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What is Endocrinology?  什麼是內分泌學?

  • Endocrine: Ductless  內分泌:無管道
  • Traditional view: Endocrine gland produce hormones rarr\rightarrow secret directly into bloodstream rarr\rightarrow effect on distant target organs
    傳統觀點:內分泌腺產生荷爾蒙 rarr\rightarrow 直接分泌到血液中 rarr\rightarrow 影響遠方的目標器官
  • Paracrine/ autocrine  旁分泌/自分泌
  • Hormone (from Greek ‘urge’, first used in 1905: Secretin) = chemical messenger
    荷爾蒙(來自希臘文「促進」,1905 年首次使用:Secretin)= 化學信使
  • Nowadays almost every organ can be considered as endocrine organ
    現在幾乎每個器官都可被視為內分泌器官
  • Study of homeostasis and metabolism
    平衡與新陳代謝的研究

**Six important characteristics of hormones
**荷爾蒙的六大重要特性

  • Circadian rhythms (e.g. ACTH, cortisol, testosterone)
    晝夜節律(例如 ACTH、皮質醇、睪酮)
  • Pineal gland  松果腺
  • Timing of blood taking important
    抽血的時間很重要
  • Very low concentration in blood with wide normal range
    血液中的濃度很低,正常範圍很廣
  • Need dynamic test (stimulatory or inhibitory tests)
    需要動態測試(刺激性或抑制性測試)
  • Most bound to binding protein (total Vs free cortisol, T4)
    與結合蛋白結合最多(總皮質醇 Vs 游離皮質醇、T4)
  • Affected by binding protein change (e.g. oral contraceptive pills)
    受結合蛋白變化的影響 (例如口服避孕藥)
  • Controlled by negative feedback (rarely positive feedback)
    由負反饋控制(很少有正反饋)
  • Primary or secondary lesions
    原發性或繼發性病變
  • Ectopic production  異位生產
  • Different tumors may product hormones (e.g. ddAVP, FGF23)
    不同的腫瘤可能會產生荷爾蒙 (例如 ddAVP、FGF23)

Endocrine disorders:Framework
內分泌失調:框架

辨證論治

-Hormones:Too high or too low
-荷爾蒙:過高或過低

-Site:Primary Vs secondary
-網站:主要與次要

-Cause:Tumor Vs non-tumor(inflammation/vascular/infection etc)
-病因:腫瘤 Vs 非腫瘤(發炎/血管/感染等)

-Investigation:  -調查:
-Screening rarr\rightarrow confirm diagnosis rarr\rightarrow localization rarr\rightarrow Medical/Surgical Rx
-篩檢 rarr\rightarrow 確診 rarr\rightarrow 定位 rarr\rightarrow 內科/外科用藥

-Measurement interference,drug effects,non-specific illness(cytokines etc)
-測量干擾、藥物效應、非特異性疾病(細胞因子等)。

-Management:  -管理:
-Surgical Vs Medical Vs Radiotherapy
-手術 Vs 內科 Vs 放射線治療

Hypothalamus-pituitary hormones: Summary
下丘腦-垂體荷爾蒙:摘要

  • Anterior pituitary  前腦下垂體
  • Prolactin  催乳素
  • LH, FSH  LH、FSH
  • GH (growth hormone)  GH(生長激素)
  • ACTH
  • TSH (Thyroid stimulating hormone)
    TSH(促甲狀腺激素)
  • Posterior pituitary  垂體後葉
  • Vasopressin (AVP)  血管加壓素 (AVP)
  • Oxytocin  催產素

Pituitary adenoma: Mass + Hormonal effects
垂體腺瘤:腫塊 + 荷爾蒙影響

Normal pituitary  正常垂體
Microadenoma  小腺瘤
Macroadenoma  巨腺瘤
Aggressive adenoma  侵襲性腺瘤

Pituitary adenoma: Mass effect
垂體腺瘤:大規模影響

  • Headache  頭痛
  • Visual field defect (Optic chiasma)
    視野缺損 (視軸)

    rarr\rightarrow Bi-temporal hemianopia
    rarr\rightarrow 雙顳葉偏盲

Pituitary adenoma: Hormonal effects
垂體腺瘤:荷爾蒙的影響

  • Low rarr\rightarrow hypopituitarism
    rarr\rightarrow 垂體功能減退
  • Low ACTH rarr\rightarrow low cortisol
    低 ACTH rarr\rightarrow 低皮質醇
  • Low TSH rarr\rightarrow low thyroxine
    低 TSH rarr\rightarrow 低甲狀腺素
  • Low LH/FSH rarr\rightarrow low sex hormones (estrogen/ testosterone)
    低 LH/FSH rarr\rightarrow 低性荷爾蒙 (雌激素/睪丸素)
  • Low GH rarr\rightarrow low IGF-1
    低 GH rarr\rightarrow 低 IGF-1
  • Low prolactin  催乳素偏低
  • (seldom affect vasopressin causing diabetes insipidus)
    (很少會影響血管加壓素,導致糖尿病性血尿)
  • High (can be mixed or non-functional)
    高 (可混合或無功能)
  • High ACTH rarr\rightarrow Cushing’s disease
    高 ACTH rarr\rightarrow 庫欣氏症
  • High GH rarr\rightarrow Acromegaly
    高 GH rarr\rightarrow 肢端肥大症
  • High prolactin rarr\rightarrow Prolactinoma
    高催乳素 rarr\rightarrow 催乳素瘤
  • (usual no consequence for high LH/FSH)
    (高 LH/FSH 通常無後果)
  • (High TSH causing TSHoma is very rare)
    (高 TSH 造成 TSHoma 的情況非常罕見)

Prolactinoma  催乳素瘤

Common cause of high prolactin
泌乳素偏高的常見原因

  • Stress  壓力
  • Pregnancy  懷孕
  • Taking medication like anti-psychotic drugs
    服用抗精神病藥物等藥物
  • Pituitary tumor  垂體瘤
  •   ...

Acromegaly: clinical features
肢端肥大症:臨床特徵

  • Facial features  臉部特徵
  • Big hands and foots
    大手大腳
  • Related complications  相關併發症
  • Hypertension  高血壓
  • Diabetes mellitus  糖尿病
  • Sleep apnea  睡眠窒息症
  • Carpal tunnel syndrome  腕隧道症候群
  • Colonic polyps  結腸息肉
  • Heart failure  心臟衰竭

Acromegaly  肢端肥大症

  • Diagnosis  診斷
  • Clinical feature  臨床特徵
  • High GH (growth hormone)
    高 GH(生長激素)
  • High IGF-1 (Insulin-like growth factor)
    高 IGF-1(類胰島素生長因子)
  • Non-suppressible GH after oral glucose tolerance test (75 gm glucose)
    口服葡萄糖耐量測試(75 公克葡萄糖)後的非抑制性 GH
  • Check other anterior pituitary hormones
    檢查其他垂體前葉激素
  • Localization  本地化
  • MRI pituitary  MRI 垂體
  • Others  其他
  • Screen complication  螢幕複雜性
  • Blood pressure  血壓
  • Glucose + HbA1c  葡萄糖 + HbA1c
  • Sleep study (Obstructive sleep apnea)
    睡眠檢查(阻塞性睡眠窒息症)
  • Nerve conduction test (carpel tunnel syndrome)
    神經傳導測試(腕管症候群)
  • Colonoscopy (colon polyps and carcinoma)
    結腸鏡檢查 (結腸息肉和癌)
  • Echocardiogram (heart failure)
    超音波心動圖(心臟衰竭)

Mx of acromegaly  肢端肥大症的 Mx

Cushing's syndrome: Diagnosis
庫欣症候群:診斷

Cushing's Vs Pseudo-Cushing's (Non-neoplastic hypercortisolism)
庫欣症與假性庫欣症(非新腫瘤性皮質醇過高症)

Screening  篩選

  • Late night salivary cortisol
    深夜唾液皮質醇
  • 1 mg overnight dexamethasone suppression test
    1 毫克隔夜地塞米松抑制試驗
  • 24-hr urine free cortisol
    24 小時尿液游離皮質醇
  • others  其他
  • Dex + corticotrophin releasing hormone
    Dex + 促皮質素釋放激素
ACTH is used to localize tumor, usually not for screening
ACTH 用於定位腫瘤,通常不是用於篩檢
Key players 主要成員 of thyroid tests
甲狀腺檢測的主要成員
Key thyroid tests  主要甲狀腺檢測
Thyroid functions  甲狀腺功能 fT4
fT3
TSH 促甲狀腺素
Thyroid antibodies  甲狀腺抗體
TSHR Ab 受體抗體
TSHR Ab 受體抗體| TSHR Ab 受體抗體 | | :--- |
TPO Ab 過氧化物酶抗體
TG Ab 球蛋白抗體
Key thyroid tests Thyroid functions fT4 fT3 TSH 促甲狀腺素 Thyroid antibodies "TSHR Ab 受體抗體" TPO Ab 過氧化物酶抗體 TG Ab 球蛋白抗體| | Key thyroid tests | | :--- | :--- | | Thyroid functions | fT4 | | | fT3 | | | TSH 促甲狀腺素 | | Thyroid antibodies | TSHR Ab 受體抗體 | | | TPO Ab 過氧化物酶抗體 | | | TG Ab 球蛋白抗體 |

TFT:How to choose 如何選擇?
TFT:如何選擇?

Tests  測試 Contents  內容 What lx  什麼 lx
TFT 01 Toxic on ATD-treatment  ATD 治療的毒性 fT4
TFT 02 Primary hypothyroid on T4
T4 原發性甲狀腺功能減退
TSH
TFT 03 Pituitary hypothyroid on T4
T4 腦垂體甲狀腺功能減退
fT4
TFT 04 Congenital hypothyroid on T4
T4 先天性甲狀腺功能減退
TSH(fT4)
TFT 05 Toxic in remission(off ATD<1 y)
毒性緩解(關閉 ATD<1 年)
fT4
TFT 06 Toxic in remission(off ATD>1y)
毒性緩解(關閉 ATD>1 年)
TSH
TFT 07 RAI<1y(not on T4 or ATD)
RAI<1y(未使用 T4 或 ATD)。
fT4
TFT 08 RAI>1y(not on T4 or ATD)
RAI>1y(未使用 T4 或 ATD)
TSH
TFT 09 New case ?Toxic  新案例? fT4+TSH
TFT 10 New case ?Primary hypothy
新病例?
TSH(fT4)
TFT 11 New case ?Pituitary hypothy
新病例?
fT4+TSH
TFT 12 In pregnancy  懷孕期間 fT4+TSH(diff N range)  fT4+TSH(差值 N 範圍)
TFT 13 Isotope protocol(toxic)  同位素協議(有毒) fT4
TFT 14

同位素協議(CA 甲狀腺)內分泌協議
Isotope protocol(CA thyroid)
Endocrine protocol
Isotope protocol(CA thyroid) Endocrine protocol| Isotope protocol(CA thyroid) | | :--- | | Endocrine protocol |
fT4+TSH
TFT 15
fT4+TSH TFT 15| fT4+TSH | | :--- | | TFT 15 |
Tests Contents What lx TFT 01 Toxic on ATD-treatment fT4 TFT 02 Primary hypothyroid on T4 TSH TFT 03 Pituitary hypothyroid on T4 fT4 TFT 04 Congenital hypothyroid on T4 TSH(fT4) TFT 05 Toxic in remission(off ATD<1 y) fT4 TFT 06 Toxic in remission(off ATD>1y) TSH TFT 07 RAI<1y(not on T4 or ATD) fT4 TFT 08 RAI>1y(not on T4 or ATD) TSH TFT 09 New case ?Toxic fT4+TSH TFT 10 New case ?Primary hypothy TSH(fT4) TFT 11 New case ?Pituitary hypothy fT4+TSH TFT 12 In pregnancy fT4+TSH(diff N range) TFT 13 Isotope protocol(toxic) fT4 TFT 14 "Isotope protocol(CA thyroid) Endocrine protocol" "fT4+TSH TFT 15"| Tests | Contents | What lx | | :--- | :--- | :--- | | TFT 01 | Toxic on ATD-treatment | fT4 | | TFT 02 | Primary hypothyroid on T4 | TSH | | TFT 03 | Pituitary hypothyroid on T4 | fT4 | | TFT 04 | Congenital hypothyroid on T4 | TSH(fT4) | | TFT 05 | Toxic in remission(off ATD<1 y) | fT4 | | TFT 06 | Toxic in remission(off ATD>1y) | TSH | | TFT 07 | RAI<1y(not on T4 or ATD) | fT4 | | TFT 08 | RAI>1y(not on T4 or ATD) | TSH | | TFT 09 | New case ?Toxic | fT4+TSH | | TFT 10 | New case ?Primary hypothy | TSH(fT4) | | TFT 11 | New case ?Pituitary hypothy | fT4+TSH | | TFT 12 | In pregnancy | fT4+TSH(diff N range) | | TFT 13 | Isotope protocol(toxic) | fT4 | | TFT 14 | Isotope protocol(CA thyroid) <br> Endocrine protocol | fT4+TSH <br> TFT 15 |
-Hyper or Hypo  -高或低

-Primary or Secondary  -初級或中級

-TSH higher sensitivity than fT4
-TSH 靈敏度高於 fT4

-TSH after suppression,need time to return back to normal (易跌難升)
-抑制 TSH 後,需要時間恢復正常(易跌難升)。

-Pregnancy different reference range
-妊娠不同的參考範圍

-fT3 only in special conditions
-fT3僅在特殊條件下使用

-Suspect T3 toxicosis  -懷疑 T3 中毒
-Some hypothyroidism  -部分甲狀腺功能減退

Hyperthvroidism  甲狀腺功能亢進

Symptoms  症狀 Signs  標誌
Constitutional  憲法

儘管食慾增加,但體重下降;與熱相關的症狀(熱不耐受、出汗和多尿症)
Weight loss despite increased appetite;
heat-related symptoms (heat intolerance,
sweating, and polydipsia)
Weight loss despite increased appetite; heat-related symptoms (heat intolerance, sweating, and polydipsia)| Weight loss despite increased appetite; | | :--- | | heat-related symptoms (heat intolerance, | | sweating, and polydipsia) |
Weight loss  減重
Neuromuscular  神經肌肉

震顫、緊張、焦慮、疲勞、虛弱、睡眠不安、注意力不集中
Tremor; nervousness; anxiety; fatigue;
weakness; disturbed sleep; poor
concentration
Tremor; nervousness; anxiety; fatigue; weakness; disturbed sleep; poor concentration| Tremor; nervousness; anxiety; fatigue; | | :--- | | weakness; disturbed sleep; poor | | concentration |

四肢顫抖;過度活躍;反射亢進;骨盆和腰肌無力
Tremor of the extremities;
hyperactivity; hyper-reflexia; pelvic
and girdle muscle weakness
Tremor of the extremities; hyperactivity; hyper-reflexia; pelvic and girdle muscle weakness| Tremor of the extremities; | | :--- | | hyperactivity; hyper-reflexia; pelvic | | and girdle muscle weakness |
Cardiovascular  心血管 Palpitations  心悸

心動過速;收縮性高血壓;心律不整(心房顫動)
Tachycardia; systolic hypertension;
irregular heartbeat (atrial
fibrillation)
Tachycardia; systolic hypertension; irregular heartbeat (atrial fibrillation)| Tachycardia; systolic hypertension; | | :--- | | irregular heartbeat (atrial | | fibrillation) |
Pulmonary  肺部 Dyspnoea, shortness of breath
呼吸困難、氣喘
Tachypnoea  心跳過速
Tachypnoea| Tachypnoea | | :--- |
Gastrointestinal  腸胃 Hyperdefecation; nausea, vomiting
排便過多;噁心、嘔吐
Abdominal tenderness  腹部觸痛
Skin  皮膚 Increased perspiration  排汗增加
Warm and moist skin
溫暖濕潤的肌膚
Warm and moist skin| Warm and moist skin | | :--- |
Reproductive  生殖 ..
Menstrual disturbances  月經不調
Menstrual disturbances| Menstrual disturbances | | :--- |
Ocular (Graves' disease)
眼部 (巴塞杜氏病)

復視;眼睛有刺激感;眼瞼腫脹;眶後疼痛或不適
Diplopia; sense of irritation in the eyes;
eyelid swelling; retro-orbital pain or
discomfort
Diplopia; sense of irritation in the eyes; eyelid swelling; retro-orbital pain or discomfort| Diplopia; sense of irritation in the eyes; | | :--- | | eyelid swelling; retro-orbital pain or | | discomfort |

突眼;眼瞼縮回和滯後;眶周水腫;結膜注射和化膿;眼球麻痺
Proptosis; eyelid retraction and lag;
periorbital oedema; conjunctival
injection and chemosis;
ophthalmoplegia
Proptosis; eyelid retraction and lag; periorbital oedema; conjunctival injection and chemosis; ophthalmoplegia| Proptosis; eyelid retraction and lag; | | :--- | | periorbital oedema; conjunctival | | injection and chemosis; | | ophthalmoplegia |
Symptoms Signs Constitutional "Weight loss despite increased appetite; heat-related symptoms (heat intolerance, sweating, and polydipsia)" Weight loss Neuromuscular "Tremor; nervousness; anxiety; fatigue; weakness; disturbed sleep; poor concentration" "Tremor of the extremities; hyperactivity; hyper-reflexia; pelvic and girdle muscle weakness" Cardiovascular Palpitations "Tachycardia; systolic hypertension; irregular heartbeat (atrial fibrillation)" Pulmonary Dyspnoea, shortness of breath "Tachypnoea" Gastrointestinal Hyperdefecation; nausea, vomiting Abdominal tenderness Skin Increased perspiration "Warm and moist skin" Reproductive .. "Menstrual disturbances" Ocular (Graves' disease) "Diplopia; sense of irritation in the eyes; eyelid swelling; retro-orbital pain or discomfort" "Proptosis; eyelid retraction and lag; periorbital oedema; conjunctival injection and chemosis; ophthalmoplegia"| | Symptoms | Signs | | :--- | :--- | :--- | | Constitutional | Weight loss despite increased appetite; <br> heat-related symptoms (heat intolerance, <br> sweating, and polydipsia) | Weight loss | | Neuromuscular | Tremor; nervousness; anxiety; fatigue; <br> weakness; disturbed sleep; poor <br> concentration | Tremor of the extremities; <br> hyperactivity; hyper-reflexia; pelvic <br> and girdle muscle weakness | | Cardiovascular | Palpitations | Tachycardia; systolic hypertension; <br> irregular heartbeat (atrial <br> fibrillation) | | Pulmonary | Dyspnoea, shortness of breath | Tachypnoea | | Gastrointestinal | Hyperdefecation; nausea, vomiting | Abdominal tenderness | | Skin | Increased perspiration | Warm and moist skin | | Reproductive | .. | Menstrual disturbances | | Ocular (Graves' disease) | Diplopia; sense of irritation in the eyes; <br> eyelid swelling; retro-orbital pain or <br> discomfort | Proptosis; eyelid retraction and lag; <br> periorbital oedema; conjunctival <br> injection and chemosis; <br> ophthalmoplegia |
Table 2: Clinical manifestation of thyrotoxicosis
表 2:甲狀腺毒症的臨床表現

Treatment of Graves' disease (autoimmune thyroid disease)
治療巴塞杜氏病(自體免疫性甲狀腺疾病)

  • Anti-thyroid drug ATD: Carbimazole CMZ or Propylthiouracil PTU
    抗甲状腺药物 ATD:卡比马唑 CMZ 或丙基硫氧嘧啶 PTU
  • Ablative therapy  燒蝕療法
  • Radioactive iodine (RAI)
    放射性碘 (RAI)
  • Thyroidectomy  甲狀腺切除術
  • Others  其他
  • Beta-blocker  β-受體阻斷劑
  • Lithium  
  • Selenium  
  • Plasmapheresis (for crisis)
    血漿置換術(用於危機)

Major side effects of ATD
ATD 的主要副作用

  • Allergy  過敏
  • Agranulocytosis 2-4/ 1000 patients
    粒細胞缺乏症 2-4/ 1000 名病患
  • Liver impairment  肝功能損傷
  • Others  其他

Radioactive iodine RAI  放射性碘 RAI

  • Efficacy (around 70% after first RAI)
    療效 (第一次 RAI 後約 70%)
  • Precaution before and immediately after RAI
    RAI 之前和之後的注意事項
  • Acute radiation thyroiditis
    急性放射性甲狀腺炎
  • Hypothyroidism  甲狀腺功能減退
  • Precipitate thyroid eye disease
    誘發甲狀腺眼疾
  • Controversial fertility and cancer risk
    具爭議性的生育與癌症風險

Adrenal gland lesion  腎上腺病變

  • Too high  太高
  • Mineralocorticoids rarr\rightarrow Primary hyperaldosteronism (Conn’s syndrome)
    礦物皮質激素 rarr\rightarrow 原發性高醛固酮症 (Conn's 綜合症)
  • Glucocorticoids rarr\rightarrow Cushing’s syndrome
    糖皮質激素 rarr\rightarrow Cushing's 綜合症
  • Catecholamines rarr\rightarrow Phaeochromocytoma
    兒茶酚胺 rarr\rightarrow 輝色細胞瘤
  • Too low  過低
  • Glucocorticoids: Adrenal insufficiency (low cortisol)
    糖皮質激素:腎上腺功能不全(低皮質醇)

Phaeochromocytoma  血色素瘤

  • Too much Catecholamines  兒茶酚胺過多
  • Adrenal or extra-adrenal (paraganglioma)
    腎上腺或腎上腺外(副肝腫瘤)
  • Paroxysmal adrenergic symptoms (anxiety, sweating, palpitation etc)
    阵发性肾上腺素能症状(焦虑、出汗、心悸等)
  • Hypertension (crisis, surge of very high blood pressure)
    高血壓(危機,血壓非常高的飆升)
  • Diagnosis: 24-hr urine catecholamines or plasma metanephrine
    診斷:24 小時尿液兒茶酚胺或血漿甲腎上腺素
  • Localization: CT/ MRI, radionuclide imaging (MIBG or DOTATATE-PET)
    定位:CT/ MRI、放射性核素造影 (MIBG 或 DOTATATE-PET)
  • Genetic test  基因測試
  • Treatment:  治療:
  • Surgical  外科手術
  • Medical (pre-operative blood pressure control)
    醫療(術前血壓控制)
  • Alpha-blocker  α-受體阻滯劑
  • Beta-blocker  β-受體阻斷劑
  • others  其他
Targeted Treatments for Mediating Pathways of Hyperglycemia
調節高血糖通路的靶向療法

The Time Is Right for a New Classification System for Diabetes: Rationale and Implications of the β β beta\beta-Cell-Centric Classification Schema
糖尿病新分類系統的時機已成熟:以細胞為中心的分類模式 β β beta\beta 的理據和意義

DM: Diagnosis  DM:診斷

  • Fasting blood glucose > / = 7 mmol / l > / = 7 mmol / l > //=7mmol//l>/=7 \mathrm{mmol} / \mathrm{l}
    空腹血糖 > / = 7 mmol / l > / = 7 mmol / l > //=7mmol//l>/=7 \mathrm{mmol} / \mathrm{l}
  • Random/ 2-h post oral glucose tolerance test >/= 11.0 mmol/l
    隨機/ 2 小時後口服葡萄糖耐量測試 >/= 11.0 mmol/l
  • HbA1c >/=6.5%
  • If no symptom, need to repeat at least once
    如果沒有症狀,需要重複至少一次
  • New 2024 IDF proposal also include 1-h post oral glucose tolerance test >/= 11.6 mmol / I 11.6 mmol / I 11.6mmol//I11.6 \mathrm{mmol} / \mathrm{I} (not yet routine practice)
    新的 2024 IDF 建議也包括 1 小時口服後葡萄糖耐量測試 >/= 11.6 mmol / I 11.6 mmol / I 11.6mmol//I11.6 \mathrm{mmol} / \mathrm{I} (尚未成為常規做法)

HbA1c: pitfalls of measurement
HbA1c:測量的陷阱

  • Falsely high  假高
  • Chronic Fe deficiency anaemia
    慢性缺鐵性貧血
  • HyperTG
  • Hyperbilirubinemia  高膽固醇血症
  • Uremia  尿毒症
  • High dose aspirin  大劑量阿斯匹靈
  • Falsely low  假低
  • Acute blood loss  急性失血
  • Hemolytic anemia  溶血性貧血
  • Variable  可變
  • Hemoglobinopathies/ variants
    血紅蛋白病/變異體
  • After blood transfusion  輸血後
  • Opiate/ alcohol  鴉片/酒精
Continuous glucose monitoring system (CGMS): continuous measurement of interstitial fluid glucose through a small tubule inserted through skin
連續葡萄糖監測系統 (CGMS):透過皮膚插入的小管連續測量組織間液葡萄糖。


Glucose Variability  葡萄糖變異性

21 April 2020-4 May 2020
1) % Time CGM is Active
2020 年 4 月 21 日至 2020 年 5 月 4 日 1) CGM 啟動時間百分比

14 Days  14 天
75%
(2)
Defined as percent confficient of variation (%.cy): target sse% 38.4 % 38.4 % quad38.4%\quad 38.4 \%
定義為變異係數百分比 (%.cy):目標 sse% 38.4 % 38.4 % quad38.4%\quad 38.4 \%

(3) AMBULATORY GLUCOSE PROFILE (AGP)
(3) 動態血糖測試 (agp)


5) DAILY GLUCOSE PROFILES
5) 每日血糖檔案


Ambulatory Glucose Profile (AGP)
動態血糖檢測 (AGP)

AGP is a summary of glucose values from the report period, with median (50%) and other percentiles shown as if they occurred in a single day.
AGP 是報告期間葡萄糖值的摘要,中位數 (50%) 和其他百分位數顯示為單日發生的葡萄糖值。

Daily Glucose Profiles  每日血糖譜

Each daily profile represents a midnight-to-midnight period.
每個每日輪廓代表一個午夜到午夜的時段。


  • Frequent/ suspected hypoglycemia
    經常/疑似低血糖
  • Wide variability within day
    日內變化大
  • Drug adjustment  藥物調整
  • Discrepancy between home monitoring & A1c
    家庭監測與 A1c 之間的差異
  • Empowerment & personal preference
    授權與個人偏好

DM complications  DM 併發症

  • Microvascular  微血管
  • Diabetic retinopathy  糖尿病視網膜病變
  • Diabetic nephropathy  糖尿病腎病
  • Diabetic neuropathy  糖尿病神經病變
  • Macrovascular  大血管
  • Cardiac diseases  心臟疾病
  • (ischemic heart, heart failure)
    (缺血性心臟、心力衰竭)
  • Peripheral vascular diseases
    周邊血管疾病
  • Strokes  中風
  • Others  其他
  • Hypoglycemia  低血糖症
  • Infection  感染
  • Periodontal disease  牙周病
  • Dementia  失智症

What are we managing?
我們在管理什麼?

USE OF GLUCOSE-LOWERING MEDICATIONS IN THE MANAGEMENT OF TYPE 2 DIABETES
使用降血糖藥物治療 2 型糖尿病

HEALTHY LIFESTYLE BEHAVIORS; DLABETES SELF-MAMAGEMENT EDUCATION AND SUPPORT (DSMES); SOCLAL DETERMIMANTS OF HEALTH (SDOH)
健康生活方式行為;糖尿病自我管理教育與支援 (DSME);健康的社會決定因素 (SDOH)


Coast Activevement and Meintenance of flycemic and Weipht Wenayement Goals
海岸活動及維護蒼蠅和鳥類的目標

Obesity  肥胖症

  • BMI >23 (overweight), > 25 (obesity), lower criteria comparing to western countries
    BMI >23(超重),>25(肥胖),與西方國家相比標準較低
  • Higher complications with the same BMI
    相同 BMI 的併發症較高

Figure 2: Age-adjusted and sex-adjusted BMI cutoffs in minority ethnic populations in England equivalent to a BMI cutoff of 30.0 kg / m 2 30.0 kg / m 2 30.0kg//m^(2)30.0 \mathrm{~kg} / \mathrm{m}^{2} in White populations in relation to type 2 diabetes incidence
圖 2:英格蘭少數族群中經年齡與性別調整的 BMI 臨界值,相當於白人族群中與 2 型糖尿病發病率相關的 30.0 kg / m 2 30.0 kg / m 2 30.0kg//m^(2)30.0 \mathrm{~kg} / \mathrm{m}^{2} BMI 臨界值。

The incidence of type 2 diabetes for a BMI of 30.0 kg / m 2 30.0 kg / m 2 30.0kg//m^(2)30.0 \mathrm{~kg} / \mathrm{m}^{2} in the White population can be read off the graph at the intersection of the grey horizontal line and the fitted line for the White population.
白種人口中 BMI 為 30.0 kg / m 2 30.0 kg / m 2 30.0kg//m^(2)30.0 \mathrm{~kg} / \mathrm{m}^{2} 的 2 型糖尿病發病率可從圖中灰色水平線與白種人口擬合線的交點讀出。


Metabolically healthy lean (MHL)
新陳代謝健康的瘦人 (MHL)

Metabolically healthy obesity (MHO)
代謝健康型肥胖 (MHO)

Metabolically unhealthy obesity (MUO)
新陳代謝不健康的肥胖 (MUO)

Obesity - Treatment  肥胖症 - 治療

Diet therapy  飲食治療
(Macronutrient/ Caloric restriction/ Intermittent fasting)
(宏量營養素/熱量限制/間歇性禁食)
Physical activity  體能活動
Behavior therapy  行為治療
Pharmacotherapy  藥物治療
Surgery  手術
Others  其他

Caloric restriction  熱量限制

>>

Macronutrient  宏量營養素

compositions  組合

Powerful medication  強效藥物

  • Sodium glucose co-transporter 2- inhibitor (SGLT2i)
    葡萄糖鈉共轉運體 2- 抑制劑 (SGLT2i)
  • Long acting GLP1 agonist (Semaglutide = Ozempic)
    長效 GLP1 促效劑 (Semaglutide = Ozempic)
  • GLP1A + GIP co-agonist (Tirzepatide = Mounjaro)
    GLP1A + GIP 協同劑 (Tirzepatide = Mounjaro)
The Science of Obesity Management: An Endocrine
肥胖管理的科學:內分泌學

Society Scientific Statement
協會科學聲明



Table 11. Weight Loss and Reversal of Diabetes Mellitus after Metabolic/Bariatric Surgery
表 11.代謝/減肥手術後的體重下降和糖尿病逆轉情況
Procedure  程序

過度減重 (%)
Excess Weight
Loss (%)
Excess Weight Loss (%)| Excess Weight | | :--- | | Loss (%) |

T2DM 解析度 (%)
Resolution of
T2DM (%)
Resolution of T2DM (%)| Resolution of | | :--- | | T2DM (%) |
Gastric banding  胃束帶 46.2 56.7
Gastroplasty  胃成形術 55.5 79.7
RYGB 59.7 80.3

膽胰轉流
Biliopancreatic
diversion
Biliopancreatic diversion| Biliopancreatic | | :--- | | diversion |
63.6 95.1
Procedure "Excess Weight Loss (%)" "Resolution of T2DM (%)" Gastric banding 46.2 56.7 Gastroplasty 55.5 79.7 RYGB 59.7 80.3 "Biliopancreatic diversion" 63.6 95.1| Procedure | Excess Weight <br> Loss (%) | Resolution of <br> T2DM (%) | | :--- | :--- | :--- | | Gastric banding | 46.2 | 56.7 | | Gastroplasty | 55.5 | 79.7 | | RYGB | 59.7 | 80.3 | | Biliopancreatic <br> diversion | 63.6 | 95.1 |

Osteoporosis  骨質疏鬆症

Table 5  表五
World Health Organization
世界衛生組織
Criteria for Classification of Osteopenia and Osteoporosis
骨質疏鬆症和骨質疏鬆症的分類標準
Category  類別 T-score
Normal  正常 -1.0 or above  -1.0或以上
Low bone mass (osteopenia) a ^("a "){ }^{\text {a }}
骨質密度低(骨質疏鬆症) a ^("a "){ }^{\text {a }}
Between -1.0 and -2.5
介於 -1.0 和 -2.5 之間
Osteoporosis  骨質疏鬆症 -2.5 or below  -2.5或以下
Severe or established osteoporosis
嚴重或已確診的骨質疏鬆症
-2.5 or below with fragility fracture
-2.5或以下,有脆性骨折

a 此類別中的骨折率差異很大。骨質疏鬆」類型對於流行病學研究和臨床研究很有用,但應用在個別病患身上就有問題,必須結合臨床資訊才能做出治療決定。
a Fracture rates within this category vary widely. The category of "osteopenia" is useful for
epidemiology studies and clinical research but is problematic when applied to individual patients and
must be combined with clinical information to make treatment decisions.
a Fracture rates within this category vary widely. The category of "osteopenia" is useful for epidemiology studies and clinical research but is problematic when applied to individual patients and must be combined with clinical information to make treatment decisions.| a Fracture rates within this category vary widely. The category of "osteopenia" is useful for | | :--- | | epidemiology studies and clinical research but is problematic when applied to individual patients and | | must be combined with clinical information to make treatment decisions. |
Table 5 World Health Organization Criteria for Classification of Osteopenia and Osteoporosis Category T-score Normal -1.0 or above Low bone mass (osteopenia) ^("a ") Between -1.0 and -2.5 Osteoporosis -2.5 or below Severe or established osteoporosis -2.5 or below with fragility fracture "a Fracture rates within this category vary widely. The category of "osteopenia" is useful for epidemiology studies and clinical research but is problematic when applied to individual patients and must be combined with clinical information to make treatment decisions." | Table 5 | | | :--- | :--- | | World Health Organization | Criteria for Classification of Osteopenia and Osteoporosis | | Category | T-score | | Normal | -1.0 or above | | Low bone mass (osteopenia) ${ }^{\text {a }}$ | Between -1.0 and -2.5 | | Osteoporosis | -2.5 or below | | Severe or established osteoporosis | -2.5 or below with fragility fracture | | a Fracture rates within this category vary widely. The category of "osteopenia" is useful for <br> epidemiology studies and clinical research but is problematic when applied to individual patients and <br> must be combined with clinical information to make treatment decisions. | |

表 6 2020 AACE 絕經後女性骨質疏鬆症診斷表
Table 6
2020 AACE Diagnosis of Osteoporosis in Postmenopausal women
Table 6 2020 AACE Diagnosis of Osteoporosis in Postmenopausal women| Table 6 | | :---: | | 2020 AACE Diagnosis of Osteoporosis in Postmenopausal women |
1. T-score -2.5 or below in the lumbar spine, femoral neck, total proximal femur, or 1 / 3 1 / 3 1//31 / 3 radius
腰椎、股骨頸、全股骨近端或 1 / 3 1 / 3 1//31 / 3 橈骨的 T 值 -2.5 或以下
2. Low-trauma spine or hip fracture (regardless of bone mineral density)
2.低創傷脊椎或髖部骨折(不論骨礦密度為何)
3. T-score between -1.0 and -2.5 and a fragility fracture of proximal humerus, pelvis, or distal forearm
T 值介於 -1.0 和 -2.5 之間,且肱骨近端、骨盆或前臂遠端的脆性骨折
4.

T-score 介於 -1.0 和 -2.5 之間,且 FRAX 高於特定國家的臨界值
T-score between -1.0 and -2.5 and high FRAX
on country-specific thresholds
T-score between -1.0 and -2.5 and high FRAX on country-specific thresholds| T-score between -1.0 and -2.5 and high FRAX | | :--- | | on country-specific thresholds |

縮寫:縮寫:AACE = = == 美國臨床內分泌學家協會;FRAXtrabecular bone score。
Abbreviations: AACE = = == American Association of Clinical Endocrinologists; FRAX
trabecular bone score.
Abbreviations: AACE = American Association of Clinical Endocrinologists; FRAX trabecular bone score.| Abbreviations: AACE $=$ American Association of Clinical Endocrinologists; FRAX | | :--- | | trabecular bone score. |
"Table 6 2020 AACE Diagnosis of Osteoporosis in Postmenopausal women" 1. T-score -2.5 or below in the lumbar spine, femoral neck, total proximal femur, or 1//3 radius 2. Low-trauma spine or hip fracture (regardless of bone mineral density) 3. T-score between -1.0 and -2.5 and a fragility fracture of proximal humerus, pelvis, or distal forearm 4. "T-score between -1.0 and -2.5 and high FRAX on country-specific thresholds" "Abbreviations: AACE = American Association of Clinical Endocrinologists; FRAX trabecular bone score." | | Table 6 <br> 2020 AACE Diagnosis of Osteoporosis in Postmenopausal women | | :--- | :--- | | 1. | T-score -2.5 or below in the lumbar spine, femoral neck, total proximal femur, or $1 / 3$ radius | | 2. Low-trauma spine or hip fracture (regardless of bone mineral density) | | | 3. | T-score between -1.0 and -2.5 and a fragility fracture of proximal humerus, pelvis, or distal forearm | | 4. | T-score between -1.0 and -2.5 and high FRAX <br> on country-specific thresholds | | Abbreviations: AACE $=$ American Association of Clinical Endocrinologists; FRAX <br> trabecular bone score. | |
Name:  名稱:
Patient ID:  病人 ID:
Ideatifier 2:  Ideatifier 2:
Postal Code:  郵遞區號:
Sex:  性: Fenale
Ethnicity:  種族: 163.4 cm  163.4 公分
Height:  高度: 52.9 kg  52.9 公斤
Weight:  重量: 29.10 .1966
DOB:  出生日期: 56
Age:  年齡 53
Menopanse Age:  Menopanse 年齡:
Referriag Physiciaa:  Referriag Physiciaa:
Name: Patient ID: Ideatifier 2: Postal Code: Sex: Fenale Ethnicity: 163.4 cm Height: 52.9 kg Weight: 29.10 .1966 DOB: 56 Age: 53 Menopanse Age: Referriag Physiciaa: | Name: | | | :--- | :--- | | Patient ID: | | | Ideatifier 2: | | | Postal Code: | | | Sex: | Fenale | | Ethnicity: | 163.4 cm | | Height: | 52.9 kg | | Weight: | 29.10 .1966 | | DOB: | 56 | | Age: | 53 | | Menopanse Age: | | | Referriag Physiciaa: | |

Results Suminary:  結果總和:
Region  地區 Area[cmi]  區域[cmi] BMC|(g)] BMD [ g / cm 2 ] g / cm 2 [g//cm^(2)]\left[\mathrm{g} / \mathrm{cm}^{2}\right] T-score PR (Peak Refereace)  PR (峰值參考) Z-score  Z 值 AM (Age Matched)  AM(年齡匹配)
L. 1  L.1 1252 881 0703 -26 71 -0.9 87
12 13.23 9.82 0.742 2.6 2.6 -2.6-2.6 72 -0.9 87
13 14.16 11.26 0.795 2.6 2.6 -2.6-2.6 73 -0.7 90
14 1536 10.64 0.693 -3.3 65 -16 77
Total  總計 55.27 40.52 0.733 -2.9 70 1.0 1.0 -1.0-1.0 85
Region Area[cmi] BMC|(g)] BMD [g//cm^(2)] T-score PR (Peak Refereace) Z-score AM (Age Matched) L. 1 1252 881 0703 -26 71 -0.9 87 12 13.23 9.82 0.742 -2.6 72 -0.9 87 13 14.16 11.26 0.795 -2.6 73 -0.7 90 14 1536 10.64 0.693 -3.3 65 -16 77 Total 55.27 40.52 0.733 -2.9 70 -1.0 85| Region | Area[cmi] | BMC\|(g)] | BMD $\left[\mathrm{g} / \mathrm{cm}^{2}\right]$ | T-score | PR (Peak Refereace) | Z-score | AM (Age Matched) | | :---: | :---: | :---: | :---: | :---: | :---: | :---: | :---: | | L. 1 | 1252 | 881 | 0703 | -26 | 71 | -0.9 | 87 | | 12 | 13.23 | 9.82 | 0.742 | $-2.6$ | 72 | -0.9 | 87 | | 13 | 14.16 | 11.26 | 0.795 | $-2.6$ | 73 | -0.7 | 90 | | 14 | 1536 | 10.64 | 0.693 | -3.3 | 65 | -16 | 77 | | Total | 55.27 | 40.52 | 0.733 | -2.9 | 70 | $-1.0$ | 85 |
Totel BMD CV 1.056, ACF = 1.033 , BCF = 1.009 . TH = 6.496 = 1.033 , BCF = 1.009 . TH = 6.496 =1.033,BCF=1.009.TH=6.496=1.033, \mathrm{BCF}=1.009 . \mathrm{TH}=6.496

Table 8  表八

Risk Factors Included in FRAX ® ®  ^("® "){ }^{\text {® }}
FRAX ® ®  ^("® "){ }^{\text {® }} 包含的風險因素

Country of residence  居住國家
Ethnicity (U.S. models only - white, black, Hispanic, and Asian)
種族(僅限美國機型 - 白人、黑人、西班牙裔和亞洲人)

Age (accepts ages between 40 and 90 years)
年齡(接受年齡介於 40 至 90 歲之間)

Sex  
Weight (kg) and height (cm) used to calculate body mass index; a converter from English to metric units is provided within the FRAX ® ®  ^("® "){ }^{\text {® }} tool
用於計算體重指數的體重(公斤)和身高(公分);FRAX ® ®  ^("® "){ }^{\text {® }} 工具內提供英制到公制單位的轉換器

Family history (either parent with a hip fracture)
家族史(父母任何一方曾髖關節骨折)

Personal history of fragility fracture, including radiographic vertebral fracture
個人有脆性骨折病史,包括放射診斷脊椎骨折

Glucocorticoid use (prednisolone 5 mg daily or more for 3 months or longer, current or past)
使用糖皮質類激素 (潑尼松龍每日 5 毫克或以上,持續 3 個月或以上,目前或過去)

Rheumatoid arthritis (confirmed diagnosis)
類風濕關節炎(確診)

Smoking (current)  吸煙(目前)
Alcohol use (2 or more units daily)
飲酒(每天 2 單位或以上)

Secondary osteoporosis a a ^(a){ }^{\mathrm{a}} (specifically mentioned are type 1 diabetes, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism or premature menopause, chronic malnutrition or malabsorption, and chronic liver disease)
繼發性骨質疏鬆症 a a ^(a){ }^{\mathrm{a}} (特別提到 1 型糖尿病、成人成骨不全症、長期未治療的甲狀腺功能亢進症、性腺功能減退或更年期過早、長期營養不良或吸收不良,以及慢性肝病)。

BMD. Femoral neck BMD should be entered. The model also works without BMD.
BMD。應輸入股骨頸 BMD。模型在沒有 BMD 的情況下也能運作。

Abbreviations: BMD = BMD = BMD=\mathrm{BMD}= bone mineral density; FRAX ® = FRAX ® = FRAX^(®)=\mathrm{FRAX}^{\circledR}= fracture risk assessment tool .
縮寫:縮寫: BMD = BMD = BMD=\mathrm{BMD}= 骨礦物密度; FRAX ® = FRAX ® = FRAX^(®)=\mathrm{FRAX}^{\circledR}= 骨折風險評估工具 。

a ^("a "){ }^{\text {a }} Because the effects of causes of secondary osteoporosis on fracture risk are assumed to be mediated through changes in BMD, a “yes” answer to this question does not change fracture risk if BMD is entered into the risk tool.
a ^("a "){ }^{\text {a }} 因為假設繼發性骨質疏鬆的原因對骨折風險的影響是透過 BMD 的改變來中介,所以如果將 BMD 輸入風險工具中,對這個問題的回答「是」並不會改變骨折風險。

Reproduced with permission from Watts NB, et al. J Bone Miner Res. 2009;24:975-979 (274).
J Bone Miner Res. 2009;24:975-979 (274)。

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計算工具

請回答下列問題以計算含有BMD的十年骨折機率  請回答下列問題以計算含有 Bmd 的十年骨折機率

6368 Individuals with fracture risk Individuals with fracture risk
6368 有骨折風險的個人 有骨折風險的個人

assessed since 1st June 2011
自 2011 年 6 月 1 日起接受評估
Table 12  表十二
Causes of Secondary Osteoporosis in Adults a ^("a "){ }^{\text {a }}
成人繼發性骨質疏鬆症的成因 a ^("a "){ }^{\text {a }}
Endocrine or metabolic causes
內分泌或代謝原因
Nutritional/ GI conditions
營養/ GI 狀況
Drugs  藥物 Disorders of collagen metabolism
膠原蛋白代謝紊亂
Other  其他

肢端肥大症 糖尿病 1 型 2 型 生長激素缺乏症 高皮質醇血症 甲状旁腺功能亢進症 甲狀腺功能亢進症 性腺功能減退症 低磷血症 卟啉症 懷孕
Acromegaly
Diabetes mellitus
Type 1
Type 2
Growth hormone deficiency
Hypercortisolism
Hyperparathyroidism
Hyperthyroidism
Hypogonadism
Hypophosphatasia
Porphyria
Pregnancy
Acromegaly Diabetes mellitus Type 1 Type 2 Growth hormone deficiency Hypercortisolism Hyperparathyroidism Hyperthyroidism Hypogonadism Hypophosphatasia Porphyria Pregnancy| Acromegaly | | :--- | | Diabetes mellitus | | Type 1 | | Type 2 | | Growth hormone deficiency | | Hypercortisolism | | Hyperparathyroidism | | Hyperthyroidism | | Hypogonadism | | Hypophosphatasia | | Porphyria | | Pregnancy |

酗酒 神經性厭食 鈣缺乏 慢性肝病 吸收不良綜合症/營養不良(包括乳糜瀉、囊腫纖維化、克隆氏病和胃切除或分流) 全靜脈外營養 維生素 D 缺乏症
Alcoholism
Anorexia nervosa Calcium deficiency Chronic liver disease Malabsorption syndromes/ malnutrition (including celiac disease, cystic fibrosis, Crohn disease, and gastric resection or bypass)
Total parenteral nutrition
Vitamin D deficiency
Alcoholism Anorexia nervosa Calcium deficiency Chronic liver disease Malabsorption syndromes/ malnutrition (including celiac disease, cystic fibrosis, Crohn disease, and gastric resection or bypass) Total parenteral nutrition Vitamin D deficiency| Alcoholism | | :--- | | Anorexia nervosa Calcium deficiency Chronic liver disease Malabsorption syndromes/ malnutrition (including celiac disease, cystic fibrosis, Crohn disease, and gastric resection or bypass) | | Total parenteral nutrition | | Vitamin D deficiency |

抗癲癇藥 b ^("b "){ }^{\text {b }} 芳香化酶抑制劑 化療/免疫抑制剂 甲羟孕酮醋酸酯 糖皮质激素 促性腺激素釋放激素製劑 肝素 鋰 質子泵抑制劑 選擇性血清素再吸收抑制劑 SGLT2 抑制劑 噻唑烷二酮类 甲状腺激素(超生理剂量)
Anti-epileptic drugs b ^("b "){ }^{\text {b }}
Aromatase inhibitors
Chemotherapy/
immunosuppressants
Medroxyprogesterone acetate
Glucocorticoids
Gonadotropin-releasing
hormone agents
Heparin
Lithium
Proton pump inhibitors
Selective serotonin- reuptake inhibitors
SGLT2-inhibitors
Thiazolidinediones
Thyroid hormone (in supraphysiologic doses)
Anti-epileptic drugs ^("b ") Aromatase inhibitors Chemotherapy/ immunosuppressants Medroxyprogesterone acetate Glucocorticoids Gonadotropin-releasing hormone agents Heparin Lithium Proton pump inhibitors Selective serotonin- reuptake inhibitors SGLT2-inhibitors Thiazolidinediones Thyroid hormone (in supraphysiologic doses)| Anti-epileptic drugs ${ }^{\text {b }}$ | | :--- | | Aromatase inhibitors | | Chemotherapy/ | | immunosuppressants | | Medroxyprogesterone acetate | | Glucocorticoids | | Gonadotropin-releasing | | hormone agents | | Heparin | | Lithium | | Proton pump inhibitors | | Selective serotonin- reuptake inhibitors | | SGLT2-inhibitors | | Thiazolidinediones | | Thyroid hormone (in supraphysiologic doses) |

Ehlers-Danlos 綜合症 胱硫醚缺乏引起的高胱氨酸尿症 馬凡綜合症 成骨不全症
Ehlers-Danlos syndrome
Homocystinuria due to cystathionine deficiency
Marfan syndrome Osteogenesis imperfecta
Ehlers-Danlos syndrome Homocystinuria due to cystathionine deficiency Marfan syndrome Osteogenesis imperfecta| Ehlers-Danlos syndrome | | :--- | | Homocystinuria due to cystathionine deficiency | | Marfan syndrome Osteogenesis imperfecta |

AIDS/HIV 強直性脊椎炎 慢性阻塞性肺病 戈謝病 血友病 高鈣尿症 不動症 重度抑鬱 骨髓瘤和某些癌症 器官移植 腎功能不全/衰竭 腎小管酸中毒 類風濕關節炎 系統性肥大細胞病 地中海貧血
AIDS/HIV
Ankylosing spondylitis Chronic obstructive pulmonary disease Gaucher disease Hemophilia
Hypercalciuria
Immobilization
Major depression
Myeloma and some cancers
Organ transplantation Renal insufficiency/ failure
Renal tubular acidosis Rheumatoid arthritis Systemic mastocytosis Thalassemia
AIDS/HIV Ankylosing spondylitis Chronic obstructive pulmonary disease Gaucher disease Hemophilia Hypercalciuria Immobilization Major depression Myeloma and some cancers Organ transplantation Renal insufficiency/ failure Renal tubular acidosis Rheumatoid arthritis Systemic mastocytosis Thalassemia| AIDS/HIV | | :--- | | Ankylosing spondylitis Chronic obstructive pulmonary disease Gaucher disease Hemophilia | | Hypercalciuria | | Immobilization | | Major depression | | Myeloma and some cancers | | Organ transplantation Renal insufficiency/ failure | | Renal tubular acidosis Rheumatoid arthritis Systemic mastocytosis Thalassemia |
AIDS = acquired immunodeficiency syndrome; GI = GI = GI=\mathrm{GI}= gastrointestinal; HIV = human immunodeficiency virus; SCL
AIDS = 獲得性免疫缺陷綜合症; GI = GI = GI=\mathrm{GI}= 胃腸道;HIV = 人類免疫缺陷病毒;SCL

glucose cotransporter 2 .
葡萄糖共轉移因子 2 .

ant meant to be a complete list.
螞蟻的意思是完整的清單。

bPhenobarbital, phenytoin, primidone, valproate, and carbamazepine have been associated with low bone mass.
b 苯巴比妥、苯妥英、primidone、丙戊酸钠和卡马西平与低骨量有关。
Endocrine or metabolic causes Nutritional/ GI conditions Drugs Disorders of collagen metabolism Other "Acromegaly Diabetes mellitus Type 1 Type 2 Growth hormone deficiency Hypercortisolism Hyperparathyroidism Hyperthyroidism Hypogonadism Hypophosphatasia Porphyria Pregnancy" "Alcoholism Anorexia nervosa Calcium deficiency Chronic liver disease Malabsorption syndromes/ malnutrition (including celiac disease, cystic fibrosis, Crohn disease, and gastric resection or bypass) Total parenteral nutrition Vitamin D deficiency" "Anti-epileptic drugs ^("b ") Aromatase inhibitors Chemotherapy/ immunosuppressants Medroxyprogesterone acetate Glucocorticoids Gonadotropin-releasing hormone agents Heparin Lithium Proton pump inhibitors Selective serotonin- reuptake inhibitors SGLT2-inhibitors Thiazolidinediones Thyroid hormone (in supraphysiologic doses)" "Ehlers-Danlos syndrome Homocystinuria due to cystathionine deficiency Marfan syndrome Osteogenesis imperfecta" "AIDS/HIV Ankylosing spondylitis Chronic obstructive pulmonary disease Gaucher disease Hemophilia Hypercalciuria Immobilization Major depression Myeloma and some cancers Organ transplantation Renal insufficiency/ failure Renal tubular acidosis Rheumatoid arthritis Systemic mastocytosis Thalassemia" AIDS = acquired immunodeficiency syndrome; GI= gastrointestinal; HIV = human immunodeficiency virus; SCLglucose cotransporter 2 .ant meant to be a complete list.bPhenobarbital, phenytoin, primidone, valproate, and carbamazepine have been associated with low bone mass. | Endocrine or metabolic causes | Nutritional/ GI conditions | Drugs | Disorders of collagen metabolism | Other | | :---: | :---: | :---: | :---: | :---: | | Acromegaly <br> Diabetes mellitus <br> Type 1 <br> Type 2 <br> Growth hormone deficiency <br> Hypercortisolism <br> Hyperparathyroidism <br> Hyperthyroidism <br> Hypogonadism <br> Hypophosphatasia <br> Porphyria <br> Pregnancy | Alcoholism <br> Anorexia nervosa Calcium deficiency Chronic liver disease Malabsorption syndromes/ malnutrition (including celiac disease, cystic fibrosis, Crohn disease, and gastric resection or bypass) <br> Total parenteral nutrition <br> Vitamin D deficiency | Anti-epileptic drugs ${ }^{\text {b }}$ <br> Aromatase inhibitors <br> Chemotherapy/ <br> immunosuppressants <br> Medroxyprogesterone acetate <br> Glucocorticoids <br> Gonadotropin-releasing <br> hormone agents <br> Heparin <br> Lithium <br> Proton pump inhibitors <br> Selective serotonin- reuptake inhibitors <br> SGLT2-inhibitors <br> Thiazolidinediones <br> Thyroid hormone (in supraphysiologic doses) | Ehlers-Danlos syndrome <br> Homocystinuria due to cystathionine deficiency <br> Marfan syndrome Osteogenesis imperfecta | AIDS/HIV <br> Ankylosing spondylitis Chronic obstructive pulmonary disease Gaucher disease Hemophilia <br> Hypercalciuria <br> Immobilization <br> Major depression <br> Myeloma and some cancers <br> Organ transplantation Renal insufficiency/ failure <br> Renal tubular acidosis Rheumatoid arthritis Systemic mastocytosis Thalassemia | | AIDS = acquired immunodeficiency syndrome; $\mathrm{GI}=$ gastrointestinal; HIV = human immunodeficiency virus; SCLglucose cotransporter 2 .ant meant to be a complete list.bPhenobarbital, phenytoin, primidone, valproate, and carbamazepine have been associated with low bone mass. | | | | |
Drug Name  藥物名稱 Brand Name  品牌名稱 Drug Class  藥物類別 Form/Dosing  形式/劑量
Alendronate  阿仑膦酸钠 Fosamax  福善美 Bisphosphonate  雙磷酸鹽 Oral (daily, weekly)  口服(每日、每週)
lbandronate Boniva Bisphosphonate  雙磷酸鹽 Oral or injection (daily, monthly)
口服或注射(每日、每月)
Risedronate  利塞膦酸鈉 Actonel/Atelvia Bisphosphonate  雙磷酸鹽 Women and Men  女性與男性
Zoledronic acid  唑來膦酸 Reclast Bisphosphonate  雙磷酸鹽 Women  婦女
Raloxifene  雷洛昔芬 Evista SERM IV (yearly/once every 2 years)
靜脈注射(每年/每兩年一次)
Abaloparatide  阿巴帕肽 Tymlos Parathyroid hormone analog
甲狀旁腺激素類似物
Wom and Men  女性與男性
Teriparatide  特立帕肽 Forteo Parathyroid hormone analog
甲狀旁腺激素類似物
Injection daily for 2 years
每日注射,連續 2 年
Denosumab Prolia RANKL inhibitor  RANKL 抑制劑 Injection daily for 2 years
每日注射,連續 2 年
Romosozumab Evenity  平均性 Sclerostin Inhibitor  硬骨蛋白抑制劑 Women  婦女
Drug Name Brand Name Drug Class Form/Dosing Alendronate Fosamax Bisphosphonate Oral (daily, weekly) lbandronate Boniva Bisphosphonate Oral or injection (daily, monthly) Risedronate Actonel/Atelvia Bisphosphonate Women and Men Zoledronic acid Reclast Bisphosphonate Women Raloxifene Evista SERM IV (yearly/once every 2 years) Abaloparatide Tymlos Parathyroid hormone analog Wom and Men Teriparatide Forteo Parathyroid hormone analog Injection daily for 2 years Denosumab Prolia RANKL inhibitor Injection daily for 2 years Romosozumab Evenity Sclerostin Inhibitor Women| Drug Name | Brand Name | Drug Class | Form/Dosing | | :--- | :--- | :--- | :--- | | Alendronate | Fosamax | Bisphosphonate | Oral (daily, weekly) | | lbandronate | Boniva | Bisphosphonate | Oral or injection (daily, monthly) | | Risedronate | Actonel/Atelvia | Bisphosphonate | Women and Men | | Zoledronic acid | Reclast | Bisphosphonate | Women | | Raloxifene | Evista | SERM | IV (yearly/once every 2 years) | | Abaloparatide | Tymlos | Parathyroid hormone analog | Wom and Men | | Teriparatide | Forteo | Parathyroid hormone analog | Injection daily for 2 years | | Denosumab | Prolia | RANKL inhibitor | Injection daily for 2 years | | Romosozumab | Evenity | Sclerostin Inhibitor | Women |
  • Anti-resorptive: bisphosphonate, SERM, RANKL inhibitor
    抗還原劑:雙磷酸鹽、SERM、RANKL 抑制劑
  • Bone-forming: Parathyroid hormone analog, Sclerostin inhibitor
    成骨:甲狀旁腺激素類似物、硬骨素抑制劑
  • Others:  其他:
  • Calcium and vitamin D
    鈣和維生素 D
  • Hormonal replacement for post-menopause patient
    更年期後病人的荷爾蒙替代品

Complications of anti-resorptive drugs
抗還原藥物的併發症

  • Osteonecrosis of jaw ONJ
    顎骨壞死 ONJ
  • Atypical femoral fracture AFF
    非典型股骨骨折 AFF
  • Both bisphosphonate (Alendronate etc) and RANK-L inhibitor (Denosumab or Prolia)
    雙磷酸鹽(Alendronate 等)和 RANK-L 抑制劑(Denosumab 或 Prolia)。

Polycystic ovary syndrome: Summary
多囊卵巢症候群:摘要

  • Diagnostic triad: Hyperandrogenism + irregular menses /ovulation dysfunction + Polycystic ovaries
    診斷三要素:高雄激素 + 月經不規律 / 排卵功能障礙 + 多囊卵巢
  • Pathogenesis: Hyperandrogenism & insulin resistance
    發病機制:高雄激素和胰島素抵抗
  • Clinical: Endocrine; reproductive & obstetric; metabolic & psychological complications
    臨床:內分泌;生殖與產科;代謝與心理併發症
  • Treatment: Focused on hyper-androgen symptoms (hirsutism + irregular menses), fertility and related metabolic & psychological complications
    治療:著重於高雄激素症狀 (多毛症 + 經期不規則)、生育能力及相關的代謝與心理併發症