Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update

Abstract

Background: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older.

Methods: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework.

Recommendations: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized.

Interpretation: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life.

Figure 1:

Integrated approach to the management of bone health and fracture prevention in postmenopausal females and males aged 50 years and older. See Appendix 1, Supplementary Tables 1–6 (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221647/tab-related-content) for more information on exercise and nutrition, secondary causes of osteoporosis and vertebral fracture assessment. Note: BMD = bone mineral density. ^*Consider lateral spine imaging to identify vertebral fracture(s). Finding of undiagnosed vertebral fracture(s) can guide appropriate choice and duration of therapy (Appendix 1, Supplementary Table 6). †Fractures that occur after the age of 40 years, in the setting of low trauma. Fractures of the hands, feet and craniofacial bones are not considered osteoporotic fractures. ‡Conditions known to cause secondary osteoporosis (Appendix 1, Supplementary able 5); consider referral to specialists with expertise for co-management. §Should be reassessed earlier if patient develops secondary causes (Appendix 1, Supplementary Table 5), new fracture or other risk factor for rapid bone loss.

Figure 2:

Approach to pharmacotherapy to prevent fractures. Note: Rec. = recommendation (see Tables 4, 6 and 7 for full recommendations). ^* Menopausal hormone therapy is a suggested alternative for females younger than 60 years or within 10 years after menopause who prioritize alleviation of substantial menopausal symptoms (Rec. 4.4). †Antiresorptive therapy includes bisphosphonates (alendronate, risedronate and zoledronic acid), denosumab, raloxifene and menopausal hormone therapy. ‡Raloxifene is suggested rather than no treatment for females who have contraindications or substantial intolerance to, or who choose not to take, other suggested therapies) (Rec. 4.7). §See Figure 1 for list of risk factors and Appendix 1, Supplementary Table 5, for causes of secondary osteoporosis.