI treatment.

At the end of our study all BMD data showed significant bone loss in aromatase inhibitors treated

patients relative to SERMs treated postmenopausal women. The rapid bone loss occurred in lumbar

spine from baseline to 2 years compared with 2 to 5 years.

It is known that bone loss accelerates substantially in the late perimenopause and continues at a

similar pace in the first postmenopausal years.

We also found out that the rate of BMD loss at 1, 2, and 5 years at the lumbar spine for AI group

was greater for women in the immediate postmenopausal period (within 3 years of their last menstrual

period) than for patients more than 3 years since their menopause.

Breast cancer patients treated with tamoxifen showed protection against postmenopausal bone

loss.

We noticed that at 1, 2, and 5 years BMD increase was greater in Tamoxifen group patients within

3 years of their last menstrual period. Patients in the control group experienced little change in lumbar

spine and total hip BMD.

The current analysis shows that no woman with a normal BMD at baseline had become

osteoporotic at 5 years and the data suggest that only those women with a T-score of less than - 1.5

are at risk of developing osteoporosis during the treatment period.

Based on this, we can say that if pre-existing osteopenia is excluded no further preventive actions

are required for all postmenopausal women.

For patients with pre-existing osteopenia (and risk factors including age, family history, smoking,

and concomitant use of drugs such as corticosteroids), who are on AI treatment regular monitoring

of BMD and bone-protection strategies are necessary.

Clinical trial evidence indicates that intravenous and oral bisphosphonates are effective in

maintaining BMD in breast cancer patients receiving hormonal (endocrine) therapy.

ავტორის სტილი დაცულია

82

Given that AIs reduce estrogen levels by approximately 90%, it might be expected that bone loss

would be accelerated. However, it is critical to understand the relationship between AIs and fracture

risk.

Overall, findings from our study suggest that adjuvant anastrozole/letrozole therapy for

postmenopausal women with early breast cancer leads to accelerated bone loss. Many studies suggest

that the risk of developing treatment-related osteoporosis seems to be confined to those patients

already osteopenic at baseline, and other data suggest that bone loss can be managed in this group by

DXA scanning and use of bisphosphonates as needed.

Conclusion:

The present study showed that Aromatase inhibitors are associated with accelerated bone loss over

the 5-year treatment period. The rapid bone loss occurred in lumbar spine from baseline to 2 years

compared with 2 to 5 years. In postmenopausal women, treatment with tamoxifen is associated with

preservation of the bone mineral density of the lumbar spine.

ავტორის სტილი დაცულია

83

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