2. Osteoporosis is a silent disease until it is complicated by fractures - fractures that can
occur following minimal trauma.
Osteoporosis can be prevented and can be diagnosed and treated before any fracture
occurs.
Importantly, even after the first fracture has occurred, there are effective treatments to
decrease the risk of further fractures.
This updated guide offers concise recommendations regarding prevention, risk
assessment, diagnosis and treatment of osteoporosis in postmenopausal women and
men age 50 and older.
3. The following organizations have issued recommendations on measurement of bone
mineral density (BMD) for osteoporosis screening:
American Association of Clinical Endocrinologists (AACE)
(guidelines for postmenopausal women)
National Osteoporosis Foundation (NOF)
American College of Endocrinology (ACE)
International Society for Clinical Densitometry(ISCD)
US Preventive Services Task Force(USPSTF)
4. National Osteoporosis Foundation(NOF)
The 2014 NOF guidelines recommend BMD measurement in the following patients:
Women age 65 years and older and men age 70 years and older.
Younger postmenopausal women and women in menopausal transition with clinical risk factors for
fracture
Men age 50-69 years with clinical risk factors for fracture
5. International Society for Clinical Densitometry
(ISCD)
The 2015 ISCD Official Positions recommend BMD testing in the following patients:
Women aged 65 and older
Postmenopausal women younger than age 65 with a risk factor for low bone mass (eg, low body
weight, prior fracture, high-risk medication use, disease or condition associated with bone loss)
Men age 70 years and older.
Men younger than 70 years with a risk factor for low bone mass.
Adults taking medications associated with low bone mass or bone loss
Adults with a disease or condition associated with low bone mass or bone loss
6. American Association of Clinical
Endocrinologists (AACE)
The 2020 update of the American Association of Clinical Endocrinologists (AACE)
guidelines recommends evaluation of all women age 50 or older for osteoporosis risk.
The AACE recommends BMD testing in the following patients
Women age 65 or older
Postmenopausal women with a history of fracture(s) without major trauma, with osteopenia
identified radio graphically, or starting long-term systemic glucocorticoid therapy (≥3 months)
Premenopausal or postmenopausal women with risk factors for osteoporosis if willing to consider
pharmacologic interventions, with low body weight (< 127 lb or body mass index < 20 kg/m 2),
taking long-term systemic glucocorticoid therapy (≥3 months), or with a family history of
osteoporotic fracture
7. Diagnosis
According to National Osteoporosis Foundation guidelines, a clinical diagnosis of
osteoporosis may be made in a postmenopausal woman or in a man over age 50 years
who is at an elevated risk for fracture, as indicated by any of the following:
◦ T-score of -2.5 or less at the spine or hip as determined by dual-energy x-ray
absorptiometry (DXA)
◦ Hip fracture, with or without bone mineral density (BMD) testing
◦ Vertebral; proximal humerus; pelvis; or, in some cases, distal forearm fracture in the
setting of low bone mass (osteopenia) confirmed by DXA
◦ FRAX score with 10-year risk for hip fracture ≥3% or for major osteoporotic fracture
≥20% in a patient with osteopenia
8. The 2020 update of the American Association of Clinical Endocrinologists (AACE)
guidelines provides the following criteria for the diagnosis of osteoporosis in
postmenopausal women:
◦ T-score −2.5 or below in the lumbar spine, femoral neck, total proximal femur, or
1/3 radius
◦ Low-trauma spine or hip fracture (regardless of BMD)
◦ T-score between −1.0 and −2.5 and a fragility fracture of proximal humerus, pelvis,
or distal forearm
9. Treatment
The 2020 updated guidelines from the American Association of Clinical
Endocrinologists (AACE) are similar to NOF guidelines.
The National Osteoporosis Foundation (NOF) recommends that pharmacologic
therapy should be reserved for postmenopausal women and men aged 50 years or
older who present with the following:
A hip or vertebral fracture
T-score of –2.5 or less at the femoral neck or spine
Low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) and a
10-year probability of a hip fracture of 3% or greater or a 10-year probability of a
major osteoporosis-related fracture of 20% or greater based on the US-adapted
WHO algorithm
10. Guidelines from the American Association of Clinical Endocrinologists (AACE),
updated in 2020, include the following recommendations for choosing drugs to treat
osteoporosis in postmenopausal women:
◦ First-line agents for most high fracture risk patients: alendronate, Risedronate,
Zoledronate, Denosumab.
◦ First-line agents for high fracture risk patients unable to use oral therapy:
Denosumab, romosozumab, teriparatide, and Zoledronate
◦ First-line agents for spine-specific indications in select patients: Ibandronate
and raloxifene
◦ Sequential agents: anabolic agents (eg, romosozumab, teriparatide) should be
followed with a bisphosphonate or Denosumab
11. The ACP recommends against the use of estrogen or estrogen plus progestogen or
raloxifene for the treatment of osteoporosis in postmenopausal women. Additional
recommendations, based on low-quality evidence, include the following:
In women with osteoporosis, pharmacologic treatment should last for 5 years.
Monitoring of bone mineral density (BMD) during the 5 years of treatment in women with
osteoporosis is not advised, as evidence suggests that fracture risk may be reduced regardless of
BMD changes
For women aged 65 and older who have osteopenia and are at high fracture risk, decisions to treat
should take into account patient preference, fracture-risk profile, benefits, harms, and price of
medications
In men with clinically recognized osteoporosis, clinicians should offer bisphosphonate therapy to
reduce the risk of vertebral fracture; evidence is lacking on BMD monitoring in men.
12. Calcium Recommended for all patients with osteoporosis to maintain normal calcium
concentration and to prevent hypocalcaemia associated with other drug treatment for
Osteoporosis.
NOF recommend no more than 1200-1500mg/day.
Most Common forms :
Calcium carbonate(take with food)
Calcium Citrate (take with or without food)
Vitamin D Recommended for all patients with osteoporosis promote calcium
reabsorption
NOF recommend 800-1000IU/day for those 50yrs or older
13. Length of therapy
American College of Physician (ACP) recommends 3-5 years of pharmacologic
therapy for Women with osteoporosis.
5yr (Oral) & 3yr (IV)
14. Recommendations for follow up
Recommendations for follow up on BMD_DXA vary
◦ ACP recommend on 5yr osteoporosis therapy.
◦ Other suggest every 2yr.
◦ But some situation warrant sooner than 2yr
