โรคกระดูกพรุน (Osteoporosis) 17-A

โรคกระดูกพรุน (Osteoporosis)
นพ.วีระ สถิรอังกูร
นพ.ชัยวัฒน ปยะสกุลแกว
นพ.ชวนนท สุมนะเศรษฐกุล
นพ.วิชาญ กาญจนถวัลย
นพ.ปฤศนัย พฤฒิกุล

17

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

โรคกระดูกพรุน (Osteoporosis) 17-1

โรคกระดูกพรุน (Osteoporosis)
นพ.วีระ สถิรอังกูร* นพ.ชัยวัฒน ปยะสกุลแกว*
นพ.ชวนนท สุมนะเศรษฐกุล* นพ.วิชาญ กาญจนถวัลย*
นพ.ปฤศนัย พฤฒิกุล*

ēøÙÖøąéĎÖóøčî ÙČĂ ēøÙìĊęöĊÙüćöĒ×ĘÜĒÖøŠÜ×ĂÜÖøąéĎÖ (bone strength) úéúÜ ÿŠÜñúĔĀšöĊÙüćöđÿĊę÷ÜêŠĂÖøąéĎÖĀĆÖ

ÿĎÜ×ċĚîêćöîĉ÷ćö×ĂÜ National Institute of Health ×ĂÜÿĀøĆåĂđöøĉÖć ĔîðŘ 25431 ÙüćöĒ×ĘÜĒÖøŠÜ×ĂÜÖøąéĎÖðøąÖĂïéšü÷
2 ÿŠüîĀúĆÖ ÙČĂ ÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖ (bone density) ĒúąÙčèõćó×ĂÜÖøąéĎÖ (bone quality)2 ÿŠüîĂÜÙŤÖćøĂîćöĆ÷
ēúÖ3 ĕéšĔĀšÙĞćîĉ÷ćöĕüšüŠć “đðŨîēøÙÖøąéĎÖìĊęđÖĉé×ċĚîìĆęüøŠćÜÖć÷ (systemic skeletal disease) àċęÜöĊöüúÖøąéĎÖêęĞć (low bone
mass) øŠüöÖĆïÖćøđÿČęĂö×ĂÜēÙøÜÿćøøąéĆïÝčúõćó×ĂÜÖøąéĎÖ (micro architecture deterioration) ÿŠÜñúĔĀšÖøąéĎÖöĊÙüćö
đðøćąïćÜĒúąĀĆÖÜŠć÷” ĒúąĕéšÖĞćĀîéđÖèæŤĔîÖćøüĉîĉÝÞĆ÷ēé÷ĂćýĆ÷ÖćøêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖēé÷ĔĀšÖćøüĉîĉÝÞĆ÷ēøÙ
ÖøąéĎÖóøčîđöČęĂöĊÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖêęĞćÖüŠć -2.5 ×ĂÜÿŠüîđïĊę÷Üđïîöćêøåćî (T-score Œ -2.5) đöČęĂđðøĊ÷ïđìĊ÷ïÖĆï
ÙŠćđÞúĊę÷ĒúąÿŠüîđïĊę÷Üđïîöćêøåćî×ĂÜöüúÖøąéĎÖĔîüĆ÷ÿćüàċęÜëČĂüŠćđðŨîߊüÜìĊęöĊöüúÖøąéĎÖÿĎÜÿčé (êćøćÜìĊę 17.1)

êćøćÜìĊę 17.1 ÖćøüĉîĉÝÞĆ÷ēøÙÖøąéĎÖóøčîêćöÙüćöĀîćĒîŠîÖøąéĎÖ3

ðÖêĉ (normal)
ÖøąéĎÖïćÜ (osteopenia)
ÖøąéĎÖóøčî (osteoporosis)
ÖøąéĎÖóøčîøąéĆïøčîĒøÜ
(severe/established
osteoporosis)
ÙüćöĀîćĒîŠîÖøąéĎÖĂ÷ĎŠĔîđÖèæŤðÖêĉ ÙČĂöĊÙŠćöćÖÖüŠćĀøČĂđìŠćÖĆï -1 ÿŠüîđïĊę÷Üđïî
öćêøåćîđöČęĂđðøĊ÷ïđìĊ÷ïÖĆïÙŠćđÞúĊę÷öüúÖøąéĎÖÿĎÜÿčéĔîñĎšĀâĉÜüĆ÷ÿćü (T-score œ -1)
ÙüćöĀîćĒîŠîÖøąéĎÖĂ÷ĎŠĔîđÖèæŤêęĞćÖüŠć -1 ÿŠüîđïĊę÷ÜđïîöćêøåćîĒêŠöćÖÖüŠć -2.5
đöČęĂđðøĊ÷ïđìĊ÷ïÖĆïÙŠćđÞúĊę÷öüúÖøąéĎÖÿĎÜÿčéĔîñĎšĀâĉÜüĆ÷ÿćü (-2.5 > T-score -1)
ÙüćöĀîćĒîŠîÖøąéĎÖêęĞćÖüŠćĀøČĂđìŠćÖĆï -2.5 ÿŠüîđïĊę÷ÜđïîöćêøåćîđöČęĂđðøĊ÷ïđìĊ÷ï
ÖĆïÙŠćđÞúĊę÷öüúÖøąéĎÖÿĎÜÿčéĔîñĎšĀâĉÜüĆ÷ÿćü (T-score Œ -2.5)
ÙüćöĀîćĒîŠîÖøąéĎÖêęĞćÖüŠćĀøČĂđìŠćÖĆï -2.5 ÿŠüîđïĊę÷ÜđïîöćêøåćîđöČęĂđðøĊ÷ïđìĊ÷ï
ÖĆïÙŠćđÞúĊę÷öüúÖøąéĎÖÿĎÜÿčéĔîñĎšĀâĉÜüĆ÷ÿćü (T-score Œ -2.5)
øŠüöÖĆïöĊÖøąéĎÖĀĆÖÝćÖÙüćöđðøćąïćÜ (fragility fracture)

ēøÙÖøąéĎÖóøčîđðŨîðŦâĀćìćÜÿćíćøèÿč×ìĊęöĊĒîüēîšöÿĎÜĔîìčÖõĎöĉõćÙ×ĂÜēúÖøüöìĆĚÜðøąđìýĕì÷ ēøÙÖøąéĎÖóøčî
ÝąìĞ ć ĔĀš ñĎš ðś ü ÷ÖøąéĎ Ö ĀĆ Ö ĕéš ÜŠ ć ÷ îĞ ć öćàċę Ü õćüąìč ó óúõćóìĞ ć ĔĀš ĕ öŠ ÿ ćöćøëÖúĆ ï ĕðéĞ ć øÜßĊ üĉ ê ĕéš ð Öêĉ ĒúąĂćÝđÖĉ é
õćüąĒìøÖàšĂîìĞćĔĀšđÿĊ÷ßĊüĉêĕéš ÝćÖÖćøÿĞćøüÝðŦâĀćÿč×õćó×ĂÜñĎšÿĎÜĂć÷čĕì÷ìĊęñŠćîēé÷ÿĞćîĆÖÜćîÿëĉêĉĒĀŠÜßćêĉ óïüŠćðŦâĀć
ìĊęÿĞćÙĆâĂĆîéĆïêšîė ÝąđÖĊę÷üךĂÜÖĆïøąïïÖøąéĎÖĒúąÖúšćöđîČĚĂ
ēøÙÖøąéĎÖóøčîđðŨîēøÙđøČĚĂøĆÜìĊęöĊĒîüēîšöđóĉęöÿĎÜ×ċĚî đîČęĂÜÝćÖðøąßćÖøñĎšÿĎÜĂć÷čđóĉęöÿĎÜ×ċĚî îĂÖÝćÖîĊĚÖćøđÖĉé
ÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčîÝąÿŠÜñúĔĀšĂĆêøćÖćøêć÷đóĉęööćÖ×ċĚîĂ÷ŠćÜöćÖ ÝćÖÖćøýċÖþćĂĆêøćêć÷õć÷ĀúĆÜÖøąéĎÖÿąēóÖìĊę
ÝĆÜĀüĆéđßĊ÷ÜĔĀöŠ ĔîðŘ 1997-1998 óïüŠćøšĂ÷úą 2.1 đÿĊ÷ßĊüĉêøąĀüŠćÜđךćøĆïÖćøøĆÖþćĔîēøÜó÷ćïćú ĂĆêøćêć÷ĀúĆÜÝćÖ
ÖøąéĎÖÿąēóÖĀĆÖìĊę 3 đéČĂî, 6 đéČĂî Ēúą 1 ðŘ đìŠćÖĆïøšĂ÷úą 9.0, 12.0 Ēúą 17.0 êćöúĞćéĆï ÝćÖÖćøýċÖþćēé÷êĉéêćöđðŨî
øą÷ą 5 ðŘ4 óïüŠćĂĆêøćêć÷Ă÷ĎŠìĊęøšĂ÷úą 29.0 ĒúąÖćøýċÖþć×ĂÜ Jitapunkul ðŘ 1995-19975 óïüŠćñĎšĀâĉÜĂć÷č 50 ðŘ ìĊęöĊ
ÖøąéĎÖÿąēóÖĀĆÖöĊĂĆêøćêć÷öćÖÖüŠćüĆ÷đéĊ÷üÖĆîìĊęĕöŠöĊÖøąéĎÖÿąēóÖĀĆÖ îĂÖÝćÖîĊĚ Chariyalertsak ĔîðŘ 1997-19986 ýċÖþć
óïüŠćĂĆêøćêć÷ĔîñĎšßć÷ìĊęđÖĉéÖøąéĎÖÿąēóÖĀĆÖÝąÿĎÜÖüŠćñĎšĀâĉÜ ĒúąñĎšìĊęĕéšøĆïÖćøøĆÖþćĒïïðøąÙĆïðøąÙĂÜÝąöĊĂĆêøćêć÷
öćÖÖüŠćñĎšìĊęĕéšøĆïÖćøøĆÖþćéšü÷ÖćøñŠćêĆé 2 đìŠć
ÖćøýċÖþćÙčèõćóßĊüĉêõć÷ĀúĆÜđÖĉéÖøąéĎÖĀĆÖĔîÙîĕì÷óïüŠćúéúÜĂ÷ŠćÜßĆéđÝî ñĎšðśü÷ìĊęđÖĉéÖøąéĎÖÿąēóÖĀĆÖ
17
óïüŠćøšĂ÷úą 22.1 ×ĂÜñĎšðśü÷ĕöŠÿćöćøëđéĉîĕéš øšĂ÷úą 23.2 êšĂÜĔßšøëđ×Ęî øšĂ÷úą11.2 êšĂÜöĊÙîߊü÷ĔîÖćøđÙúČęĂî÷šć÷7
Pongchaiyakul8 ĕéšĔßšĒïïÿĞćøüÝÿč×õćó SF-36 óïüŠćÙčèõćóßĊüĉê×ĂÜñĎšðśü÷ÖøąéĎÖÿąēóÖĀĆÖēé÷øüöúéúÜøšĂ÷úą 60.0
ĒúąöĊîšĂ÷ÖüŠćøšĂ÷úą 5.0 ìĊęÖúĆïĕðöĊÿč×õćóĒ×ĘÜĒøÜđĀöČĂîđéĉö
*ēøÜó÷ćïćúđúĉéÿĉî

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-2 โรคกระดูกพรุน (Osteoporosis)

øąïćéüĉì÷ć (Epidemiology)

ÿćđĀêč×ĂÜÖćøđÖĉéēøÙ (Cause)
ēøÙÖøąéĎÖóøčî ÙČĂ ēøÙ×ĂÜÖøąéĎÖìĊęöĊÙüćöĒ×ĘÜĒÖøŠÜ×ĂÜÖøąéĎÖúéúÜ öĊ 2 ÿćđĀêčĀúĆÖĔĀâŠė ÙČĂ ðøĉöćèöüú
ÖøąéĎÖìĊęÿąÿöĕüšöĊîšĂ÷ÖüŠćìĊęÙüøÝąđðŨî (peak bone mass) ĀøČĂöĊÖćøÿúć÷ÖøąéĎÖöćÖÖüŠćðÖêĉ ĔîߊüÜĂć÷č 40-45 ðŘ Ýą
đøĉęööĊÖ ćøÿúć÷ÖøąéĎÖ öćÖÖüŠ ć Öćøÿøšć ÜÖøąéĎÖ ìĞć ĔĀš öüúÖøąéĎ Öđøĉęö úéúÜĔîĂĆê øćßšć ė ĒêŠĀ úĆÜ ÝćÖñĎšĀâĉ Ü đך ć üĆ÷Āöé
ðøąÝĞćđéČĂî ĂĆêøćÖćøÿúć÷ÖøąéĎÖÝąÿĎÜ×ċĚîĂ÷ŠćÜöćÖ ìĞćĔĀšöüúÖøąéĎÖúéúÜêęĞćÝîëċÜđÖèæŤìĊęìĞćĔĀšÙüćöđÿĊę÷ÜêŠĂÖøąéĎÖĀĆÖ
đóĉęööćÖ×ċĚî

ðŦÝÝĆ÷ìĊęđÖĊę÷üךĂÜÖĆïÖćøđÖĉéēøÙ (Risk factor)

ðŦÝÝĆ÷đÿĊę÷ÜìĊęĕöŠÿćöćøëðøĆïđðúĊę÷îĕéš (non-modifiable risk factors)
1. Ăć÷čêĚÜĆ ĒêŠ 65 ðŘ×ċĚîĕð
2. đóýĀâĉÜ
3. ßîßćêĉñĉü×ćüĒúąđĀúČĂÜ9
4. ĀöéðøąÝĞćđéČĂîÖŠĂîĂć÷č 45 ðŘ øüöìĆĚÜñĎšìĊęëĎÖêĆéøĆÜĕ׊ÿĂÜךćÜÖŠĂîĀöéðøąÝĞćđéČĂî (early menopause)
5. ēÙøÜÿøšćÜ×ĂÜøŠćÜÖć÷đúĘÖ (small body build)
6. ïĉéć öćøéć óĊęîšĂÜđðŨîēøÙÖøąéĎÖóøčîĀøČĂÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî
7. ÖøąéĎÖĀĆÖÝćÖõćüąÖøąéĎÖđðøćąïćÜ (fragility fracture)
ðŦÝÝĆ÷đÿĊę÷ÜìĊęðøĆïđðúĊę÷îĕéš (modifiable risk factors)
1. ïøĉēõÙĒÙúđàĊ÷öĕöŠóĂđóĊ÷Ü (inadequate calcium intake)
2. ĕöŠÙŠĂ÷ĕéšĔßšĒøÜÖć÷ (sedentary lifestyle)10
3. ÿĎïïčĀøĊęđðŨîðøąÝĞć
4. éČęöÿčøć/ÖćĒôđÖĉî×îćéđðŨîðøąÝĞć
5. éĆßîĊöüúÖć÷êęĞćÖüŠć 19 ÖÖ./êø.ö.
6. öĊõćüą×ćéăĂøŤēöîđĂÿēêøđÝîÖŠĂîđךćÿĎŠüĆ÷ĀöéðøąÝĞćđéČĂî
7. öĊÙüćöđÿĊę÷ÜêŠĂÖćøĀÖúšö (propensity to falls)
ĔîðøąđìýÿĀøĆåĂđöøĉÖćðŘ 1993 öĊñĎšìĊęđÖĉéõćüąÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî (osteoporotic fractures)
öćÖÖüŠć 1.3 úšćîÙøĆĚÜĔîĒêŠúąðŘ ēé÷óïüŠćøšĂ÷úą 50.0 đÖĉéìĊęÖøąéĎÖÿĆîĀúĆÜ (vertebral fractures) øšĂ÷úą 25.0 đÖĉéìĊę
ÖøąéĎÖÿąēóÖ (hip fractures) ĒúąøšĂ÷úą 25.0 đÖĉéìĊęÖøąéĎÖðúć÷Ē×î (Colles’ fractures) ÿĞćĀøĆïÙüćößčÖ×ĂÜēøÙ
ÖøąéĎÖóøčîöĊøć÷ÜćîüŠć ÖüŠćøšĂ÷úą 30.0 ×ĂÜÿêøĊĔîìüĊð÷čēøðìĊęöĊĂć÷čêĆĚÜĒêŠ 50 ðŘ×ċĚîĕðÝąđðŨîēøÙÖøąéĎÖóøčî11
Ĕîðøąđìýĕì÷öĊÖćøÿĞćøüÝÙüćößčÖ×ĂÜēøÙÖøąéĎÖóøčîĔîñĎšìĊęöćøĆïïøĉÖćøĔîēøÜó÷ćïćú×ĂÜøĆåïćÜĒĀŠÜ ĒúąÝćÖ
ÖćøÿčŠöêøüÝÿêøĊĔîßčößîÝćÖìĆęüìčÖõćÙ×ĂÜðøąđìýĔîðŘ 254112 Ēúą 254413 êćöúĞćéĆï óïüŠćøšĂ÷úą 19.0-21.0 ×ĂÜÿêøĊ
ìĊęöĊĂć÷čêĆĚÜĒêŠ 40 ðŘ×ċĚîĕð đðŨîēøÙÖøąéĎÖóøčî×ĂÜÖøąéĎÖÿĆîĀúĆÜÿŠüîđĂü (lumbar spine, L1-L4) ĒúąøšĂ÷úą 11.0-13.0
đðŨîēøÙÖøąéĎÖóøčî×ĂÜÖøąéĎÖÙĂÿąēóÖ (femoral neck osteoporosis)

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-3

êćøćÜìĊę 17.2 ÙüćößčÖ×ĂÜÖøąéĎÖïćÜĒúąēøÙÖøąéĎÖóøčîĔîñĎšĀâĉÜĕì÷ ðŘ 254413

ÖøąéĎÖÿĆîĀúĆÜÿŠüîđĂüøąéĆïìĊę 1-4 ÖøąéĎÖÙĂÿąēóÖ
Ăć÷č ÖøąéĎÖïćÜ ÖøąéĎÖóøčî ÖøąéĎÖïćÜ ÖøąéĎÖóøčî
(øšĂ÷úą) (øšĂ÷úą) (øšĂ÷úą) (øšĂ÷úą)
40-44 14.1 1.7 24.0 0.4
45-49 19.2 4.0 25.0 1.6
50-54 35.5 9.4 38.0 4.9
55-59 38.0 22.6 47.0 10.3
60-64 37.3 39.4 57.0 20.1
65-69 41.7 40.8 58.0 32.6
70-74 28.2 57.7 48.0 49.6
75 ðŘ×Ěîċ ĕð 28.0 59.6 34.0 59.2

ÿĞćĀøĆïĂčïĆêĉÖćøèŤ×ĂÜÿąēóÖĀĆÖ (hip fractures) Ĕîðøąđìýĕì÷öĊøć÷ÜćîÝćÖÖćøÿĞćøüÝìĊęÝĆÜĀüĆéđßĊ÷ÜĔĀöŠ

øąĀüŠćÜðŘ 2540-254114 óïĂčïĆêĉÖćøèŤ×ĂÜÖøąéĎÖÿąēóÖĀĆÖĔîðøąßćÖøìĆĚÜßć÷ĒúąĀâĉÜìĊęöĊĂć÷čêĆĚÜĒêŠ 50 ðŘ×ċĚîĕð ÝĞćîüî
162 ÙøĆĚÜêŠĂ 100,000 ðøąßćÖøêŠĂðŘ ĒêŠÝąđóĉęö×ċĚîđðŨî 851 ÙøĆĚÜĔîðøąßćÖøìĊęĂć÷čđÖĉî 75 ðŘ×ċĚîĕð ĒêŠđöČęĂóĉÝćøèćđÞóćąĔî
ðøąßćÖøđóýĀâĉÜÝąóïĂčïĆêĉÖćøèŤ×ĂÜÖøąéĎÖÿąēóÖĀĆÖ 289 ÙøĆĚÜêŠĂðŘĔîĀâĉÜìĊęĂć÷čđÖĉî 50 ðŘ×ċĚîĕð ĒúąÝąđóĉęö×ċĚîđðŨî
1,011 ÙøĆĚÜëšćĂć÷čđÖĉî 75 ðŘ Öćøđóĉęö×ċĚî×ĂÜēøÙÖøąéĎÖóøčîĒúąÖøąéĎÖĀĆÖÿŠüîĀîċęÜđßČęĂüŠćđðŨîñúöćÝćÖĂć÷č×Ć÷ìĊęđóĉęö×ċĚî éĆÜìĊę
óïüŠćĂć÷č×Ć÷đÞúĊę÷×ĂÜðøąßćÖøēúÖĕéšđóĉęö×ċĚîÝćÖ 45.1 ðŘĔîßć÷ Ēúą 47.8 ðŘĔîĀâĉÜøąĀüŠćÜðŘ 2493-2498 đðŨî 65.1 ðŘĔî
ßć÷ Ēúą 69.3 ðŘĔîĀâĉÜøąĀüŠćÜðŘ 2543-254815 đߊîđéĊ÷üÖĆïĔîðøąđìýĕì÷ìĊęóïüŠćĂć÷č×Ć÷đÞúĊę÷×ĂÜðøąßćÖøĕì÷ĕéšđóĉęö
ÝćÖ 62 ðŘĔîßć÷ Ēúą 68 ðŘĔîĀâĉÜøąĀüŠćÜðŘ 2523-252816 đðŨî 68 ðŘĔîßć÷ Ēúą 72 ðŘĔîĀâĉÜøąĀüŠćÜðŘ 2543-2548 Ēúą
đðŨî 69.5 ðŘĔîßć÷ Ēúą 76.3 ðŘĔîĀâĉÜ ĔîðŘ 2551 ìĆĚÜîĊĚđîČęĂÜÝćÖõć÷ĀúĆÜöüúÖøąéĎÖđóĉęö×ċĚîÿĎÜÿčéĒúšü (peak bone mass)
ÝąđðŨîøą÷ąìĊęđøĉęööĊÖćøÿĎâđÿĊ÷öüúÖøąéĎÖĂ÷ŠćÜÙŠĂ÷đðŨîÙŠĂ÷ĕð ēé÷óïüŠćĔîÿêøĊĕì÷öüúÖøąéĎÖÝąđóĉęöÿĎÜÿčéĂć÷čøąĀüŠćÜ 30-
34 ðŘ ĂĆêøćÖćøÿĎâđÿĊ÷ÖøąéĎÖÝąđóĉęö×ċĚîĂ÷ŠćÜøüéđøĘüĔîÿêøĊđöČęĂđךćÿĎŠüĆ÷ĀöéðøąÝĞćđéČĂî ēé÷đÞóćąõć÷Ĕî 5 ðŘĒøÖ×ĂÜÖćø
ĀöéðøąÝĞćđéČĂî

đÙøČęĂÜßĊĚüĆéõćøąēøÙ (Burden of Disease)

ēé÷ìĆęüĕðēøÙÖøąéĎÖóøčîđðŨîēøÙìĊęĕöŠöĊĂćÖćøĔéė ĒêŠñúìĊęêćööćĀøČĂ clinical consequence ìĊęÿĞćÙĆâ×ĂÜēøÙîĊĚ
ÙČĂ ÖćøđÖĉéÖøąéĎÖĀĆÖĕéšÜŠć÷ àċęÜĒïŠÜĂĂÖĕéšđðŨî 2 ÖøèĊ ÙČĂ
1) ÖøąéĎÖĀĆÖÝćÖõ÷Ćîêøć÷ĒïïĕöŠøčîĒøÜ (low-energy trauma) đߊî ÖøąéĎÖÿąēóÖĀĆÖÝćÖÖćøĀÖúšö
ÝćÖìŠć÷Čî ĀøČĂêÖÝćÖìĊęÿĎÜĔîøąéĆïĔÖúšđÙĊ÷ÜÖĆïÖćøúšöÝćÖìŠć÷Čî đðŨîêšî
2) ÖøąéĎÖĀĆÖēé÷ĕöŠöĊĒøÜÖøąĒìÖÝćÖõć÷îĂÖ đߊî ÖøąéĎÖÿĆîĀúĆÜĀĆÖÝćÖÖćøÖšöêĆü ĀøČĂÖćø÷Ö×ĂÜ
ĀîĆÖ đðŨîêšî
ÖøąéĎÖĀĆÖđĀúŠćîĊĚÝąđøĊ÷Öøüöė üŠć ÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî ĀøČĂ osteoporotic fractures ìĊęđðŨîñúúĆóíŤ
ĀúĆÖìĊęđÖĉé×ċĚîÝćÖÖćøìĊęÖøąéĎÖÿĎâđÿĊ÷ÙüćöĒ×ĘÜĒÖøŠÜĕð àċęÜÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčîîĊĚđĂÜìĊęđðŨîêĆüÖŠĂĔĀšđÖĉéõćøąĒúą
ñúÖøąìïêćööć

ĂĆêøćêć÷ĒúąóĉÖćøÝćÖÖćøđÖĉéÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî (osteoporosis related mortality and

morbidity)
1. ÖćøđÖĉéÖøąéĎÖÿĆîĀúĆÜĀĆÖÝćÖēøÙÖøąéĎÖóøčî (osteoporotic vertebral fractures) ÝąđÖĉéÝćÖÖćø
ìĞćÜćîêćöðÖêĉĀøČĂÖĉÝüĆêøðøąÝĞćüĆî ēé÷ÿŠüîöćÖÝąĕöŠöĊðøąüĆêĉĕéšøĆïĂčïĆêĉđĀêčĔéė ÝċÜđðŨîđĀêčñúüŠćöĊđóĊ÷Ü øšĂ÷úą 40.0 ×ĂÜ 17
ñĎšĀâĉÜìĊęöĊÖøąéĎÖÿĆîĀúĆÜĀĆÖđĀúŠćîĊĚđìŠćîĆĚîìĊęøĎšêĆüüŠćđðŨî
2. ÖøąéĎÖĀúĆÜĀĆÖÝćÖēøÙÖøąéĎÖóøčî ĂćÝÝąöĊĂćÖćøđóĊ÷ÜĒÙŠðüéđúĘÖîšĂ÷ĕðÝîëċÜðüéöćÖÝîêšĂÜîĂî
ēøÜó÷ćïćú ĒêŠēé÷ìĆęüĕðñĎšìĊęöĊÖøąéĎÖÿĆîĀúĆÜĀĆÖÝćÖēøÙÖøąéĎÖóøčîÝąöĊĂĆêøćÖćøđÝĘïðśü÷ (morbidity)17 ĒúąĂĆêøćêć÷
(mortality) öćÖÖüŠćñĎšìĊę÷ĆÜĕöŠöĊÖøąéĎÖĀĆÖĂ÷ŠćÜßĆéđÝî18ñĎšðśü÷ÝąöĊĂćÖćøðüéĀúĆÜđøČĚĂøĆÜ êĆüđêĊĚ÷úÜ (height loss) ĀúĆÜÙŠĂö

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-4 โรคกระดูกพรุน (Osteoporosis)

(kyphosis) ĀúĆÜÙé (scoliosis) ìšĂÜĂČé đïČęĂĂćĀćø đîČęĂÜÝćÖÙüćöÝčߊĂÜìšĂÜúéúÜ ĒúąĂćÝÝąöĊĂćÖćøðüéđĂüđîČęĂÜÝćÖ

ÖøąéĎÖßć÷ēÙøÜúÜöćÖøąìïÖĆïÖøąéĎÖđßĉÜÖøćî
3. ÖćøÿĎâđÿĊ÷ÙüćöÿćöćøëĔîÖćøìĞćÖĉÝüĆêøðøąÝĞćüĆî (functional disability) ÖćøöĊÝĞćîüîðúšĂÜךĂ
ÖøąéĎÖÿĆîĀúĆÜìĊęĀĆÖĀúć÷ðúšĂÜ ÷ĉęÜĀĆÖöćÖđìŠćĕøÝą÷ĉęÜđóĉęöĂĆêøćÖćøđÝĘïðśü÷ ĒúąĂĆêøćêć÷öćÖ×ċĚîđìŠćîĆĚî Ēúą÷ĆÜđóĉęöÙüćö
đÿĊę÷ÜìĊęÝąđÖĉéÖøąéĎÖĀúĆÜĀĆÖĔîðúšĂÜìĊęđĀúČĂ ĒúąÖøąéĎÖÿąēóÖĀĆÖéšü÷19
4. ÖøąéĎÖÿąēóÖĀĆÖ (hip fractures) đðŨîÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčîìĊęöĊðŦâĀćöćÖìĊęÿčé îĂÖÝćÖÝą
öĊĂĆêøćêć÷ìĊęÿĎÜöćÖêćöĀúĆÜÖćøĀĆÖĒúšü ÷ĆÜöĊÙüćöóĉÖćøĒúąÖćøÿĎâđÿĊ÷ÙüćöÿćöćøëĔîÖćøìĞćÖĉÝüĆêøðøąÝĞćüĆîĔîĂĆêøćìĊęÿĎÜ
ĂĊÖéšü÷ îĂÖÝćÖîĊĚÙŠćĔߚ݊ć÷ĔîÖćøéĎĒúøĆÖþćĀúĆÜÖøąéĎÖÿąēóÖĀĆÖÖĘ÷ĆÜÿĎÜöćÖÖüŠćÖøąéĎÖĀĆÖìĊęĂČęîė đîČęĂÜÝćÖëšćĕöŠĕéšøĆïÖćø
ñŠćêĆéøĆÖþćñĎšðśü÷ÝąĕöŠÿćöćøëđéĉîĕéš ĂĊÖìĆĚÜēøÙĒúąõćüąĒìøÖàšĂîĀúĆÜñŠćêĆéÖĘóïĕéšïŠĂ÷ĒúąøčîĒøÜ
5. öĊÖćøýċÖþćĂĆêøćêć÷ĒúąĂĆêøćÖćøđÝĘïðśü÷õć÷ĀúĆÜÖøąéĎÖÿąēóÖĀĆÖĔîÙîñĉü×ćüÿĎÜĂć÷č óïĂĆêøć
êć÷ÿĎÜëċÜðøąöćèøšĂ÷úą 20.0 õć÷Ĕî 1 ðŘĀúĆÜÖøąéĎÖĀĆÖ ÿĞćĀøĆïñĎšìęĊøĂéßĊüĉê óïüŠćøšĂ÷úą 30.0 ÝąöĊÙüćöóĉÖćøđÖĉé×ċĚî
Ēïïëćüø (permanent disability) êšĂÜĕéšøĆïÖćøéĎĒúÝćÖñĎšĂČęî ĀøČĂĂ÷ĎŠĔîÿëćîó÷ćïćú (nursing home) øšĂ÷úą 40.0 ĕöŠ
ÿćöćøëđéĉîĕéšĂ÷ŠćÜðÖêĉêšĂÜĔßšđÙøČęĂÜߊü÷đéĉîĂ÷ŠćÜĔéĂ÷ŠćÜĀîċęÜ ĒúąøšĂ÷úą 80.0 ĕöŠÿćöćøëðäĉïĆêĉÖĉÝüĆêøðøąÝĞćüĆîĂ÷ŠćÜ
îšĂ÷ĀîċęÜĂ÷ŠćÜ ìĊęđÙ÷ìĞćĕéšđĂÜÖŠĂîÖøąéĎÖÿąēóÖĀĆÖ20
6. Ĕîðøąđìýĕì÷ ĂĆêøćêć÷õć÷ĀúĆÜÖøąéĎÖÿąēóÖĀĆÖÝćÖÖćøýċÖþćìĊęÝĆÜĀüĆéđßĊ÷ÜĔĀöŠ4 óïüŠć øšĂ÷úą
2.1 êć÷øąĀüŠćÜ÷ĆÜøĆÖþćêĆüĔîēøÜó÷ćïćú ĒúąĂĆêøćêć÷ĀúĆÜÝćÖÖøąéĎÖÿąēóÖĀĆÖìĊę 3 đéČĂî 6 đéČĂî Ēúą 1 ðŘ đìŠćÖĆï
øšĂ÷úą 9.0, 12.0 Ēúą 17.0 êćöúĞćéĆï ÿĞćĀøĆïÖćøýċÖþćđÖĊę÷üÖĆïÙčèõćóßĊüĉêĀúĆÜÖøąéĎÖÿąēóÖĀĆÖĔîÙîĕì÷7 óïüŠć 1 Ĕî
5 ×ĂÜñĎšðśü÷ (øšĂ÷úą 22.0) ĕöŠÿćöćøëđéĉîĕéš øšĂ÷úą 23.0 êšĂÜĔßš wheel chair ĔîÖćøđÙúČęĂî÷šć÷ îĂÖÝćÖîĆĚîñĎšðśü÷đĀúŠćîĊĚ
÷ĆÜêšĂÜĕéšøĆïÖćøߊü÷đĀúČĂĔîÖćøðäĉïĆêĉÖĉÝüĆêøðøąÝĞćüĆîêŠćÜė ĔîĂĆêøćìĊęÿĎÜ đߊî øšĂ÷úą 11.0 êšĂÜߊü÷ĂćïîĚĞć øšĂ÷úą 10.0
êšĂÜߊü÷ĒêŠÜêĆü øšĂ÷úą 22.0 êšĂÜߊü÷ĔîÖćø×ĆïëŠć÷ ĒúąøšĂ÷úą 5.0 êšĂÜߊü÷ĔîÖćøøĆïðøąìćîĂćĀćø

ÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčîĔîđßĉÜđýøþåýćÿêøŤìćÜÿćíćøèÿč× (health economics aspects of osteoporotic

fractures)
Ĕîðøąđìýĕì÷÷ĆÜĕöŠóïÖćøýċÖþćÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčîĔîđßĉÜđýøþåýćÿêøŤìćÜÿćíćøèÿč×ìĊęßĆéđÝî ÝćÖ
øć÷Üćî×ĂÜ International Osteoporosis Foundation (IOF) ìĊęĕéšÿĞćøüÝÙŠćĔߚ݊ć÷ (cost) ĔîÖćøéĎĒúøĆÖþćÖøąéĎÖĀĆÖÝćÖ
ēøÙÖøąéĎÖóøčî (osteoporotic fractures) Ĕî÷čēøð óïüŠćÿĀõćó÷čēøðĔߚ݊ć÷đÜĉîĔîÖćøéĎĒúøĆÖþćÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖ
óøčîÿĎÜëċÜðŘúą 25 óĆîúšćî÷Ďēø ÝćÖךĂöĎú×ĂÜðøąđìýĂĆÜÖùþðøąđìýđéĊ÷ü óïüŠćöĊÖćøĔßšđÜĉîĔîÖćøéĎĒúøĆÖþćÖøąéĎÖĀĆÖÝćÖ
ēøÙÖøąéĎÖóøčîëċÜðŘúą 1.8 óĆîúšćîðĂîéŤ21 ĒúąÝćÖÖćøðøąöćèēé÷ National Osteoporosis Foundation (NOF) ×ĂÜ
ÿĀøĆåĂđöøĉÖćĔîðŘ 1995 óïüŠćÙŠćĔߚ݊ć÷ĔîÖćøéĎĒúøĆÖþćÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî îŠćÝąÿĎÜëċÜðŘúą 17 óĆîúšćîđĀøĊ÷â22

Cost and Interventions

đîČę Ă ÜÝćÖēøÙÖøąéĎ Ö óøč î ÝąĕöŠ Ē ÿéÜĂćÖćøñĉ é ðÖêĉ Ý îÖüŠ ć ÝąđÖĉ é ÖøąéĎ Ö ĀĆ Ö Ĕî×èąìĊę đ öČę Ă óĉ Ý ćøèćĔîđßĉ Ü
đýøþåýćÿêøŤìćÜÿćíćøèÿč×Ēúšü ĕöŠöĊÙüćöÙčšöÙŠćìĊęÝąìĞćÖćøêøüÝÙĆéÖøĂÜéšü÷đÙøČęĂÜüĆéÙüćöĀîćĒîŠîÖøąéĎÖĔîðøąßćÖø
ēé÷ìĆęüĕðìĆĚÜĀöé éĆÜîĆĚîÝċÜĔßšÖćøðøąđöĉîðŦÝÝĆ÷đÿĊę÷Ü àċęÜđðŨîđÙøČęĂÜöČĂìĊęĔßšĕéšÜŠć÷ ÿąéüÖ ĒúąðøąĀ÷ĆéĔîìćÜðäĉïĆêĉ đóČęĂÙšîĀć
ñĎšìĊęöĊðŦÝÝĆ÷đÿĊę÷ÜìĊęÝąđÖĉéēøÙÖøąéĎÖóøčîĀøČĂÖøąéĎÖĀĆÖ23

ÖćøðøąđöĉîðŦÝÝĆ÷đÿĊę÷Ü êøüÝÙĆéÖøĂÜ ĒúąüĉîĉÝÞĆ÷

1. ÖćøðøąđöĉîðŦÝÝĆ÷đÿĊę÷Ü×ĂÜÖćøđÖĉéÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî ēé÷Ĕßš FRAXTM (Risk assessment of
osteoporotic fracture) ×ĂÜĂÜÙŤÖćøĂîćöĆ÷úĞć (WHO-FRAX) ëČĂđðŨîöćêøåćîđðŨîìĊę÷ĂöøĆïĂ÷ŠćÜÖüšćÜ×üćÜ
ðŦÝÝĆ÷đÿĊę÷ÜÿĞćÙĆâìĊę WHO îĞćöćĔßšĔî FRAXTM 24
- Age
- BMD (FN)/BMI (T-score or kg/m2)
- Prior fragility fracture (yes/no)
- Parental history of hip fracture (yes/no)

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-5

- Current tobacco smoking (yes/no)

- Ever long-term use of oral glucocorticoids (yes/no)
- Rheumatoid arthritis (yes/no)
- Other causes of secondary osteoporosis (yes/no)
- Daily alcohol consumption of three or more units daily (yes/no)
Āöć÷đĀêč: BMD (FN) = femoral neck bone mass density, BMI = bone mass index

ךĂöĎúĒúąðŦÝÝĆ÷đÿĊę÷ÜêŠćÜė éĆÜÖúŠćüëĎÖÖĞćĀîéĕüšĒúąÙĞćîüèēé÷ìĞćđðŨîēðøĒÖøöÿĞćđøĘÝøĎð àċęÜÝąÿćöćøëÙĞćîüè

ĂĂÖöćđðŨîÙüćöîŠćÝąđðŨîìĊęÝąđÖĉéÖøąéĎÖĀĆÖĔîøą÷ą 10 ðŘ (10-year probability of fracture) ēé÷ēðøĒÖøö FRAXTM îĊĚ
ÿćöćøëđךćĕðĔßšĕéšìćÜ internet ìĊę http://www.shef.ac.uk/FRAX25 àċęÜĔîÙüćöđðŨîÝøĉÜ 10-year probability îĊĚöĊÙüćö
ñĆîĒðøÖĆïðøąđìýđßČĚĂßćêĉêŠćÜė éšü÷ àċęÜÝąĕéšñúúĆóíŤ 2 ĒïïÙČĂ 10-year probability of hip fracture Ēúą 10-year
probability of other major osteoporotic fractures ìĆĚÜîĊĚÿćöćøëîĞćìĆĚÜÿĂÜÙŠćöćĔßšðøąđöĉîÙüćöđÿĊę÷Ü×ĂÜñĎšðśü÷đóČęĂĔßš
đøĉęöÖćøøĆÖþćĕéš (therapeutic threshold) ÙČĂëšćñĎšðśü÷öĊ 10-year probability of hip fracture œ3% ĀøČĂ 10-year
probability of other major osteoporotic fractures œ20% ÖĘĔĀš÷ćøĆÖþćĕéš
ðŦÝÝčïĆî÷ĆÜĕöŠöĊךĂöĎú×ĂÜðøąßćÖøĕì÷ĔîÖćøÙĞćîüè FRAXTM ìćÜöĎúîĉíĉēøÙÖøąéĎÖóøčîĒĀŠÜðøąđìýĕì÷ÝċÜĕéš
ìĞćÖćøýċÖþćĒúąìĞćÖćøìéÿĂï FRAXTM ēé÷ÖćøĂšćÜĂĉÜךĂöĎúĔîßîßćêĉđĂđßĊ÷ ĔîđïČĚĂÜêšîóïüŠć ÖćøĔßš FRAXTM ×ĂÜ
ðøąßćÖøđßČĚĂßćêĉđĂđßĊ÷ ĕéšĒÖŠ US-Asian ĒúąâĊęðčśî îŠćÝąöĊÙüćöđĀöćąÿö đöČęĂóĉÝćøèćÝćÖךĂöĎúìćÜøąïćéüĉì÷ć×ĂÜēøÙ
ÖøąéĎÖóøčîĔîðøąđìýĕì÷ Ă÷ŠćÜĕøÖĘêćöđîČęĂÜÝćÖ÷ĆÜĕöŠöĊÖćøýċÖþćÝčéêĆéìĊęđĀöćąÿöĔîÖćøĔĀšÖćøøĆÖþćéšü÷÷ćĔîÙîĕì÷ ÝċÜ
ĒîąîĞćĔĀšĔßšÙŠćÝčéêĆéêćöÙĞćĒîąîĞć×ĂÜ NOF ÙČĂ 10-year probability of hip fracture œ3% ĀøČĂ 10-year probability
of other major osteoporotic fractures œ20% ÖĘĔĀš÷ćøĆÖþćĕéš

2. ÖćøÙĆéÖøĂÜðŦÝÝĆ÷đÿĊę÷Üēé÷ OSTA, KKOS, Nomogram

ÖćøêøüÝÙĆéÖøĂÜĀćñĎšìĊęöĊÙüćöđÿĊę÷ÜĔîÖćøđÖĉéēøÙÖøąéĎÖóøčîĔîðŦÝÝčïĆî öĊ 3 üĉíĊ ÙČĂ Osteoporosis Self–
Assessment Tool for Asian (OSTA)26, Khon Kaen Osteoporosis Study (KKOS) Score27 ĒúąēîēöĒÖøö
(nomogram)28

2.1 OSTA (Osteoporosis Self-Assessment Tool for Asians)

êćøćÜìĊę 17.3 ÖćøÙĆéÖøĂÜÙüćöđÿĊę÷Üéšü÷üĉíĊ Osteoporosis Self-Assessment Tool for Asians26

Ăć÷č îĚĞćĀîĆÖ (ÖĉēúÖøĆö)
(ðŘ) 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94
40-44
45-49
50-54 ÙüćöđÿĊę÷ÜêęćĞ
55-59
60-64
65-69
70-74 ÙüćöđÿĊę÷ÜðćîÖúćÜ
75-79
80-84 17
85-89 ÙüćöđÿĊę÷ÜÿĎÜ
90-94
95-99

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-6 โรคกระดูกพรุน (Osteoporosis)

ÖćøÙĞćîüèÙüćöđÿĊę÷Ü OSTA index ēé÷ĔßšÿĎêøéĆÜîĊĚ

OSTA index = 0.2 X [îĚĞćĀîĆÖ (ÖĉēúÖøĆö)–Ăć÷č (ðŘ)] (ñúúĆóíŤìĊęĕéšĔĀšêĆéÝčéìýîĉ÷öĂĂÖ)
ÖćøĒðúñú
OSTA index îšĂ÷ÖüŠć -4 Āöć÷ëċÜ ÙüćöđÿĊę÷ÜÿĎÜ
øąĀüŠćÜ -4 ëċÜ -1 Āöć÷ëċÜ ÙüćöđÿĊę÷ÜðćîÖúćÜ
öćÖÖüŠć -1 Āöć÷ëċÜ ÙüćöđÿĊę÷ÜêęĞć
ĔîÖøèĊìĊęöĊÙüćöđÿĊę÷ÜÿĎÜøŠüöÖĆïöĊ osteopenia ÝćÖõćóøĆÜÿĊìĊęêĞćĒĀîŠÜ TL-spine ĒúąĕöŠÿćöćøëÿŠÜêøüÝÙüćö
ĀîćĒîŠîÖøąéĎÖéšü÷đÙøČęĂÜ dual-energy x-ray absorptiometry (DXA) ĕéš ĂćÝóĉÝćøèćĔĀšÖćøøĆÖþć ÿŠüîÖøèĊìĊęöĊÙüćö
đÿĊę÷ÜðćîÖúćÜÙüøÿŠÜêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖÖŠĂîóĉÝćøèćĔĀšÖćøøĆÖþć ÿĞćĀøĆïÖúčŠöÙüćöđÿĊę÷ÜêęĞćĕöŠêšĂÜÿŠÜêøüÝÙüćö
ĀîćĒîŠî×ĂÜÖøąéĎÖđóøćąöĊÙüćöđÿĊę÷ÜêęĞćĔîÖćøđÖĉéēøÙÖøąéĎÖóøčî

2.2 Khon Kaen Osteoporosis Study (KKOS) Score

êćøćÜìĊę 17.4 ÖćøÙĆéÖøĂÜÙüćöđÿĊę÷Üéšü÷üĉíĊ Khon Kaen Osteoporosis Study (KKOS) Score27

Age (yr) Score Weight (kg) Score
<45 +7.5 <30 -14
45-49 +6.0 30-34 -12
50-54 +4.5 35-39 -10
55-59 +3.0 40-44 -8
60-64 +1.5 45-49 -6
65-69 0 50-54 -4
70-74 -1.5 55-59 -2
75-79 -3.0 60-64 0
80-84 -4.5 65-69 +2
85-89 -6.0 70-74 +4
>90 -7.5 75-79 +6
80-84 +8
85-89 +10
>90 +12

ÖćøÙĞćîüè KKOS ĔĀšîĞćÙŠćÙąĒîîÝćÖĂć÷č (ðŘ) ĒúąîĚĞćĀîĆÖ (ÖĉēúÖøĆö) öćïüÖÖĆî

KKOS < -1 Āöć÷ëċÜ ÙüćöđÿĊę÷ÜÿĎÜĔîÖćøđÖĉéēøÙÖøąéĎÖóøčî
KKOS > -1 Āöć÷ëċÜ ÙüćöđÿĊę÷ÜêęĞćĔîÖćøđÖĉéēøÙÖøąéĎÖóøčî
êĆüĂ÷ŠćÜÖćøÙĞćîüè
ñĎšĀâĉÜĂć÷č 52 ðŘ îĚĞćĀîĆÖ 48 ÖĉēúÖøĆö KKOS = (+4.5) + (-6) = -1.5 = ÙüćöđÿĊę÷ÜÿĎÜ

KKOS ÷ĆÜÿćöćøëÙĞćîüèēĂÖćÿ×ĂÜÖćøđÖĉéēøÙÖøąéĎÖóøčîĕéšēé÷éĎÝćÖêćøćÜìĊę 17.5 ĔîÖøèĊìĊęêĆĚÜĒêŠøšĂ÷úą

80.0 ×ċĚîĕðÝĆéĂ÷ĎŠÖúčŠöÙüćöđÿĊę÷ÜÿĎÜ øąĀüŠćÜ 20.0-79.0 ÝĆéĂ÷ĎŠĔîÖúčŠöÙüćöđÿĊę÷ÜðćîÖúćÜ ĒúąÖüŠćøšĂ÷úą 20.0 ÝĆéĂ÷ĎŠÖúčŠö
ÙüćöđÿĊę÷ÜêęĞć

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-7

êćøćÜìĊę 17.5 êĆüĂ÷ŠćÜÖćøÙĞćîüèēĂÖćÿ×ĂÜÖćøđÖĉéēøÙÖøąéĎÖóøčîéšü÷üĉíĊ KKOS27

îĚĞćĀîĆÖ Ăć÷č (ðŘ)
(ÖĉēúÖøĆö) <45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 >90
< 30 58.7 67.4 75.0 81.3 86.3 90.2 93.0 95.1 96.6 97.6 98.3
30-34 47.5 56.8 65.6 73.5 80.1 85.4 89.5 92.5 94.7 96.3 97.4
35-39 36.6 45.6 54.9 63.8 71.9 78.8 84.4 88.7 91.9 94.3 96.0
40-44 26.9 34.8 43.6 52.9 62.0 70.3 77.5 83.3 87.9 91.3 93.9
45-49 19.0 25.4 33.0 41.7 51.0 60.2 68.7 76.1 82.2 87.0 90.7
50-54 13.0 17.5 23.9 31.3 39.8 49.0 58.3 67.0 74.6 81.0 86.1
55-59 8.7 12.1 16.7 22.5 29.7 38.0 47.1 56.4 65.2 73.1 80.0
60-64 5.7 8.1 11.3 15.6 21.2 28.1 36.2 45.1 54.4 63.4 71.6
65-69 3.7 5.3 7.5 10.5 14.6 19.9 26.5 34.4 43.2 52.5 61.6
70-74 2.4 3.4 4.9 7.0 9.8 13.7 18.7 25.0 32.6 41.3 50.5
75-79 1.5 2.2 3.2 4.6 6.5 9.2 12.8 17.5 23.6 30.9 39.4
80-84 1.0 1.4 2.1 3.0 4.2 6.0 8.5 11.9 16.4 22.2 29.3
85-89 0.6 0.9 1.3 1.9 2.7 3.9 5.6 7.9 11.1 15.4 20.9
> 90 0.4 0.6 0.8 1.2 1.8 2.5 3.6 5.2 7.4 10.4 14.4

2.3 Nomogram ĔîÖćøìĞćîć÷ÖćøđÖĉéēøÙÖøąéĎÖóøčîĔîñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂîēé÷ĔßšĂć÷č îĚĞćĀîĆÖ

28
Ēúą QUS

õćóìĊę 17.1 ÖćøìĞćîć÷ÖćøđÖĉéēøÙÖøąéĎÖóøčîĔîñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂîēé÷ĔßšĂć÷č îĚĞćĀîĆÖ Ēúą QUS28

17

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-8 โรคกระดูกพรุน (Osteoporosis)

üĉíĊÖćøÙĞćîüè
1. úćÖđÿšîÝćÖĒÖîĂć÷č×ċĚîĕð÷ĆÜĒÖîÙąĒîî (point)
2. úćÖđÿšîÝćÖĒÖîîĚĞćĀîĆÖĕð÷ĆÜĒÖîÙąĒîî (point)
3. úćÖđÿšîÝćÖĒÖî QUS (T-score) ĕð÷ĆÜĒÖîÙąĒîî (point)
4. îĞćìĆĚÜ 3 ÙąĒîîöćøüöÖĆî (total points)
5. úćÖđÿšîÝćÖĒÖîÙąĒîîøüö (total points) úÜöć÷ĆÜĒÖîÙüćöđÿĊę÷Ü×ĂÜēøÙÖøąéĎÖóøčî (risk of
osteoporosis)
6. ĔîÖøèĊìĊęÙüćöđÿĊę÷Ü×ĂÜÖćøđÖĉéēøÙÖøąéĎÖóøčîêĆĚÜĒêŠ 0.3 ×ċĚîĕðÝĆéđðŨîÖúčŠöìĊęöĊÙüćöđÿĊę÷ÜÿĎÜĔîÖćø
đÖĉéēøÙÖøąéĎÖóøčîÙüøÿŠÜêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖéšü÷đÙøČęĂÜ DXA êŠĂĕð
ĔîÖćøêøüÝÙĆéÖøĂÜðøąđöĉîðŦÝÝĆ÷đÿĊę÷Ü ÖćøđúČĂÖĔßš FRAXTM ĔîÖćøðøąđöĉîëČĂđðŨîìĊęĔßšÖĆîĂ÷ŠćÜÖüšćÜ×üćÜđðŨîìĊę
÷ĂöøĆï ÿćöćøëđךćëċÜĕéšÜŠć÷ ĒêŠđĀöćąÖĆïñĎšöĊÙüćöøĎšĔîõćþćĂĆÜÖùþĒúąÿćöćøëđךćëċÜךĂöĎúìćÜ internet ĕéš ÿŠüî OSTA
index Ēúą KKOS score ÖĘđðŨîêĆüÙĆéÖøĂÜìĊęéĊ đךćĔÝÜŠć÷ ÿŠüî nomogram ÙŠĂîךćÜđךćĔÝĕéš÷ćÖÖüŠć ĒîąîĞćĔĀšđúČĂÖĔßšêćö
ÙüćöđĀöćąÿö

3. ÖćøêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖ
3.1 ÖćøÿŠÜêøüÝ BMD éšü÷đÙøČęĂÜ axial DXA29
WHO ÖĞćĀîéĔĀšđðŨîöćêøåćîĔîÖćøüĉîĉÝÞĆ÷õćüąēøÙÖøąéĎÖóøčî ÙČĂ axial dual-energy x-ray
absorptiometry (axial DXA) đìŠćîĆĚî ĔîÖćøêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖđóČęĂüĉîĉÝÞĆ÷ēøÙÖøąéĎÖóøčî ĔĀšêøüÝìĊęÖøąéĎÖ
ÿĆîĀúĆÜÿŠüîđĂü ĒúąÖøąéĎÖÿąēóÖךćÜìĊęĕöŠëîĆéĒúą/ĀøČĂךćÜìĊęĕöŠĀĆÖđìŠćîĆĚî àċęÜđøĊ÷ÖüŠć axial DXA ĔîìĊęîĊĚĀöć÷ëċÜ dual
energy X-ray absorptiometry đìŠćîĆĚî ĕöŠĒîąîĞćĔĀšêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖðúć÷Ē×î (peripheral DXA) ÷Öđüšî
ĔîñĎšðśü÷ìĊęĂšüîöćÖ (>130 ÖĉēúÖøĆö) ĀøČĂĕöŠÿćöćøëêøüÝĀøČĂĒðúñúÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖÝćÖ axial DXA ĕéš
ךĂïŠÜßĊĚĔîÖćøÿŠÜêøüÝ BMD éšü÷đÙøČęĂÜ axial DXA29
1) ñĎšĀâĉÜĂć÷čêĆĚÜĒêŠ 65 ðŘ×ċĚîĕð ĒúąñĎšßć÷Ăć÷čêĆĚÜĒêŠ 70 ðŘ×ċĚîĕð
2) ÿĞćĀøĆïñĎšĀâĉÜìĊęöĊĂć÷čêęĞćÖüŠć 65 ðŘ ĒúąñĎšßć÷ìĊęöĊĂć÷čêęĞćÖüŠć 70 ðŘ ìĊęöĊðŦÝÝĆ÷đÿĊę÷ÜéĆÜêŠĂĕðîĊĚĂ÷ŠćÜîšĂ÷
1 ךĂ
- ĀöéðøąÝĞćđéČĂîÖŠĂîĂć÷č 45 ðŘ (early menopause) àċęÜĀöć÷øüöëċÜñĎšìĊęëĎÖêĆéøĆÜĕ׊ìĆĚÜÿĂÜךćÜ
- öĊõćüą×ćéăĂøŤēöîđĂÿēêøđÝî (estrogen deficiency) ÖŠĂîđךćÿĎŠüĆ÷ĀöéðøąÝĞćđéČĂî êŠĂđîČęĂÜ
îćîÖüŠć 1 ðŘ ÷ÖđüšîÖøèĊêĆĚÜÙøøõŤĒúąĔĀšîöïčêø
- ĕéšøĆï÷ćÖúĎēÙÙĂøŤêĉÙĂ÷éŤđðŨîøą÷ąđüúćîćî (đóøéîĉēàēúî×îćéêĆĚÜĒêŠ 5 öÖ.êŠĂüĆî×ċĚîĕðĀøČĂ
đìĊ÷ïđìŠćđðŨîđüúćîćîÖüŠć 3 đéČĂî)
- öĊðøąüĆêĉïĉéćĀøČĂöćøéćÖøąéĎÖÿąēóÖĀĆÖĔîñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂîĀøČĂñĎšßć÷Ăć÷čêĆĚÜĒêŠ 50
ðŘ×ċĚîĕð
- ñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂîìĊęöĊéĆßîĊöüúÖć÷îšĂ÷ÖüŠć 19 ÖĉēúÖøĆöêŠĂêćøćÜđöêø
3) êøüÝóïõćüąÖøąéĎ Ö ïćÜĀøČ Ă ÖøąéĎ Ö ÿĆ î ĀúĆ Ü ñĉ é øĎ ð ÝćÖÖćøëŠ ć ÷õćóøĆ Ü ÿĊ đ ĂÖàŤ (radiographic
osteopenia and/or vertebral deformity by x-ray)
4) öĊðøąüĆêĉÖøąéĎÖĀĆÖÝćÖõ÷Ćîêøć÷ĒïïĕöŠøčîĒøÜĀúĆÜĂć÷č 40 ðŘ
5) öĊðøąüĆêĉÿŠüîÿĎÜúéúÜöćÖÖüŠć 4 đàîêĉđöêø ĀøČĂúéúÜöćÖÖüŠć 2 đàîêĉđöêøêŠĂðŘ
6) Ă÷ĎŠĔîÖúčŠöìĊęöĊÙüćöđÿĊę÷ÜðćîÖúćÜ×ċĚîĕðÝćÖÖćøêøüÝÙĆéÖøĂÜéšü÷ OSTA score, KKOS score ĀøČĂ
ēĂÖćÿđÿĊę÷ÜÝćÖēîēöĒÖøö (nomogram probability) êĆĚÜĒêŠ 0.3 ×ċĚîĕðÿĞćĀøĆïñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂî

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-9

3.2 Quantitative CT scan (QCT)

ðŦÝÝčïĆî QCT ÿćöćøëðøąđöĉîÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖĕéš ĒêŠđîČęĂÜÝćÖøĆÜÿĊÝćÖÖćøüĆéöĊðøĉöćèÿĎÜ øćÙć
ĒóÜĒúąĕöŠĔߊđÖèæŤöćêøåćîêćöĂÜÙŤÖćøĂîćöĆ÷ēúÖ ÝċÜĕöŠĒîąîĞćĔĀšÿŠÜêøüÝ

3.3 Quantitative ultrasound ìĊęÖøąéĎÖÿšîđìšć

ðŦÝÝčïĆî÷ĆÜĕöŠöĊךĂĒîąîĞćĔĀšĔßšĔîÖćøüĉîĉÝÞĆ÷ēøÙÖøąéĎÖóøčî ÷ÖđüšîĔîÖøèĊêøüÝÙĆéÖøĂÜēé÷ĔßšøŠüöÖĆï
éĆßîĊÙüćöđÿĊę÷ÜìćÜÙúĉîĉÖ đߊî Ăć÷č îĚĞćĀîĆÖ ĀøČĂĔîÖøèĊìĊęÿëćîó÷ćïćúĕöŠöĊ ĀøČĂĕöŠÿćöćøëÿŠÜñĎšðśü÷ĕðêøüÝéšü÷đÙøČęĂÜ
DXA
ÝćÖÖćøýċÖþć×ĂÜ Pongchaiyakul33 óïüŠćÖćøĔßš Quantitative ultrasound øŠüöÖĆï clinical risk
indices (OSTA/KKOS) óïüŠćöĊ senvitivity ×ċĚî 88% Ĕî×èąìĊęÖćøĔßš Quantitative ultrasound đóĊ÷ÜĂ÷ŠćÜđéĊ÷üöĊ
sensitivity đóĊ÷Ü 60%

3.4 ÖćøêøüÝÙŠćìćÜßĊüđÙöĊ×ĂÜÖćøĀöčîđüĊ÷îÖøąéĎÖ (biochemical markers of bone turnover)

ÙŠć ìćÜßĊü đÙöĊ× ĂÜÖøąïüîÖćøÿøš ć ÜĒúąÿúć÷ÖøąéĎÖ ĕöŠĒîąîĞćĔĀšĔßšĔ îÖćøüĉîĉÝ ÞĆ÷ēøÙÖøąéĎÖóøčî
đîČęĂÜÝćÖÙŠćìĊęüĆéĕéšĂćÝëĎÖøïÖüîĕéšÝćÖĀúć÷ðŦÝÝĆ÷ ĒúąĂćÝóïÙüćöñĉéðÖêĉĕéšĔîĀúć÷ēøÙìĊęĕöŠĔߊēøÙÖøąéĎÖóøčîĒêŠĂćÝĔßš
øŠüöÖĆïñúêøüÝÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖđóČęĂðøąđöĉîÙüćöđÿĊę÷Ü×ĂÜÖćøđÖĉéÖøąéĎÖĀĆÖĕéšĂ÷ŠćÜĕøÖĘêćöÙŠćìćÜßĊüđÙöĊ×ĂÜÖćø
ĀöčîđüĊ÷îÖøąéĎÖéĆÜÖúŠćü ĂćÝöĊðøąē÷ßîŤĔîÖćøêĉéêćöÖćøøĆÖþćēé÷ĒîąîĞćĔĀšêøüÝÖŠĂîđøĉęöĔĀš÷ćĒúąðøąđöĉîàĚĞćõć÷ĀúĆÜ
ÖćøøĆÖþćìĊę 3 đéČĂî 6 đéČĂî ĀøČĂ 1 ðŘ àċęÜߊü÷ĔĀšìøćïÖćøêĂïÿîĂÜêŠĂÖćøøĆÖþćéšü÷÷ćĕéšøüéđøĘüÖüŠćÖćøêøüÝÙüćö
ĀîćĒîŠî×ĂÜÖøąéĎÖéšü÷đÙøČęĂÜ DXA

êćøćÜìĊę 17.6 ñúÖćøðøąđöĉîÙüćöđÿĊę÷ÜĒúąÖćøêøüÝÙĆéÖøĂÜēøÙÖøąéĎÖóøčîéšü÷üĉíĊÖćøêŠćÜė

sensitivity specificity positive predictive negative predictive
Tools
(%) (%) value (%) value (%)
30
FRAX 60.1 85.8 3.3 99.6
31
OSTA 51.7 71.4 20.9 96.9
Khon Kaen 72.5 73.0 36.0 NA
Osteoporosis study
(KKOS) score32
Quantitative 21-60 88-96 72.4 73.1
33
ultrasound

17

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-10 โรคกระดูกพรุน (Osteoporosis)

õćóìĊę 17.2 ÖćøéĎĒúøĆÖþćēøÙÖøąéĎÖóøčî34

ÙüćöÙčšöÙŠćĒúąñúÖøąìïéšćîÜïðøąöćè×ĂÜÖćøÙĆéÖøĂÜēøÙÖøąéĎÖóøčî
ÝćÖøć÷ÜćîÖćøüĉđÙøćąĀŤÙüćöÙčšöÙŠćĒúąñúÖøąìïéšćîÜïðøąöćè×ĂÜÖćøÙĆéÖøĂÜēøÙÖøąéĎÖóøčîĔîñĎšĀâĉÜüĆ÷
ĀöéðøąÝĞ ć đéČ Ă îïîóČĚ î åćî×ĂÜÖćøĔßš Ē ïïÝĞ ć úĂÜìćÜđýøþåýćÿêøŤ ēé÷õćÙüĉ ß ćĂć÷č ø ýćÿêøŤ ÙèąĒóì÷Ť ý ćÿêøŤ
öĀćüĉì÷ćúĆ÷×ĂîĒÖŠîĔîðŘ 255635 óïüŠćđöČęĂđðøĊ÷ïđìĊ÷ïÖćøÙĆéÖøĂÜéšü÷ĒîüìćÜêŠćÜė ÖĆïĕöŠöĊÖćøÙĆéÖøĂÜĔîñĎšĀâĉÜüĆ÷Āöé
ðøąÝĞćđéČĂî óïüŠćÖćøÙĆéÖøĂÜéšü÷éĆßîĊÙĆéÖøĂÜÙüćöđÿĊę÷Ü KKOS öĊÙüćöÙčšöÙŠćöćÖìĊęÿčé øĂÜúÜöćÙČĂ éĆßîĊÙĆéÖøĂÜÙüćö
đÿĊę÷Ü OSTA éĆßîĊÙĆéÖøĂÜÙüćöđÿĊę÷Ü KKOS øŠüöÖĆïÖćøüĆéÖøąéĎÖÿšîđìšć (QUS) éĆßîĊÙĆéÖøĂÜÙüćöđÿĊę÷Ü OSTA øŠüöÖĆï QUS
ĒúąÖćøðøąđöĉîÙüćöđÿĊę÷ÜÖćøđÖĉéÖøąéĎÖĀĆÖéšü÷đÙøČęĂÜöČĂðøąđöĉîÙüćöđÿĊę÷ÜÖćøđÖĉéÖøąéĎÖĀĆÖÝćÖĂÜÙŤÖćøĂîćöĆ÷ēúÖ
(FRAXTM) êćöúĞćéĆï ĒúąÖćøÙĆéÖøĂÜēøÙÖøąéĎÖóøčîéšü÷éĆßîĊÙĆéÖøĂÜÙüćöđÿĊę÷Ü OSTA ĀøČĂ KKOS öĊÙüćöÙčšöÙŠćđöČęĂÙĆé
ÖøĂÜñĎšĀâĉÜĂć÷č 65 ðŘ×ċĚîĕð ēé÷öĊĂĆêøćÿŠüîêšîìčîðøąÿĉìíĉñúÿŠüîđóĉęöìĊęĔÖúšđÙĊ÷ÜÖĆî ĒúąÖćøÙĆéÖøĂÜßîĉéĂČęîė ÝąöĊÙüćö
ÙčšöÙŠćđöČęĂÙĆéÖøĂÜñĎšĀâĉÜĂć÷č 70-75 ðŘ (êćøćÜìĊę 17.7)

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-11

êćøćÜìĊę 17.7 ĂĆêøćÿŠüîêšîìčîðøąÿĉìíĉñúÿŠüîđóĉęö×ĂÜÖćøÙĆéÖøĂÜēøÙÖøąéĎÖóøčîđðøĊ÷ïđìĊ÷ïÖĆïÖćøĕöŠöĊÖćøÙĆéÖøĂÜ

ĒúąøĆÖþćéšü÷÷ć ÝĞćĒîÖêćöÖćøÙĆéÖøĂÜìĊęĂć÷čêŠćÜė (öčööĂÜìćÜÿĆÜÙö)35
ĂĆêøćÿŠüîêšîìčîðøąÿĉìíĉñúÿŠüîđóĉęö (ïćìêŠĂðŘÿč×õćüąìĊęđóĉęö×ċĚî)*
Ăć÷č OSTA KKOS OSTA Ēúą QUS KKOS Ēúą QUS FRAXTM
50 469,000 446,000 677,000 651,000 731,000
55 272,000 263,000 360,000 350,000 381,000
60 191,000 187,000 233,000 228,000 241,000
65 117,000 115,000 137,000 135,000 141,000
70 78,000 78,000 90,000 89,000 92,000
75 98,000 98,000 110,000 109,000 111,000
80 126,000 125,000 138,000 137,000 139,000
85 135,000 134,000 148,000 147,000 149,000
Āöć÷đĀêč: * ĕéšðøĆïêĆüđú×ĔĀšĔÖúšđÙĊ÷ÜĀúĆÖóĆî (1,000)

ÖćøøĆÖþćēøÙÖøąéĎÖóøčî
1. ÖćøøĆÖþćēé÷ĕöŠĔßš÷ć (non-pharmacologic treatment)
ÖćøĕéšøĆïðøĉöćèĒÙúđàĊ÷öĒúąüĉêćöĉîéĊìĊęđóĊ÷ÜóĂ ÝćÖÖćøýċÖþć meta-analysis36 óïüŠćÖćøĔĀšüĉêćöĉî
D ×îćé 700-800 IU êŠĂüĆî øŠüöÖĆïĒÙúđàĊ÷öÝąúéĂčïĆêĉÖćøèŤ×ĂÜÖøąéĎÖÿąēóÖĒúąÖøąéĎÖìĊęêĞćĒĀîŠÜĂČęîîĂÖđĀîČĂÝćÖ
ÖøąéĎÖÿĆîĀúĆÜ (non-vertebral fracture)
ÖćøĂĂÖÖĞćúĆÜÖć÷ öĊĀúĆÖåćîìĊęĒÿéÜĔĀšđĀĘîüŠćÖćøĂĂÖÖĞćúĆÜÖć÷ߊü÷úéÖćøÿĎâđÿĊ÷öüúÖøąéĎÖ ēé÷đÞóćą
ÖćøĂĂÖÖĞćúĆÜÖć÷ìĊęöĊÖćøĒïÖøĆïîĚĞćĀîĆÖìĊęđĀöćąÿö (appropriate weight-bearing exercise) ÖćøĂĂÖÖĞćúĆÜÖć÷ìĊęöĊĒøÜ
ÖøąĒìÖÿĎÜ (high impact aerobic exercise) ĒúąÖćøĂĂÖÖĞćúĆÜÖć÷ìĊęĂĂÖĒøÜêšćî (resistance exercise) ݹߊü÷đóĉęö
ÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖĕéš37
2. ÖćøøĆÖþćéšü÷ÖćøĔßš÷ć (pharmacologic treatment)
ĔîêŠćÜðøąđìýöĊÖćøýċÖþćÙüćöÙčšöÙŠć×ĂÜÖćøĔĀš÷ć Bisphosphonate ĔîñĎšðśü÷ÖúčŠöêŠćÜė éĆÜîĊĚ
2.1 ÖúčŠöñĎšðśü÷ĀâĉÜìĊęöĊöüúÖøąéĎÖêęĞćĒúąöĊÖøąéĎÖĀĆÖöćÖŠĂî (women with low BMD and
previous fractures ÝćÖÖćøýċÖþć×ĂÜ Stevenson38 ĔîÿĀøćßĂćèćÝĆÖøìĊęĂć÷č 70 ðŘ êšîìčî×ĂÜÖćøĔßš Bisphosphonate
êŠĂ QALY gained đìŠćÖĆï 16,934 ðĂîéŤ (33,601 đĀøĊ÷â) ÿĞćĀøĆï Alendronate đìŠćÖĆï 22,001 ðĂîéŤ (43,655 đĀøĊ÷â)
ÿĞć ĀøĆï Risedronate đìĊ÷ïÖĆïÖćøĕöŠĕéš ĔĀš÷ćĔîÖúčŠöîĊĚ ĂĊÖÖćøýċÖþćĀîċęÜ ×ĂÜ Kanis39 đðŨîÖćøüĉđÙøćąĀŤ ÖćøĔĀš÷ć
Bisphosphonate (Alendronate and Etidronate) đìĊ÷ïÖĆïÖćøĕöŠĕéš÷ćĔîÖúčŠöîĊĚìĊęĂć÷čêŠćÜė ÙŠćĔߚ݊ć÷êŠĂ QALY gained
đìŠćÖĆï 36,100 ðĂîéŤ (71,631 đĀøĊ÷â) ìĊęĂć÷č 50 ðŘ, 19,800 ðĂîéŤ (39,288 đĀøĊ÷â) ìĊęĂć÷č 60 ðŘ Ēúą 5700 ðĂîéŤ
(11,310 đĀøĊ÷â) ìĊęĂć÷č 70 ðŘ
2.2 ñĎšĀâĉÜìĊęöĊöüúÖøąéĎÖêęĞćĒêŠ÷ĆÜĕöŠöĊÖøąéĎÖĀĆÖ ĔîÿĀøĆåĂđöøĉÖćÖćøĔßš Bisphosphonate ìĊęöĊ
ÖøąéĎÖóøčîìĊęĂć÷čöćÖÖüŠć 60 ðŘ ëČĂüŠć cost effectiveness ĔîÖćøðŜĂÜÖĆîÖøąéĎÖĀĆÖÝćÖÖøąéĎÖóøčî ÖćøýċÖþćóïüŠć costs
per QALY gained đìŠćÖĆï 37,482 đĀøĊ÷â
2.3 ñĎšĀâĉÜìĊęöĊÖøąéĎÖïćÜĔîÿĀøĆåĂđöøĉÖć óïüŠćĔîñĎšĀâĉÜìĊęöĊĂć÷čöćÖÖüŠć 65 ðŘ ìĊę BMD T-score
-2.4 SD öĊ cost êŠĂ QALY đìŠćÖĆï 70,732 Ĕî×èąđéĊ÷üÖĆîñĎšĀâĉÜìĊęöĊĂć÷č 75 ðŘ ìĊę BMD T-score -1.5 SD öĊ cost êŠĂ
QALY đìŠćÖĆï 332,250 đĀøĊ÷â40
÷ćìĊęöĊðøąÿĉìíĉñúéĊĔîÖćøðŜĂÜÖĆîÖćøđÖĉéēøÙÖøąéĎÖóøčî ēé÷đÞóćąĂ÷ŠćÜ÷ĉęÜëšćÿćöćøëðŜĂÜÖĆîÖćøđÖĉé
ÖøąéĎÖĀĆÖĕéšöćÖĒúąĀúć÷êĞćĒĀîŠÜÝą÷ĉęÜÿŠÜñúéĊĔîÖćøîĞćöćĔßšøĆÖþćñĎšðśü÷ (êćøćÜìĊę 17.8)41-44 ĕéšøüïøüöðøąÿĉìíĉñú×ĂÜ÷ć
17
øĆÖþćēøÙÖøąéĎÖóøčîßîĉéêŠćÜė ĔîÖćøúéĂčïĆêĉÖćøèŤ×ĂÜÖøąéĎÖĀĆÖìĊęêĞćĒĀîŠÜÖøąéĎÖÿĆîĀúĆÜĒúąÖøąéĎÖêĞćĒĀîŠÜĂČęî

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-12 โรคกระดูกพรุน (Osteoporosis)

êćøćÜìĊę 17.8 ðøąÿĉìíĉñú×ĂÜÖćøĔßš÷ćøĆÖþćÖćøĀĆÖ×ĂÜÖøąéĎÖ41-44

ñúêŠĂÖćøúéÖøąéĎÖÿĆîĀúĆÜĀĆÖ ñúêŠĂÖćøúéÖøąéĎÖĀĆÖĔîêĞćĒĀîŠÜĂČęî
(Vertebral fracture) (Non-vertebral fracture)
÷ć Osteoporosis Osteoporosis
Osteoporosis + Previous Osteoporosis + Previous vertebral
vertebral fracture fracture
Alendronate + + + +
Risedronate + + + +
Ibandronate ĕöŠöĊĀúĆÖåćî + ĕöŠöĊĀúĆÖåćî +
Zoledronic acid + + ĕöŠöĊĀúĆÖåćî +
HRT + + + +
Raloxifene + + ĕöŠöĊĀúĆÖåćî ĕöŠöĊĀúĆÖåćî
Calcitonin + + ĕöŠöĊĀúĆÖåćî ĕöŠöĊĀúĆÖåćî
Strontium + + + +
ranelate
Teriparatide ĕöŠöĊĀúĆÖåćî + ĕöŠöĊĀúĆÖåćî +
Āöć÷đĀêč: + Āöć÷ëċÜ øĆÖþćĕéšñú

ÙüćöÙčšöÙŠćĒúąñúÖøąìïéšćîÜïðøąöćè×ĂÜÖćøĔßš÷ćêšćîÖøąéĎÖóøčî
ÝćÖÖćøýċÖþć×ĂÜ Fleurence45 óïüŠćĔîìćÜ÷čēøðĒúąĂđöøĉÖćöĊÖćøýċÖþćēé÷đĂćêĆüêĆéÿĉîìĊęüŠć ÙŠćĔߚ݊ć÷êŠĂ
Quality-adjusted Life Year (QALY) îšĂ÷ÖüŠć 30,000 ðĂîéŤ46 ĀøČĂ 50,000 đĀøĊ÷â ëČĂüŠć cost effective ךĂÿøčðìĊę
ßĆéđÝîìĊęĕéšÝćÖÖćøýċÖþćóïüŠć ñĎšĀâĉÜìĊęöĊĂć÷čêĆĚÜĒêŠ 70 ðŘ×ċĚîĕð ĒúąöĊÙŠć BMD îšĂ÷ÖüŠćĀøČĂđìŠćÖĆï 2.5 øŠüöÖĆïöĊÖøąéĎÖĀĆÖ
ÖŠĂîĀîšćîĊĚ ÖćøĔßš Bisphosphonate ëČĂüŠć cost effective ÿŠüîÖćøĔßšĔîñĎšĀâĉÜìĊęĂć÷čìĊęîšĂ÷ÖüŠć 50 ðŘ ëČĂüŠćĕöŠ cost
effective ÿŠüîĂć÷čìĊęĂ÷ĎŠøąĀüŠćÜîĊĚñúìĊęĕéš÷ĆÜĕöŠßĆéđÝî
đöČęĂĔßšĒïïÝĞćúĂÜìćÜđýøþåýćÿêøŤ óïüŠćÖćøøĆÖþćēøÙÖøąéĎÖóøčîéšü÷÷ć Alendronate è øćÙćðŦÝÝčïĆî
öĊÙüćöÙčšöÙŠćìćÜđýøþåýćÿêøŤìĊęđÖèæŤ 120,000 ïćìêŠĂðŘÿč×õćüąìĊęđóĉęö×ċĚîĔîñĎšĀâĉÜĂć÷č 65 ðŘ×ċĚîĕð ìĊęöĊ BMD T-score
îšĂ÷ÖüŠć -2.5 ĀøČĂñĎšĀâĉÜìĊęÙĞćîüèÙŠć FRAXTM with BMD ĒúšüđÖĉéēĂÖćÿđÿĊę÷Ü×ĂÜÖćøđÖĉéÖøąéĎÖĀĆÖìĊęêĞćĒĀîŠÜÿĞćÙĆâìĊę
øą÷ąđüúć 10 ðŘ öćÖÖüŠćĀøČĂđìŠćÖĆïøšĂ÷úą 7.4 ĒúąēĂÖćÿđÿĊę÷Ü×ĂÜÖćøđÖĉéÖøąéĎÖĀĆÖìĊęÿąēóÖìĊęøą÷ąđüúć 10 ðŘ öćÖÖüŠć
ĀøČĂđìŠćÖĆïøšĂ÷úą 2.4 Ă÷ŠćÜĕøÖĘêćöÖćøøĆÖþćēøÙÖøąéĎÖóøčîđóČęĂÖćøðŜĂÜÖĆîÖøąéĎÖĀĆÖàĚĞć óïüŠć÷ćìčÖêĆüĕöŠöĊÙüćöÙčšöÙŠć
ìćÜđýøþåýćÿêøŤìĊęđÖèæŤóĉÝćøèćÙüćöÙčšöÙŠćéĆÜÖúŠćü øćÙć÷ć Alendronate ÝąêšĂÜúéøćÙćúÜøšĂ÷úą 60.0 ĒúąøćÙć÷ć
Zoledronic acid ÝąêšĂÜúéøćÙćúÜøšĂ÷úą 70.0 ÝċÜÝąöĊÙüćöÙčšöÙŠćìĊęÖćøøĆÖþćĔîñĎšĀâĉÜĂć÷č 65 ðŘ ×ċĚîĕðìĊęöĊ BMD T-score
îšĂ÷ÖüŠć -2.535
ÿĞćĀøĆïÖćøÙĆéÖøĂÜēøÙÖøąéĎÖóøčîóøšĂöìĆĚÜÖćøøĆÖþćđöČęĂđðøĊ÷ïđìĊ÷ïÖĆïĕöŠöĊÖćøÙĆéÖøĂÜĒúąÖćøøĆÖþćéšü÷
ĒÙúđàĊ÷öĒúąüĉêćöĉîéĊ óïüŠćÖćøÙĆéÖøĂÜĔîñĎšìĊęĂć÷č 65 ðŘ×ċĚîĕð éšü÷ÖćøĔßšéĆßîĊÙüćöđÿĊę÷ÜìćÜÙúĉîĉÖ OSTA ĀøČĂ KKOS Ēúšü
÷Čî÷ĆîēøÙÖøąéĎÖóøčîéšü÷đÙøČęĂÜ DXA óøšĂöìĆĚÜøĆÖþćñĎšðśü÷ēøÙÖøąéĎÖóøčîéšü÷÷ć Alendronate öĊÙüćöÙčšöÙŠćìćÜ
đýøþåýćÿêøŤ Ă÷ŠćÜĕøÖĘêćö ĀćÖìĞćÖćøÙĆéÖøĂÜĔîñĎšìĊęĂć÷č 70 ðŘ×ċĚîĕð đÙøČęĂÜöČĂÙĆéÖøĂÜìčÖßîĉéöĊøąéĆïÙüćöÙčšöÙŠćìĊęêęĞćÖüŠć
đÖèæŤ 120,000 ïćìêŠĂðŘÿč×õćüąìĊęđóĉęö×ċĚîìĆĚÜÿĉĚî35
Ă÷ŠćÜĕøÖĘêćö ēøÙÖøąéĎÖóøčîĔîñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂîîĆĚîóïĕéšöćÖ ĀćÖìĞćÖćøøĆÖþćĔîñĎšðśü÷ìčÖøć÷Ýą
ÿŠÜñúÖøąìïéšćîÜïðøąöćèêŠĂõćÙøĆåđðŨîÝĞćîüîöćÖÙČĂðøąöćè 12,866 úšćîïćìêŠĂðŘ éĆÜîĆĚîÝċÜÙüøöĊÖćøÖĞćĀîéđÖèæŤ
ÖćøøĆÖþćĔîñĎšìĊęöĊÙüćöđÿĊę÷ÜêŠĂÖćøđÖĉéÖøąéĎÖĀĆÖÿĎÜđðŨîúĞćéĆïĒøÖÖŠĂî ÷ÖêĆüĂ÷ŠćÜđߊî ÖćøĔßš ēĂÖćÿđÿĊę÷Ü×ĂÜÖćøđÖĉé
ÖøąéĎÖĀĆÖìĊęêĞćĒĀîŠÜÿĞćÙĆâìĊęøą÷ąđüúć 10 ðŘ đìŠćÖĆïøšĂ÷úą 20.0 ĀøČĂöćÖÖüŠćîĆĚî đóČęĂĕöŠÖŠĂðŦâĀćêŠĂÙüćööĆęîÙÜéšćî
ÖćøđÜĉî×ĂÜÖĂÜìčîðøąÖĆîÿč×õćóêŠćÜė

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-13

öĊÖćøýċÖþćĔîÖćøĔßš Alendronate đóČęĂðŜĂÜÖĆîÖćøđÖĉéÖøąéĎÖĀĆÖĔîÖúčŠöñĎšðśü÷ìĊęöĊ BMD ìĊęîšĂ÷ÖüŠć -2.5 Ēúą

öćÖÖüŠć -2.047 óïüŠćëšćĔîÖúčŠö -2.5 êšĂÜĔĀš÷ćĔîÖćøðŜĂÜÖĆîÖøąéĎÖĀĆÖĒÖŠñĎšðśü÷ÝĞćîüî 15 Ùî ĒúąðŜĂÜÖĆîÖøąéĎÖÿąēóÖ
ĀĆÖ 81 Ùî ÝċÜÝąÿćöćøëðŜĂÜÖĆîÖćøđÖĉéÖøąéĎÖĀĆÖĕéš 1 Ùî ×èąđéĊ÷üÖĆîĔîÖúčŠöñĎšðśü÷ìĊęöĊ BMD ìĊęöćÖÖüŠć -2.0 êšĂÜĔĀš÷ćĔî
ÖćøðŜĂÜÖĆîÖøąéĎÖĀĆÖĒÖŠñĎšðśü÷ÝĞćîüî 30 Ùî ÝċÜÝąÿćöćøëðŜĂÜÖĆîÖćøđÖĉéÖøąéĎÖĀĆÖĕéš 1 Ùî (êćøćÜìĊę 17.9)

êćøćÜìĊę 17.9 ÝĞćîüî Number needed to treat ×ĂÜÖćøĔßš÷ć Alendronate ĔîÿêøĊìĊęöĊÙüćöĀîćĒîŠîöüúÖøąéĎÖêęĞćìĊę

đךćøĆïÖćøøĆÖþćđðŨîđüúć 4 ðŘ đóČęĂðŜĂÜÖĆîÖćøđÖĉéÖøąéĎÖĀĆÖ47
NNT to prevent one clinical NNT to prevent one hip
Category
fracture fracture
Alendronate
baseline bone density at femoral
neck
T-score < –2.5 15 81
T-score > –2.0 30 no effect
Āöć÷đĀêč: NNT = Number needed to treat (ÝĞćîüî×ĂÜñĎšðśü÷ìĊęîšĂ÷ìĊęÿčéìĊęĕéšøĆï÷ćðŜĂÜÖĆîÖćøđÖĉéÖøąéĎÖĀĆÖđóČęĂúéÖćøđÖĉéÖøąéĎÖĀĆÖ 1 øć÷)

ðøąöćèÖćøÜïðøąöćèÖćøĔßš÷ćêšćîÖøąéĎÖóøčî×ĂÜðøąđìýĕì÷
ÝćÖøć÷ÜćîÖćøüĉđÙøćąĀŤñúÖøąìïéšćîÜïðøąöćè×ĂÜÖćøøĆÖþćēøÙÖøąéĎÖóøčîĔîñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂî
éšü÷÷ćïîóČĚîåćî×ĂÜÖćøĔßšĒïïÝĞćúĂÜìćÜđýøþåýćÿêøŤ ēé÷õćÙüĉßćĂć÷čøýćÿêøŤ ÙèąĒóì÷ŤýćÿêøŤ öĀćüĉì÷ćúĆ÷×ĂîĒÖŠî
ĔîðŘ 255635 óïüŠćĀćÖóĉÝćøèćĔĀšÖćøøĆÖþćéšü÷÷ć Alendronate ĔîñĎšĀâĉÜüĆ÷ĀöéðøąÝĞćđéČĂîĂć÷č 65 ðŘ×ċĚîĕð ìĊęöĊ BMD
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ÖćøđךćëċÜÖćøÙĆéÖøĂÜ 17
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การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-14 โรคกระดูกพรุน (Osteoporosis)

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Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-15

đÙøČęĂÜöČĂ ĂčðÖøèŤ đìÙēîēú÷ĊìćÜÖćøĒóì÷Ť

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3. ĔĀšÙüćöøĎšÿĎŠðøąßćßîĔĀšêøąĀîĆÖëċÜÙüćöÿĞćÙĆâ×ĂÜēøÙÖøąéĎÖóøčî ĒîüìćÜðŜĂÜÖĆîĒúąøĆÖþćìĊęëĎÖêšĂÜ
4. öĊÖćøÝĆéêĆĚÜĀîŠü÷ĔĀšïøĉÖćøøĆÖþćđÞóćąēøÙÖøąéĎÖóøčî đߊî ÙúĉîĉÖēøÙÖøąéĎÖóøčî ĀĂñĎšðśü÷ÿĞćĀøĆï
ñĎšðśü÷ÿĎÜĂć÷čìĊęöĊõćüąÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčî ēé÷ïčÙúćÖøìĞćÜćîøŠüöÖĆîĒïïÿĀÿć×ćüĉßćßĊóđóČęĂéĎĒúñĎšðśü÷
5. öĊÖćøÿîĆïÿîčîĔĀšñĎšðśü÷ìĊęöĊēøÙÖøąéĎÖóøčî ĒúąÖøąéĎÖĀĆÖÝćÖõćüąÖøąéĎÖóøčî ĕéšÖćøøĆÖþćìĊęëĎÖêšĂÜ
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6. ÿøšćÜđÙøČĂ׊ć÷ÖĆïÿëćîó÷ćïćúøąéĆïðåöõĎöĉ ìčêĉõĎöĉ ēé÷óĆçîćøąïïđìÙēîēú÷Ċÿćøÿîđìý đóČęĂĔĀšöĊ
øąïïðøċÖþć (consultation) øąĀüŠćÜÿëćîó÷ćïćúĕéšÿąéüÖ đóČęĂĔĀšÿëćîó÷ćïćúøąéĆïêšîÿćöćøëéĎĒúñĎšðśü÷ĕéš úéÖćø
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7. ÿîĆïÿîčîÖćøöĊÿŠüîøüö×ĂÜßčößîĔîÖćøéĎĒúߊü÷ôŚŪîôĎÿöøøëõćó×ĂÜñĎšÿĎÜĂć÷čìĊęöĊõćüąÖøąéĎÖĀĆÖ öĊ
ēÙøÜÖćøÿîĆïÿîčîĔĀšÙüćöøĎšđóĉęöÙüćöÿćöćøëĒÖŠĂćÿćÿöĆÙøßčößîĔîÖćøéĎĒúñĎšÿĎÜĂć÷čēøÙÖøąéĎÖóøčî
8. ÿîĆïÿîčîïčÙúćÖøĔĀšòřÖĂïøöÖćøéĎĒúøĆÖþćñĎšðśü÷ÿĎÜĂć÷čìĊęöĊõćüąÖøąéĎÖóøčî ĒúąÖćøøĆÖþćÖøąéĎÖĀĆÖ
9. ÖĞćĀîéêĆüßĊĚüĆéìĊęïŠÜïĂÖëċÜðøąÿĉìíĉõćóÖćøéĎĒúñĎšðśü÷ĒúąÖćøïøĉĀćøÝĆéÖćøõćüąēøÙÖøąéĎÖóøčî đߊî
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×ĂÜñĎšðśü÷ÖøąéĎÖĀĆÖÝćÖēøÙÖøąéĎÖóøčîĔîēøÜó÷ćïćú öĊÖćøÝĆéìĞćÖćøðøąßčö Morbidity and Mortality conference,
Root Cause Analysis
10. öĊøąïïêĉéêćöñĎšðśü÷ìĊęĕéšøĆïÖćøøĆÖþćõćüąÖøąéĎÖĀĆÖĀúĆÜĂĂÖÝćÖēøÜó÷ćïćúĔĀšÙüćöߊü÷đĀúČĂ 17
ñĎšðśü÷ĒúąÙøĂïÙøĆüĔîÖćøôŚŪîôĎ ÿöøøëõćó ĒúąĒîąîĞćĒîüðŜĂÜÖćøĀÖúšöĔîñĎšÿĎÜĂć÷č øüöìĆĚÜêĉéêćöĔĀšñĎšðśü÷øĆïÖćøøĆÖþć
õćüąÖøąéĎÖóøčîêŠĂđîČęĂÜ ÖćøðŜĂÜÖĆîĀÖúšöēé÷đÞóćąÖćøĂĂÖÖĞćúĆÜÖć÷ óïüŠćÿćöćøëúéÖćøĀÖúšöĔîñĎšÿĎÜĂć÷čĕéšñúÝøĉÜ
ÖćøýċÖþćĔî Cochrane review óïüŠćÖćøĂĂÖÖĞćúĆÜÖć÷ đߊî ÖćøøĞćĕìđÖŢÖĔîñĎšÿĎÜĂć÷čߊü÷úéÖćøĀÖúšöĕéš50 Tousignant51
ĕéšìĞćÖćøýċÖþćĒïïÿčŠöđÖĊę÷üÖĆïÖćøøĞćĕìđÖŢÖĔîñĎšðśü÷Ăć÷čöćÖìĊęĂŠĂîĒĂĔîðøąđìýĒÙîćéć ÝĞćîüî 76 Ùî Ĕî 15 ÿĆðéćĀŤ ÖĆï

การแพทยไทย ๒๕๕๔-๒๕๕๗ First Edition

17-16 โรคกระดูกพรุน (Osteoporosis)

ÖćøìĞćÖć÷õćóïĞćïĆéĒïïðÖêĉ óïüŠćìĆĚÜ 2 Ă÷ŠćÜÿćöćøëúéÖćøĀÖúšöĕéš ēé÷ÖúčŠöìĊęøĞćĕìđÖŢÖúéÖćøúšöĕéšéĊÖüŠć ÿĞćĀøĆïĔî

đøČęĂÜ cost effectiveness îĆĚî Frick52 ĕéšìĞćÖćøýċÖþćđðøĊ÷ïđìĊ÷ïÙüćöÙčšöÙŠć ēé÷Ĕßš mathematical epidemiological
model ÙĞćîüèĒúšüóïüŠć ÖćøøĆÖþćēé÷ psychotropics ĒúąøĞćĕìđÖŢÖđðŨîÖćøøĆÖþćìĊęëĎÖìĊęÿčé ĒúąĔĀšñúéĊöćÖìĊęÿčéĔîÖćø
øąüĆÜÖćøúšö

ךĂđÿîĂđóČęĂÖćøýċÖþć üĉÝĆ÷ ĒúąÝĆéÖćøÙüćöøĎš

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ìćÜÙúĉ îĉÖ ĒêŠÖĘ ÷ĆÜ öĊךà ÝĞć ÖĆé Āúć÷ðøąÖćø ñúÖćøýċ Ö þćïćÜĂ÷Šć Ü÷Ć Ü öĊך Ă ēêšĒ ÷šÜ ÖĆ î Ýċ Ü ÝĞć đðŨî êš Ă ÜöĊÖ ćøýċÖ þćđóĉęö đêĉ ö
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ÖøąéĎÖìĊęúéúÜĒêŠöĊÙüćöđÿĊę÷ÜìĊęÝąđÖĉéÖøąéĎÖĀĆÖöćÖ×ċĚî23 ĒêŠøć÷ÜćîĀúć÷ÞïĆïìĊęóïüŠćñĎšðśü÷ÖøąéĎÖÿąēóÖĀĆÖđÖČĂïøšĂ÷úą
50.0 öĊÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖĕöŠĂ÷ĎŠĔîđÖèæŤÖøąéĎÖóøčî53-55 ĒúąñúÝćÖÖćøøĆÖþćéšü÷÷ćøĆÖþćÖøąéĎÖóøčî óïüŠćìĞćĔĀš
ÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖđóĉęö×ċĚî ĒêŠñúĔîÖćøðŜĂÜÖĆîÖćøđÖĉéÖøąéĎÖĀĆÖÖúĆïúéúÜđóĊ÷ÜđúĘÖîšĂ÷ ĒúąĕöŠÿĆöóĆîíŤÖĆïÙüćö
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ÖøąéĎÖđóĊ÷ÜĂ÷ŠćÜđéĊ÷ü
ÜćîüĉÝĆ÷ìćÜÙúĉîĉÖ×ĂÜēøÙÖøąéĎÖóøčî đߊî ðŦÝÝĆ÷đÿĊę÷ÜĀøČĂÙüćöîŠćÝąđðŨîĔîÖćøđÖĉéÖøąéĎÖĀĆÖ (fracture
probability) ĀøČĂ éĆßîĊÙüćöđÿĊę÷ÜìćÜÙúĉîĉÖ (clinical risk index) ÿŠüîĔĀâŠđðŨîÖćøýċÖþćĔîðøąđìýêąüĆîêÖĔîðøąßćÖø
ñĉü×ćü àċęÜöĊךĂÝĞćÖĆéĔîÖćøîĞćöćĔßšĔîìćÜðäĉïĆêĉ đîČęĂÜÝćÖ÷ĆÜ×ćéÖćøìéÿĂïĔîÙîĕì÷ éĆÜîĆĚîĒîüìćÜÖćøýċÖþćüĉÝĆ÷Ùüø
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îĞćöćĔßšĔîìćÜðäĉïĆêĉ àċęÜݹߊü÷ÙĆéÖøĂÜñĎšìĊęĕöŠöĊÙüćöÝĞćđðŨîĔîÖćøÿŠÜêøüÝüĆéÙüćöĀîćĒîŠî×ĂÜÖøąéĎÖ øüöìĆĚÜ÷ĆÜđðŨîđÙøČęĂÜ
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đîČęĂÜÝćÖÖćøêøüÝĀćēøÙÖøąéĎÖóøčîéšü÷ÖćøüĆéÙüćöĀîćĒîŠîÖøąéĎÖĒúą÷ćøĆÖþćēøÙÖøąéĎÖóøčîöĊøćÙćĒóÜ
éĆÜîĆĚîÙüøöĊÖćøýċÖþćÙüćöÙčšöÙŠćĔîđßĉÜđýøþåýćÿêøŤìćÜÿćíćøèÿč×đóČęĂĔĀšđÖĉéÙüćöÙčšöÙŠćÿĎÜÿčéĔîøąéĆïðøąđìý ðŦÝÝčïĆî
ðøąđìýĕì÷÷ĆÜĕöŠöĊךĂöĎúÖćøýċÖþćøą÷ą÷ćüđóČęĂêĉéêćöÖćøđÖĉéÖøąéĎÖĀĆÖĔîøąéĆïðøąßćÖø éĆÜîĆĚîÝċÜÙüøöĊøąïïÖćøÝĆéđÖĘï
ךĂöĎúìćÜøąïćéüĉì÷ć đߊî ÙüćößčÖ×ĂÜēøÙÖøąéĎÖóøčî ĂčïĆêĉÖćøèŤ×ĂÜÖøąéĎÖÿąēóÖĀĆÖ ÖøąéĎÖÿĆîĀúĆÜĀĆÖ ĂĆêøćêć÷
øüöìĆĚÜÿč×õćóēé÷øüöõć÷ĀúĆÜÖøąéĎÖĀĆÖ

Thailand Medical Services Profile 2011 - 2014

โรคกระดูกพรุน (Osteoporosis) 17-17

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