Guidelines for the management of osteoporosis and fragility fractures

Internal and Emergency Medicine https://doi.org/10.1007/s11739-018-1874-2 EM - ORIGINAL Guidelines for the management of osteoporosis and fragility fractures Ranuccio Nuti1 · Maria Luisa Brandi2 · Giovanni Checchia3 · Ombretta Di Munno4 · Ligia Dominguez5 · Paolo Falaschi6 · Carmelo Erio Fiore1 · Giovanni Iolascon3 · Stefania Maggi6 · Raffaella Michieli7 · Silvia Migliaccio2 · Salvatore Minisola1 · Maurizio Rossini4 · Giuseppe Sessa8 · Umberto Tarantino8 · Antonella Toselli7 · Giovanni Carlo Isaia5 Received: 20 April 2018 / Accepted: 6 May 2018 © The Author(s) 2018 Abstract The purpose of this document,a result of the harmonisation and revision of Guidelines published separately by the SIMFER, SIOMMMS/SIR, and SIOT associations, is to provide practical indications based on specific levels of evidence and various grades of recommendations, drawn from available literature, for the management of osteoporosis and for the diagnosis, prevention, and treatment of fragility fractures. These indications were discussed and formally approved by the delegates of the Italian Scientific Associations involved in the project (SIE, SIGG, SIMFER, SIMG, SIMI, SIOMMMS, SIR, and SIOT). Keywords Osteoporosis · Fractures · Therapy * Salvatore Minisola 1 SIMI, (Italian Society of Internal Medicine), Rome, Italy 2 SIE (Italian Society of Endocrinology), Rome, Italy 3 SIMFER (Italian Society of Physical and Rehabilitation Medicine), Rome, Italy 4 SIR (Italian Society of Rheumatology), Milan, Italy 5 SIOMMMS (Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases), Rome, Italy 6 SIGG (Italian Society of Gerontology and Geriatrics), Firenze, Italy 7 SIMG (Italian Society of General Medicine and of Primary Care), Firenze, Italy 8 SIOT (Italian Society of Orthopaedics), Genoa, Italy 13 Vol.:(0123456789) Internal and Emergency Medicine Definition Osteoporosis is a systemic skeletal disease characterized by a reduction in bone mass and qualitative skeletal changes (macro- and microarchitecture, material properties, geometry, and micro-damage) that cause an increase in bone fragility and higher fracture risk. There are two forms of the disease: (a) primary osteoporosis, which includes juvenile, postmenopausal, and male and senile osteoporosis; and (b) secondary osteoporosis, which is caused by a large number of diseases and medications. Fragility fractures may occur in almost all skeletal segments, but the preferential locations are the vertebral column, the proximal ends of the femur and humerus, and the distal end of the radius (Colles fracture). Trauma due to a fall is by far the most frequent cause of fractures affecting long bones (femur, humerus, and radius), while it is more difficult to determine the cause and the exact time of fragility fractures of the vertebral body, which often go undiagnosed. During patient evaluation, there are some clinical history details that can suggest a vertebral fracture: recent trauma, prolonged use of corticosteroids, age, structural spinal deformity, loss of height > 6 cm, and a distance between the last rib and the iliac crest < 2 fingers. It is, therefore, advisable to carefully evaluate the presence of dorso-lumbar pain, progressive loss of height, or dorsal kyphosis, which may result in alterations of the respiratory or gastrointestinal functions. Primary osteoporosis (a) Juvenile osteoporosis The expression juvenile osteoporosis is commonly used to indicate a form of osteoporosis found in childhood and adolescence: this disease is mostly due to genetic mutations that can lead to quantitative or qualitative alterations in the connective tissue component of bone (as in osteogenesis imperfecta, which is also characterized by extra-skeletal alterations), or to an altered osteoblastic activity with the particular involvement of the trabecular bone (as in the autosomal dominant form caused by inappropriate activation of the Wnt-β catenin signal). It can also be secondary to leukaemia, prolonged immobilisation, or chronic inflammatory diseases; or it can be due to the chronic administration of drugs such as anti-epileptics and glucocorticoids. When it is not possible to identify possible causes of bone loss and fragility fractures, this condition is referred to as juvenile idiopathic osteoporosis. In accordance with the Pediatric Official Positions of the International Society for Clinical Densitometry (ISCD), the 13 diagnosis of osteoporosis in childhood is made on the basis of a history of one or more vertebral fragility fractures, or of a history of at least two fractures of the long bones before the age of 10, or of three or more long bone fractures before the age of 19 in the absence of local pathologies, high-energy trauma, and bone mineral density (BMD) Z-score ≤ 2.0 standard deviation (SD) at the lumbar spine or total body less head (TBLH) scans. (b) Postmenopausal osteoporosis Postmenopausal osteoporosis is the most frequent primary form of the pathology, and is due to oestrogen deficiency associated with menopause, which provokes an acceleration of bone loss due to age. It is characterized by rapid loss of trabecular bone mass with perforation of the trabecular bone, while cortical bone is partially spared. This loss is responsible for fragility fractures due to load bearing, especially by the vertebrae and the distal radius. It is also generally characterized by a high bone turnover rate, with bone marrow expansion, and a prevalence of increased endosteal resorption, and also by inhibition of periosteal bone formation. BMD as determined by dual-X-ray absorptiometry (DXA) is unanimously considered to be the most important predictor of osteoporotic fractures, and is indicated, according to Italian Ministerial Decree regulating Essential Assistance Levels (EAL), in women of any age, in the presence of a major risk factor (for example, previous fragility fracture caused by minimal trauma, maternal family history of osteoporotic fracture at less than 75 years of age, menopause before 45 years of age, body mass index (BMI) < 19 kg/m2, and prolonged glucocorticoid therapy) and, for postmenopausal women only, the presence of at least three or more of the following minor risk factors: 1. Age greater than 65 years 2. Family history of severe osteoporosis 3. Premenopausal amenorrhoea for a period greater than 6 months 4. Inadequate calcium intake (< 1200 mg/day) 5. Smoking > 20 cigarettes/day 6. Alcoholism (> 60 g/day) (c) Male osteoporosis. Osteoporosis is a major public health problem for men, as well; in fact, more than 20% of all hip fractures occur in males, and the incidence of vertebral fractures is about half that reported in women. Male osteoporosis is frequently secondary (about two-thirds of cases in males versus one-third in females), so it is always advisable to exclude other pathological conditions associated with osteoporosis (Table 1). Moreover, in men, the BMD DXA technique is the method of choice to d (...truncated)