2. Diagnosis of osteoporosis
3. Investigation of osteoporosis
- •exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma);
- •identify the cause of osteoporosis and contributory factors;
- •assess the risk of subsequent fractures;
- •select the most appropriate form of treatment;
|History and physical examination|
|Blood cell count, sedimentation rate or C-reactive protein, serum calcium, albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases|
|Thyroid function tests|
|Bone densitometry (DXA)|
|Other procedures, if indicated|
|Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging|
|Protein immunoelectrophoresis and urinary Bence-Jones proteins|
|Serum 25-hydroxyvitamin D and PTH|
|Serum testosterone, SHBG, FSH, LH (in men)|
|24 h urinary cortisol/dexamethasone suppression test|
|Endomysial and/or tissue transglutaminase antibodies (coeliac disease)|
|Isotope bone scan|
|Markers of bone turnover, when available|
|Urinary calcium excretion|
4. Clinical risk factors
|Low body mass index (≤19 kg/m2)|
|Previous fragility fracture, particularly of the hip, wrist and spine including morphometric vertebral fracture|
|Parental history of hip fracture|
|Current glucocorticoid treatment (any dose, by mouth for three months or more)|
|Alcohol intake of three or more units daily|
|Secondary causes of osteoporosis including|
|Untreated hypogonadism in men and women|
|Type I diabetes|
|Chronic liver disease|
|Chronic obstructive pulmonary disease|
5. Case finding
5.1 Postmenopausal women and men aged ≥50 years
- •Women with a prior fragility fracture should be considered for treatment without the need for further risk assessment although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.
5.2 Individuals treated with oral glucocorticoids
6. Intervention thresholds
7. Treatment of osteoporosis
7.1 Postmenopausal women and men aged ≥50 years
|Vertebral fracture||Non-vertebral fracture||Hip fracture|
7.2 Individuals taking oral glucocorticoids
8. Calcium and vitamin D supplementation
- Li K.
- Kaaks R.
- Linseisen J.
- Rohrmann S.
9. Duration and monitoring of therapy
9.1 Alendronate, ibandronate and risedronate
- •High-risk individuals, for example:
- ∘those aged 75 years or more;
- ∘those who have previously sustained a hip or vertebral fracture;
- ∘those who are taking continuous oral glucocorticoids in a dose of ≥7.5 mg/d prednisolone or equivalent.
- •Individuals who sustain one or more low trauma fractures during treatment, after exclusion of poor adherence to treatment (for example less than 80% of treatment has been taken) and after causes of secondary osteoporosis have been excluded. In such cases the treatment option should be re-evaluated.
- •If the total hip or femoral neck BMD T-score is ≤−2.5 SD, continuation of treatment should generally be advised.
- •after a new fracture regardless of when this occurs;
- •if no new fracture occurs, after two years.
9.2 Zoledronic acid
9.3 Assessment of fracture risk in treated individuals
- •Reassessment of fracture risk in treated individuals can be performed using FRAX with femoral neck BMD []. The NOGG intervention thresholds can then be used to guide the decision as to whether treatment can be stopped for a period of time (Fig. 2).
- •If biochemical markers of bone turnover indicate relapse from suppressed bone turnover and BMD has decreased following withdrawal, resumption of treatment should be considered.
- Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK.Maturitas. 2009; 62: 105-108
Osteoporosis, Clinical guideline for prevention and treatment, www.shef.ac.uk/NOGG, Updated May 2013.
- Assessment of osteoporosis at the primary health-care level. Technical report.WHO Collaborating Centre, University of Sheffield, UK2008
- FRAX® and the assessment of fracture probability in men and women from the UK.Osteoporosis International. 2008; 19: 385-397
- Case finding for the management of osteoporosis with FRAX® – assessment and intervention thresholds for the UK.Osteoporosis International. 2008; 19: 1395-1408
- Guidance for the adjustment of FRAX according to the dose of glucocorticoids.Osteoporosis International. 2011; 22: 809-816
- A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis.Osteoporosis International. 2012; 23: 2257-2276
- Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis.BMJ. 2010; 341: c3691
- Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women's Health Initiative limited access dataset and meta-analysis.BMJ. 2011; 342: d2040
- Do calcium plus vitamin D supplements increase cardiovascular risk?.BMJ. 2011; 342: d2080
- Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg).Heart. 2012; 98: 920-925
- Vitamin D and bone health: a practical clinical guideline for patient management.2013
- Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-Term Extension (FLEX): a randomized trial.JAMA: The Journal of the American Medical Association. 2006; 296: 2927-2938
- Changes in biochemical markers and bone mass after withdrawal of ibandronate treatment: prediction of bone mass changes during treatment.Bone. 1998; 22: 559-564
- Fracture risk remains reduced one year after discontinuation of risedronate.Osteoporosis International. 2008; 19: 365-372
- The effect of 3 versus 6 years of zoledronic acid treatment in osteoporosis: a randomized extension to the HORIZON-Pivotal Fracture Trial (PFT).Journal of Bone and Mineral Research. 2012; 27: 243-254
- Does osteoporosis therapy invalidate FRAX for fracture prediction?.Journal of Bone and Mineral Research. 2012; 27: 1243-1251