Clinician’s Guide to Prevention and Treatment of Osteoporosis

F. Cosman 0 1 2 3 4 S. J. de Beur 0 1 2 3 4 M. S. LeBoff 0 1 2 3 4 E. M. Lewiecki 0 1 2 3 4 B. Tanner 0 1 2 3 4 S. Randall 0 1 2 3 4 R. Lindsay 0 1 2 3 4 0 M. S. LeBoff Brigham and Women's Hospital , Boston, MA, USA 1 S. J. de Beur Johns Hopkins Bayview Medical Center , Baltimore, MD, USA 2 S. Randall National Osteoporosis Foundation , Washington, DC, USA 3 B. Tanner Vanderbilt University Medical Center , Nashville, TN, USA 4 E. M. Lewiecki New Mexico Clinical Research and Osteoporosis Center , Albuquerque, NM, USA The Clinician's Guide to Prevention and Treatment of Osteoporosis was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device, or procedure discussed in this publication. Osteoporosis is a silent disease until it is complicated by fracturesfractures that occur following minimal trauma or, in some cases, with no trauma. Fractures are common and - place an enormous medical and personal burden on the aging individuals who suffer them and take a major economic toll on the nation. Osteoporosis can be prevented, diagnosed, and treated before fractures occur. Importantly, even after the first fracture has occurred, there are effective treatments to decrease the risk of further fractures. Prevention, detection, and treatment of osteoporosis should be a mandate of primary care providers. Since the National Osteoporosis Foundation (NOF) first published the Guide in 1999, it has become increasingly clear that many patients are not being given appropriate information about prevention and many patients are not receiving appropriate testing to diagnose osteoporosis or establish osteoporosis risk. Most importantly, many patients who have osteoporosis-related fractures are not being diagnosed with osteoporosis and are not receiving any of the Food and Drug Administration (FDA)-approved, effective therapies. This Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men age 50 and older. It includes indications for bone densitometry and fracture risk thresholds for intervention with pharmacologic agents. The absolute risk thresholds at which consideration of osteoporosis treatment is recommended were guided by a costeffectiveness analysis. Synopsis of major recommendations to the clinician Recommendations apply to postmenopausal women and men age 50 and older. Universal recommendations Counsel on the risk of osteoporosis and related fractures. Advise on a diet that includes adequate amounts of total calcium intake (1000 mg/day for men 5070; 1200 mg/day for women 51 and older and men 71 and older), incorporating dietary supplements if diet is insufficient. Advise on vitamin D intake (8001000 IU/day), including supplements if necessary for individuals age 50 and older. Recommend regular weight-bearing and musclestrengthening exercise to improve agility, strength, posture, and balance; maintain or improve bone strength; and reduce the risk of falls and fractures. Assess risk factors for falls and offer appropriate modifications (e.g., home safety assessment, balance training exercises, correction of vitamin D insufficiency, avoidance of central nervous system depressant medications, careful monitoring of antihypertensive medication, and visual correction when needed). Advise on cessation of tobacco smoking and avoidance of excessive alcohol intake. Measure height annually, preferably with a wall-mounted stadiometer. Bone mineral density (BMD) testing should be performed: Pharmacologic treatment recommendations & Initiate pharmacologic treatment: Biochemical markers of bone turnover can aid in risk assessment and serve as an additional monitoring tool when treatment is initiated. Perform BMD testing 1 to 2 years after initiating medical therapy for osteoporosis and every 2 years thereafter. More frequent BMD testing may be warranted in certain clinical situations. The interval between repeat BMD screenings may be longer for patients without major risk factors and who have an initial T-score in the normal or upper low bone mass range. Biochemical markers can be repeated to determine if treatment is producing expected effect. In women age 65 and older and men age 70 and older In postmenopausal women and men above age 5069, based on risk factor profile In postmenopausal women and men age 50 and older who have had an adult age fracture, to diagnose and determine degree of osteoporosis At dual-energy X-ray absorptiometry (DXA) facilities using accepted quality assurance measures Vertebral imaging should be performed: In all women age 70 and older and all men age 80 and older if BMD T-score is 1.0 at the spine, total hip, or femoral neck In women age 65 to 69 and men age 70 to 79 if BMD Tscore is 1.5 at the spine, total hip, or femoral neck In postmenopausal women and men age 50 and older with specific risk factors: Low-trauma fracture during adulthood (age 50 and older) Historical height loss (difference between the current height and peak height at age 20) of 1.5 in. or more (4 cm) Prospective height loss (difference between the current height and a previously documented height measurement) of 0.8 in. or more (2 cm) Recent or ongoing long-term glucocorticoid treatment If bone density testing is not available, vertebral imaging may be considered based on age alone. Check for secondary causes of osteoporosis. In those with hip or vertebral (clinical or asymptomatic) fractures In those with T-scores 2.5 at the femoral neck, total hip, or lumbar spine by DXA In postmenopausal women and men age 50 and older with low bone mass (T-score between 1.0 and 2.5, osteopenia) at the femoral neck, total hip, or lumbar spine by DXA and a 10-year hip fracture probability 3 % or a 10-year major osteoporosis-related fracture probability 20 % based on the USA-adapted WHO absolute fracture risk model (Fracture Risk Algorithm (FRAX); www. NOF.org and www.shef.ac.uk/FRAX) & Current FDA-approved pharmacologic options for osteoporosis are bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid), calcitonin, estrogen agonist/antagonist (raloxifene), estrogens and/or hormone therapy, tissue-selective estrogen complex (conjugated estrogens/bazedoxifene), parathyroid hormone 134 (teriparatide), and receptor activator of nuclear factor kappa-B (RANK) ligand inhibitor (denosumab). & No pharmacologic therapy should be considered indefinite in duration. After the initial treatment period, which depends on the pharmacologic agent, a comprehensive risk assessment should be performed. There is no uniform recommendation that applies to all patients and duration decisions need to be individualized. & In adults age 50 and older, after a fracture, institute appropriate risk ass (...truncated)