Osteoporosis

Adam Samosh

PGY-2 Family Medicine

Schulich School of Medicine

University of Western Ontario

Guidelines for Screening and Diagnosis of

Osteoporosis:A Review of Current Guidelines and

Recent Changes

A learning resource for Residents in Family Medicine Residency Programs

Online Learning Module

Osteoporosis

DefinitionsFamily MedicineAssessmentInvestigationsScreeningRisk AssessmentTreatment SummaryReferences

Outline

Review the basics of what osteoporosis isReview key aspects of history taking and

physical exam related to osteoporosisBe 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)

Learning Objectives

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)

Osteoporosis

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.

Normal: t-score ≥ -1

Osteopenia: -1 > t-score > -2.5

Osteoporosis: t-score < -2.5

Bone Density (3)

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.

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)

Relevance for Family Medicine

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/.

Osteoporosis Guidelines can be found from several different sources:Canadian Task Force on LTCSOGC/JOGCCMAOsteoporosis 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

Family Medicine

Fall Risk Assessment – Topics to ask patients about(5):Previous history of fallsAlcohol intake (≥ 3 drinks per day)Poor strengthBalance or gait issuesDizzinessPoor vision

History – Fall Risk

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].

Main Risks for Developing Osteoporosis (5):History of fragility fractureParent with a hip fractureRheumatoid ArthritisChronic (≥3 months) glucocorticoid useSmoking (any amount has the potential to be

detrimental to bone health)Chronic Liver/Kidney diseaseEarly Menopause (before age 45 years old –

including surgically induced menopause)Caffeine intake (≥4 cups/day)Androgen Deficiency (in men)

History

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)

Physical Exam

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.

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 years

Investigations – DEXA(7)

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.aspx

Bloodwork is indicated to rule out secondary causes of osteoporosis (8)CBC – malabsorption or bone marrow

malignancyCreatinine – chronic renal diseaseCalcium (+ Albumin) – hyperparathyroidismTSH - hyperthyroidismAlkaline Phosphatase – chronic liver diseaseVitamin D – malabsorption Serum protein electrophoresis – multiple

myeloma

Investigations - Bloodwork

8.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

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 slides

Screening

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.

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)

Screening (>65 year olds)

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)

Screening (50-64 year olds)

Screening is only indicated if patient has one of the following risk factors (8):history of fragility fractureprolonged use of glucocorticoids (>3 months)hypogonadismpremature menopause (<45 years old)malabsorption syndromeprimary hyperparathyroidism

Screening (<50 year olds)

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 stratification

Fracture Risk

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.

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.

FRAX vs CAROC(12)

Note – Entire Table can be found at: 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.

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)

CAROC(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 in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.

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)

Fracture Risk

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.

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 patient

Risk Stratification

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):243-50

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

Treatment

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)

Treatment – Low Risk

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 therapy

Conservative Therapy

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. 20105.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].

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)

Supplementation

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.

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 released

Calcium

15. 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.

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)

Treatment – Moderate Risk

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

Evidence for benefit from pharmacotherapy (5)

The following pharmacologic treatment options are briefly discussed on the following slides:BisphosphonatesSelective Estrogen Receptor Modulators (SERMs)Hormone Replacement Therapy (HRT)CalcitoninMiscellaneous

Treatment – High Risk

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 prevention

Bisphosphonates

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 daily

Monoclonal Antibody

Parathyroid Hormone (PTH) Analog

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)

Other Treatments (16)

Teriparatide (Forteo®) 20 μg subcutaneously daily

Denosumab (Prolia®) 60 mg subcutaneous injection every six months

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).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.

Second line therapies include calcitonin, and etidronate (Grade B)

Calcitonin

Etidronate

Testosterone is not recommended as a treatment in men (Grade B)

Second-Line Treatments (13)

Calcitonin (Miacalcin®) 200 IU intranasally daily

Etidronate (Didrocal®)Cyclical therapy of daily 200 mg for 14 days followed by calcium supplements for 10 weeks

Consider referral to a specialist in patients who meet one of the following criteria:decrease in bone density while on therapynew fracture while on therapypoor drug tolerance to several first line agentsrare drug therapy complications such as

osteonecrosis of the jaw or atypical femoral fractures (13)

Referrals

Osteoporosis corresponds to a BMD t-score < -2.5Review falls risks and risk of developing osteoporosis when

concerned about a patient’s future risk of fractureScreening 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

Summary

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/.

References

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.aspx

8. 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.

References

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):243-50

15. 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).

References

Osteoporosis

osteoporosis guidelines

diagnosis of osteoporosis

osteoporosis international

bc guidelines internet

ontario ministry of

fracture prevention

year guidelines

increased risk of fractures

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