Download Care Working Group - Osteoporosis Canada

2010 Guidelines
2010 Clinical Practice
Guidelines for the
Diagnosis and Management
of Osteoporosis in Canada
Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].
2010 Guidelines
Clinical Approach to
Osteoporosis
Section Three
2010 Guidelines
Recommendations for Clinical Assessment
Assessment
Recommended Elements of Clinical Assessment
Identify risk factors for low bone-mineral density (BMD),
future fractures, and falls
History

Prior fragility fractures

Parental hip fracture

Glucocorticoid use

Current smoking

High alcohol intake (> 3 units per day)

Rheumatoid arthritis

Inquire about falls in the previous 12 months

Inquire about gait and balance
2010 Guidelines
Recommendations for Clinical Assessment
Assessment Recommended Elements of Clinical Assessment
Measure weight (weight loss of >10% since age 25 is significant)
Measure height annually
(prospective loss > 2cm)
(historical height loss > 6 cm)
Physical
Measure rib to pelvis distance < 2 fingers' breadth
examination
Measure occiput-to-wall distance (for kyphosis) > 5cm
Diagnosis
of vertebral
fractures
Assess fall risk by using Get-Up-and-Go Test (ability to get out of
chair without using arms, walk several steps and return)
2010 Guidelines
Radiologic Investigation of the Spine
• Recognition and reporting
of vertebral fractures is of
paramount importance
• Several different types of
radiologic investigations can
be ordered, depending on
the clinical needs
• Vertebral fractures are under reported in emergency
department radiology reports1
1. Majumdar SR, et al. Arch Intern Med 2009; 165(8):905-909.
2010 Guidelines
Consider Secondary Causes
of Low BMD
• Simple biochemical investigation should be
considered in all patients prior to initiating
pharmacologic treatment for osteoporosis
• Additional tests may be needed when a
particular cause is suspected*
• Testosterone testing is not recommended for
men with osteoporosis unless there are clinical
features of hypogonadism
*see Jamal SA, et al. Osteoporos Int 2005; 16(5):534-40.
2010 Guidelines
Clinical Assessment:
Summary Statements
Statement
Strength
A fragility fracture is a major risk factor for predicting another
fracture
Level 1
Fractures of the hip and of the vertebra are associated with
significant morbidity and mortality
Level 1
There is an important osteoporosis care gap in Canada
Level 1
A history of a fall in the past year is predictive of future falls
Level 1
Click here for a summary of the system for levels of evidence.
2010 Guidelines
Clinical Assessment:
Recommendations
Recommendation
Grade
Individuals age 50 and older who have experienced a fragility
fracture should be assessed and considered for treatment
A
A history should be performed to determine the presence of risk
factors associated with osteoporosis and fragility fractures in
individuals age 50 and older
A
A history of falls over the past year should be elicited, and if
positive should prompt a falls risk assessment
A
Height should be measured annually and prospective height
loss should be determined to identify those who may have
experienced a vertebral fracture during the period of monitoring
A
Click here for a summary of the system for grades of recommendations.
2010 Guidelines
Clinical Assessment:
Recommendations (Cont'd)
Recommendation
Grade
A multifactorial falls risk assessment that includes assessment
of the ability to rise from a chair without using the arm rest
should be assessed, as this predicts falls and fractures
A
If clinical evidence is suggestive of a vertebral fracture
(significant historical height loss, prospective height loss, wallto-occiput distance or rib-pelvis distance), then lateral thoracic
and lumbar spine radiographs should be performed
A
2010 Guidelines
Clinical Assessment:
Recommendations (Cont'd)
Recommendation
Patients with osteoporosis need only limited laboratory investigations
performed: complete blood count, calcium corrected for albumin,
creatinine, alkaline phosphatase, and thyroid stimulating hormone
Measurement of serum 25-OH-D is recommended among
individuals with the following conditions: treatment with
pharmacologic therapy for osteoporosis, recurrent fractures, bone
loss despite osteoporosis treatment, or those with co-morbid
conditions that affect vitamin D absorption or action
Serum protein electrophoresis should be performed in individuals
with vertebral fractures
In selected patients, based on clinical assessment, additional
biochemical testing should be considered to rule out secondary
causes of osteoporosis
Grade
D
D
D
D
2010 Guidelines
Back-up Material
Additional slides that can be accessed from
hyperlinks on core slides
Section Three – Clinical Approach to Osteoporosis
2010 Guidelines
Risk Factors for Fracture1-5
•
•
•
•
•
•
•
•
Fragility fracture after the age of 40
Parental history of hip fracture
Premature menopause
Glucocorticoid use (> 7.5 mg/d)
> 3 months in the prior year
Lifestyle factors: smoking, excessive
alcohol, and physical inactivity
Weight loss since age 25 >10%
Poor nutrition, calcium intake, vitamin D status
Recurrent falls
Return to main presentation
1. Papaioannou A, et al. Osteoporos Int 2009; 20:507-518.
2. Waugh EJ, et al. Osteoporos Int 2009; 20:1-21.
3. Cummings SR, et al. N Engl J Med 1995; 332(12):767-773.
4. Papaioannou A, et al. Osteoporos Int 2005; 16(5):568-578.
5. van Staa TP, et al. J Bone Miner Res 2000; 15(6):993-1000.
2010 Guidelines
Importance of Weight
• In men > 50 years and postmenopausal
women, the following are associated with low
BMD and fractures
– Low body weight (< 60 kg)
– Major weight loss (> 10% of
weight at age 25)
Return to main presentation
1. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.
2. Waugh EJ, et al. Osteoporos Int 2009; 20:1-21.
3. Cummings SR,et al. N Engl J Med 1995; 332(12):767-773.
4. Papaioannou A, et al. Osteoporos Int 2005; 16(5):568-578.
5. Kanis J, et al. Osteoporos Int 1999; 9:45-54.
6. Morin S, et al. Osteoporos Int 2009; 20(3):363-70.
2010 Guidelines
Importance of Height Loss
• Increased risk of vertebral
fracture
– Historical height loss (> 6 cm)1,2
– Measured height loss (< 2 cm)3-5
• Significant height loss should
be investigated by a lateral
thoracic and lumbar spine
X-ray
1. Siminoski K, et al. Osteoporos Int 2006; 17(2):290-296.
2. Briot K, et al. CMAJ 2010; 182(6):558-562.
3. Moayyeri A, et al. J Bone Miner Res 2008; 23:425-432.
4. Siminoski K, et al. Osteoporos Int 2005; 16(4):403-410.
5. Kaptoge S, et al. J Bone Miner Res 2004; 19:1982-1993.
2010 Guidelines
Appropriate Measurement of Height
• Use a wall-mounted
stadiometer
• Instructions for subjects:
– Shoes off
– Heels, buttocks, and back
against the upright board
– Face directly forward,
head stable
• Record height after
exhalation
Return to main presentation
Siminoski K, et al. Osteoporos Int 2005; 16(4):403-410.
2010 Guidelines
Additional Tests for Clinical
Identification of Vertebral Fracture
Test
Rationale
Method
Interpretation
Rib-pelvis
distance1
To identify
lumbar fractures
Measure the
< 2 fingerbreadths
distance between is associated with
the costal margin vertebral fractures
and the pelvic rim
on the mid-axillary
line
Occiput-towall
distance2,3
To help identify
thoracic spine
fractures
Stand straight
with heels and
back against the
wall
> 5 cm raises
suspicion of
vertebral fracture
1. Olszynski WP, et al. BMC Musculoskeletal Disorders 2002; 3:22.
2. Green AD, et al. JAMA 2004; 292(23):2890-2900.
3. Siminoski K, et al. J Bone Miner Res 2001; 16(Suppl):S274.
2010 Guidelines
Rib-Pelvis and Occiput-to-Wall Distances
4 cm
8 cm
3 cm
Height loss
12 cm
3 FBs
Return to main presentation
2 FBs
8 cm
2010 Guidelines
Plain Radiographic
Examinations of the Spine
Type
Use(s)
Plain radiographs,
complete
To investigate symptoms such as back pain, or after
trauma
Plain radiographs,
limited
Specifically to look for osteoporotic fracturing
Plain radiographs,
incidental
Incidental views of the spine on radiographs
undertaken for other purposes (e.g., lateral chest films)
2010 Guidelines
Other Radiographic
Examinations of the Spine
Type
Use(s)
Incidental to dual X-ray absorptiometry (DXA)
Vertebral fracture
– provides lower-resolution images of the
assessment (VFA), T4 to L4
spine, not subject to projection distortion
Computed tomography (CT) To clarify subtle or uncertain findings on
of the spine
radiographs
Magnetic resonance
imaging (MRI) of the spine
Radionuclide bone
scanning
Return to main presentation
To examine soft tissues or clarify the
acuteness of spinal fracturing
To look for disease activity or distribution
May also be helpful in diagnosing such
conditions as metastatic disease and
acuteness of injury
2010 Guidelines
% of Confirmed Vertebral Fractures
Mentioned in ER Radiology Reports*
40%
60%
Reported
Not reported
*n = 500 patients undergoing chest radiograph for any indication
ER = emergency room
Return to main presentation
Majumdar SR, et al. Arch Intern Med 2009; 165(8):905-909.
2010 Guidelines
Recommended Biochemical Tests for
Patients Being Assessed for Osteoporosis
•
•
•
•
•
•
Calcium, corrected for albumin
Complete blood count
Creatinine
Alkaline phosphatase
Thyroid stimulating hormone (TSH)
Serum protein electrophoresis for patients with
vertebral fractures
• 25-hydroxy vitamin D (25-OH-D)*
Return to main presentation
* Should be measured after 3-4 months of adequate supplementation
and should not be repeated if an optimal level ≥75 nmol/L is achieved.
2010 Guidelines
Tests for Potential Secondary Causes
In patients with
Condition /
Disease
Persistently elevated serum
Hyperparathyroidism
calcium
Multiple or atypical vertebral
Multiple myeloma
fractures
Symptoms/signs of
malabsorption or non
Celiac disease
response to vitamin D therapy
Signs and symptoms of
androgen deficiency (in men)
Hypogonadism
History of kidney stones
Hypercalciuria
Return to main presentation
Test
Parathyroid hormone
(PTH)
Protein electrophoresis
Immunoelectrophoresis
Antibodies associated
with gluten enteropathy
Testosterone (bioavailable
or total)
Serum prolactin
24-hour urine for calcium
2010 Guidelines
Reasons Why Routine Testosterone
Testing is NOT Recommended
• Variability in the assay
• Lack of clarity concerning which assay to use
(bioavailable, total, free)
• Wide diurnal fluctuation
Return to main presentation
2010 Guidelines
Criteria Used to Assign Levels of
Evidence: Studies of Diagnosis
Level
Criteria
i
ii
1
Independent interpretation of test results
Independent interpretation of the diagnostic standard
iii Selection of people suspected, but not known to have the
disorder
iv Reproducible description of the test and diagnostic standard
v
At least 50 people with and 50 people without the disorder
2
Meets four of the Level 1 criteria
3
Meets two of the Level 1 criteria
4
Meets one or two of the Level 1 criteria
2010 Guidelines
Criteria Used to Assign Levels of Evidence:
Studies of Treatment and Intervention
Level Criteria
1+
Systematic overview of meta-analysis of RCTs
1
One RCT with adequate power
2+
Systematic overview or meta-analysis of Level 2 RCTs
2
RCT that does not meet Level 1 criteria
3
Non-RCT or cohort study
Before/after study, cohort study with non-contemporaneous
controls, case-control study
4
5
Case series without controls
6
Case report or case series of < 10 patients
RCT = randomized, controlled study
2010 Guidelines
Criteria Used to Assign Levels of
Evidence: Studies of Prognosis
Level
Criteria
i
ii
1
Inception cohort of patients with the condition of interest, but
free of the outcome of interest
Reproducible inclusion and exclusion criteria
iii Follow-up of at least 80% of participants
iv Statistical adjustment for confounders
v
Reproducible description of the outcome measures
2
Meets criterion i and three of the other four Level 1 criteria
3
Meets criterion i and two of the other four Level 1 criteria
4
Meets criterion i and one of the other four Level 1 criteria
Return to main presentation
2010 Guidelines
Criteria Used to Assign
Grades of Recommendation
Level
Criteria
A
Need supportive level 1 or 1+ evidence plus consensus*
B
Need supportive level 2 or 2+ evidence plus consensus*
C
Need supportive level 3 evidence plus consensus
D
Any lower level of evidence supported by consensus
* As appropriate level of evidence was necessary, but not sufficient to assign
a grade in recommendation; consensus was required in addition.
Return to main presentation
2010 Guidelines
Falls Risk Assessment
• History of falls in the last
year is one of the most
significant risk factors for
predicting future fall1-6
• Dementia and poor physical
function have also been
found to be associated with
falls and fractures in older
adults2,4,5
Age 80
Age 60
1. Tinetti ME. N Engl J Med 2003; 348:42-49.
2. J Am Geriatr Soc 2001; 49:664-672.
3. Ganz DA, et al. JAMA 2007; 297:77-86.
4. Bensen R, et al. BMC Musculoskeletal Disorders 2005; 6:47.
5. Cawthon PM, et al. J Bone Miner Res 2008; 23:1037-1044.
6. Gates S,et al. BMJ 2008; 336(7636):130-133.
2010 Guidelines
Assessment and Management of Falls
Periodic case
finding in
primary care:
Ask all
patients
about falls
in past year
• From a joint guideline
issued in 2001 by:
• American Geriatrics Society
• British Geriatrics Society
• American Academy of
Orthopaedic Surgeons
Recurrent
falls
Check for gait/balance
problem
No
problem
Full evaluation*
Assessment
History
Medications
Vision
Gait and balance
Lower limb joints
Neurological
Cardiovascular
Return to main presentation
No
intervention
Single
fall
Gait/
balance
problems
Patient
presents
to medical
facility after
a fall
No
falls
Multifactorial intervention
(as appropriate)
Gait, balance & exercise programs
Medication modifications
Posteral hypotension treatment
Environmental hazard modification
Cardiovascular disorder treatment
J Am Geriatr Soc 2001; 49(5):664-72.