2010 Guidelines 2010 Clinical Practice Guidelines for the

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2010 Guidelines 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in

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 Clinical Approach to Osteoporosis Section Three

2010 Guidelines Recommendations for Clinical Assessment Recommended Elements of Clinical Assessment Identify risk factors

2010 Guidelines Recommendations for Clinical 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 Recommended Elements of Clinical Assessment Measure weight (weight

2010 Guidelines Recommendations for Clinical Assessment Recommended Elements of Clinical Assessment Measure weight (weight loss of >10% since age 25 is significant) Measure height annually (prospective loss > 2 cm) (historical height loss > 6 cm) Physical Measure rib to pelvis distance < 2 fingers' breadth examination Measure occiput-to-wall distance (for kyphosis) > 5 cm 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

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 reports 1 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

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

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

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

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, wall-to -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 Grade Patients with osteoporosis need only limited

2010 Guidelines Clinical Assessment: Recommendations (Cont'd) Recommendation Grade Patients with osteoporosis need only limited laboratory investigations performed: complete blood count, calcium corrected for albumin, creatinine, alkaline phosphatase, and thyroid stimulating hormone D 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 D Serum protein electrophoresis should be performed in individuals with vertebral fractures D In selected patients, based on clinical assessment, additional biochemical testing should be considered to rule out secondary causes of osteoporosis D

2010 Guidelines Back-up Material Additional slides that can be accessed from hyperlinks on core

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 Fracture 1 -5 • • Fragility fracture after the

2010 Guidelines Risk Factors for Fracture 1 -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,

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

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

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

2010 Guidelines Additional Tests for Clinical Identification of Vertebral Fracture Test Rationale Method Interpretation Rib-pelvis distance 1 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 distance 2, 3 To help identify thoracic spine fractures Stand straight with > 5 cm raises heels and back suspicion of against the wall 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): S 274.

2010 Guidelines Rib-Pelvis and Occiput-to-Wall Distances 4 cm 8 cm 3 cm Height loss

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

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

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), T 4 to L 4 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 To examine soft tissues or clarify the acuteness of spinal fracturing To look for disease activity or distribution Radionuclide bone scanning May also be helpful in diagnosing such conditions as metastatic disease and acuteness of injury Return to main presentation

2010 Guidelines % of Confirmed Vertebral Fractures Mentioned in ER Radiology Reports* *n =

2010 Guidelines % of Confirmed Vertebral Fractures Mentioned in ER Radiology Reports* *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 • • •

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

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

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

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

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

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

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

2010 Guidelines Falls Risk Assessment • History of falls in the last year is one of the most significant risk factors for predicting future fall 1 -6 • Dementia and poor physical function have also been found to be associated with falls and fractures in older adults 2, 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

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 Single fall Gait/ balance problems Patient presents to medical facility after a fall 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 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.