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General Background
- The guidelines were developed under the auspices of the Scientific
Advisory Council of Osteoporosis Canada.
- 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.
- The objective was to revise and expand the "1996 Osteoporosis Society of
Canada Clinical [now Osteoporosis Canada] 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.
- All recommendations were developed using a justifiable and reproducible
process involving an explicit method for the evaluation and citation of supporting evidence.
- All recommendations were reviewed by members of the Scientific Advisory
Council of Osteoporosis Canada, an expert Steering Committee, and others including family physicians,
dietitians, therapists and representatives of various medical specialties involved in osteoporosis from
across Canada.
- 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
- 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).
- 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.
- 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
- Osteoporosis Canada recommends that all men and women over the age of 50
talk to their physician about their risk factors for osteoporosis.
- 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).
- 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.
- 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.
- Major risk factors, in combination with low BMD, increase one's risk of
fracture. Individuals with a high risk of fracture should receive treatment.
- Individuals over 50 with at least one major risk factor or two minor
risk factors should have a BMD test.
- Everyone over the age of 65 should have a BMD test.
- 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.
- 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.
- 2002 guidelines recommend a higher intake of daily calcium and vitamin
D, particularly in adults over the age of 50. The following calcium (mg./day) intake levels are
recommended:
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
- The following daily vitamin D (IU/day) intake levels are
recommended:
women and men (ages 19-50) - 400
women and men (ages > 50) - 800
pregnant or lactating women (ages ( 18) - 400
- Maintain adequate protein intake
- Avoid excess caffeine
- Limit intake of salty foods
- Limit alcohol intake
- No evidence exists to suggest that the additional intakes of the
following nutrients are necessary for the prevention and treatment of osteoporosis:
magnesium
copper
zinc
phosphorus
manganese
iron
essential fatty acids
Physical Activity
Recommendations
- Children, particularly those entering and passing through puberty,
should be encouraged to participate in impact exercises or sports (mainly field and court
sports).
- 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.
- 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
- For prevention, impact-type exercise, and appropriate calcium and
vitamin D intake are recommended.
- 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.
- Bisphosphonates are the first-line therapy for prevention and treatment
of osteoporosis in patients requiring prolonged glucocorticoid therapy and for men with
osteoporosis.
- Estrogen and progestin/progesterone therapy is a first-line choice in
prevention and a second-line therapy in treatment of postmenopausal osteoporosis.
- Nasal calcitonin is a second-line therapy in the treatment of
postmenopausal osteoporosis.
- Nasal or parenteral calcitonin is a first-line treatment choice for pain
associated with acute vertebral fractures.
- Although not yet approved for use in Canada, it is anticipated that
parathyroid hormone (PTH) will become a first-line treatment for postmenopausal women with severe
osteoporosis.
- 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.
For more information on the new standards on BMD
testing, please see document entitled "Standards for Bone Mineral Density Testing." A printed copy of the
2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada can be obtained
by contacting Osteoporosis Canada or visit the OC web site at www.osteoporosis.ca
November, 2002
Julie
Foley
President & CEO
416-696-2663, ext. 236
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