Our clinical guidelines for the prevention and treatment of osteoporosis are the result of the shared expertise and collaboration of Mass General's Divisions of Endocrinology, Primary Care, Obstetrics and Gynecology, Orthopaedics, and the Women's Health Coordinating Council.
Clinical Guidelines for the Prevention and Treatment of Osteoporosis
Who should be screened for osteoporosis?
- Women or men of any age with fractures after minimal trauma
- All women over age 65
- All men over 75
- Younger women and men with major risk factors
What are the major risk factors for osteoporosis?
- Low body weight (BMI <23)
- Family history of osteoporosis
- Significant history of smoking or alcohol excess
- Premature menopause in women
- Testosterone deficiency in men
- Chronic glucocorticoid use
What are the major risk factors for fractures?
- Prior fractures with minimal trauma, including asymptomatic vertebral fractures
- Low bone mineral density
- History of falls or impaired physical function
- Impaired cognition
How should patients be screened for osteoporosis?
- Bone mineral densitometry of hip, with or without lumbar spine measurement
- Use the lowest T-score to determine need for treatment (T-score provides a comparison to healthy young adults; negative scores reflect low bone mineral density)
What should be done to prevent osteoporosis?
- Weight bearing exercise
- Calcium (1,000 - 1,500 mg/day) & Vitamin D (400 - 800 IU/day)
- Adequate calcium & vitamin D is essential for other therapies to be effective. Calcium is best taken in divided doses, with meals
- Stop smoking
- Avoid excess alcohol
- Maintain a healthy body weight
- Avoid thyroid hormone excess
When is drug treatment needed?
- In addition to basic recommendations for prevention of osteoporosis, treatment is recommended for T scores < - 2.5
- Consider treatment, if T-score is < -2 and other risk factors are present, or if there is documented bone loss over time
- All patients on chronic glucocorticoids need drug treatment
- Bisphosphonates (Cost in 2004: ~$1,100/year)
- Fosamax (Alendronate) (70 mg/week)
- Actonel (Risedronate) (35 mg/week)
- Additional potential benefits: none
- Potential risks: esophageal ulcers
- Side effects: GI distress, arthralgias/myalgias
Hormone Therapy (Cost in 2004: ~$660/year)
- Estrogen or Estrogen/Progestin Therapy
- Appropriate if primary indication is relief of vasomotor symptoms
- Additional potential benefits: treatment of vasomotor symptoms and genitourinary atrophy
- Potential risks: breast cancer, gallbladder disease, venous thrombosis, cardiovascular disease, stroke
- Side effects: vaginal bleeding, breast tenderness
SERMS (Cost in 2004: ~$1,100/year)
- Evista (Raloxifene) (60 mg/day)
- Additional potential benefits: reduced risk of breast cancer, LDL
- Potential risks: venous thromboembolic events
- Side effects: vasomotor symptoms, leg cramps
Anabolic Agents (Cost in 2004: ~ $7,900/year)
- Forteo (Teriparatide) (20 mcg/day by injection)
- Additional potential benefits: none unless high risk of fracture
- Potential risks: osteosarcoma after long-term use in rodents
- Side effects: hypercalcemia, leg cramps
How can fractures be prevented in patients at increased risk? Fall prevention strategies:
- Safety devices in home (e.g., non-skid rugs, night lights, tub or shower bars, stair banisters)
- Balance, strength, gait and weight-bearing exercises
- Proper footwear
- Optimize vision
- Minimize sedative and psychotropic drug use
- Consider devices (e.g., canes, walkers, hip protectors)
How should patients be followed?
- Assess compliance with recommended calcium and vitamin D intake, exercise program, and prescribed medications
- Monitor bone mineral density every 2 years (or annually if osteoporosis is severe) until stable, then less frequently
When should patients be referred to a specialist?
- Lack of response to conventional treatment, especially evidence of continued bone loss
- New fracture on therapy
- Inability to tolerate oral medications
- Unexplained Z-score of < - 2, to rule out secondary causes of osteoporosis (Z-score provides comparison to age-matched adults)