Canada leads the way with first evidence-based guidelines for osteoporosis

Osteoporosis Canada has launched the first evidence-based clinical practice guidelines for osteoporosis in the world.  The guidelines were published in the November 12th issue of the Canadian Medical Association Journal (CMAJ) and are intended to provide Canadian physicians with the information they need to effectively diagnose and treat this debilitating disease. Osteoporosis Canada updated the "1996 Clinical Practice Guidelines for the Management of Osteoporosis" using an evidence-based approach consisting of the retrieval of 89,804 abstracts and the review, evaluation and grading of 6,941 full citations according to the strengths of the evidence.

"With the publication of these guidelines, Osteoporosis Canada will continue to advocate for improved patient care in Canada and to work with provincial and federal governments to ensure the 2002 recommendations are adhered to and utilized when formulating and implementing new health policies on osteoporosis," says Joyce Gordon, President and CEO, Osteoporosis Canada.   This in turn minimizes injury and disability, enhances quality of life for patients, and reduces health care costs to society," adds Gordon.

Osteoporosis affects 1.4 million Canadian men and women and the cost of treating this disease and the fractures it causes was estimated to be $1.3 billion in Canada alone.1  The public health and clinical importance of osteoporosis lies in the fractures that occur.  Conservative estimates have suggested that a 50-year-old Caucasian woman has a remaining lifetime fragility fracture risk of 40 per cent (for hip, vertebra or wrist).2  In addition, osteoporosis can drastically alter one's quality of life, often taking away an individual's ability to do the simplest tasks such as climbing stairs or going for a walk.

Key Recommendations

The 2002 guidelines focus on the prevention, diagnosis, and treatment of osteoporosis with recommendations on bone mineral density (BMD) testing, fracture risks, nutrition, physical activity, and available treatment options. 

Diagnosis

• Osteoporosis Canada recommends that all postmenopausal women and men 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.
• Four major risk factors for fracture include low bone mineral density (BMD), fragility fracture after age 40, age, and family history of osteoporosis.
  BMD testing should follow standards and minimum levels of acceptable performance as stated in the new standards document from the Canadian Panel of the International Society for Clinical Densitometry.
• Standards recommend that osteoporosis can be diagnosed with a DXA bone densitometer at assessments of the hip, spine, and forearm only.
  Everyone over the age of 65 should have a BMD test.
• Individuals over the age of 50 with at least one major risk factor or two minor risk factors, should have a BMD test.
• Bone density testing is also recommended for postmenopausal individuals with risk factors for fracture.
• The bone density result has to be considered along with other risk factors for fracture.
  Combination of clinical evaluation and BMD testing out-performs any other method of risk-assessment with age, BMD and prevalent fracture(s) being the best risk indicators.
  Using techniques such as ultrasound or other bone density machines at different locations such as the hand or heel are not yet approved and the diagnosis of osteoporosis cannot be made using these technologies.

Prevention and Treatment

• Higher intakes of calcium and vitamin D are recommended, particularly in adults over 50 (calcium 1500 mg/day and vitamin D 800 IU/day).
• Children, particularly those entering and passing through puberty, should participate in impact exercise or sports (mainly field and court sports).
• Men and women throughout life should participate in exercise, particularly weight-bearing exercises such as brisk walking, running or dancing.
• Bisphosphonates (Didrocal, Fosamax and Actonel) and raloxifene (Evista) are first choice therapies for individuals without menopausal (vasomotor) symptoms.  Hormone Replacement Therapy (HRT) is no longer the "gold standard" for treatment of osteoporosis. 

Alternative treatments such as ipriflavone and vitamin K are not recommended for the treatment of postmenopausal women with osteoporosis.  In addition, these therapies are not recommended in men or premenopausal women.  However, ipriflavone may be considered as a second-line preventive therapy in postmenopausal women.

"There have been many scientific advances in osteoporosis research in recent years, but this knowledge has not been successfully transferred into current clinical practice.  As a result, many high-risk patients still remain undiagnosed and untreated," says Dr. Jacques Brown, Chair, Scientific Advisory Council for Osteoporosis Canada and Head of the Division of Rheumatology, Le Centre hospitalier universitaire de Québec.

Osteoporosis Canada also enabled the development of the first international standards for bone density testing.  These standards establish the minimum level of quality necessary for BMD testing and reporting, and were developed by the Canadian Panel of the International Society of Clinical Densitometry.

While osteoporotic fractures are an important cause of morbidity, disability and mortality, they are preventable.  There are important steps that individuals can take and various treatment options available to help reduce the risk of developing osteoporosis.  By making lifestyle changes such as maintaining a balanced diet rich in calcium and vitamin D, getting enough physical activity, especially weight-bearing exercise, and quitting smoking, individuals can significantly enhance their bone health.

"I was only 40 when I was diagnosed with osteoporosis.  I had fallen from a ladder and x-rays confirmed that I had the disease.  I was completely taken aback.  How could I have osteoporosis at such a young age?" says Anne Allin, an active information volunteer for Osteoporosis Canada national office.

To maintain her busy lifestyle, Anne had to modify her behaviour and learn to be more cautious about the way she carried out her daily routine - less rushing, climbing and lifting, and careful bending and stretching became the norm.  "However, with the help of drug treatment and by maximizing my calcium and vitamin D intake, I have had no further fractures and my bone density has actually improved.  I encourage everyone to educate themselves about osteoporosis, and to talk to their doctors about the preventative measures they can take to help reduce their risk of developing this disease," Anne adds.

November marks Osteoporosis Month and Osteoporosis Canada's 20th anniversary.  Osteoporosis Canada is the preeminent source of credible information on osteoporosis in Canada.  Osteoporosis Canada is dedicated to working with volunteers, chapters, and support groups across the country to educate, empower, and support individuals and communities in the prevention and treatment of osteoporosis. To improve the process of care, Osteoporosis Canada also works with physicians and other health care professionals to improve their knowledge of osteoporosis, its diagnosis, and treatment.  Osteoporosis Canada offers a 1-800 service for the public, as well as a wide variety of resource materials and educational programs.  For more information in English call 1-800-463-6842 and for information in French call 1-800-977-1778.

References

1. Osteoporosis Canada Web Site (www.osteoporosis.ca).
2. Brown, JP, Josse, RG et. al.  2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada.  2002:5.