Summary for the Diagnosis and Management of
Osteoporosis
Summary of the 2002 Canadian Guidelines for the Diagnosis and Management of Osteoporosis
Who Should be Assessed for Osteoporosis?
• All people ≥ 65 years SHOULD have BMD testing
• All postmenopausal women as well as men over 50 years of age should be assessed for risk factors for osteoporosis
• BMD measurements should only be performed when: results are likely to alter patient care; and patients have at
least one major or two minor risk factors for osteoporosis
Table 1: Risk Factors
Risk factors
• Vertebral compresson fracture
• Fragility fracture after age 40
• Family history of osteoporotic fracture
• Systemic glucocorticoid therapy > 3 months duration
• Malabsorption syndrome
• Primary hyperparathyroidism
• Propensity to fall
• Osteopenia apparent on x-ray
• Hypogonadism
• Early menopause (before age 45)
Minor risk factors
• Rheumatoid arthritis
• Past history of hyperthyroidism
• Chronic anticonvulsant therapy
• Low dietary calcium intake • Smoker • Excessive alcohol intake • Excessive caffeine intake • Weight <57 kg • Weight loss >10% of weight at age 25
• Chronic heparin therapy.
Who Should be Tested for Osteoporosis?
Note:Risk factors are additive and should not be considered independently of one another. Postmenopausal women and men over
age 50 with at least 1 major or 2 minor risk factors should undergo testing for BMD
Height loss1- Kyphosis
Spine radiography
Long term moderate to high
Yes
dose
glucocorticoids?2
No
No
History of low trauma fracture
confirmed by radiography?
Age
≥ 65
< 65
Yes
Measure BMD if available
Clinical and risk factor evaluation
Evaluate for treatment
1 major or 2 minor risk factors
Yes
Repeat BMD to evaluate
response to treatment
(at 1 - 2 years)
No
Stop (re-assess at age 65)
Measure BMD by central DXA3
Normal4
Osteopenia4
Osteoporosis4
Consider repeat BMD testing at 2-3
years to monitor changing risk
Notes
1. 4cm historical height loss; 2 cm prospective height loss.
2. Low to moderate: 2.5 - 7.5 mg prednisone/day; moderate to high: >7.5mg prednisone/day
3. Central DXA = spine and hip. 4. As defined by the WHO: Normal (T-score between +2.5 and -1.0 inclusive);
Osteopenia (T-score between -1.0 and -2.5); Osteoporosis (T-score ≤ - 2.5); Severe osteoporosis
(T-score ≤ - 2.5 plus fragility fracture)
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The above recommendations are systematically developed
statements to assist practitioner and patient decisions about
appropriate health care for specific clinical circumstances. They
should be used as an adjunct to sound clinical decision making.
Osteoporosis
Who Should Not be Tested for Osteoporosis?
•
•
Premenopausal women, and men under age 50 without fractures or secondary causes of
osteoporosis, such as high dose glucocorticoid therapy or hypogonadism not treatable
by hormone replacement.
- Even if they have several risk factors other than secondary causes of osteoporosis,
such patients are unlikely to fracture over a 5-10 year period. However, they should
decrease modifiable risk factors and take appropriate amounts of Vitamin D and
calcium. The need for drug therapy can be re-assessed after menopause or age 50.
Men and women less than 65 years old who have no risk factors for osteoporotic fractures
Inappropriate Indications for BMD Measurement
•
•
•
Chronic back pain (aiming to rule out vertebral fractures)
Kyphosis (best investigated using lateral thoracic spine x-rays to rule out anterior
compression fractures)
Menopause, in the absence of risk factors
Who is at High Risk for Fractures
•
•
•
•
Low BMD
Prior fragility fracture after age 40
Family history of osteoporosis
Age
There are two situations where patients can be assumed to have osteoporosis and BMD is not
required to make the diagnosis, however, it may be useful to monitor the effects of treatment:
• Low trauma fracturea (due to an injury that would be insufficient to fracture normal bone)
• Loss of ≥ 2cm of height in one year or over 5cm over a lifetime (not resulting from other
causes)
Note: With a prior fragility fracture after age 40, the risk of fracture increases by 1.5 to 9.5
times, depending on age at assessment and number and site of previous fractures.
Who Should Undergo Fracture Risk Assessment
Long term
glucocorticoids1
Start bisphosphonate
therapy
Obtain BMD by DXA
for follow-up
Fragility fracture
after age 40
Non traumatic
vertebral
compression
deformities
Clinical risk
factors
(1 major or 2
minor)
Low BMD by
DXA (T-score at
or below -2.5)
+ Low BMD by DXA (T-score below -1.5)2
Consider therapy
Repeat BMD by DXA after 1 or 2 years
Notes:
1. ≥7.5mg prednisone for more than 3 months.
2. T - scores arbitrarily chosen below -1.5; nontraumatic vertebral compression deformities; personal history of fragility
fracture after age 40; clinical risk factors.
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Osteoporosis
•
Bisphosphonates (alendronate, etidronate, risedronate, zoledronic acid) are a firstline preventive therapy in post menopausal women with low bone density and for
prevention of glucocorticoid induced osteoporosis.
• Raloxifene is a first line therapy in the prevention of further bone loss in
postmenopausal women with low bone density.
• Hormone Replacement Therapy (HRT) is the first line preventive therapy for
menopause before age 45 [treat until average age of menopause (51 years)]; and can
be considered first line for postmenopausal women with low bone density and estrogen
deficiency symptoms [treat 4-5 years].
• Change modifiable risk factors, daily calcium and vitamin D3 as below:
Table 2: Modifiable Risk Factors
Age Group
Calcium (daily)
Vitamin D3 (daily)
Children 4 to 8 years
800 mg
Adolescents 9 to 18 years
1300 mg
Women (including pregnant or lactating
women) and men ages 19 to 50
1000 mg
400 IU
Women and men >50 years
1500 mg
800-1000 IU
What is the Best Treatment for Osteoporosis in Post Menopausal
Women
1st Choice
2nd Choice
Without fragility fracture
With fragility fracture
Vasomotor symptoms
Alendronate
Risedronate
Raloxifene1
Zoledronic acid
Yes
No
HRT
Alendronate
Risedronate
Raloxifene1
Zoledronic acid
Alendronate
Risedronate
Raloxifene1
Zoledronic acid
Calcitonin
Calcitonin
Etidronate
HRT
Calcitonin
Etidronate
HRT
Note 1) All three first line therapies for patients with fragility fractures have been clearly shown to prevent
vertebral fractures, but only alendronate and risedronate have been shown to decrease hip fracture risk.
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Osteoporosis
What is the Best Treatment for Other Cases of Osteoporosis
• Bisphosphonates (risedronate, alendronate, etidronate, zoledronic acid) for treatment of
glucocorticoid induced osteoporosis
• Bisphosphonates (alendronate, etidronate) are a 1st-line treatment for men with low bone
mass or osteoporosis
• Nasal calcitonin can be considered for use in men and non-pregnant, premenopausal
women with osteoporosis. It is a 1st-line treatment for pain associated with acute vertebral
fractures.
Note: Zoledronic acid, 5mg intravenously on an annual basis has been approved in Canada for the
treatment of postmenopausal osteoporosis.
What Therapies are NOT Recommended
•
Ipriflavone, vitamin K, and fluoride should not be used for the prevention or treatment
of osteoporosis.
• No evidence exists to recommend additional intakes of the following nutrients for the
prevention of osteoporosis: magnesium, copper, zinc, phosphorus, manganese, iron, or
essential fatty acids.
Follow-up BMD Measurements using DXA
• Not required more frequently than q2 years, except in patients:
- On 7.5 mg prednisone/day (or equivalent) x 3 months who require baseline and q6
month DXA while on treatment
- With existing fractures or very low bone density where early DXA is indicated
Note: BMD measurement is generally performed using dual energy x-ray absorptiometry
(acronym is DXA or DEXA)
Summary for the Diagnosis and
Management of Osteoporosis, 2003
Revised 2004
Revised 2005
Revised February 2010
For complete guidelinerefer to CMAJ NOV, 12, 2002:167(10 Suppl)
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