The grades of recommendations (A-E and L) and levels of evidence (I, II-1, II-2, II-3, and III) are defined at the end of the "Major Recommendations" field.
- The goals of osteoporosis management include assessment of fracture risk and prevention of fracture and height loss. (1B)
- A stable or increasing bone mineral density (BMD) reflects a response to therapy in the absence of low trauma fracture or height loss. Progressive decreases in BMD, with the magnitude of bone loss being greater than the precision error of the bone densitometer, indicate a lack of response to current therapy. Management should be reviewed and modified appropriately. (1A)
- Physicians should identify the absolute fracture risk in postmenopausal women by integrating the key risk factors for fracture; namely, age, BMD, prior fracture, and glucocorticoid use. (1B)
- Physicians should be aware that a prevalent vertebral or nonvertebral fragility fracture markedly increases the risk of a future fracture and confirms the diagnosis of osteoporosis irrespective of the results of the bone density assessment. (1A)
- Treatment should be initiated according to the results of the 10-year absolute fracture risk assessment. (1B)
Calcium and Vitamin D
- Adequate calcium and vitamin D supplementation is key to ensuring prevention of progressive bone loss. For postmenopausal women, a total intake of 1500 mg of elemental calcium from dietary and supplemental sources and supplementation with 800 IU/d of vitamin D are recommended. Calcium and vitamin D supplementation alone is insufficient to prevent fracture in those with osteoporosis; however, it is an important adjunct to pharmacologic intervention with antiresorptive and anabolic drugs. (1B)
Hormone Therapy
- Usual-dosage hormone therapy (HT) should be prescribed for symptomatic postmenopausal women as the most effective therapy for menopausal symptom relief (1A) and a reasonable choice for the prevention of bone loss and fracture. (1A)
- Physicians may recommend low- and ultralow-dosage estrogen therapy to symptomatic women for relief of menopausal symptoms (1A) but should inform their patients that despite the fact that such therapy has demonstrated a beneficial effect in osteoporosis prevention (1A), no data are yet available on reduction of fracture risk.
Bisphosphonates
- Treatment with alendronate, risedronate, or zoledronic acid should be considered to decrease the risk of vertebral, nonvertebral, and hip fractures. (1A)
- Etidronate is a weak antiresorptive agent and may be effective in decreasing the risk of vertebral fracture in those at high risk. (1B)
Selective Estrogen Receptor Modulators
- Treatment with raloxifene should be considered to decrease the risk of vertebral fractures. (1A)
Calcitonin
- Treatment with calcitonin can be considered to decrease the risk of vertebral fractures and to reduce pain associated with acute vertebral fractures. (1B)
Parathyroid Hormone
- Treatment with teriparatide should be considered to decrease the risk of vertebral and nonvertebral fractures in postmenopausal women with severe osteoporosis. (1A)
Definitions:
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial.
II-1: Evidence from well-designed controlled trials without randomization.
II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group.
II-3: Evidence from comparisons between times or places with or without the intervention. Dramatic results from uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Classification of Recommendations**
A. There is good evidence to recommend the clinical preventive action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive action
L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making
*The quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.***
**Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.***
***Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care. Can Med Assoc J 2003;169(3):207-8.
