2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary

Abstract

Since the publication of the Osteoporosis Canada guidelines in 2002, there has been a paradigm shift in the prevention and treatment of osteoporosis and fractures.1,2 The focus now is on preventing fragility fractures and their negative consequences, rather than on treating low bone mineral density, which is viewed as only one of several risk factors for fracture. Given that certain clinical factors increase the risk of fracture independent of bone mineral density, it is important to take an integrated approach and to base treatment decisions on the absolute risk of fracture. Current data suggest that many patients with fractures do not undergo appropriate assessment or treatment.3 To address this care gap for high-risk patients, the 2010 guidelines concentrate on the assessment and management of women and men over age 50 who are at high risk of fragility fractures and the integration of new tools for assessing the 10-year risk of fracture into overall management. Burden and care gapsFragility fractures, the consequence of osteoporosis, are responsible for excess mortality, morbidity, chronic pain, admission to institutions and economic costs. [4][5][6] They represent 80% of all fractures in menopausal women over age 50.3 Those with hip or vertebral fractures have substantially increased risk of death after the fracture.5 Postfracture mortality and institutionalization rates are higher for men than for women. 7Despite the high prevalence of fragility fractures in the Canadian population and the knowledge that fractures predict future fractures, 8 fewer than 20% of women 3,9 and 10% of men 10 receive therapies to prevent further fractures. These statistics contrast sharply with the situation for cardiovascular disease, where 75% of patients who have had myocardial infarction receive β-blockers to prevent another event. 11 Scope of the guidelinesThe target population for these guidelines is women and men over age 50, because of the overall burden of illness in that age group. As a consequence, we focused our systematic literature reviews on this population. The application of these guidelines to children and young adults, as well as high-risk groups such as transplant recipients, was considered, but indepth reviews of conditions that increase risk were largely beyond the scope of these guidelines. Development of the guidelinesThe development of these guidelines followed the Appraisal of Guidelines, Research and Evaluation (AGREE) framework. 12 We surveyed primary care physicians, patients, osteoporosis specialists from various disciplines, radiologists, allied health professionals and health policy-makers to identify priorities for these guidelines. We then conducted system-

Osteoporosis Prescribing in Long-Term Care: Impact of a Provincial Knowledge Translation Strategy

“…To date, knowledge translation activities have included (a) environmental scans, (b) systematic reviews, (c) barrier analysis, (d) creating and disseminating a 10-minute educational video and Fracture Prevention Toolkits, (e) launching a website (www.osteoporosislongtermcare.ca), and (f) educational outreach Ioannidis et al, 2012b;Kennedy et al, 2011b;Kennedy et al, 2012a;Lau et al, 2010; Sawka, Ismaila, Cranney, et al, 2010; Sawka, Ismaila, Raina, et al, 2010 2010b). For residents at highest risk of fractures, hip protectors and osteoporosis medications are options that should be considered (Sawka, Ismaila, Cranney, et al, 2010;Papaioannou et al, 2010b). Pharmacologic therapy is indicated for patients at (1) high absolute fracture risk (> 20% probability over 10 years) based on risk tools Leslie et al, 2011a) and (2) individuals over age 50 with a hip or vertebral fracture or more than one fragility fracture (Papaioannou et al, 2010b).…”

“…For residents at highest risk of fractures, hip protectors and osteoporosis medications are options that should be considered (Sawka, Ismaila, Cranney, et al, 2010;Papaioannou et al, 2010b). Pharmacologic therapy is indicated for patients at (1) high absolute fracture risk (> 20% probability over 10 years) based on risk tools Leslie et al, 2011a) and (2) individuals over age 50 with a hip or vertebral fracture or more than one fragility fracture (Papaioannou et al, 2010b).…”

Effects of Long-Term Low-Molecular-Weight Heparin on Fractures and Bone Density in Non-Pregnant Adults: A Systematic Review With Meta-Analysis

“…62 Currently, LMWH is not recognized as a major modifying factor for fractures in standardized fracture risk assessment tools such as FRAX or CAROC. 63,64 Using the FRAX 10-year fracture risk assessment tool, 65,66 one can show that if LMWH were to induce a bone loss of 4.8 % over 2 years in a 68-year-old male patient [BMI = 26 kg/ cm 2 ; baseline BMD T-score = −2.0 corresponding to mean BMD (femoral neck) = 0.620 g/cm 2 ], the 10-year probability of a major osteoporotic fracture would increase by 2.1 % (from baseline 7.9 % to 10 %) and that of a hip fracture by 1.8 % (from 2.2 % to 4.0 %), 67 making the patient potentially eligible for pharmacologic treatment. 63 Thus, it is important for clinicians to make sure adults on long-term LMWH get adequate calcium and vitamin D to minimize bone loss and to consider monitoring BMD in those who are at increased risk of bone loss or fractures.…”

A backbone for FRAX?

“…(6) However, a younger woman with a T-score of À2.5 (and without other risk factors) is not at high risk, and an older woman with a spine T-score of À2.4 might be. In Canada, one is allowed to substitute lowest T-score (the spine T-score can be used if its lower than the hip), (7) but this probably overestimates fracture risk.…”