Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
The strength of recommendation grading (A-D) and level of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Risk Factors for Osteoporosis
B - Patients who have suffered one or more fragility fractures should be priority targets for investigation and treatment of osteoporosis.
C - Use of family history in assessing risk of osteoporosis should include maternal, paternal, and sister history.
C - Family history should include not only a given diagnosis of osteoporosis but also kyphosis and low trauma fracture after age 50.
B - Smokers should be considered at greater risk of osteoporosis than non-smokers, and advised to stop, for this and other reasons.
Measurement, Diagnosis and Monitoring
B - Conventional radiographs should not be used for the diagnosis or exclusion of osteoporosis.
B - When plain films are interpreted as "severe osteopaenia" it is appropriate to suggest referral for dual-energy X-ray absorptiometry (DXA).
A – Bone mineral density (BMD) should normally be measured by DXA scanning performed on two sites, preferably anteroposterior spine and hip.
B - Repeat measurements should only be performed if they influence treatment.
C - If DXA investigations are repeated, anteroposterior (AP) spine and total hip measurements should be used to follow response to treatment.
C - Following a DXA scan of the hip, the annual hip fracture risk (or 10 year fracture risk) should be included in the DXA report.
C - Where lateral spine scans acquired with fan-beam DXA are available, visual assessment should be used to assess prevalent vertebral fractures.
B - Evidence of existing vertebral deformity should be used to modify the hip fracture risk estimated from age, sex, and BMD.
A - Biochemical markers of bone turnover should have no role in the diagnosis of osteoporosis or in the selection of patients for BMD measurement.
Non-pharmacological Interventions
B - High intensity strength training is recommended as part of a management strategy for osteoporosis.
B - Low impact weight bearing exercise is recommended as part of a management strategy for osteoporosis.
A - Postmenopausal women should aim for a dietary intake of 1,000 mg calcium per day.
B - Ipriflavone should not be used as a sole therapy for fracture reduction in patients with osteoporosis.
Pharmacological Management
For postmenopausal women with multiple vertebral fractures
A - To reduce fracture risk at all sites: treatment with oral risedronate (5 mg daily or 35 mg once weekly + calcium + vitamin D).
A - To reduce vertebral fracture risk: treatment with intermittent cyclical etidronate (400 mg daily for 14 days + 500 mg calcium daily for 76 days, repeating 3 monthly cyclical therapy).
For postmenopausal women with osteoporosis determined by axial DXA and with a history of at least one vertebral fracture
A - To reduce fracture risk at all sites: treatment with oral alendronate (10 mg daily or 70 mg once weekly + calcium + vitamin D).
A - To reduce vertebral fracture risk: treatment with oral raloxifene (60 mg daily + calcium + vitamin D).
B - To reduce vertebral fracture risk: treatment with intranasal calcitonin (200 IU daily + calcium + vitamin D).
For postmenopausal women with osteoporosis determined by axial DXA, with or without previous non-vertebral fracture
A - To reduce fracture risk at all sites: treatment with either oral alendronate (10 mg daily or 70 mg once weekly + calcium + vitamin D) or oral risedronate (5 mg daily or 35 mg once weekly + calcium + vitamin D).
A - To reduce vertebral fracture risk: treatment with oral raloxifene (60 mg per day + calcium + vitamin D).
For frail, elderly (aged 80+ years) women with a diagnosis of osteoporosis, with or without previous non-vertebral fractures
A - To reduce fracture risk at all sites, elderly women who have suffered multiple vertebral fractures or who have had osteoporosis confirmed by DXA scanning should be considered for treatment with either oral risedronate (5 mg daily or 35 mg once weekly+ calcium + vitamin D) or oral alendronate (10 mg daily or 70 mg once weekly + calcium + vitamin D).
A - To reduce hip fracture risk, frail elderly women who are housebound should receive oral calcium 1,000 to 1,200 mg daily + 800 IU vitamin D.
For men with a diagnosis of osteoporosis determined by axial DXA with or without previous osteoporotic fracture
A - To reduce fracture risk at all sites, men with low BMD and/or a history of one or more vertebral fractures or one non-vertebral osteoporotic fracture should be treated with oral alendronate (10 mg + 500mg calcium + 400 IU vitamin D daily).
Definitions:
Grades of Recommendation
A: At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies; high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies, e.g. case reports, case series
4: Expert opinion
