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  • Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. Journal of bone and mineral research. 1994, 9:1137.Kanis JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990, 5:209-11.
  • 3. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporosis International. 2002, 12:417–24.
  • 15. Osteoporosis Canada. Osteoporosis Facts & Statistics [Internet]. Toronto, Ontario. Osteoporosis Canada. 2012 March. Available from: http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-facts-and-statistics/.
  • 5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
  • 5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
  • 6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
  • 6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
  • 6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
  • 6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
  • 8. World Health Organization Collaborating Centre for Metabolic Bone Diseases. FRAX [Internet]. Sheffield, UK: University of Sheffield; 2013. Available from: http://www.shef.ac.uk/FRAX/tool.aspx?country=19.9. Osteoporosis Canada. Assessment of 10-year Fracture Risk – Women and Men [Internet]. Canada. Canadian Association of Radiologists and Osteoporosis Canada (CAROC); 2013. Available from: http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.
  • 10. The Foundation for Medical Practice Education. Osteoporosis: Applying the paradigm shift from new guidelines. Practice Based Learning Program Educational Module. 2012 May;20(5)1-20.
  • 11.Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP, Feldman S, Hodsman AB, Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K. Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk. Can Assoc Radiol J. 2011 Nov;62(4):243-50.
  • 5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
  • 12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
  • 12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
  • 13. Kuanrong Li, Rudolf Kaaks, Jakob Linseisen. Associations of dietary calcium intake and overall calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012 98: 920-5.
  • 5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
  • 5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
  • 12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
  • 12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
  • 14. Papaioannou A. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Oct]. Available from: http://www.osteoporosis.ca/health-care-professionals/clinical-tools-and-resources/2010-clinical-guidelines-slideset/. Select Slide Deck 05 (Strategies for Fracture Prevention).
  • 12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
  • 12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.

Osteoporosis Osteoporosis Presentation Transcript

  • Adam Samosh PGY-2 Family Medicine Schulich School of MedicineUniversity of Western Ontario 1
  • A learning resource for Residents in Family MedicineResidency ProgramsOnline Learning Module 2
  •  Definitions Family Medicine Assessment Investigations Screening Risk Assessment Treatment Summary References 3
  •  Review the basics of what osteoporosis is Review key aspects of history taking and physical exam related to osteoporosis Be able to determine appropriate screening and fracture risk stratification for different patient demographics Become familiar with basic management options for osteoporosis (note: thorough discussion of pharmacological management of osteoporosis is beyond the scope of this learning module) 4
  • Skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fractures (1) WHO Definition: BMD value at the spine, hip, or forearm of 2.5 or more standard deviations below the young adult mean (i.e. t-score ≤-2.5), with or without the presence of a fragility fracture (2) Fragility Fracture: no, or low trauma fracture (3)1. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. Journal of Bone and Mineral Research. 1994, 9:1137.2. Kanis JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990, 5:209-11. 53. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporosis International. 2002, 12:417–24.
  • Normal: t-score ≥ -1 Osteopenia: -1 > t-score > -2.5 Osteoporosis: t-score < -2.53. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for settingintervention thresholds. Osteoporosis International. 2002, 12:417–24. 6
  •  Primary care physicians are often responsible for screening and initiating management in patients with osteoporosis  Canada: 1 in 3 women and 1 in 5 men will experience a fracture from osteoporosis  Approximately 80% of fractures in Canadians over 50 years old are due to osteoporosis  The annual cost to the health care system from Osteoporosis is estimated at $2.3 billion each year  Guidelines for management have changed several times over the last few decades - most notably in 2002, 2004, 2010, 2011 and 2012(4)4. Osteoporosis Canada. Osteoporosis Facts & Statistics [Internet]. Toronto, Ontario. Osteoporosis Canada. 2012 March.Available from: http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-facts-and-statistics/. 7
  •  Osteoporosis Guidelines can be found from several different sources:  Canadian Task Force on LTC  SOGC/JOGC  CMA  Osteoporosis Canada One of the main purposes of this online learning module is to combine these guidelines into one resource for use in Family Medicine practice 8
  •  Fall Risk Assessment – Topics to ask patients about(5):  Previous history of falls  Alcohol intake (≥ 3 drinks per day)  Poor strength  Balance or gait issues  Dizziness  Poor vision5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines andProtocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 91];[about 2 screens].
  •  Main Risks for Developing Osteoporosis (5):  History of fragility fracture  Parent with a hip fracture  Rheumatoid Arthritis  Chronic (≥3 months) glucocorticoid use  Smoking (any amount has the potential to be detrimental to bone health)  Chronic Liver/Kidney disease  Early Menopause (before age 45 years old – including surgically induced menopause)  Caffeine intake (≥4 cups/day)  Androgen Deficiency (in men)5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines andProtocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 101];[about 2 screens].
  •  Physical Exam:  Check occiput-to-wall distance (look for >5cm)  Serial heights of patient – looking for >2cm loss of height, or >6cm loss of height based on patient history (6)6. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada.CMAJ 2002; 167(10 Suppl):S1-34. 11
  • Confirm Diagnosis with Dual-energy X-ray Absorptiometry (DXA or DEXA) scan to determine BMD of the patient In Ontario, OHIP (Ontario Health Insurance) will cover DEXA scans: -For patients at high risk for osteoporosis and future fractures, annual scans are covered -For patients at low/intermediate risk for osteoporosis and future fractures, initial BMD testing is covered. A second test can be ordered 3 years after the baseline (i.e. first) test. After those two tests, OHIP will cover any further BMD testing up to every 5 years7. Ontario Ministry of Health and Long-Term Care. BMD Testing [Internet]. Toronto, Ontario. Queen’s Printer for Ontario. July2010 [updated June 28, 2012; cited 2013 March 2]. Available from:http://www.health.gov.on.ca/en/public/publications/ohip/bone.aspx 12
  •  Bloodwork is indicated to rule out secondary causes of osteoporosis (8)  CBC – malabsorption or bone marrow malignancy  Creatinine – chronic renal disease  Calcium (+ Albumin) – hyperparathyroidism  TSH - hyperthyroidism  Alkaline Phosphatase – chronic liver disease  Vitamin D – malabsorption  Serum protein electrophoresis – multiple myeloma8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management ofOsteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 13http://www.osteoporosis.ca
  •  The Canadian Task Force on Preventative Health Care made several screening recommendations in 2004(9):  There is fair evidence to recommend screening postmenopausal women to prevent fragility fractures (grade B)  There is no direct evidence that screening reduces fractures, however, there is good evidence that screening is effective in identifying postmenopausal women with low bone mineral density and that treating osteoporosis can reduce the risk of fractures in this population (grade A)  Screening is determined based on age and presence of medical comorbidities  The most current osteoporosis screening guidelines used in Ontario are from 2010 and are outlined in the following slides9. Wathen CN, Feig DS, Feightner JW, Abramson BL, Cheung AM. Hormone replacement therapy for the primary preventionof chronic diseases: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2004 May, 14170(10):1535-7.
  •  DXA scans (to determine BMD and fracture risk) are indicated for screening in all men and women over the age of 65 years old (8)8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management ofOsteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 15http://www.osteoporosis.ca
  •  Screening is indicated in a patient between the age of 50-64 years old if they have a risk factor for developing osteoporosis (discussed on slide #10)  In addition to the risk factors already mentioned, consider screening in patients with:  primary hyperparathyroidism, type 1 diabetes, osteogenesis imperfecta, hyperthyroidism, hypogonadism, Cushing’s disease, malabsorption syndrome, IBD, COPD (8)8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management ofOsteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 16http://www.osteoporosis.ca
  •  Screening is only indicated if patient has one of the following risk factors (8):  history of fragility fracture  prolonged use of glucocorticoids (>3 months)  hypogonadism  premature menopause (<45 years old)  malabsorption syndrome  primary hyperparathyroidism8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management ofOsteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 17http://www.osteoporosis.ca
  •  Assess 10-year fracture risk using BMD and one of two risk assessment tools (available online)  FRAX score (10) (developed by the WHO – has settings that can be set for the Canadian population specifically) http://www.shef.ac.uk/FRAX/tool.aspx?country=19  CAROC (11) (Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment tool) http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf  These tools enable risk stratification10. World Health Organization Collaborating Centre for Metabolic Bone Diseases. FRAX [Internet]. Sheffield, UK: University of Sheffield; 2013. Available from: http://www.shef.ac.uk/FRAX/tool.aspx?country=19.11. Osteoporosis Canada. Assessment of 10-year Fracture Risk – Women and Men [Internet]. Canada. Canadian Association of Radiologists and Osteoporosis Canada (CAROC); 2013. Available from: 18 http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.
  • Note – Entire Table can be found at: 12. The Foundation for Medical Practice Education. Osteoporosis: Applying the paradigmshift from new guidelines. Practice Based Learning Program Educational Module. 2012 May;20(5)1-20. 19
  •  The current 2010 guidelines recommend using the CAROC tool (rather than FRAX) for assessing fracture risk in patients in Canada  The same guidelines recommend using only the BMD t-score for the femoral neck when calculating fracture risk (with CAROC being the preferred tool)13 Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM,Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis inCanada: summary. CMAJ. 2010 Nov 23;182(17):1-10. 20
  •  In previous years, guidelines focussed on treating a patient’s BMD t-score  Currently the focus has shifted to managing a patient’s fracture risk level (rather than the t-score)  The main key point of the 2010 clinical practice guidelines for osteoporosis in Canada states:  The management of osteoporosis should be guided by an assessment of the patient’s absolute RISK OF OSTEOPOROSIS RELATED FRACTURES (13)13 Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM,Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis inCanada: summary. CMAJ. 2010 Nov 23;182(17):1-10. 21
  •  Risk Categories based on 10-year fracture risk (14):  Low (< 10%)  Moderate (10 - 20%)  High (> 20%)  Risk categorization helps determine the most appropriate (evidence based) treatment for each patient14. Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP, Feldman S, Hodsman AB,Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K. Osteoporosis Canada 2010 Guidelines for the Assessment ofFracture Risk. Can Assoc Radiol J. 2011 Nov;62(4):243-50 22
  •  Thorough discussion of treatment options for osteoporosis is beyond the scope of this learning module but will briefly be discussed on the following slides to introduce the learner to commonly used medications for fracture reduction management 23
  •  No evidence for benefit (i.e. prevention of future fractures) from pharmacotherapy  May benefit from vitamin D and calcium supplementation as well as conservative treatments (see slide #25 and 26)  BMD should be repeated in 5 years to reassess risk levels (5)5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines andProtocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 241];[about 2 screens].
  •  Recommend (13):  Weight bearing exercise such as walking or weights (grade B)  Balance training (such as Tai Chi ) (grade A evidence for those at risk of falls)  Home safety assessments (PT/OT) (grade B)  Treating poor vision (i.e. glasses, cataract removal) (grade B)  Hip-protectors (for patients in long-term care facilities) (grade B)  Smoking cessation  Limiting alcohol intake (<2 drinks/day)  Consider Referral (if appropriate) to (5):  Geriatric medicine  Falls prevention program  Homecare  Occupational therapy or Physical therapy13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B,Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary.CMAJ. 20105.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols 25Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2screens].
  •  Daily Calcium Intake (from all sources):  1200mg (grade B) (discussed further on next slide)  Daily Vitamin D Intake:  <50 years old 400-1000IU (grade D)  >50 years old 800-2000IU (grade C)  Recheck Vitamin D levels 3 months after initiating supplementation (OHIP will only cover Vitamin D Testing for patients with Osteoporosis/Osteopenia)  Daily doses up to 2000 IU is safe and does not require serial monitoring (grade C) (13)13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, KvernB, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 26summary. CMAJ 2010 Nov 23;182(17):1-10.
  •  Recent article (June 2012) in the journal Heart suggests there may be increase cardiovascular risk with taking calcium supplements  Conclusion:  “this study suggests that increasing calcium intake from diet might not confer significant cardiovascular benefits, while calcium supplements, which might raise MI risk, should be taken with caution” (15)  There has been no official change to guidelines in Canada for calcium supplementation since this article was published  Anecdotally, many family doctors are avoiding use of calcium supplements (and encouraging adequate calcium intake from diet instead) until formal guidelines are released15. Kuanrong Li, Rudolf Kaaks, Jakob Linseisen. Associations of dietary calcium intake and overall calcium supplementation withmyocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European ProspectiveInvestigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012 98: 920-5. 27
  •  May benefit from conservative management and adequate supplementation of Calcium and Vitamin D (see slide #27 for concerns around calcium supplementation)  Use clinical judgement in considering that individuals at increase risk for falls or fracture in particular may benefit from treatment (5)5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines andProtocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html 28
  •  Evidence for benefit from pharmacotherapy (5)  The following pharmacologic treatment options are briefly discussed on the following slides:  Bisphosphonates  Selective Estrogen Receptor Modulators (SERMs)  Hormone Replacement Therapy (HRT)  Calcitonin  Miscellaneous5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines andProtocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html 29
  •  Generally a bisphosphonate is used as first line treatments for prevention of fracture for both men and women (Grade A for women, Grade D for men) (13)  However, there are other first line options (with evidence in post-menopausal women) for fracture prevention13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, KvernB, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 30summary. CMAJ 2010 Nov 23;182(17):1-10.
  •  Raloxifene can be used as a first line therapy for prevention of vertebral fractures in menopausal women with osteoporosis (grade A) (13) Raloxifene (Evista®) 60 mg daily13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, KvernB, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 31summary. CMAJ 2010 Nov 23;182(17):1-10.
  •  Monoclonal Antibody Denosumab (Prolia®) 60 mg subcutaneous injection every six months  Parathyroid Hormone (PTH) Analog Teriparatide (Forteo®) 20 μg subcutaneously daily  In menopausal women with vasomotor symptoms and osteoporosis, Hormone Replacement Therapy (HRT) can be used to treat both  HRT is available as oral medication, patches applied to skin or as a topical cream (13)16. Papaioannou A. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet].Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Oct]. Available from: http://www.osteoporosis.ca/health-care-professionals/clinical-tools-and-resources/2010-clinical-guidelines-slideset/. Select Slide Deck 05 (Strategies for FracturePrevention).13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern 32B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada:summary. CMAJ 2010 Nov 23;182(17):1-10.
  •  Second line therapies include calcitonin, and etidronate (Grade B)  Calcitonin Calcitonin (Miacalcin®) 200 IU intranasally daily  Etidronate Cyclical therapy of daily 200 mg for 14 days Etidronate (Didrocal®) followed by calcium supplements for 10 weeks  Testosterone is not recommended as a treatment in men (Grade B)13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, KvernB, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 33summary. CMAJ 2010 Nov 23;182(17):1-10.
  •  Consider referral to a specialist in patients who meet one of the following criteria:  decrease in bone density while on therapy  new fracture while on therapy  poor drug tolerance to several first line agents  rare drug therapy complications such as osteonecrosis of the jaw or atypical femoral fractures (13)13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, KvernB, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 34summary. CMAJ 2010 Nov 23;182(17):1-10.
  •  Osteoporosis corresponds to a BMD t-score < -2.5 Review falls risks and risk of developing osteoporosis when concerned about a patient’s future risk of fracture Screening for osteoporosis is appropriate in individuals over the age of 65 years old, or younger patients at risk of developing osteoporosis Screening generally involves using a DEXA scan to determine BMD, which is then used by a risk-assessment tool (CAROC is preferred) to determine a patient’s fracture risk Fracture risk level (low, intermediate or high) will determine what type of management is appropriate to prevent future fractures Ultimately, the goal of osteoporosis management is fracture risk reduction 35
  • 1. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. Journal of Bone and Mineral Research. 1994, 9:1137.2. Kanis JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990, 5:209-11.3. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporosis International. 2002, 12:417–24.4. Osteoporosis Canada. Osteoporosis Facts & Statistics [Internet]. Toronto, Ontario. Osteoporosis Canada. 2012 March. Available from: http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis- facts-and-statistics/.5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html 36
  • 6. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 2002; 167(10 Suppl):S1-34.7. Ontario Ministry of Health and Long-Term Care. BMD Testing [Internet]. Toronto, Ontario. Queen’s Printer for Ontario. July 2010 [updated June 28, 2012; cited 2013 March 2]. Available from: http://www.health.gov.on.ca/en/public/publications/ohip/bone.aspx8. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.9. Wathen CN, Feig DS, Feightner JW, Abramson BL, Cheung AM. Hormone replacement therapy for the primary prevention of chronic diseases: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2004 May, 170(10):1535-7.10. World Health Organization Collaborating Centre for Metabolic Bone Diseases. FRAX [Internet]. Sheffield, UK: University of Sheffield; 2013. Available from: http://www.shef.ac.uk/FRAX/tool.aspx?country=19. 37
  • 11. Osteoporosis Canada. Assessment of 10-year Fracture Risk – Women and Men [Internet]. Canada. Canadian Association of Radiologists and Osteoporosis Canada (CAROC); 2013. Available from: http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.12. The Foundation for Medical Practice Education. Osteoporosis: Applying the paradigm shift from new guidelines. Practice Based Learning Program Educational Module. 2012 May;20(5)1-20.13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.14. Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP, Feldman S, Hodsman AB, Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K. Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk. Can Assoc Radiol J. 2011 Nov;62(4):243-5015. Kuanrong L, Rudolf K, Jakob L. Associations of dietary calcium intake and overall calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC- Heidelberg). Heart 2012 98: 920-5.16. Papaioannou A. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Oct]. Available from: http://www.osteoporosis.ca/health-care- professionals/clinical-tools-and-resources/2010-clinical-guidelines-slideset/. Select Slide Deck 05 (Strategies for Fracture Prevention). 38