• University of Michigan Health System. Osteoporosis: prevention and treatment. Ann Arbor (MI): University of Michigan Health System; 2005 Jul. 13 p.

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Osteoporosis: prevention and treatment. Ann Arbor (MI): University of Michigan Health System; 2002 Mar. 12 p.

Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information on drug dosing, Dexa-T scoring, and patient screening criteria.

The levels of evidence (A, B, C, D) are repeated at the end of the "Major Recommendations" field.

Definitions

• Bone mineral density (BMD) correlates with skeletal strength and fracture risk.
• Dual emission X-ray absorptiometry (DEXA) measures BMD.
• A DEXA T-score is the number of standard deviations from mean BMD in young adult women.
• Osteoporosis is defined as a DEXA T-score <-2.5, osteopenia as >-2.5 but <-1.0 (refer to Table 1 in the original guideline document for details).

General Clinical Relevance

Fractures related to osteoporosis are common and have high morbidity [C].

Glucocorticoids can cause significant bone loss, particularly during the first 6 to 12 months of use [C].

Prevention

Recommend weight bearing exercise and adequate calcium (1200-1500 mg/day) and vitamin D (400-800 IU/day) across the life span (refer to Table 6 in the original guideline document for details) [D]. Most older persons need vitamin D 700-800 IU/day [A].

Risk Assessment and Diagnosis

• Assess all adults for clinical risk factors for osteoporotic fracture (refer to Table 2 in the original guideline document for details) [C]
  • Postmenopausal woman with one or more of the following:
    • Age >65 years
    • Current smoking
    • Low body weight
    • Frailty
    • Personal history of fracture without substantial trauma age >40
    • Hip, wrist, or spine fracture without substantial trauma in 1st degree relative >50
  • Chronic glucocorticoid use (prednisone >7.5 mg daily, or equivalent, for >6 months)
  • Organ transplant or pending transplant
  • Other associated medical conditions and medications
• Order DEXA based on clinical risk factors and potential impact of results on management (refer to Table 3 in the original guideline document for details).
• Evaluate appropriately and refer, when indicated, for secondary causes of osteoporosis (refer to Table 4 in the original guideline document for details) [D].

Treatment

• Treat based on DEXA T-score and clinical risk factors for fracture (refer to Table 2 and Table 6 in the original guideline document for details)
  • Prior osteoporosis-related fracture [A].
  • T-score <-1 and (a) glucocorticoid use or (b) pending or post-transplant, especially if on steroids or (c) postmenopausal woman at high risk (i.e., with other risk factors for fracture but not already receiving hormone replacement therapy [HRT] [A]).
  • T-score <-2 and (a) postmenopausal woman [A] or (b) man [A] or (c) person with other risk factors [D].
• When starting glucocorticoids consider therapy for prevention or treatment of osteoporosis [A].
• Base management strategies on benefits and risks (refer to Table 6, Table 7, and Table 8 in the original guideline document for details)
  • In post-menopausal women with osteoporosis:
    • Alendronate and risedronate reduce hip and vertebral fracture risk [A].
    • Raloxifene and calcitonin reduce vertebral fracture risk [A].
    • HRT reduces vertebral [A] and hip [A] fracture risk, but overall poses health risks >placebo [A]. Consider use of HRT for osteoporosis only if there are other indications to use HRT.
  • In men with osteoporosis, alendronate reduces vertebral fracture risk [A].
  • In glucocorticoid use, risedronate (and perhaps alendronate) reduces vertebral fracture risk [A].

Follow-up

• Follow-up osteoporosis or osteopenia with a repeat DEXA based on a patient's situation (refer to Table 3 and Table 5 in the original guideline document for details).
• For most persons an interval of >2 years between DEXAs provides the most meaningful information.
• Early in glucocorticoid use and/or after transplantation consider repeating DEXA in 6 to 12 months.

Definitions:

Levels of Evidence

Levels of evidence reflect the best available literature in support of an intervention or test.

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

None provided

The type of supporting evidence is identified and graded for each recommendation (see Major Recommendations).

Conclusions were based on prospective randomized clinical trials, if available, to the exclusion of other data. If randomized controlled trials (RCTs) were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

• University of Michigan Health System. Osteoporosis: prevention and treatment. Ann Arbor (MI): University of Michigan Health System; 2005 Jul. 13 p.

Not applicable: The guideline was not adapted from another source.

2002 Mar (revised 2005 Jul)

University of Michigan Health System - Academic Institution

University of Michigan Health System

Osteoporosis Guideline Team

Team Leader: Jane McCort, MD, General Medicine

Team Members: Van Harrison, PhD, Medical Education; Robert Lash, MD, Endocrinology; Yolanda Smith, MD, Obstetrics/Gynecology; Lourdes Velez, MD, Family Medicine

Guidelines Oversight Team: Connie Standiford, MD; Lee Green, MD, MPH; Van Harrison, PhD

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Osteoporosis: prevention and treatment. Ann Arbor (MI): University of Michigan Health System; 2002 Mar. 12 p.

This NGC summary was completed by ECRI on March 19, 2003. The information was verified by the guideline developer on April 23, 2003. This NGC summary was updated by ECRI on September 22, 2005. The updated information was verified by the guideline developer on November 1, 2005.

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).