Osteoporosis prevention, diagnosis and management in ...

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

2nd edition

.au

Healthy Profession. Healthy Australia.

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age, 2nd edition

Disclaimer

The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

While the text is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, The Royal Australian College of General Practitioners (RACGP) and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in this publication for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error, negligent act, omission or misrepresentation in the information.

Recommended citation

The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd edn. East Melbourne, Vic: RACGP, 2017.

The Royal Australian College of General Practitioners 100 Wellington Parade East Melbourne, Victoria 3002

Tel 03 8699 0414 Fax 03 8699 0400 .au

Osteoporosis Australia 255 Broadway Glebe, NSW 2037

Tel 02 9518 8140 Outside Australia + 61 2 9518 8140 Fax 02 9518 6306 .au

ISBN: 978-0-86906-466-5 (Web)

First edition published 2010 Second edition published 2017

This guideline was developed by Osteoporosis Australia and published by The Royal Australian College of General Practitioners.

? The Royal Australian College of General Practitioners 2017

Copies of this guideline can be downloaded from the Osteoporosis Australia website: .au and the website of the Royal Australian College of General Practitioners: .au

This work is subject to copyright. Unless permitted under the Copyright Act 1968, no part may be reproduced in any way without The Royal Australian College of General Practitioners' permission. Requests and enquiries should be sent to permissions@.au

We recognise the traditional custodians of the land and sea on which we work and live.

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age 2nd edition

i

Executive summary

This guideline is an evidence update of Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men, published in 2010 by The Royal Australian College of General Practitioners (RACGP).1 The accumulation of high-quality evidence supporting changes to clinical practice over the last six years, the need for expert consensus in areas of conflicting evidence or variable practice, and new developments in the pharmacological management of osteoporosis were important factors in the decision to undertake this revision.

The publication of new data on the prevalence of osteoporosis in Australia and the health and economic impacts of this disease has also highlighted the need to clarify and re-enforce clinical guidance for health professionals at the front line of osteoporosis management. A burden of disease analysis recently published by Osteoporosis Australia estimates that in 2012, 4.74 million Australians older than 50 years of age (66%) had poor bone health, including more than one million with osteoporosis.2 By 2022, it is estimated that 6.2 million Australians older than 50 years of age will have osteoporosis or osteopenia, a rise of 31% from 2012. A similar increase in the rate of fracture, from 140,882 in 2012 to 183,105 in 2022, is anticipated if action is not taken to improve the diagnosis and management of osteoporosis.2

In addition to its significant health and social burden, osteoporosis exerts considerable economic pressures on government. The total direct and indirect costs of osteoporosis and osteopenia in Australia were $2.75 billion in 2012.2 This total annual cost is predicted to reach $3.84 billion by 2022. Hip fractures constitute the major burden, costing nearly $800 million in 2012.2 Evidence shows that timely diagnosis and appropriate pharmacological management reduces fracture rates. However, osteoporosis remains significantly underdiagnosed and inadequately managed in Australia. Less than 20% of patients presenting to healthcare services with minimal trauma fractures are investigated or treated for osteoporosis.3,4

Purpose

This guideline is designed to provide clear, evidence-based recommendations to assist general practitioners and other health professionals in managing older patients with osteoporosis. The purpose of the guideline is to support clinical judgement, not to replace it.

Scope

A 12-member expert Working Group has developed 42 recommendations for this guideline, constituting Australian best practice in the identification, diagnosis, treatment and management of osteoporosis in the following populations:

? Postmenopausal women and men older than 50 years of age who may be at risk of minimal trauma fracture.

? Postmenopausal women and men older than 50 years of age diagnosed as having at least one fracture following minimal trauma (equivalent to a fall from standing height or less).

? Postmenopausal women and men older than 50 years of age diagnosed with osteoporosis, defined as a T-score of ?2.5 or less, but without evidence of a minimal trauma fracture.

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Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age 2nd edition

The majority of the recommendations are based on critical analysis of the body of published, peer-reviewed evidence that has accumulated from September 2006 to February 2016, following a systematic review of the available evidence to support these recommendations. Where insufficient evidence is available, or where the quality of the evidence does not meet minimum requirements (as described in Appendix A), recommendations have been developed through Working Group consensus. Details on the guideline development process and Working Group membership can be found in Appendices A and B.

What's new?

Certain areas of osteoporosis management have developed significantly since the publication of the first guideline in 2010, and evidence has accumulated in other areas that supports change to clinical practice. Several new recommendations have been developed for the update to reflect this changing landscape. Recommendations on the use of denosumab, the only new medication approved since the publication of the 2010 guideline, have been added. Comprehensive information on the evaluation of absolute fracture risk and guidance on the use of fracture risk calculators is included, and new recommendations on exercise and the appropriate use of calcium and vitamin D supplements have been developed. A `special issues' section makes several recommendations in the areas of osteoporosis management in the elderly, including minimising falls risk, as well as fracture risk reduction in patients undergoing androgen deprivation therapy for prostate cancer or aromatase inhibitor therapy for breast cancer.

Professor Peter R Ebeling AO MBBS MD FRACP Chair, Osteoporosis Australia Guidelines Working Group

References

1. The Royal Australian College of General Practitioners. Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. 1st edn. South Melbourne, Vic: RACGP, 2010.

2. Watts JJ, Abimanyi-Ochom J, Sanders K. Osteoporosis costing all Australians: A new burden of disease analysis ? 2012 to 2022. Glebe, NSW: Osteoporosis Australia, 2013.

3. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: A systematic review. Osteoporos Int 2004;15:767?78.

4. Eisman J, Clapman S, Kehow L. Osteoporosis prevalence and levels of treatment in primary care: The Australian BoneCare Study. J Bone Miner Res 2004;19(12):1969?75.

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age 2nd edition

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Summary of recommendations

Risk factor assessment, diagnosis and referral

Chapter

No. Recommendation

Identifying patients 1 to investigate for osteoporosis

All individuals over the age of 50 who sustain a fracture following minimal trauma (such as a fall from standing height or less) should be considered to have a presumptive diagnosis of osteoporosis.

2

A presumptive diagnosis of osteoporosis can be made in a patient with a

spinal compression fracture in whom there is no history of significant trauma

and/or the patient is deemed to be at high risk of osteoporotic fracture.

Caution regarding diagnosis and treatment should be exercised if only a

single mild deformity is detected, especially in a patient under the age of 60.

3

Conduct a clinical risk-factor assessment in postmenopausal women and

men over the age of 50 with one or more major risk factors for minimal

trauma fracture. Individual risk-factor profile should determine the need for

assessment.

Diagnostic investigations

4

Measure bone mineral density (BMD) by dual energy X-ray absorptiometry

(DXA) scanning on at least two skeletal sites, including the lumbar spine and

hip, unless these sites are unsuitable (eg hip prosthesis).

5

Diagnostic assessment for osteoporosis should consist of medical history,

clinical examination and BMD measurement by DXA. If applicable, laboratory

tests and radiographs of the thoracic and lumbar spine should also be

performed.

Diagnostic investigations

6

Assessment of absolute fracture risk, using either the Garvan Fracture Risk

Calculator (.au/bone-fracture-risk) or the Fracture Risk

Assessment Tool (shef.ac.uk/FRAX) may be useful in assessing the

need for treatment in individuals who do not clearly fit established criteria.

Referral to a

7

medical specialist

Refer postmenopausal women and older men to a specialist or a specialist bone centre according to individual need, or when there is restricted access to appropriate resources or required expertise.

Grade A B

B A D D D

General bone health maintenance and fracture prevention

Chapter

No. Recommendation

Diet and lifestyle

8

Promote the following important lifestyle choices for all postmenopausal

women and men over 50 years of age:

? Adequate calcium and protein intake

? Adequate but safe exposure to sunlight as a source of vitamin D

? Maintenance of a healthy weight and body mass index

? Cessation of smoking

? Avoidance of excessive alcohol consumption

Education and psychosocial support

9

Provide postmenopausal women and men over 50 years of age at risk of or

diagnosed with osteoporosis, access to education, psychosocial support

and encouragement to seek support from appropriate sources according to

individual needs.

Reducing the risk

10

Conduct falls risk assessments and initiate targeted fall-prevention programs

of falls

in older adults.

Grade C

D A

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