Addressing Skeletal Health and Fracture Prevention

A comprehensive guide from Osteoporosis Canada aims to help primary care professionals provide care to optimize skeletal health and prevent fractures in postmenopausal women and men aged 50 years and older. It is published in CMAJ ( Canadian Medical Association Journal ).

Summary

Background:

In Canada, more than 2 million people live with osteoporosis , a disease that increases the risk of fractures, resulting in excess mortality and morbidity, decreased quality of life, and loss of autonomy.

This guideline update is intended to assist Canadian healthcare professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal women and men aged 50 years and older.

Methods:

This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and treatment of osteoporosis in Canada. We follow the Recommendations Assessment, Development and Evaluation (GRADE) framework and quality control according to the Assessment Guidelines for Research and Evaluation (AGREE II) quality and reporting standards.

Primary care physicians and patient partners were represented at all levels of committees and guideline groups, and were involved throughout the process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the development of the guide, informed by the principles of the International Guide Network.

We consider benefits and harms, patient values ​​and preferences, resources, equity, acceptability, and feasibility when developing recommendations; The strength of each recommendation was assigned according to the GRADE framework.

Results

The 25 recommendations and 10 good practice statements are grouped into the sections of exercise, nutrition, fracture risk assessment and initiation of treatment, pharmacological interventions, duration and sequence of therapy, and follow-up.

Treatment of osteoporosis should be guided by the patient’s fracture risk, based on clinical assessment and using a validated fracture risk assessment tool.

Exercise, nutrition, and pharmacotherapy are key elements of the treatment strategy for fracture prevention and must be individualized.

Interpretation:

The goal of this guideline is to empower healthcare professionals and patients to have meaningful discussions about the importance of skeletal health and fracture risk during adulthood. Identification and appropriate treatment of skeletal fragility can reduce fractures and preserve mobility, autonomy, and quality of life.

Fracture risk increases with age, as a result of decreased skeletal strength and increased risk of falls. In Canada, more than 2 million people live with osteoporosis. Each year in Canada, about 150 people out of every 100,000 suffer a hip fracture, which is considered one of the most serious fractures associated with osteoporosis.

Fractures cause increased morbidity, excess mortality, decreased quality of life, and loss of autonomy. Although osteoporosis is often considered a disease of older women, men are notably undervalued and undertreated for this condition despite suffering poorer outcomes after fracture, highlighting the importance of providing counseling in men.

Osteoporosis, defined as a bone mineral density (BMD) of 2.5 or more standard deviations below maximum bone mass (i.e., T score ≤ −2.5), is an indicator of increased fracture risk; This risk varies depending on age, sex and other factors.

A clinical diagnosis of osteoporosis can be made in people aged 50 years or older if they have suffered a hip, vertebral, humerus, or pelvic fracture due to mild trauma after age 40. , or if they have an absolute risk of fracture of 20% or more in the next 10 years, using a fracture risk assessment tool (FRAX or Canadian Association of Radiologists and Osteoporosis of Canada [CAROC]).

Advances in risk assessment and pharmacological and non-pharmacological management warranted an update to the Osteoporosis Canada 2010 clinical practice guideline for the diagnosis and treatment of osteoporosis in Canada.8

Comments

With 25 recommendations and 10 good practice statements, this update to the 2010 guideline contains sections on exercise, nutrition, fracture risk assessment, treatment, and more, reflecting advances in risk assessment and drug and non-medical treatment. pharmacology of osteoporosis.

In Canada, there are more than 2 million people living with osteoporosis, defined as bone mineral density (BMD) at a level below maximum bone mass, which increases the risk of fracture. Fractures usually occur after a fall and can affect the hip, wrist, arm and spine, in particular.

"We are hopeful that this Canadian guideline will enable healthcare professionals and patients to have meaningful discussions about the importance of skeletal health and fracture prevention to preserve mobility and autonomy throughout adulthood," said Dr. Suzanne Morin, lead author and chair of the guideline. Steering Committee.

The guideline is based on the most recent evidence and included patient partners in the development of the recommendations.

Other guidelines

A guideline from the Canadian Task Force on Preventive Healthcare published in spring 2023 based on randomized controlled trials (RCTs) recommends risk assessment: first screening for primary prevention of fragility fractures in women aged 65 years and older using the Fracture Risk Assessment Tool without BMD. The task force guideline recommends against screening younger women and men of any age. The Osteoporosis Canada guideline differs in that it included a variety of studies in addition to RCTs and several studies included men. The new guideline recommends screening in younger men and women, unlike the task force guideline.

"Identifying and appropriately treating skeletal fragility in Canadians can reduce fractures and preserve mobility, autonomy and quality of life in this population," says Dr. Morin.

Start of treatment

There is no consensus on the optimal approach to establishing a treatment threshold. When establishing pharmacotherapy initiation thresholds, we considered the burden of fractures in the Canadian population, how fracture outcomes were affected by baseline fracture risk. , the effectiveness of pharmacotherapy on fracture outcomes, the importance of identifying those at high risk of fracture to prevent most fractures, and the importance of limiting overtreatment in those at lower risk, from the perspective of population and patient.

A previous fracture of the vertebra (clinical or documented by imaging) or hip, and more than one fracture, indicate a high risk of future fractures. Randomized controlled trials provide moderate to high certainty of evidence showing important benefits of fracture reduction with pharmacotherapy in people with osteoporosis (defined as T score ≤ −2.5 or history of previous fracture), with a reduced risk of approximately 50% for vertebral fractures, 30% for hip and 20% for non-vertebral fractures after 3 years of treatment.

Furthermore, given observational data from a large clinical registry, a 20% intervention threshold for greater than 10-year fracture risk (measured by FRAX or CAROC) was also selected (as a conditional recommendation), as this strategy was highly classified in terms of the number of fractures prevented among women aged 50 years and older and the number of women treated (to limit overtreatment).38 We did not rate the certainty of the evidence in men, as the evidence suggests that there are no differences between benefits and harms of treatment according to sex.

Fracture Liaison Service programs (https://fls.osteoporosis.ca/), which provide postfracture investigation and treatment initiation and are currently implemented in some Canadian jurisdictions, increase the appropriate use of fracture risk assessment and antifracture treatment, and are expensive. -cash.

We recommend that postmenopausal women and men aged 50 years and older with a recent fracture have access to a Fracture Liaison Service to improve the identification and initiation of treatment for osteoporosis.