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2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada Scientific Advisory Council Osteoporosis Society of Canada.

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Presentation on theme: "2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada Scientific Advisory Council Osteoporosis Society of Canada."— Presentation transcript:

1 2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada Scientific Advisory Council Osteoporosis Society of Canada Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

2 Definitions: Osteoporosis 1993 consensus conference “A systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue with a resultant increase in fragility and risk of fracture.” 1“A systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue with a resultant increase in fragility and risk of fracture.” NIH (US) modifications “A skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength reflects the integration of two main features; bone density and bone quality.” 2“A skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength reflects the integration of two main features; bone density and bone quality.” 2 1. Consensus development conference. Am J Med 1993;94: NIH Consensus Development Panel. JAMA 2001;285: Guidelines

3 Osteoporotic bone with trabecular thinning and perforation Dempster D. J Bone Miner Res 1986;1: Osteoporosis 2002 Guidelines Normal trabecular bone

4 Using Risk Factors in the Assessment of Osteoporosis Section Two

5 Factors Predicting Osteoporotic (Fragility) Fractures Key Risk FactorsKey Risk Factors 1. Low bone mineral density (BMD) 2. Prior fragility fracture (after age 40) 3. Age 4. Family history of osteoporotic fracture

6 Risk Factors: Mary Jones — History/Physical 51-year-old female; last menstrual period 7 months ago51-year-old female; last menstrual period 7 months ago Requests a bone density because a friend had one; friend has osteopeniaRequests a bone density because a friend had one; friend has osteopenia No fractures; no family history of fractures or osteoporosisNo fractures; no family history of fractures or osteoporosis No estrogen deficiency symptoms; physical exam is normalNo estrogen deficiency symptoms; physical exam is normal

7 Risk Factors Mary Jones Question A Should she have a bone density because she has entered menopause?Should she have a bone density because she has entered menopause? Answer NoNo

8 Risk Factors Mary Jones Question B If she smokes 15 cigarettes per day, has done so since age 22, but no other risk factors for osteoporosis can be identified, would these facts change your answer to question A?If she smokes 15 cigarettes per day, has done so since age 22, but no other risk factors for osteoporosis can be identified, would these facts change your answer to question A? Answer No No

9 Risk Factors Mary Jones Question C A year later, she develops an acute arthritis which is diagnosed as rheumatoid arthritis. Does this change your answer to question A?A year later, she develops an acute arthritis which is diagnosed as rheumatoid arthritis. Does this change your answer to question A? Answer Yes Yes

10 Factors identifying those who should be assessedFactors identifying those who should be assessed –Age ≥65 years –Vertebral compression fracture –Fragility fracture after age 40 –Family history of osteoporotic fracture (especially maternal hip fracture) –Systemic glucocorticoid therapy >3 months –Malabsorption syndrome –Primary hyperparathyroidism –Propensity to fall –X-ray appearance of osteopenia –Hypogonadism –Early menopause (before age 45) Major Risk Factors Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

11 Factors identifying those who should be assessedFactors identifying those who should be assessed –Rheumatoid arthritis –Past history of clinical hyperthyroidism –Chronic anticonvulsant therapy –Weight <57 kg –Weight loss >10% of weight at age 25 –Smoker –Excess alcohol intake –Excess caffeine intake –Low dietary calcium intake –Chronic heparin therapy Minor Risk Factors Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

12 Risk Factors: Summary BMD measurement should be performed on all postmenopausal women and men >50 years with 1 major OR 2 minor risk factors Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

13 BMD, Age, and Fracture Risk Hui et al. J Clin Invest 1988;81: Bone mass (g/cm) > < <45 Age (years) Fracture risk per 1,000 person - years

14 Risk Factors 1. Low BMD (cont’d) Age is a major risk factor for both fracture and reduced bone densityAge is a major risk factor for both fracture and reduced bone density Low BMD is a major risk factor for fractureLow BMD is a major risk factor for fracture Therefore, there must be an age at which it is appropriate to obtain a BMDTherefore, there must be an age at which it is appropriate to obtain a BMD

15 Risk Factors The OSC Position BMD testing is appropriateBMD testing is appropriate –in targeted case finding for postmenopausal women 50 years of age –for all men and women ≥65 years of age Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

16 SHOULD have BMD testing Taking > 2.5 mg prednisone/d > 3 mo irrespective of ageTaking > 2.5 mg prednisone/d > 3 mo irrespective of age With 1 major or 2 minor risk factors:With 1 major or 2 minor risk factors: - postmenopausal women - postmenopausal women - men over age 50 - men over age 50 - all persons > 65 years old - all persons > 65 years old Persons with fragility or vertebral fracturesPersons with fragility or vertebral fractures

17 CONSIDER for BMD testing: Chronic conditions or on drugs predisposing to osteoporosisChronic conditions or on drugs predisposing to osteoporosis Factors influencing this decision:Factors influencing this decision: - age - age - severity and duration of illness - severity and duration of illness - other risk factor for osteoporosis and fracture - other risk factor for osteoporosis and fracture

18 DO NOT require BMD testing: Pre-menopausal women and men < age 50 years EVEN IF they have several risk factors other than those causing secondary osteoporosisPre-menopausal women and men < age 50 years EVEN IF they have several risk factors other than those causing secondary osteoporosis - low short-term fracture risk - low short-term fracture risk - should decrease modifiable risk factors - should decrease modifiable risk factors - reassess need for anti-resorptive at menopause or age 50 (men) - reassess need for anti-resorptive at menopause or age 50 (men) Men and women < age 65 years who have NO risk factors for osteoporotic fracturesMen and women < age 65 years who have NO risk factors for osteoporotic fractures

19 Risk Factors 2. Prior fragility fracture (after age 40): Mariah Wind — History/Physical Mrs Mariah Wind is 61 years oldMrs Mariah Wind is 61 years old She experiences severe mid-back pain when reaching into back seat of carShe experiences severe mid-back pain when reaching into back seat of car She visits the emergency roomShe visits the emergency room

20 Risk Factors Mariah Wind — History /Physical Spine x-ray shows evidence of an acute compression fracture of L2Spine x-ray shows evidence of an acute compression fracture of L2 Minor anterior wedging noted at T10 and T12Minor anterior wedging noted at T10 and T12 Sent home with 2 ASA tablets; told to call in the morningSent home with 2 ASA tablets; told to call in the morning

21 Risk Factors Mariah Wind — Investigations Physical exam and laboratory tests all normal (except for pain and tenderness related to the spine fracture)Physical exam and laboratory tests all normal (except for pain and tenderness related to the spine fracture) Suggested laboratory testsSuggested laboratory tests –Complete blood count (CBC) –Serum calcium –Total alkaline phosphatase –Serum creatinine –Serum protein electrophoresis

22 Risk Factors Mariah Wind Question B Does she need a bone density before making a treatment decision?Does she need a bone density before making a treatment decision? Answer No. But if available, BMD may be useful to monitor therapyNo. But if available, BMD may be useful to monitor therapy

23 Risk Factors 4. Family history of osteoporotic fracture: Hannah Lee — History/Physical 35-year-old female comes to your office with a bone density T-score of year-old female comes to your office with a bone density T-score of Obtained the BMD because her 67-year- old mother recently had a hip fracture and was diagnosed with osteoporosisObtained the BMD because her 67-year- old mother recently had a hip fracture and was diagnosed with osteoporosis Has no other risk factors for osteoporosisHas no other risk factors for osteoporosis

24 Risk Factors Hannah Lee Question A Should she have a spine x-ray?Should she have a spine x-ray? Answer NoNo

25 Risk Factors Hannah Lee Question B Should she have had a bone density exam?Should she have had a bone density exam? Answer NoNo

26 Risk Factors Hannah Lee Question C Now that we have her BMD score, should she be treated with a bisphosphonate?Now that we have her BMD score, should she be treated with a bisphosphonate? Answer NoNo

27 Risk Factors Hannah Lee Question D What do you recommend for her management?What do you recommend for her management? Answer Rule out secondary causes of bone lossRule out secondary causes of bone loss Lifestyle interventions — exercise, limit alcohol, smoking cessationLifestyle interventions — exercise, limit alcohol, smoking cessation Diet — increase calcium and vitamin D intakeDiet — increase calcium and vitamin D intake Reassess at menopause or before if fragility fracture occursReassess at menopause or before if fragility fracture occurs

28 Who Should Be Tested for Osteoporosis? Long-term moderate- to high-dose glucocorticoids Spine x-rays Age History of radiographically confirmed low trauma fracture History of radiographically confirmed low trauma fracture Height loss Kyphosis Height loss Kyphosis YESNOYESNO Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

29 Who Should Be Tested for Osteoporosis? (cont’d) Long-term moderate- to high-dose glucocorticoids Measure BMD if available Spine x-rays Age History of radiographically confirmed low trauma fracture History of radiographically confirmed low trauma fracture Height loss Kyphosis Height loss Kyphosis YESNOYESNO Evaluate for treatment Repeat BMD to evaluate Rx response (at 1 to 2 years) Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

30 Who Should Be Tested for Osteoporosis? (cont’d) Long-term moderate- to high-dose glucocorticoids Measure BMD if available Spine x-rays Age History of radiographically confirmed low trauma fracture History of radiographically confirmed low trauma fracture Height loss Kyphosis Height loss Kyphosis Clinical and risk factor evaluation YESNOYESNOAge <65Age ≥65 Evaluate for treatment 1 major or 2 minor risk factors Repeat BMD to evaluate Rx response (at 1 to 2 years) YESNO Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

31 Who Should Be Tested for Osteoporosis? (cont’d) Long-term moderate- to high-dose glucocorticoids Measure BMD if available Spine x-rays Age History of radiographically confirmed low trauma fracture History of radiographically confirmed low trauma fracture Height loss Kyphosis Height loss Kyphosis Clinical and risk factor evaluation YESNOYESNOAge <65Age ≥65 Evaluate for treatment 1 major or 2 minor risk factors Repeat BMD to evaluate Rx response (at 1 to 2 years) Stop Reassess at age 65 YESNO Measure BMD by central DXA WHO osteoporosis WHO osteopenia WHO normal Consider repeat BMD testing at 2–3 years to monitor changing risk Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

32 Risk Factors Summary Statements Four key factors - low BMD, prior fragility fracture (after age 40), age, family history of osteoporosis - predict osteoporosis-related fracture [Level 1]Four key factors - low BMD, prior fragility fracture (after age 40), age, family history of osteoporosis - predict osteoporosis-related fracture [Level 1] Low BMD is a major risk factor, but those with a vertebral or other osteoporotic fracture should be considered to have osteoporosis even without low BMD [Level 1]Low BMD is a major risk factor, but those with a vertebral or other osteoporotic fracture should be considered to have osteoporosis even without low BMD [Level 1] Systemic glucocorticoid therapy >3 months is a major risk factor for osteoporosis and fracture even at low doses [Level 2]Systemic glucocorticoid therapy >3 months is a major risk factor for osteoporosis and fracture even at low doses [Level 2] Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

33 Diagnosis Section Three

34 Diagnosis Dorothy Bass — History/Physical A 75-year-old woman fell and fractured her left wrist. She had not been aware of back pain but had developed some progressive kyphosis. She was surprised to discover that she had lost 3 inches in height!A 75-year-old woman fell and fractured her left wrist. She had not been aware of back pain but had developed some progressive kyphosis. She was surprised to discover that she had lost 3 inches in height!Questions Does this patient have osteoporosis?Does this patient have osteoporosis? Should this patient have a thoraco-lumbar x-ray?Should this patient have a thoraco-lumbar x-ray?

35 Diagnosis Dorothy Bass (cont’d) Answer Based on clinical findings of wrist fracture, presumed multiple wedge compression fractures with kyphosis and loss of height, this woman has osteoporosisBased on clinical findings of wrist fracture, presumed multiple wedge compression fractures with kyphosis and loss of height, this woman has osteoporosis

36 Diagnosis Dorothy Bass (cont’d) An x-ray of her thoracic spine shows multiple wedge compression fracturesAn x-ray of her thoracic spine shows multiple wedge compression fracturesQuestions Should you order bone densitometry?Should you order bone densitometry? Why?Why?

37 Diagnosis Dorothy Bass (cont’d) Answer YesYes This woman has severe osteoporosis until proved otherwise. Dual-energy x-ray absorptiometry (DXA) is indicated as baselineThis woman has severe osteoporosis until proved otherwise. Dual-energy x-ray absorptiometry (DXA) is indicated as baseline – Proximal femur for evaluation – Spine for follow-up

38 Diagnosis Hilda Orwell — History/Physical A 39-year-old woman presents with kyphosis but no history of back painA 39-year-old woman presents with kyphosis but no history of back pain She questions a diagnosis of osteoporosisShe questions a diagnosis of osteoporosisQuestion Should she have DXA?Should she have DXA?

39 Diagnosis Hilda Orwell (cont’d) Answer This woman does not need DXA as a first strategy, but a spine radiograph to explore the kyphosisThis woman does not need DXA as a first strategy, but a spine radiograph to explore the kyphosis –If it were done it would be inappropriate to report T-scores without comment as the patient is not menopausal –If radiographs indicate that the kyphosis is due to fractures which are low trauma then DXA is indicated (differential diagnosis: Scheuermann's disease, congenital anomalies — eg, hemi-vertebra) –Any inference made should not relate to postmenopausal osteoporosis (PMO) since any lack of mineralization may relate to a failure to reach peak BMD, or secondary causes

40 Laboratory Tests To exclude secondary causes 1To exclude secondary causes 1 –Complete blood count (CBC) –Serum calcium –Total alkaline phosphatase –Serum creatinine –Serum protein electrophoresis 1. Osteoporosis Society of Canada. Can Med Assoc J 1996;155:

41 Who Should Be Treated for Osteoporosis? Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34. Long-term glucocorticoid therapy Start bisphosphonate therapy Start bisphosphonate therapy Obtain DXA BMD for follow-up Personal history of fragility fracture after age 40 Low DXA BMD (T-score ≤−2.5) Clinical risk factors (1 major or 2 minor) Non-traumatic vertebral compression deformities AND Low DXA BMD (T-score <−1.5) AND Low DXA BMD (T-score <−1.5) Consider therapy Consider therapy Repeat DXA BMD after 1 or 2 years

42 Prevention and Treatment Pharmacological Therapies Section Four

43 What is the Optimal Treatment? (cont’d) Osteoporosis in postmenopausal women Non-pharmacological treatment calcium: 1500 mg/dvitamin D: 800 IU/d Physical activity for 30+ min, 3 times/wk Non-pharmacological treatment calcium: 1500 mg/dvitamin D: 800 IU/d Physical activity for 30+ min, 3 times/wk Without fragility fracture* YES With fragility fracture* Vasomotor symptoms alendronate, risedronate and raloxifene calcitonin, etidronate, HRT alendronate, risedronate and raloxifene calcitonin, etidronate, HRT HRT alendronate, etidronate, risedronate, calcitonin NO Ist choice Ist choice 2nd choice 2nd choice * Mainly vertebral fracture Note: Only alendronate, risedronate and recently continuous estrogen/ progesterone have been shown to decrease hip fracture risk. Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

44 Prevention and Treatment Alternative Therapies Section Five

45 Nutrition Recommendations Grade A Maintain adequate daily calcium and vitamin D intake* Maintain adequate daily calcium and vitamin D intake* Grade B Maintain adequate daily calcium intake* Maintain adequate daily calcium intake* Avoid excess caffeine (>4 cups coffee/day) Avoid excess caffeine (>4 cups coffee/day) Grade C Maintain adequate daily calcium intake*Maintain adequate daily calcium intake* Avoid excess dietary sodium (>2100 mg/day or >90 mmol/day)Avoid excess dietary sodium (>2100 mg/day or >90 mmol/day) Maintain adequate protein intakeMaintain adequate protein intake Grade D Maintain adequate daily vitamin D intake*Maintain adequate daily vitamin D intake* No evidence for magnesium; copper; zinc; phosphorus; manganese; iron; essential fatty acidsNo evidence for magnesium; copper; zinc; phosphorus; manganese; iron; essential fatty acids *Grades vary with age Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

46 Physical Activity — Impact Exercise Summary Statements (cont’d) Level 3 Children who exercise have better bonesChildren who exercise have better bones Both impact exercise and non-impact exercise prevent bone loss of the lumbar spine in premenopausal womenBoth impact exercise and non-impact exercise prevent bone loss of the lumbar spine in premenopausal women Level 4 Impact exercises are more efficacious at all ages than strength, endurance or non-weight bearing activitiesImpact exercises are more efficacious at all ages than strength, endurance or non-weight bearing activities Impact exercise in men is associated with higher BMDImpact exercise in men is associated with higher BMD Both impact exercise and non-impact exercise prevent bone loss of the lumbar spine in premenopausal womenBoth impact exercise and non-impact exercise prevent bone loss of the lumbar spine in premenopausal women Excessive physical activity can be detrimentalExcessive physical activity can be detrimental Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

47 P hysical Activity — Falls Prevention Summary Statement Individually tailored programs of muscle strengthening, balance training, and walking are effective in reducing falls [Level 1+] and injuries [Level 2+]Individually tailored programs of muscle strengthening, balance training, and walking are effective in reducing falls [Level 1+] and injuries [Level 2+] Multifactorial programs are effective in reducing falls in both un-selected individuals and those with a history of falling or with known risk factors for falls [Level 1+]Multifactorial programs are effective in reducing falls in both un-selected individuals and those with a history of falling or with known risk factors for falls [Level 1+] Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.

48 P hysical Activity — Fracture Prevention Summary Statement A higher level of activity throughout middle life is associated with a reduced risk of hip fracture in old age [Consensus]A higher level of activity throughout middle life is associated with a reduced risk of hip fracture in old age [Consensus] Brown JP, Josse RG. CMAJ 2002;167(10 suppl):S1-S34.


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