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Eval/counsel on osteoporosis/fx risk;1 then assess for scanning/imaging - Ca++ intake: men 50-70 yo = 1,000 mg/day; supplement if needed
- Vit D intake: 800–1,000 IU/day for ≥50 yo; supplement if needed,2 correct deficiency3
- Exercise: wt-bear/muscle strengthen4 + fall/fx risk prevention1
- If tobacco smoker: advise cessation
- √ ht annually (wall-mount stadiometer preferred)
Consider DXA BMD5 +/- vertebral imaging6 based on fx risk factors: - If hx of low-trauma fx at/after age 50:7,8 √ BMD + vertebral imaging6
- If ↓ht, recent/ongoing glucocorticoid10 tx: √ BMD + vertebral imaging6
- If on certain meds assoc. w/ bone loss10,11 or hx conditions12 assoc. w/ bone loss (eg, RA, metabolic bone dz): √ BMD
Footnotes 1 Assess/manage fall risks, eg, previous hx falling, home safety (rugs, low lighting, etc), balance training/muscle strengthening, correct poor vision, avoid CNS depressants (narcotics, anticonvulsants, psychotropics)/excessive EtOH, monitor BP meds, dehydration, urgent urinary incontinence, cognitive issues, etc.
2 Vitamin D-deficiency risks include: malabsorption (eg, celiac dz, IBD, gastric bypass), chronic renal insufficiency, meds that ↑vitamin D breakdown (eg, some antiseizure drugs), ↓sun exposure, very dark skin, obesity.
3 Vitamin D-deficient adults: tx w/ 50,000 IU vitamin D2 or D3 once/wk (or 7,000 IU vitamin D2 or D3 daily) x8–12wk to achieve 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,500–2,000 IU/day or as required for target blood levels.
4 Wt-bearing: walk, jog, Tai Chi, stairs, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Before an osteoporosis pt starts new vigorous program (eg, running, heavy wt-lifting), 1st eval by clinician.
5 DXA @ hip = best predictor of hip fx risk. Results of peripheral DXA (forearm, finger, heel) or quantitative US densitometry (heel, tibia, patella, etc) not equivalent to central skeletal DXA.
6 Vertebral imaging = lateral T + L-spine x-ray, or lateral vertebral fx assessment (VFA) (available on most modern DXA machines).
7 Osteoporosis dx is established by BMD or by adulthood hip/vertebral fx in absence of major trauma (eg, MVA, multiple-story fall). Any adult fx may indicate osteoporosis and should prompt eval; hip and vertebral fx indicate osteoporosis unless excluded by clinical eval and imaging. Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology.
8 Vertebral fx is consistent w/ osteoporosis dx, even in absence of a bone density dx, and is an indication for osteoporosis drug tx to ↓ subsequent fx risk.
9 Historical ht loss = peak ht @ 20 yo – current ht ≥1.5” (4 cm); or prospective ht loss = any previously documented ht – current ht ≥0.8” (2 cm).
10 ≥5 mg prednisone or equivalent daily for ≥3 mo: consider BMD + vertebral imaging.
11 Meds: aluminum (antacids), anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, cyclosporine A, depo-medroxyprogesterone, steroids (oral, ≥5 mg/day prednisone for >3 mo, ever), GnRH agonists, Li, MTX, TPN, PPIs, SSRIs, tamoxifen, tacrolimus, thyroid hormone (excess), TZDs.
12 Metabolic bone dz (eg, hyperparathyroidism, osteomalacia) may be assoc. w/ low BMD. EtOH: >3 drinks/day in men may detriment bone health, ↑falling, and requires eval for possible alcoholism. Other conditions: celiac, central obesity, IBD, etc.
Eval/counsel on osteoporosis/fx risk;13 √ DXA BMD14,15 +/- vertebral imaging16 - Ca++ intake: men 50-70 yo = 1,000 mg/day; men ≥71 yo = 1,200 mg/day; supplement if needed
- Vit D intake: 800–1,000 IU/day for ≥50 yo; supplement if needed,17 correct deficiency18
- Exercise: wt-bear/muscle strengthen19 + fall/fx risk prevention13
- If tobacco smoker: advise cessation
- √ ht annually (wall-mount stadiometer preferred)
√ DXA central-skeletal BMD14 based on age, regardless of risk factors If hx low-trauma fx at/after age 50,20,21↓ht,22 or recent/ongoing glucocorticoid23 tx: consider vertebral imaging16 in addition to BMD Footnotes 13 Assess/manage fall risks, eg, previous hx falling, home safety (rugs, low lighting, etc), balance training/muscle strengthening, correct poor vision, avoid CNS depressants (narcotics, anticonvulsants, psychotropics)/excessive EtOH, monitor BP meds, dehydration, urgent urinary incontinence, cognitive issues, etc.
14 DXA @ hip = best predictor of future hip fx risk. L-spine/hip DXA requires appropriately trained technologists, properly maintained instruments. Community-based screening w/ peripheral DXA (forearm, finger, heel) or quantitative US densitometry (heel, tibia, patella, etc): Results not equivalent to DXA; abnl results should be confirmed by exam, risk assessment, central DXA.
15 Osteoporosis dx is established by BMD or by an adulthood hip/vertebral fx in absence of major trauma (eg, MVA or multiple-story fall). Any adult fx may indicate osteoporosis and should prompt eval; hip and vertebral fx indicate osteoporosis unless excluded by clinical eval and imaging. Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology.
16 Vertebral imaging = lateral T + L-spine x-ray, or lateral vertebral fx assessment (VFA) (available on most modern DXA machines).
17 Vitamin D-deficiency risks include: malabsorption (eg, celiac dz, IBD, gastric bypass), chronic renal insufficiency, meds that ↑ vitamin D breakdown (eg, some anti-seizure drugs), limited sun exposure, very dark skin, obesity.
18 Vitamin D-deficient adults: tx w/ 50,000 IU vitamin D2 or D3 once/wk (or 7,000 IU vitamin D2 or D3 daily) x8–12wk to achieve 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,500–2,000 IU/day or as required for target blood levels.
19 Wt-bearing: walk, jog, Tai Chi, stairs, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Before an osteoporosis pt starts new vigorous program (eg, running, heavy wt-lifting), 1st eval by clinician.
20 Osteoporosis dx is established by BMD or by adulthood hip/vertebral fx in absence of major trauma (eg, MVA, multiple-story fall). Any adult fx may indicate osteoporosis and should prompt eval; hip and vertebral fx indicate osteoporosis unless excluded by clinical eval and imaging. Recent fx, multiple fx, or very low BMD should prompt eval for 2°etiology.
21 Vertebral fx is consistent w/ osteoporosis dx, even in absence of a bone density dx, and is an indication for osteoporosis drug tx to ↓ subsequent fx risk.
22 Historical ht loss = peak ht @ 20 yo – current ht ≥1.5” (4 cm); or prospective ht loss = any previously documented ht – current ht ≥0.8” (2 cm).
23 ≥5 mg prednisone or equivalent daily for ≥3 mo: consider vertebral imaging in addition to BMD.
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Normal BMD (T-score ≥-1.0) Counsel on osteoporosis risk reduction (Ca++,24 vit D,25 exercise26) including diet/supplements if needed,24,25 consider vertebral imaging in select pts - Modify lifestyle prn, including wt-bear/muscle-strength exercise,26 balance training, smoking cessation
- Estimate 10-yr fx probability w/ US-adapted FRAX if appropriate27
- If hx of low-trauma fx at/after age 50,28,29↓ ht,30 or recent/ongoing glucocorticoid31 tx: consider vertebral imaging32
- If age ≥80 yo w/ T-score ≤-1.0 @ spine/total hip/femoral neck: consider vertebral imaging32
- √ ht annually (wall-mount stadiometer preferred)
Footnotes 24 Ca++ intake: men 50-70 yo = 1,000 mg/day; men ≥71 yo = 1,200 mg/day; supplement if needed.
25 Vit D intake: 800–1,000 IU/day for ≥50 yo; supplement if needed, correct deficiency. In vitamin D-deficient adult: tx w/ 50,000 IU vitamin D2 or D3 once/wk or equivalent daily dose (7,000 IU vitamin D2 or D3) x8–12wk to achieve a 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,500–2,000 IU/day or as required for target blood levels.
26 Wt-bearing: walk, jog, Tai Chi, stairs, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Before an osteoporosis pt starts new vigorous program (eg, running, heavy wt-lifting), 1st eval by clinician.
27 USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculate w/ either femoral-neck or total-hip BMD; femoral neck preferred; nonhip sites not recommended. FRAX underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑fall risk. FRAX is most useful in low femoral-neck BMD. If low L-spine BMD but relatively NL femoral-neck BMD, it underestimates fx risk. WHO algorithm not validated for use w/ L-spine BMD (NOF recommends osteoporosis tx of L-spine as well as hip). FRAX not validated in pts currently/previously treated for osteoporosis; however, pts off osteoporosis meds ≥1-2 yrs might be considered untreated.
28 Osteoporosis dx is established by BMD or by an adulthood hip/vertebral fx in absence of major trauma (eg, MVA or multiple-story fall). Any adult fx may indicate osteoporosis and should prompt eval; hip and vertebral fx indicate osteoporosis unless excluded by clinical eval and imaging. Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology.
29 Vertebral fx is consistent w/ osteoporosis dx, even in absence of a bone density dx, and is an indication for osteoporosis drug tx to ↓ subsequent fx risk.
30 Historical ht loss = peak ht @ 20 yo – current ht ≥1.5” (4 cm); or prospective ht loss = any previously documented ht – current ht ≥0.8” (2 cm).
31 ≥5 mg prednisone or equivalent daily for ≥3 mo: consider vertebral imaging in addition to BMD.
32 Vertebral imaging = lateral T + L-spine x-ray, or lateral vertebral fx assessment (VFA) (available on most modern DXA machines).
Counsel on risks, consider additional diagnostics, then consider meds - Detailed hx, exam for osteoporosis-related fx/falls.33,34 √ FRAX risk if appropriate.35 Modify fall risks, consider OT/PT eval (eg, walk aids, assist devices)33
- Modify diet/supplements, correct deficiencies (Ca++,36 vit D37), wt-bear/muscle-strength exercise,38,39 balance training prn, smoking cessation
- Consider eval for 2° osteoporosis causes40
√ vertebral imaging41 if: - Hx low-trauma fx at/after age 50,42,43↓ ht,44 or recent/ongoing glucocorticoid45 tx
- ≥80 yo w/ T-score ≤−1.0 @ spine/total hip/femoral neck
- 70–79 yo w/ T-score ≤−1.5 @ spine/total hip/femoral neck
Consider FDA-approved drug on case-by-case basis, in light of pt preference, if: - Hip/vertebral fx (clinical or asymptomatic)34,46,47
- T-score ≤−2.548 @ femoral neck/total hip/L-spine
- T-score −1.0 to−2.548 (osteopenia) @ femoral neck/total hip/L-spine: if 10-yr hip fx probability ≥3%, or 10-yr major osteoporosis-related fx probability ≥20% per FRAX49
Individualize tx w/ FDA-approved options:50,51 - Bisphosphonate (alendronate, ibandronate, risedronate, zoledronic acid), calcitonin, PTH (1-34) (teriparatide), RANKLi (denosumab)
- Arrange follow-up at least annually; √ biochemical markers52 if planning to monitor tx effects
Footnotes 33 Assess/manage fall risks, eg, previous hx falling, home safety (rugs, low lighting, etc), balance training/muscle strengthening, correct poor vision, avoid CNS depressants (narcotics, anticonvulsants, psychotropics)/excessive EtOH, monitor BP meds, dehydration, urgent urinary incontinence, cognitive issues, etc.
34 If recent fx: fx liaison service programs demonstrate quality-of-care improvements.
35 USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculate w/ either femoral-neck or total-hip BMD; femoral neck preferred; nonhip sites not recommended. FRAX underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑ fall risk. FRAX is most useful in low femoral-neck BMD. If low L-spine BMD but relatively NL femoral-neck BMD, it underestimates fx risk. WHO algorithm not validated for use w/ L-spine BMD (NOF recommends osteoporosis tx of L-spine as well as hip). FRAX not validated in pts currently/previously treated for osteoporosis; however, pts off osteoporosis meds ≥1-2 yrs might be considered untreated.
36 Ca++ intake: men 50-70 yo = 1,000 mg/day; men ≥71 yo = 1,200 mg/day; supplement if needed.
37 Vit D intake: 800–1,000 IU/day for ≥50 yo; supplement if needed, correct deficiency. In vitamin D-deficient adult: tx w/ 50,000 IU vitamin D2 or D3 once/wk or equivalent daily dose (7,000 IU vitamin D2 or D3) x8–12wk to achieve a 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,500–2,000 IU/day or as require for target blood levels.
38 Wt-bearing: walk, jog, Tai Chi, stairs, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Before an osteoporosis pt starts new vigorous program (eg, running, heavy wt-lifting), 1st eval by clinician.
39 Lack of evidence that hip protectors in community-dwellers ↓ hip/pelvis fx risk/fall rate. Some studies in long-term care/residential care show marginally significant ↓ hip fx risk. Adherence is poor, most marketed products not tested in RCTs.
40 Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology. Secondary osteoporosis causes: type 1 DM, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism, chronic malnutrition/malabsorption, chronic liver dz. Consider labs: CBC, chem panel (Ca++, Phos, Mg), LFTs, TSH +/- free T4, 25(OH)D, PTH, total testosterone + gonadotropin (younger men), bone turnover markers, 24-hr urinary calcium. In select pts: SPEP, serum immunofixation, serum-free light chains, tTG Abs (IgA, IgG), Fe + ferritin, homocysteine, prolactin, tryptase, UPEP, urinary free cortisol, urinary histamine.
41 Vertebral imaging = lateral T + L-spine x-ray, or lateral vertebral fx assessment (VFA) (available on most modern DXA machines).
42 Osteoporosis dx is established by BMD or by an adulthood hip/vertebral fx in absence of major trauma (eg, MVA or multiple-story fall). Any adult fx may indicate osteoporosis and should prompt eval; hip and vertebral fx indicate osteoporosis unless excluded by clinical eval and imaging. Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology.
43 Vertebral fx is consistent w/ osteoporosis dx, even in absence of a bone density dx, and is an indication for osteoporosis drug tx to ↓ subsequent fx risk.
44 Historical ht loss = peak ht @ 20 yo – current ht ≥1.5” (4 cm); or prospective ht loss = any previously documented ht – current ht ≥0.8” (2 cm).
45 ≥5 mg prednisone or equivalent daily for ≥3 mo: consider vertebral imaging in addition to BMD.
46 Including pts w/ BMD in low-bone-mass and osteoporosis range; hip/spine fx itself is more important than T-score. Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology.
47 Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology. Secondary osteoporosis causes: type 1 DM, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism, chronic malnutrition/malabsorption, chronic liver dz. Consider labs: CBC, chem panel (Ca++, Phos, Mg), LFTs, TSH +/- free T4, 25(OH)D, PTH, total testosterone + gonadotropin (younger men), bone turnover markers, 24-hr urinary calcium. In select pts: SPEP, serum immunofixation, serum-free light chains, tTG Abs (IgA, IgG), Fe + ferritin, homocysteine, prolactin, tryptase, UPEP, urinary free cortisol, urinary histamine.
48 Pt preferences may indicate tx for pts w/ 10-yr fx probabilities above/below these levels.
49 USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculate w/ either femoral-neck or total-hip BMD; femoral neck preferred; nonhip sites not recommended. FRAX underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑fall risk. FRAX is most useful in low femoral-neck BMD. If low L-spine BMD but relatively NL femoral-neck BMD, it underestimates fx risk. WHO algorithm not validated for use w/ L-spine BMD (NOF recommends osteoporosis tx of L-spine as well as hip). FRAX not validated in pts currently/previously treated for osteoporosis; however, pts off osteoporosis meds ≥1-2 yrs might be considered untreated.
50 Drugs in alpha order. Without head-to-head trials, avoid direct comparisons of risk reduction between drugs. Anti-fx benefits mostly studied in postmenopausal osteoporosis; limited fx data in glucocorticoid-induced osteoporosis and in men. Non-FDA-approved drugs not advocated for osteoporosis tx (eg, calcitriol, genistein, etidronate, pamidronate, tiludronate, PTH (1-84), sodium fluoride, strontium ranelate, tibolone).
51 If osteoporosis in young person: sequential mono-tx allows best benefit/risk @ each life stage. If more severe dz: sequential tx w/ anabolic tx followed by antiresorptive agent preferred to combo tx; however, combo teriparatide + antiresorptive may be considered in a few clinical settings w/ very severe dz (eg, spine/hip fx). Few indications for combo of 2 antiresorptive agents.
52 Biochemical bone turnover/remodeling markers (CTX, NTX, BSAP, OC, PINP) are best collected in morning while fasting. In untreated pts, markers may predict fx risk independently of bone density, and may predict bone-loss rapidity.
Abnormal BMD, tx-experienced Monitor at least annually while on meds. After 1-2 yrs (or sooner) re-assess BMD + labs; individualize drug duration - Annually review the need for continued osteoporosis meds; assess adherence, diet/supplements,53,54 exercise,55 fall prevention,56,57 etc.
- √ ht annually58 (wall-mount stadiometer preferred)
- √ central DXA59,60 BMD 1-2 yrs after tx start, then q2 yrs (or more frequently). If no major risk factors w/ initial T-score NL/upper-low bone mass range: may extend interval b/t BMDs
- If new documented ht ↓, new back pain/posture change or suspicious CXR finding: √ repeat vertebral imaging;61 otherwise, repeat imaging not indicated
- Consider √ biochemical markers62 to assess tx effect after 3–6 mo
Individualize drug tx: no drug tx duration should be considered indefinite. Given absence of evidence-based guidance, no universal recommendations apply to all pts - After initial 3-5 yrs of tx, do comprehensive risk assessment (hx, incl. intercurrent fxs and new chronic conditions, med list, √ BMD, √ ht; if ht ↓, then √ vertebral imaging)63
- If high fx risk: consider continued tx w/ bisphosphonate or alternative tx63,64
- If modest fx risk after initial tx: reasonable to d/c bisphosphonates64 after 3-5 yrs. If d/c meds: monitor serially for fx/falls/new chronic diseases; consider serial BMD, biochemical markers, vertebral imaging
- If considering “drug holiday”: re-√ vertebral imaging, as med d/c not recommended if recent vertebral fx. Biochemical markers63 may help determine “drug-holiday” duration.
Footnotes 53 Ca++ intake: men 50-70 yo = 1,000 mg/day; men ≥71 yo = 1,200 mg/day; supplement if needed.
54 Vit D intake: 800–1,000 IU/day for ≥50 yo, supplement if needed, correct deficiency. In vitamin D-deficient adult: tx w/ 50,000 IU vitamin D2 or D3 once/wk or equivalent daily dose (7,000 IU vitamin D2 or D3) x8–12wk to achieve a 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,500–2,000 IU/day or as required for target blood levels.
55 Wt-bearing: walk, jog, Tai Chi, stairs, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Before an osteoporosis pt starts new vigorous program (eg, running, heavy wt-lifting), 1st eval by clinician.
56 Assess/manage fall risks, eg, previous hx falling, home safety (rugs, low lighting, etc.), balance training/muscle strengthening, correct poor vision, avoid CNS depressants (narcotics, anticonvulsants, psychotropics)/excessive EtOH, monitor BP meds, dehydration, urgent urinary incontinence, cognitive issues, etc.
57 Lack of evidence that hip protectors in community-dwellers ↓ hip/pelvis fx risk/fall rate. Some studies in long-term care/residential care show marginally significant ↓hip fx risk. Adherence is poor, most marketed products not tested in RCTs.
58 Annual ht measurement is critical; if pt loses ≥2 cm (0.8”) acutely or cumulatively, repeat vertebral imaging for fx.
59 DXA @ hip = best predictor of hip fx risk. QCT volumetric BMD of L-spine can monitor change related to age/dz/tx in men and women. Peripheral skeletal sites (via DXA, QCT, US) do not respond w/ same magnitude as spine/hip. Peripheral DXA not appropriate for monitoring BMD after tx.
60 Recent fx, multiple fx, or very low BMD should prompt eval for 2° etiology. Secondary osteoporosis causes: type 1 DM, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism, chronic malnutrition/malabsorption, chronic liver dz. Consider labs: CBC, chem panel (Ca++, Phos, Mg), LFTs, TSH +/- free T4, 25(OH)D, PTH, total testosterone + gonadotropin (younger men), bone turnover markers, 24-hr urinary calcium. In select pts: SPEP, serum immunofixation, serum-free light chains, tTG Abs (IgA, IgG), Fe + ferritin, homocysteine, prolactin, tryptase, UPEP, urinary free cortisol, urinary histamine.
61 If recent fx: fx liaison service programs demonstrate quality-of-care improvements.
62 Biochemical bone turnover/remodeling markers (CTX, NTX, BSAP, OC, PINP): turnover markers suppressed after 3-6 mo tx, biochemical markers increase after 1-3 mo anabolic tx. Obtain samples in early AM after overnight fast, same time of day @ same lab. In treated pts, markers may predict extent of fx risk reduction (when repeated after 3–6 mo of tx), as well as predict magnitude of BMD increase w/ tx, and help assess adequacy of tx compliance/persistence. Markers may help determine “drug-holiday” duration and when/if meds should be restarted (data limited, studies underway).
63 If osteoporosis in young person: sequential mono-tx allows best benefit/risk @ each life stage. If more severe dz: sequential tx w/ anabolic tx followed by antiresorptive agent preferred to combo tx; however, combo teriparatide + antiresorptive may be considered in a few clinical settings w/ very severe dz (eg, spine/hip fx). Few indications for combo of 2 antiresorptive agents.
64 All nonbisphosphonate meds produce temporary effects that wane after d/c; benefits disappear rapidly. Bisphosphonates may allow residual effects post-d/c, at least for several years.
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