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November 12, 2002
2002 Clinical Practice
Guidelines for the Diagnosis and Management of Osteoporosis in
Canada.
HIGHLIGHTS SUMMARY
General
Background
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The guidelines were developed
under the auspices of the Scientific Advisory Council of the Osteoporosis
Society of Canada.
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These are the first
evidence-based guidelines for the diagnosis, prevention and management of
osteoporosis in the world, and a total of 89,804 abstracts were retrieved;
from these 6,941 full citations were obtained for
review.
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The objective was 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 the disease, and to identify and
assess the evidence.
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All recommendations were
developed using a justifiable and reproducible process involving an explicit
method for the evaluation and citation of supporting
evidence.
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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 from across Canada.
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All recommendations were graded
according to the strengths of the evidence; where the evidence was
insufficient and recommendations were based on consensus alone, this is
documented. These guidelines will
be a work in progress and will be updated periodically to accommodate advances
in this field.
Prevalence of
Osteoporosis
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The public health and clinical
importance of osteoporosis lie in the fractures that occur. Estimates suggest that a 50-year-old
Caucasian woman has a remaining lifetime fragility fracture risk of 40 per
cent (for hip, vertebra or wrist).
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The one-in-six lifetime risk of
getting a hip fracture is greater than the one-in-nine risk of developing
breast cancer, and the death rate is higher.
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50 per cent of women who suffer a
hip fracture need to depend on others for daily activities and do not have the
same quality of life. About 20
per cent require long-term care.
Diagnosis
Recommendations
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The Osteoporosis Society of
Canada recommends that all men and women over the age of 50 talk to their
physician about their risk factors for
osteoporosis.
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Major
risk factors that identify
people who should be assessed for osteoporosis, include age greater than 65
years, vertebral compression fracture, fragility fracture after age 40, family
history of osteoporotic fracture (especially maternal hip fracture), systemic
glucocorticoid therapy of greater than 3 months, malabsorption syndrome,
primary hyperparathyroidism, propensity to fall, osteopenia apparent on x-ray
film, hypogonadism and early menopause (before age
45).
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Minor
risk factors that identify people who
should be assessed for osteoporosis, include rheumatoid arthritis, past history
of clinical hyperthyroidism, chronic anticonvulsant therapy, low dietary calcium
intake, smoker, excessive alcohol intake, excessive caffeine intake, weight
less than 57 kg (125 lbs.), weight loss > 10 % of weight at
age 25 and chronic heparin therapy.
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The more major risk factors one
has, the more likely he/she is to fracture. Four major
risk factors for fracture
include low bone mineral density (BMD), fragility fracture after the age of
40, age, and family history of osteoporosis.
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Major risk factors, in
combination with low BMD, increase one's risk of fracture. Individuals with a high risk of
fracture should receive treatment.
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Individuals over 50 with at least
one major risk factor or two minor risk factors should have a BMD
test.
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Everyone over the age of 65
should have a BMD test.
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There is evidence that the use of
a combination of clinical evaluation and BMD assessment out-performs any
single method of risk-assessment with age, BMD and prevalent fracture(s) being
the best risk indicators.
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The decision whether an
individual should have a BMD test should be discussed with a physician and
should be based on age-related risk and the presence of other risk factors for
fracture.
Dietary
Recommendations
Though there is no cure for
osteoporosis, there are treatments available and steps individuals can take to
help reduce their risk of developing the disease.
prepubertal children
(ages 4-8) - 800
adolescents (ages
9-18) - 1300
women and men (ages 19-50) - 1000
women and men (ages >
50) - 1500
pregnant or lactating
women (ages ( 18) - 1000
women and men (ages 19-50) -
400
women and men (ages > 50) - 800
pregnant or lactating women (ages (
18) - 400
magnesium
copper
zinc
phosphorus
manganese
iron
essential fatty
acids
Physical Activity
Recommendations
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Both men and women throughout
life should be encouraged to participate in exercise, particularly in
weight-bearing exercises including walking, running or dancing or sports such
as tennis, bowling or soccer.
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For older men and women at risk
of falling, or who have fallen, tailored programs based on individual
assessment, containing exercises to improve strength and balance, and where
necessary, multidisciplinary in nature, should be made
available.
Treatment
Recommendations
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Bisphosphonates (Didrocal,
Fosamax and Actonel) and raloxifene (Evista) are first choice therapies for
the prevention and treatment of osteoporosis in individuals without menopausal
(vasomotor) symptoms. HRT is no
longer the "gold standard" for treatment.
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Bisphosphonates are the
first-line therapy for prevention and treatment of osteoporosis in patients
requiring prolonged glucocorticoid therapy and for men with
osteoporosis.
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Ipriflavone, vitamin K and
fluoride are not recommended for the treatment of postmenopausal women with
osteoporosis. In addition, these
therapies are not recommended for use in men and premenopausal women. However, ipriflavone may be considered
as a second-line preventive therapy in postmenopausal
women.
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