Medikamentöse Therapie des primären Knochenmarködemsyndroms

ZUSAMMENFASSUNG

Die medikamentöse Therapie des primären Knochenmarködemsyndroms (KMÖS) stellt einen wesentlichen Bestandteil des Gesamttherapiekonzeptes des KMÖS dar, wobei eine frühe Detektion und eine zeitnahe Initiierung von therapeutischen Maßnahmen von entscheidender Bedeutung ist. Zunächst gilt es, neben dem Ausschluss von sekundären Ursachen, mögliche Störungen der Kalziumhomöostase zu untersuchen und ggf. auszugleichen, da von einem maßgeblichen Einfluss dieser Faktoren in der Pathogenese des primären KMÖS ausgegangen wird. So stellen Mangelzustände, wie ein Vitamin-D-Mangel, eine häufige Ursache einer solchen Störung der Kalziumhomöostase dar und können konsekutiv zu einer enteralen Kalziumaufnahmestörung sowie zu einer Mineralisationsstörung des Knochens führen. Da ein KMÖS häufig mit einem systemischen respektive lokalen High-Turnover-Knochenstoffwechsel einhergeht, ist die Steuerung des Knochenstoffwechsels im Rahmen der Therapie besonders wichtig. Im Falle eines High-Turnover-Knochenstoffwechsels oder anderer klinischer Faktoren, wie einer gelenknahen subchondralen Lokalisation des Knochenmarködems mit Risiko einer Infraktion, einer schnellen Progredienz, einem großen Volumen oder ausgeprägten, immobilisierenden Schmerzen, kann eine antiresorptive Therapie im Off-Label-Verfahren in die Behandlung integriert werden. So konnte für den Einsatz von intravenösen Bisphosphonaten, wie Ibandronat oder Zoledronat, als auch des subkutan zu injizierenden Denosumab eine klinisch relevante Effektivität festgestellt werden, wobei bei Letzterem der schnellste Wirkeintritt zu erwarten ist. Zoledronat scheint, allerdings auf Kosten einer höheren Anzahl potenziell unerwünschter Ereignisse, das effektivste Wirkprofil zu besitzen. Einen alternativen Therapieansatz stellt der Off-Label-Einsatz des Prostazyklin-Analogons Iloprost dar, welches gemäß der Studienlage eine probate Therapieoption in frühen Stadien des Knochenmarködems darstellt, allerdings unter stationärer Überwachung zu applizieren ist. Parallel zur medikamentösen Therapie ist die chirurgische Mitbehandlung mit regelmäßiger Evaluation zur Anbohrung (Core Decompression) als Teil des Gesamttherapiekonzeptes zu eruieren.

SUMMARY

Drug treatment of primary bone marrow edema syndrome (BMES) represents an essential part of the therapy concept of BMES. An early detection and initiation of therapeutic intervention are of crucial importance. After the exclusion of secondary causes, possible disturbances of calcium homeostasis need to be investigated and, if necessary, balanced, as these factors likely have a decisive influence on the pathogenesis of primary BMES. Deficiencies, such as that of vitamin D, are a frequent cause of a disturbed calcium homeostasis and can potentially lead to impaired enteric calcium absorption and hypomineralization of the bone. Since BMES is often associated with systemic or local high-turnover bone metabolism, optimization of bone metabolism is of pivotal importance. In the case of high-turnover bone metabolism or clinical indications, such as a subchondral localization close to the joint with risk of secondary collapse, rapid progression, large volume, or pronounced immobilizing pain, off-label antiresorptive therapy can be integrated into the treatment. Intravenous bisphosphonates, such as ibandronate or zoledronate, as well as the monoclonal RANKL-antibody denosumab, have shown good efficacy and safety, with the latter being expected to have the most rapid onset of action. Zoledronate appears to have the most effective profile, but at the cost of a higher number of potential adverse events. An alternative therapeutic approach is the off-label use of the prostacyclin analogue iloprost, which, according to the literature, is an effective treatment option in early stages of BMES but must be administered under inpatient monitoring. Parallel to drug treatment, surgical co-treatment (e. g., core decompression) with regular evaluation need to be integrated into an optimized therapy concept.

Schlüsselwörter

Knochenmarködem - Mineralisationsstörung - Vitamin D - antiresorptive Therapie

Keywords

Bone marrow edema syndrome (BMES) - mineralization defect - vitamin D - antiresorptive treatment

Publication History

Article published online:
19 August 2021

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