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

1. 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].

2. Clinical Approach to Osteoporosis Section Three

3. Recommendations for Clinical Assessment

4. Recommendations for Clinical Assessment Diagnosis of vertebralfractures

5. Radiologic Investigation of the Spine • Recognition and reportingof vertebral fractures is ofparamount importance • Several different types ofradiologic investigations canbe ordered, depending onthe clinical needs • Vertebral fractures are under reported in emergency department radiology reports1 1. Majumdar SR, et al. Arch Intern Med 2009; 165(8):905-909.

6. 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.

7. Clinical Assessment: Summary Statements Click here for a summary of the system for levels of evidence.

8. Clinical Assessment: Recommendations Click here for a summary of the system for grades of recommendations.

9. Clinical Assessment: Recommendations (Cont'd)

10. Clinical Assessment: Recommendations (Cont'd)

11. Back-up Material Additional slides that can be accessed fromhyperlinks on core slides Section Three – Clinical Approach to Osteoporosis

12. Risk Factors for Fracture1-5 • 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, excessivealcohol, and physical inactivity • Weight loss since age 25 >10% • Poor nutrition, calcium intake, vitamin D status • Recurrent falls 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. Return to main presentation

13. 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) 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. Return to main presentation

14. 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 spineX-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.

15. 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.

16. Additional Tests for ClinicalIdentification of 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):S274.

17. Height loss 4 cm 3 cm 8 cm 12 cm 8 cm 3 FBs 2 FBs Rib-Pelvis and Occiput-to-Wall Distances Return to main presentation

18. Plain RadiographicExaminations of the Spine

19. Other RadiographicExaminations of the Spine Return to main presentation

20. % of Confirmed Vertebral FracturesMentioned 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.

21. Recommended Biochemical Tests forPatients 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)* * Should be measured after 3-4 months of adequate supplementation and should not be repeated if an optimal level ≥75 nmol/L is achieved. Return to main presentation

22. Tests for Potential Secondary Causes Return to main presentation

23. Reasons Why Routine TestosteroneTesting 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

24. Criteria Used to Assign Levels ofEvidence: Studies of Diagnosis

25. Criteria Used to Assign Levels of Evidence:Studies of Treatment and Intervention RCT = randomized, controlled study

26. Criteria Used to Assign Levels ofEvidence: Studies of Prognosis Return to main presentation

27. Criteria Used to AssignGrades of Recommendation * As appropriate level of evidence was necessary, but not sufficient to assigna grade in recommendation; consensus was required in addition. Return to main presentation

28. Falls Risk Assessment Age 80 • History of falls in the lastyear is one of the mostsignificant risk factors forpredicting future fall1-6 • Dementia and poor physicalfunction have also beenfound to be associated withfalls and fractures in olderadults2,4,5 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.

29. Periodic casefinding in primary care: Ask all patients about falls in past year No falls No intervention Recurrent falls Single fall Gait/balanceproblems No problem Check for gait/balanceproblem Patientpresentsto medicalfacility aftera fall Full evaluation* Assessment History Medications Vision Gait and balance Lower limb joints Neurological Cardiovascular Multifactorial intervention (as appropriate) Gait, balance & exercise programs Medication modifications Posteral hypotension treatment Environmental hazard modification Cardiovascular disorder treatment Assessment and Management of Falls From a joint guidelineissued in 2001 by: American Geriatrics Society British Geriatrics Society American Academy ofOrthopaedic Surgeons Return to main presentation J Am Geriatr Soc 2001; 49(5):664-72.