Clinician Guidelines For the Prevention and Treatment of Osteoporosis

Endorsed by:
Endocrinology - Primary Care - Obstetrics/Gynecology
Orthopedics - Women's Health Coordinating Council
Massachusetts General Hospital

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
- Frailty
- 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.

Treatment Options:
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)