Summary for the Diagnosis and Management of Osteoporosis

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1 Summary for the Diagnosis and Management of Osteoporosis Summary of the 2002 Canadian Guidelines for the Diagnosis and Management of Osteoporosis For complete guidelinerefer to CMAJ NOV, 12, 2002:167(10 Suppl)

2 BMD measurement is NOT RECOMMENDED as a screening procedure for women under age 65 or as part of a routine evaluation around menopause. Who Should Be Assessed for Osteoporosis? All people 65 years SHOULD have BMD testing All postmenopausal women as well as men over 50 years of age should be assessed for risk factors for osteoporosis BMD measurement should only be performed when: - Results are likely to alter patient care, and - Patients have at least one major or two minor risk factors for osteoporosis (see table 1)

3 Major Risk Factors Vertebral compresson fracture Family history of osteoporotic fracture Systemic glucocorticoid therapy > 3 months duration Malabsorption syndrome Primary perparathyroidism Propensity to fall Osteopenia apparent on x-ray Hypogonadism Early menopause (before age 45) Minor Risk Factors Rheumatoid arthritis Past history of hyperthyroidism Chronic anticonvulsant therapy Low dietary calcium intake Smoker Excessive alcohol intake Excessive caffeine intake Weight <57 kg Weight loss >10% of weight at age 25 Chronic heparin therapy Note: Risk factors are additive and should not be considered independently of one another. Postmenopausal women and men over age 50 with at least 1 major or 2 minor risk factors should undergo testing for BMD Irrespective of BMD results, lifestyle modification should be recommended (adequate calcium and vitamin D, avoidance of smoking and rapid weight loss, participation in regular weight-bearing exercise, falls avoidance).

4 Who Should Not be Tested for Osteoporosis? Premenopausal women, and men under age 50 without fractures or secondary causes of osteoporosis, such as high dose glucocorticoid therapy or hypogonadism not treatable by hormone replacement. - Even if they have several risk factors other than secondary causes of osteoporosis, such patients are unlikely to fracture over a 5-10 year period. However, they should decrease modifiable risk factors and take appropriate amounts of Vitamin D and calcium. The need for drug therapy can be re-assessed after menopause or age 50. Men and women less than 65 years old who have no risk factors for osteoporotic fractures. Inappropriate indications for BMD measurement Chronic back pain (aiming to rule out vertebral fractures)

5 Kyphosis (best investigated using lateral thoracic spine x-rays to rule out anterior compression fractures) Menopause, in the absence of risk factors Who is at high risk for fracture Low BMD Prior fragility fracture after age 40 Family history of osteoporosis Age There are two situations where patients can be assumed to have osteoporosis and BMD is not required to make the diagnosis; however, it may be useful to monitor the effects of treatment: Low-trauma fractures (due to an injury that would be insufficient to fracture normal bone). Loss of 2 cm of height in one year or 5 cm over a lifetime (not resulting from other causes).

6 Note: With a prior fragility fracture after age 40, the risk of fracture increases by 1.5 to 9.5 times, depending on age at assessment and number and site of previous fractures. Who should undergo fracture risk assessment and be treated for osteoporosis? Patients who: Are on long term glucocorticoids Have had a fragility fracture after age 40 Have non-traumatic vertebral compression deformities Have 1 major or 2 minor risk factors A low BMD by DXA (T-score at or below 2.5)

7 Prevention Bisphosphonates (alendronate, etidronate, risedronate, zoledronic acid) are a first-line preventive therapy in postmenopausal women with low bone density and for prevention of glucocorticoid induced osteoporosis. Raloxifene is a first line therapy in the prevention of further bone loss in postmenopausal women with low bone density. Hormone Replacement Therapy (HRT) is the first line preventive therapy for menopause before age 45 [treat until average age of menopause (51 years)]; and can be considered first line for postmenopausal women with low bone density and estrogen deficiency symptoms [treat 4-5 years]. Change modifiable risk factors, daily calcium and vitamin D3 as below:

8 Age Group Calcium (daily) Children 4 to 8 years 800 mg Adolescents 9 to 18 years 1300 mg Vitamin D3 (daily) Women (including pregnant or lactating women) and men ages 19 to mg 400 IU Women and men >50 years 1500 mg IU

9 What is the best treatment for osteoporosis in postmenopausal women? Without fragility fracture With vasomotor symptoms: 1st choice: HRT 2nd choice: risedronate, alendronate, raloxifene, zoledronic acid Without vasomotor symptoms: 1st choice: risedronate, alendronate, raloxifene 2nd choice: calcitonin, etidronate, HRT With fragility fracture 1st choice: risedronate, alendronate, raloxifene 2nd choice: calcitonin, etidronate, HRT What is the best treatment for other cases of osteoporosis? Bisphosphonates (risedronate, alendronate, etidronate, zoledronic acid ) for treatment of glucocorticoid induced osteoporosis

10 Bisphosphonates (alendronate, risedronate, zoledronic acid, etidronate) are a 1st-line treatment for men with low bone mass or osteoporosis Nasal calcitonin can be considered for use in men and non-pregnant, premenopausal women with osteoporosis. It is a 1st-line treatment for pain associated with acute vertebral fractures * Zoledronic acid, 5 mg intravenously on an annual basis, has been approved in Canada for the treatment of postmenopausal osteoporosis. (SOGC. Menopause and Osteoporosis Update, 2009) What therapies are not recommended Ipriflavone, vitamin K, and fluoride should not be used for the prevention or treatment of osteoporosis. No evidence exists to recommend additional intakes of the following nutrients for the

11 prevention of osteoporosis: magnesium, copper, zinc, phosphorus, manganese, iron, or essential fatty acids. Follow-up BMD measurements using DXA Not required more frequently than q2years, except in patients: - On 7.5 mg prednisone/day (or equivalent) x 3 months who require baseline and q6month DXA while on treatment - With existing fractures or very low bone density where early DXA is indicated NOTE: BMD measurement is generally performed using dual energy x-ray absorptiometry (acronym is DXA or DEXA).

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