Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update

Rowan Hutchins — Sun, 15 Oct 2023 05:00:00 +0000

Date Added:

October 15, 2023

Journal/Publication:

CMAJ

Publisher:

CMA

Publication Date:

October 10, 2023

Issue:

Volume:

195

Pages:

E1333-E1348

URL:

Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.221647

Keywords

quality of life

fracture

PMID (1):

37816527

MeSH

Fractures

Bone*

Osteoporosis* / complications

Osteoporosis* / diagnosis

Osteoporosis* / drug therapy

The updated Canadian guidelines for assessing and reducing fracture risk in postmenopausal women. James W. Mold, MD, MPH

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Fracture risk increases with advancing age, as a result of declining skeletal strength and increased risk of falling. In Canada, more than 2 million people live with osteoporosis.1 Every year in Canada, about 150 people per 100 000 suffer a hip fracture, which is considered among the most serious fractures associated with osteoporosis. Fractures lead to increased morbidity, excess mortality, decreased quality of life and loss of autonomy.2 Although osteoporosis is often considered a disease of older females, males are remarkably underevaluated and undertreated for the condition despite suffering worse outcomes following fracture,3 highlighting the importance of providing guidance in males.

Osteoporosis, defined as a bone mineral density (BMD) of 2.5 or more standard deviations below the peak bone mass (i.e., T-score ≤ −2.5), is an indicator of increased fracture risk; this risk is modified by age, sex and other factors.4 A clinical diagnosis of osteoporosis can be made in people aged 50 years and older if they have sustained a low-trauma hip, vertebral, humerus or pelvic fracture after the age of 40 years, or if they have an absolute fracture risk of 20% or more over the next 10 years, using a fracture risk assessment tool (FRAX or the Canadian Association of Radiologists and Osteoporosis Canada [CAROC]).5–7

Advances in risk assessment and nonpharmacologic and pharmacologic management warranted an update to the Osteoporosis Canada 2010 clinical practice guideline for the diagnosis and management of osteoporosis in Canada

Author/s:

Suzanne N. Morin, Sidney Feldman, Larry Funnell, Lora Giangregorio, Sandra Kim, Heather McDonald-Blumer, Nancy Santesso, Rowena Ridout, Wendy Ward

Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review

Brian Desmarais — Thu, 23 May 2019 13:11:29 +0000

Date Added:

May 23, 2019

Journal/Publication:

Annals of Internal Medicine

Publisher:

U.S. Department of Health & Human Services

Publication Date:

April 23, 2019

URL:

https://www.ncbi.nlm.nih.gov/pubmed/?term=Long-Term%20Drug%20Therapy%20and%20Dru…

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.7326/M19-0533.

Keywords

MeSH

Raloxifene Hydrochloride

Databases, Bibliographic

National Institutes of Health (U.S.)

Information Storage and Retrieval

bias

Health Services Research

Femoral Fractures

This is a systematic review of current evidence regarding medications for post-menopausal osteoporosis. James W. Mold, MD, MPH

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BACKGROUND:

Optimal long-term osteoporosis drug treatment (ODT) is uncertain.

PURPOSE:

To summarize the effects of long-term ODT and ODT discontinuation and holidays.

DATA SOURCES:

Electronic bibliographic databases (January 1995 to October 2018) and systematic review bibliographies.

STUDY SELECTION:

48 studies that enrolled men or postmenopausal women aged 50 years or older who were being investigated or treated for fracture prevention, compared long-term ODT (>3 years) versus control or ODT continuation versus discontinuation, reported incident fractures (for trials) or harms (for trials and observational studies), and had low or medium risk of bias (ROB).

DATA EXTRACTION:

Two reviewers independently rated ROB and strength of evidence (SOE). One extracted data; another verified accuracy.

DATA SYNTHESIS:

Thirty-five trials (9 unique studies) and 13 observational studies (11 unique studies) had low or medium ROB. In women with osteoporosis, 4 years of alendronate reduced clinical fractures (hazard ratio [HR], 0.64 [95% CI, 0.50 to 0.82]) and radiographic vertebral fractures (both moderate SOE), whereas 4 years of raloxifene reduced vertebral but not nonvertebral fractures. In women with osteopenia or osteoporosis, 6 years of zoledronic acid reduced clinical fractures (HR, 0.73 [CI, 0.60 to 0.90]), including nonvertebral fractures (high SOE) and clinical vertebral fractures (moderate SOE). Long-term bisphosphonates increased risk for 2 rare harms: atypical femoral fractures (low SOE) and osteonecrosis of the jaw (mostly low SOE). In women with unspecified osteoporosis status, 5 to 7 years of hormone therapyreduced clinical fractures (high SOE), including hip fractures (moderate SOE), but increased serious harms. After 3 to 5 years of treatment, bisphosphonate continuation versus discontinuation reduced radiographic vertebral fractures (zoledronic acid; low SOE) and clinical vertebral fractures (alendronate; moderate SOE) but not nonvertebral fractures (low SOE).

LIMITATION:

No trials studied men, clinical fracture data were sparse, methods for estimating harms were heterogeneous, and no trials compared sequential treatments or different durations of drug holidays.

CONCLUSION:

Long-term alendronate and zoledronic acid therapies reduce fracture risk in women with osteoporosis. Long-termbisphosphonate treatment may increase risk for rare adverse events, and continuing treatment beyond 3 to 5 years may reduce risk for vertebral fractures. Long-term hormone therapy reduces hip fracture risks but has serious harms.

PRIMARY FUNDING SOURCE:

National Institutes of Health and Agency for Healthcare Research and Quality. (PROSPERO: CRD42018087006).

Author/s:

Fink, Howard A., MacDonald, Roderick, Forte, Mary L., Rosebush, Christina E., Ensrud, Kristine E., Schousboe, John T., Nelson, Victoria A., Ullman, Kristen, Butler, M., Olson, Carin M., Taylor, Brent C., Brasure, Michelle, Wilt, Timothy J.