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CLINICIAN'S GUIDE TO PREVENTION AND TREATMENT OF OSTEOPOROSIS (National Osteoporosis Foundation Guidelines)
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--attached is the full pdf document
Download the PDF : NATIONAL OSTEOPOROSIS FOUNDATION
NATIONAL OSTEOPOROSIS FOUNDATION
http://www.nof.org
Since the NOF first published the guide in 1999, it has become increasingly clear that many patients are not being given appropriate information about prevention; many patients are not having appropriate testing to diagnose osteoporosis or establish osteoporosis risk; and, once diagnosed (by testing or by the occurrence of a fracture), too many patients are not being prescribed any of the FDA-approved, effective therapies.
Risk Assessment
All postmenopausal women and older men should be evaluated clinically for osteoporosis risk in order to determine the need for BMD testing. In general, the more risk factors that are present, the greater the risk of fracture. Osteoporosis is preventable and treatable, but because there are no warning signs prior to a fracture, many people are not being diagnosed in time to receive effective therapy during the early phase of the disease.
Hip fractures result in 10% to 20% excess mortality within one year; additionally, about 10% of patients with a hip fracture will have another osteoporosis-related fracture within a year. Up to 25% of hip fracture patients may require long-term nursing home care, and only 40% fully regain their pre-fracture level of independence. Mortality is also increased following vertebral fractures, which cause significant complications including back pain, height loss and kyphosis. Postural changes associated with kyphosis may limit activity, including bending and reaching. Multiple thoracic fractures may result in restrictive lung disease, and lumbar fractures may alter abdominal anatomy, leading to constipation,
abdominal pain, distention, reduced appetite, and premature satiety. Wrist fractures are less globally disabling but can interfere with specific activities of daily living as much as hip or spine fractures.
Metabolic bone diseases other than osteoporosis, such as hyperparathyroidism or osteomalacia, may be associated with a low BMD. Many of these diseases have very specific therapies, and it is appropriate to complete a history and physical examination before making a diagnosis of osteoporosis on the basis of a low BMD alone. In patients in whom a specific secondary, treatable cause of osteoporosis is being considered (Table 1), relevant blood and urine studies (such as serum and urine calcium, serum thyrotropin, protein electrophoresis,
cortisol or antibodies associated with gluten-sensitive enteropathy) should be obtained prior to initiating therapy. For instance, elderly patients with recent fractures should be evaluated for secondary etiologies and, when considering osteomalacia or vitamin D insufficiency, a serum 25(OH)D level should be obtained. In general, biochemical testing (such as serum calcium, creatinine, etc.) should be considered in patients with documented osteoporosis prior to initiation of treatment.
Defining Osteoporosis by BMD
BMD testing is a vital component in the diagnosis and management of osteoporosis. BMD has been shown to correlate with bone strength and is an excellent predictor of future fracture risk. Instead of a specific threshold, fracture risk increases exponentially as BMD decreases.
Normal:
BMD is within 1 SD of a "young normal" adult (T-score at -1.0 and above)
Low bone mass ("osteopenia" ):
BMD is between 1.0 and 2.5 SD below that of a "young normal" adult (T-score between -1.0 and -2.5).
Osteoporosis:
BMD is 2.5 SD or more below that of a "young normal" adult (T-score at or below -2.5).
Patients in this group who have already experienced one or more fractures are deemed to have
severe or "established" osteoporosis.
Clinical Assessment of Osteoporosis in Postmenopausal Women and Men Age 50 and Older
-- Obtain a detailed patient history pertaining to clinical risk factors for osteoporosis-related fracture
-- Modify diet/supplements and other clinical risk factors for fracture
-- Estimate patient's 10-year probability of hip and any major
osteoporosis-related fracture using the
US-adapted WHO algorithm
-- Decisions on whom to treat and how to treat should be based on clinical judgment using this guide and all available clinical information
-- Consider FDA-approved medical therapies based on the following:
- A vertebral or hip fracture
- A DXA hip (femoral neck or total site) or spine T score ≦ -2.5
- Low bone mass and a U.S.-adapted WHO 10-yr probability of a hip fracture ≥ 3% or probability
of any major osteoporosis-related fracture ≥ 20%
- Patient preferences may indicate treatment for people with 10-yr fracture probabilities below
these levels
-- Consider non-medical therapeutic interventions
- Modify risk factors related to falling
- Consider physical and occupational therapy including walking aids and hip pad protectors
- Weight-bearing activities daily
-- Patients not requiring medical therapies at the time of initial evaluation should be clinically reevaluated
when medically appropriate
-- Patients taking FDA-approved medications should have laboratory and bone density re-evaluation after two years or when medically appropriate
Synopsis of Major Recommendations to the Clinician
For postmenopausal women and men age 50 and older:
1. Counsel on the risk of osteoporosis and related fractures.
2. Check for secondary causes.
3. Advise on adequate amounts of calcium (at least 1200 mg/d, including supplements if necessary) and vitamin D (800 to 1000 IU per day of vitamin D3 for individuals at risk of insufficiency).
4. Recommend regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.
5. Advise avoidance of tobacco smoking and excessive alcohol intake.
6. In women age 65 and older and men age 70 and older, recommend BMD testing.
7. In postmenopausal women and men age 50-70, recommend BMD testing when you have concern based on their risk factor profile.
8. Recommend BMD testing to those who have suffered a fracture, to determine degree of disease severity.
9. Initiate treatment in those with hip or vertebral (clinical or morphometric) fractures.
10. Initiate therapy in those with BMD T-scores < -2.5 at the femoral neck, total hip, or spine by DXA, after appropriate evaluation.
11. Initiate treatment in postmenopausal women and in men age 50 and older with low bone mass (T-score -1 to -2.5, osteopenia) at the femoral neck, total hip, or spine and 10-year hip fracture probability ≥3% or a 10-yr all major osteoporosis-related fracture probability of ≥ 20% based on the US-adapted WHO absolute fracture risk model.
12.Current FDA-approved pharmacologic options for osteoporosis prevention and/or treatment are bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate), calcitonin, estrogens and/or hormone therapy, raloxifene and parathyroid hormone (PTH
1-34).
13.BMD testing performed in DXA centers using accepted quality assurance measures is appropriate for monitoring bone loss (recommendation every 2 years). For patients on pharmacotherapy, it is typically performed two years after initiating therapy and at 2-year intervals thereafter.
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