2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada

Abstract

Objective: To revise and expand the 1996 Osteoporosis Society of Canada clinical practice guidelines for the management of osteoporosis, incorporating recent advances in diagnosis, prevention and management of osteoporosis, and to identify and assess the evidence supporting the recommendations.

Options: All aspects of osteoporosis care and its fracture complications - including classification, diagnosis, management and methods for screening, as well as prevention and reducing fracture risk - were reviewed, revised as required and expressed as a set of recommendations.

Outcomes: Strategies for identifying and evaluating those at high risk; the use of bone mineral density and biochemical markers in diagnosis and assessing response to management; recommendations regarding nutrition and physical activity; and the selection of pharmacologic therapy for the prevention and management of osteoporosis in men and women and for osteoporosis resulting from glucocorticoid treatment.

Evidence: All recommendations were developed using a justifiable and reproducible process involving an explicit method for the evaluation and citation of supporting evidence.

Values: All recommendations were reviewed by members of the Scientific Advisory Council of the Osteoporosis Society of Canada, an expert steering committee and others, including family physicians, dietitians, therapists and representatives of various medical specialties involved in osteoporosis care (geriatric medicine, rheumatology, endocrinology, obstetrics and gynecology, nephrology, radiology) as well as methodologists from across Canada.

Benefits, harm and costs: Earlier diagnosis and prevention of fractures should decrease the medical, social and economic burdens of this disease.

Recommendations: This document outlines detailed recommendations pertaining to all aspects of osteoporosis. Strategies for identifying those at increased risk (i.e., those with at least one major or 2 minor risk factors) and screening with central dual-energy x-ray absorptiometry at age 65 years are recommended. Bisphosphonates and raloxifene are first-line therapies in the prevention and treatment of postmenopausal osteoporosis. Estrogen and progestin/progesterone is a first-line therapy in the prevention and a second-line therapy in the treatment of postmenopausal osteoporosis. Nasal calcitonin is a second-line therapy in the treatment of postmenopausal osteoporosis. Although not yet approved for use in Canada, hPTH(1-34) is expected to be a first-line treatment for postmenopausal women with severe osteoporosis. Ipriflavone, vitamin K and fluoride are not recommended. Bisphosphonates are the first-line therapy for the prevention and treatment of osteoporosis in patients requiring prolonged glucocorticoid therapy and for men with osteoporosis. Nasal or parenteral calcitonin is a first-line treatment for pain associated with acute vertebral fractures. Impact-type exercise and age-appropriate calcium and vitamin D intake are recommended for the prevention of osteoporosis.

Validation: All recommendations were graded according to the strength of the evidence; where the evidence was insufficient and recommendations were based on consensus opinion alone, this is indicated. These guidelines are viewed as a work in progress and will be updated periodically in response to advances in this field.

Fig. 1: Who should be tested for osteoporosis? (Note: *4 cm historical height loss; 2 cm prospective height loss [Grade D]. †Low to moderate: 2.5–7.5 mg prednisone/day; moderate to high: > 7.5 mg prednisone/day. ‡See Fig. 2. ¶Central DXA = spine and hip. **As defined by the World Health Organization.)

Fig. 2: Who should undergo a fracture risk assessment and be treated for osteoporosis? (Note: *≥7.5 mg prednisone for more than 3 months. †See Table 3. ‡We have arbitrarily chosen T-score below –1.5; non-traumatic vertebral compression deformities [Grade A]¹¹⁷; personal history of fragility fracture after age 40 [Grade D]; clinical risk factors [Grade D].)

Fig. 3: Optimal treatment for osteoporosis in postmenopausal women. (Note: *Mainly vertebral fracture. Only alendronate and risedronate and recently continuous estrogen-progesterone have been shown to decrease hip fracture risk.)