The levels of evidence (1 through 3) are defined at the end of the "Major Recommendations" field.
Evaluation
The following patients should undergo an assessment for postmenopausal osteoporosis:
- All women 65 years old or older
- All adult women with a history of a fracture (or fractures) not caused by severe trauma (such as a motor vehicle accident)
- Younger postmenopausal women who have clinical risk factors for fractures (who have low body weight, that is, less than 57.6 kg [127 lb], or a family history of spine or hip fracturing)
The evaluation should include the following items:
- A comprehensive medical examination
- Assessment of risk factors for fractures (refer to the guideline document for a list of risk factors for fractures)
- Bone mineral density (BMD) measurements in younger postmenopausal women who have risk factors and in all women 65 years old or older
- Assessment of the patient's reliability, understanding, and willingness to accept available interventions
Medical Evaluation
A comprehensive medical evaluation, including a complete history and physical examination, is indicated in all women with postmenopausal osteoporosis in order to identify coexisting medical conditions that cause or contribute to bone loss.
The following laboratory tests should be considered for any woman who has osteoporosis. These tests will establish baseline conditions or definitively exclude secondary causes of osteoporosis, even in the absence of other clinical indications:
- Complete blood cell count
- Serum chemistry studies (especially calcium, phosphorus, total protein, albumin, liver enzymes, alkaline phosphatase, creatinine, and electrolytes)
- Urinary calcium excretion
If the medical history or physical findings suggest secondary causes of bone loss, additional laboratory evaluations are warranted and may include (but are not limited to) the following tests:
- Serum thyrotropin
- Erythrocyte sedimentation rate
- Serum parathyroid hormone concentration (for possible primary or secondary hyperparathyroidism)
- Serum 25-hydroxyvitamin D concentration
- Urinary free cortisol and other tests for suspected adrenal hypersecretion
- Acid-base studies
- Biochemical markers of bone turnover (for example, bone-specific alkaline phosphatase and urine or serum collagen cross-links)
- Serum tryptase, urine N-methylhistamine, or other tests for mastocytosis
- Serum or urine protein electrophoresis (or both)
- Bone marrow aspiration and biopsy to look for marrow-based diseases
- Undecalcified iliac bone biopsy with double tetracycline labeling (consider only when osteoporosis is diagnosed and the patient has no apparent cause for the condition, no response to therapy, or suspected osteomalacia or mastocytosis)
The causes of secondary osteoporosis in adults are listed in the original guideline document (see Table 2 titled "Causes of Generalized Secondary Osteoporosis in Adults").
Standard Radiography
In patients with known or suspected vertebral fractures or with unexplained loss of height, radiography of the thoracic and lumbar spine is indicated to identify and confirm the presence of those fractures. Radiographic studies are usually indicated to confirm the presence of fractures at other sites as well. The sensitivity and reliability of standard radiography to assess bone mineral density are poor, and in the absence of vertebral fractures, this technique cannot be used to diagnose osteoporosis.
Biochemical Markers of Bone Turnover
Biochemical markers of bone turnover may be useful for the following specific situations:
- Assessing fracture risk in elderly patients
- Assessing therapeutic responses to antiresorptive agents, such as estrogen and bisphosphonates
- Identifying patients with high bone turnover (to predict rapid bone loss)
Bone Mineral Density Measurement
In women who are at risk for postmenopausal osteoporosis, bone mineral density (BMD) measurement can accomplish the following:
- Establish the diagnosis of postmenopausal osteoporosis
- Determine fracture risk (for every 1-standard deviation decrease in age-adjusted BMD, the relative risk [RR] of fracture increases 1.5- to 2.5-fold)
- Identify candidates for intervention
- Assess changes in bone mass over time in treated and untreated patients
- Enhance acceptance of and adherence to treatment
Measurement Techniques
Dual x-ray absorptiometry of the lumbar spine and proximal femur provides reproducible values at important sites of osteoporosis-associated fracture. These central sites are also more likely than peripheral sites to show a response to treatment and are preferred for baseline and serial measurements. The most reliable comparative results for serial measurements are obtained when the same instrument and, ideally, the same technologist are used.
For bone mass measurement, several other techniques (listed alphabetically) are available:
- Quantitative computed tomography for measurement of both central and peripheral sites
- Quantitative ultrasonometry
- Radiographic absorptiometry
- Single-energy x-ray absorptiometry
The various BMD measurement techniques are outlined in the original guideline document (see Table 3 titled "Bone Mineral Density Measurement Techniques").
Measurement Sites
Peripheral measurements can identify patients with low bone mass. T-scores from peripheral devices, however, are not as sensitive or specific as those from central devices, and the risk of future fracture depends on the skeletal site even when T-scores from different skeletal sites are identical. Work is currently under way to redefine the thresholds for peripheral devices and resolve these discrepancies. In the meantime, peripheral measurements should be limited to the assessment of fracture risk.
Bone Density Reports
Bone density data are reported as T-scores and Z-scores. T-scores represent the number of standard deviations from the normal young adult mean bone density values, whereas Z-scores represent the number of standard deviations from the normal mean value for age- and sex-matched control subjects. Results showing Z-scores of -2.0 or lower may suggest a secondary cause of osteoporosis.
Bone density reports also include values for specific subregions within the proximal femur and for specific vertebrae. Diagnostic and therapeutic studies, cost analyses, and cost-effectiveness data, however, are based on total hip, femoral neck, or total lumbar spine measurements (or some combination of these measurements).
Role in Clinical Decision-Making
A clinical diagnosis of osteoporosis can be made without BMD testing in women who have fragility fractures. Nevertheless, BMD measurement is advisable in these patients to establish a baseline for assessing the response to treatment and for quantifying fracture risk.
For women with no history of fragility fracture, the World Health Organization (WHO) definitions of osteopenia and osteoporosis (please refer to Table 1 titled "World Health Organization Diagnostic Criteria for Women without Fragility Fractures" in the original guideline document) represent BMD levels associated with a high risk of fracture, as determined from prospective trials. Cutoff values, however, cannot define a true "fracture threshold" or the naturally occurring limits of a disease process because osteoporosis exerts its pathologic effects over a continuum of bone density values.
It must also be recognized that factors other than bone density have an important role in the pathogenesis of fractures. The increases in bone density that result from therapeutic interventions are modest and explain less than 50% of the observed reductions in fracture rates. When BMD is used as a surrogate endpoint in therapeutic trials, the relationship between bone mass and fracture rate is highly variable and depends on the specific agent used. For example, the relationship is reasonably strong in bisphosphonate trials, weak in raloxifene trials, and absent in trials that have used high-dose sodium fluoride or calcitonin. Clearly factors other than bone mass also contribute to fracturing.
Therefore, treatment decisions for individual patients with low BMD should be made after consideration of non-bone mass factors as well, including the following:
- Patient acceptance and understanding of the risks and benefits of the proposed treatment
- Age (fracture risk increases with advancing age independent of bone density)
- The patient's usual activity level and its historical effect on skeletal injury
- Patient expectations and functional needs
- Health status (for example, menopausal status and comorbidities)
- Lifestyle (such as use of tobacco and alcohol or risk-taking behavior)
- Medications (for example, postmenopausal women taking more than 7.5 mg of prednisone or its equivalent for more than 3 months should be considered for a preventive strategy with use of a bisphosphonate; women taking levothyroxine require periodic thyrotropin determinations and modification of thyroid hormone dose to normalize serum thyrotropin, if necessary)
Indications
The following are recommendations intended to reflect the most effective and efficient use of BMD measurement within the context of the endocrine specialty practice.
BMD measurements should be performed in the following settings:
- For risk assessment in perimenopausal or postmenopausal women who have risk factors for fractures and are willing to consider available interventions
- In women who have x-ray findings that suggest osteoporosis
- In women beginning or receiving long-term glucocorticoid therapy or other drugs associated with bone loss
- In all adult women with symptomatic hyperparathyroidism or other diseases or nutritional conditions associated with bone loss in whom evidence of bone loss would result in adjustment of management
- For establishing skeletal stability and monitoring therapeutic response in women receiving treatment for osteoporosis (baseline measurements should be made before intervention)
- In all women 40 years old or older who have sustained a fracture
- In all women beyond 65 years of age
Prevention of Osteoporosis
Effective preventive strategies that can be implemented during skeletal development (infancy and childhood) and in later life are needed to minimize the physical, social, and economic consequences of osteoporosis. The following are goals of prevention programs:
- Optimize skeletal development and maximize peak bone mass at skeletal maturity
- Prevent age-related and secondary causes of bone loss
- Preserve the structural integrity of the skeleton
- Prevent fractures
General Principles
The following general principles are applicable to all individuals, particularly children and adolescents:
- Promote a diet with adequate calcium content.
Adequate calcium intake is a fundamental element of any osteoporosis prevention or treatment program. The recommended daily calcium intake for various populations is outlined in the original guideline document (see Table 4 titled "Recommended Daily Calcium Intake for Various Populations," as is a guide to calcium-rich foods (see Table 5 titled "Calcium Content of Various Calcium-Rich Foods" in the original guideline document). Calcium supplementation should be prescribed whenever it is needed to achieve the recommended daily intake levels (see the section titled "Pharmacologic Agents," below). Although many of the effects of supplemental calcium on the developing skeleton are incompletely understood, it is well recognized that supplemental calcium substantially increases bone mass in physically active children.
- Encourage good general nutrition.
- Promote adequate vitamin D intake (at least 400 IU/day; as much as 800 IU per day in the elderly).
Vitamin D is not widely available in natural food sources. It is primarily found in fish oils (including cod liver oil), some vegetables, and fortified milk, cereals, and breads. Supplements of 400 IU daily should be prescribed for younger adults. Supplements of 800 IU daily should be prescribed for elderly patients (in whom vitamin D absorption may be reduced), malnourished patients, patients with intestinal malabsorption, and patients receiving long-term anticonvulsant or glucocorticoid therapy.
- Advocate regular weight-bearing exercise.
Weight-bearing exercise enhances bone development in children and adolescents and may slow bone loss attributable to disuse in elderly persons. In addition, regular exercise promotes mobility, agility, and muscle strength, all of which may help prevent falls.
- Strongly discourage use of tobacco.
Cigarette smokers tend to be thinner, undergo earlier menopause, have increased catabolism of endogenous estrogen, and experience more fractures.
Additional Measures
Consider the following additional measures in specific circumstances:
- Pharmacologic agents (in addition to calcium and vitamin D) to prevent bone loss in perimenopausal and postmenopausal women at high risk of developing osteoporosis
- A bisphosphonate (alendronate or risedronate) for all adult women who will require more than 7.5 mg of prednisone or its equivalent for more than 3 weeks (see the section titled "Pharmacologic Agents," below).
- Periodic monitoring of thyroid function, and adjustment of the dose of thyroid hormone to normalize serum thyrotropin concentrations in all women receiving thyroid hormone replacement therapy for nonmalignant conditions
- Identification and treatment of children and adolescents with constitutional delay of growth and puberty and other states or conditions that predispose to low peak bone mass and osteoporosis in later life
- Identification of patients who have fallen or are predisposed to falling. Some measures to reduce the risk of falling are listed in Table 6 in the original guideline document. Hip protectors do not reduce the risk of falling. Intuitively, hip protectors should reduce the risk of fracture. Positive results have been seen in some trials, but not in all. Hip protectors should be considered for patients who have sustained a prior hip fracture, for slender or frail patients who have fallen in the past, and for patients who have significant risk factors for falling, such as postural hypotension or difficulty with balance, whether they have osteoporosis or not.
Additional measures, listed below, should be personalized to the needs of each patient:
Preventive Measures for Decreasing the Risk of Osteoporosis in High-Risk Women
All Women
Identify and remedy secondary causes (refer to Table 2 titled "Causes of Generalized Secondary Osteoporosis in Adults" in the original guideline document).
Perimenopausal and Postmenopausal Women
Identify and treat women with osteoporosis-related fractures and women with low bone mass.
Identify and treat sensory defects, neurologic disease, and arthritis, which can contribute to frequency of falls.
Adjust dosage of drugs with sedative effects, which could slow reflexes or decrease coordination and impair patient's ability to break impact of a fall.
Recommend appropriate lifestyle changes, including smoking cessation, increase in weight-bearing activities, and dietary improvements.
Minimize risk of falls and injuries with gait and balance training.
Elderly Women
Same as perimenopausal and postmenopausal group plus:
Anchor rugs.
Minimize clutter.
Remove loose wires.
Use nonskid mats.
Install handrails in bathrooms and halls and along stairways.
Light hallways, stairwells, and entrances.
Encourage patient to wear sturdy, low-heeled shoes.
Patients who are predisposed to falling
Recommend hip protectors.
Treatment of Osteoporosis
Goals
The following are goals of treatment of osteoporosis:
- Prevent fractures
- Stabilize or achieve a moderate increase in bone mass
- Relieve symptoms of fractures and skeletal deformity
- Maximize physical function (for example, halt progressive deformity)
The ability to achieve these goals depends on the patient's and the physician's commitment to therapy and the potential for the chosen therapeutic program to yield results.
Candidates for Treatment
The following women may benefit from pharmacologic treatment of osteoporosis:
- Women with postmenopausal osteoporosis:
- Women with low-trauma fractures and low BMD
- Women with BMD T-scores of -2.5 and below
- Women with borderline-low BMD (e.g., T-scores of -1.5 and below) if risk factors are present
- Women in whom nonpharmacologic preventive measures are ineffective (bone loss continues or low-trauma fractures occur)
Nonpharmacologic Measures
Refer to the information provided on preventive strategies (see the section titled "General Principles," above).
Pharmacologic Agents
The American Association of Clinical Endocrinologists and the American College of Endocrinology recommend the following pharmacologic agents when pharmacotherapy is indicated:
- First priority; agents approved by the U.S. Food and Drug Administration (FDA) for the prevention or treatment (or both) of osteoporosis
- Second priority: agents that are not approved by the FDA but for which level 1 or level 2 evidence of efficacy and safety is available (these agents are appropriate for patients who are unable to take approved agents or who have complex and extenuating medical problems that preclude the effective use of approved agents)
Agents approved by the FDA for osteoporosis prevention and/or treatment include (in alphabetical order) bisphosphonates (alendronate, risedronate), salmon calcitonin, estrogen, raloxifene, and teriparatide. All act by reducing bone resorption, except for teriparatide, which has anabolic effects on bone. Although estrogen is not approved for treatment of osteoporosis, there is level 1 evidence for its efficacy in reducing vertebral fractures, non-vertebral fractures, and hip fractures. Level 1 evidence of efficacy in reducing the risk of vertebral fractures is available for all the agents approved for treatment of osteoporosis (bisphosphonates, calcitonin, raloxifene, and teriparatide). Prospective trials have demonstrated the effectiveness of bisphosphonates and teriparatide in reducing the risk of nonvertebral fractures (level 1), but only bisphosphonates have been shown to reduce the risk of hip fractures in prospective controlled trials (level 1).
Calcium and Vitamin D Supplementation
Role in Clinical Practice. Adequate calcium and vitamin D intake are fundamental to all prevention and treatment programs for postmenopausal osteoporosis.
Available Forms and Recommended Dosing. The available forms and recommended dosages of calcium supplements are outlined in the original guideline document (see Table 7 titled "Some Commercially Available Calcium Preparations"). To minimize gastrointestinal side effects and enhance absorption, patients should take calcium in conjunction with food (with meals or a bedtime snack).
Duration of Treatment. Calcium and vitamin D supplementation can be administered safely to most women indefinitely.
Bisphosphonates: Alendronate
Role in Clinical Practice. Alendronate, a nitrogen-containing bisphosphonate, is approved by the FDA for prevention of bone loss in recently menopausal women, treatment of established postmenopausal osteoporosis, and treatment of glucocorticoid-induced osteoporosis.
Available Forms and Recommended Dosing. The approved dosage of alendronate for prevention of bone loss in recently menopausal women and for treatment of corticosteroid-induced osteoporosis in men and estrogen-replete women is 5 mg daily (or 35 mg once weekly). For treatment of established postmenopausal osteoporosis and for treatment of corticosteroid-induced osteoporosis in estrogen-deficient women, 10 mg of alendronate daily (or 70 mg once weekly) is the approved dosage. Once-weekly dosing (that is, 70 mg once weekly) has been shown to be equivalent to daily dosing (10 mg/day), as reflected by changes BMD and biochemical markers (Level 2 evidence), but no fracture data are available.
Alendronate is supplied in 5- and 10-mg tablets for daily administration. It is also available in 35- and 70-mg tablets for once-weekly administration for prevention and treatment of postmenopausal osteoporosis, respectively. Alendronate should be taken with plain water on an empty stomach, at least 1/2 hour before the first food, beverage, or orally administered medication of the day. Taking alendronate in conjunction with food, any beverage other than plain water, or certain medications, or ingesting it within 2 hours after a meal, may substantially reduce or abolish the absorption of alendronate. In order to avoid irritation of the esophagus, alendronate should be taken with approximately 8 ounces of water, and the patient should remain upright (seated or standing) until food has been eaten.
Duration of Treatment. The therapeutic efficacy of alendronate has been demonstrated for 7 years. Efficacy and safety beyond 7 years have not yet been established. When alendronate therapy is discontinued, no acceleration of bone loss relative to placebo has been noted, although slow bone loss may occur.
Bisphosphonates: Risedronate
Role in Clinical Practice. Risedronate, a nitrogen-containing bisphosphonate, is approved by the FDA for prevention of bone loss in recently menopausal women, treatment of established osteoporosis, and prevention and treatment of glucocorticoid-induced osteoporosis in men and women.
Available Forms and Recommended Dosing. Risedronate is supplied as 5-mg tablets for daily administration. It is also available in 35-mg tablets for once-weekly administration. Risedronate should be taken with plain water on an empty stomach, at least 1/2 hour before the first food, beverage, or orally administered medication of the day. After taking risedronate, the patient should remain upright (seated or standing) until food has been eaten.
Duration of Treatment. The therapeutic efficacy of risedronate has been demonstrated for a 3-year period. The efficacy and safety beyond 3 years have not yet been established, and the effect of termination of treatment on the rate of bone loss has not been assessed.
Other Bisphosphonates
Etidronate and pamidronate are available but have not been approved for prevention or treatment of osteoporosis. These agents are used "off label" for patients with osteoporosis.
- Etidronate has antifracture efficacy (Level 1 evidence) and has been approved for treatment of osteoporosis in several countries. It is an alternative for patients who have gastrointestinal intolerance of approved orally administered bisphosphonates. Etidronate for treatment of osteoporosis is given in an intermittent cyclic regimen, 400 mg daily for 14 days, with cycles repeated every 3 months.
- Pamidronate, given by intravenous infusion, may be used for patients who cannot tolerate orally administered bisphosphonates or who may not absorb orally taken bisphosphonates because of gastrointestinal disease (Level 2 evidence). A typical treatment schedule for pamidronate is a loading dose of 90 mg followed by 30 mg every third month given by intravenous infusion in dextrose or saline during a 2-hour period.
Calcitonin
Role in Clinical Practice. Injectable salmon calcitonin was approved by the U.S. Food and Drug Administration for treating osteoporosis in 1984. Its use was limited by the need for subcutaneous injection and side effects such as nausea and flushing that occurred in approximately 20% of subjects. Nasal spray salmon calcitonin has been available since 1995.
Available Forms and Recommended Dosing. Injectable calcitonin is available in sterile solution. For maximal effect, 100 IU/day is administered subcutaneously or intramuscularly. Nasally administered calcitonin is available in a spray bottle that delivers 200 IU per puff. The recommended dosage is one spray (200 IU) daily.
Duration of Treatment. The optimal duration of treatment with calcitonin (either the parenterally or the nasally administered form) is unknown.
Estrogen and Menopausal Hormone Therapy
Role in Clinical Practice. In the United States, oral and transdermal forms of estrogen and combined estrogen-progestin (menopausal hormone therapy [MHT]) are approved for prevention of bone loss in recently menopausal women.
Available Forms and Recommended Dosing. A continuous daily estrogen regimen is recommended to prevent estrogen-deficiency symptoms and promote compliance. A progestin should be administered concomitantly, either cyclically or daily, in women who have not undergone hysterectomy. A partial list of estrogens and combination menopausal hormone therapy approved for prevention of bone loss in recently menopausal women are shown in Table 8 of the guideline document. Although oral estrogen is most commonly prescribed, transdermal administration has beneficial effects on bone mineral density (Level 1 evidence) and may have different effects on lipids and coagulation factors. The usual dose of conjugated estrogens prescribed for bone benefits has been 0.625 mg daily, but lower doses may be of benefit.
Duration of Treatment. Estrogen is often prescribed for relief of symptoms of estrogen deficiency (e.g., hot flashes, night sweats, and vaginal dryness), symptoms that may be mild and self-limited. The risks and benefits of estrogen in this context were not evaluated in the Women's Health Initiative Menopausal Hormone Therapy study. In absolute terms, the risks seen in the Women's Health Initiative are small, and do not preclude the use of MHT for symptom relief. Women who take estrogen or MHT for symptom relief should use the lowest dose necessary for relief of symptoms and periodically reconsider whether or not they need to continue MHT. Women who are currently taking estrogen or MHT should reconsider whether or not they should continue. Women who decide to stop estrogen or MHT should have bone mineral density testing done to determine if adding a pharmacologic agent for prevention of bone loss or treatment of osteoporosis is appropriate.
Selective Estrogen Receptor Modulators
Selective estrogen receptor modulators activate estrogen receptors in target organs selectively to produce quantitatively variable estrogenic effects on estrogen-responsive tissues. Raloxifene has been approved by the FDA for prevention and treatment of postmenopausal osteoporosis. Raloxifene has agonistic effects on bone and lipoprotein production but has antagonistic effects on breast tissue and neutral effects on uterine mucosa.
Role in Clinical Practice. Raloxifene is FDA approved for the treatment of postmenopausal osteoporosis and the prevention of bone loss in recently menopausal women.
Available Forms and Recommended Dosing. Raloxifene is available as a 60 mg tablet. The dosage of raloxifene for prevention of bone loss in recently menopausal women and for treatment of established osteoporosis is 60 mg daily.
Duration of Treatment. Efficacy and safety have been determined for up to 40 months.
Teriparatide (recombinant human parathyroid hormone [PTH] 1-34)
Role in clinical practice. The FDA has approved teriparatide for the treatment of postmenopausal osteoporosis and in men with idiopathic or hypogonadal osteoporosis who are at high risk for fracture or who have failed or are intolerant to previous osteoporosis therapy.
Available forms and recommended dosing. The dose is 20 micrograms daily and is injected subcutaneously. It is dispensed in a glass cartridge, which is pre-assembled into a disposable multiple dose pen device designed to provide 28 doses.
Duration of treatment. The efficacy and safety of teriparatide have been assessed for a period of two years and are presently unknown thereafter.
Concomitant Use of Therapeutic Agents
No data firmly establish that the combined use of two antiresorptive agents (for example, bisphosphonates plus estrogen replacement therapy or raloxifene; estrogen plus calcitonin) has an additive effect on fracture reduction. Additive effects on bone mass and bone turnover have been observed. Until the effect of combined therapy on fracture risk is understood, however, the American Association of Clinical Endocrinologists does not recommend concomitant use of these agents for prevention or treatment of post-menopausal osteoporosis.
Unapproved and Adjuvant Pharmaceutical Therapies
The unapproved and adjuvant therapies for post-menopausal osteoporosis are summarized in the original guideline document (see Table 9 titled "Unapproved and Adjuvant Pharmacotherapies for Postmenopausal Osteoporosis").
Follow-Up
The efficacy and safety of preventive and therapeutic strategies should periodically be reassessed, reinforced, and revised as needed. The American Association of Clinical Endocrinologists recommends annual reassessment, which should include the following:
- Interim history
- Complete medical examination, including breast and pelvic examinations, mammography, and Papanicolaou smear if indicated
- Assessment of adherence to recommended program, including calcium, vitamin D, exercise, and any pharmacologic therapy
- Assessment of stature and skeletal integrity, including radiographic assessment of new deformities or newly symptomatic osseous deformities
- Reinforcement of the therapeutic program and evaluation of the patient's level of understanding and concern
- Periodic assessment of BMD
Bone Mineral Density for Monitoring Treatment
Serial BMD measurements are useful for monitoring changes in bone mass. Each technique for evaluation of bone density has an inherent variability (i.e., precision error) that must be considered when the clinical significance of BMD changes is assessed. With dual x-ray absorptiometry, for example, a BMD difference between measurements must be in the range of 3 to 5% to be clinically significant. Patients treated with bisphosphonates often demonstrate changes of this magnitude at the spine within a year and at the hip after 2 or more years. No change or even a slight reduction of BMD, however, is not evidence of treatment failure and does not warrant alteration of therapy.
Until specific data about the most efficient use of BMD for monitoring become available, the following general guidelines for performing follow-up BMD measurements may be used:
- For patients with "normal" baseline BMD (T-score more than -1.0), consider a follow-up measurement every 3 to 5 years. Patients whose bone density is well above the minimal acceptable level may not need further bone density testing.
- For patients in an osteoporosis prevention program, perform a follow-up measurement every 1 to 2 years until bone mass stability is documented. After BMD has stabilized, perform follow-up measurements every 2 to 3 years.
- For patients on a therapeutic program, perform a follow-up measurement yearly for 2 years. If bone mass has stabilized after 2 years, perform a follow-up measurement every 2 years. Otherwise, continue with annual follow-up measurements until stability of bone mass is achieved.
Definitions:
Levels of Evidence
Level 1 Evidence: Recommendations were based on randomized, prospective, double-blind studies of well-defined patient populations, using the most relevant clinical endpoint, fracturing.
Level 2 Evidence: Recommendations were based on cross-sectional studies, investigations that tested smaller or nonrandomized patient populations, or studies that tested secondary or surrogate clinical endpoints for fracture, such as bone mineral density (BMD) or bone turnover markers, in treated populations.
Level 3 Evidence: Recommendations were based on reviews, editorials, and expert opinions.
