This powerpoint presentation deals with the chief recommendations of ISBMR osteoporosis recommendations. It also encompasses relevant articles which have been cited for formulation of the article.

1. ISBMR osteoporosis
guidelines
Dr. Shinjan Patra

3. Introduction
• Characterized by low bone mass and micro-
architectural deterioration of bone tissue,
with a consequent increase in bone fragility
and susceptibility to fracture
• 1 in 3 women over age 50 experience
osteoporotic fractures, as 1 in 5 men over age
50

4. Indian Scenario
• Prevalence of osteoporosis ranging from 8 to
62% in Indian women of different age groups
• Ranging from 8.5 to 24.6% in males older than
50 years
• F:M ratio of about 3:1 regarding fractures
• Urbanization leads to increased prevalence
• Low awareness

5. DXA in India
• 0.26 per million
• Judicious use of DXA facilities

7. Indications of DXA measurement
• Women > 60 + men> 65 regardless of clinical risk factors
• Postmenopausal women < 60 and men aged 50–64 years
when there are concerns for osteoporosis based on their
clinical risk factor profile
• Women in the menopausal transition if there is a specific
risk factor associated with increased fracture risk, such as
low body weight, prior low-trauma fracture, or high-risk
medication
• Individuals who have had a fragility fracture before the age
of 50 years

8. • Individuals with a condition (e.g., rheumatoid
arthritis, diabetes mellitus, malabsorption
syndrome) or who are taking medication (e.g.,
glucocorticoids in a daily dose ≥ 5 mg
prednisone or equivalent for ≥ 3 months)
associated with low bone mass or bone loss
• Any individual being considered for
pharmacologic therapy for osteoporosis

9. T-score calculation
• Caucasian female database derived from the
NHANES III

11. BTM
• Dynamic parameters that reflect short-term,
acute changes in bone remodeling status
• No role in the diagnosis of osteoporosis
• Baseline BTM level estimated prior to
initiation of therapy for subsequent
comparison during follow-up
• P1NP/CTX recommended

13. Screening tools (Indians)
• SCORE (Simple Calculated Osteoporosis Risk
Estimation) (value > 6 having good sensitivity)
• OSTA (osteoporosis self-assessment tool for
Asians)
• MORES (male osteoporosis risk estimation
score)

14. Pharmacological T/t

15. General Advice
• Limit alcohol intake to no more than 2 units per
day
• Stop smoking
• Maintain an active lifestyle, including weight-
bearing and balance exercises
• Counseling on reducing the risk of falls,
particularly among older patients

16. Vit D + Calcium
• 25 (OH) D > 20 ng/ml
• 1000 to 2000 (IU) of daily maintenance
therapy
• Adequate dietary intake of calcium with a
total intake (including diet plus supplement, if
needed) of at least 1000 mg/day

17. Therapy for prevalent VF
• Teriparatide : 24 months of therapy followed
by Anti-Resorptives
• Inj Zoledronic acid for 3-5 years
• Oral BPN

18. Therapy for prevalent HF
• IV Zoledronic
• Denosumab

19. Therapy without prevalent F (high risk)
• Oral/IV BPN
(Alendronate/Risedronate/Zoledronic)
• Denosumab
• Teriparatide ( T < -3.5)

20. Therapy without prevalent F
(low/moderate risk)
• BPN
• Denosumab

21. In CKD/HD
• BPN C/I in stage IV/V
• Denosumab : risk of Hypocalcemia
• Adynamic bone disease

22. HRT
• Not recommended
• Testosterone in hypogonadal male ( T < 200
ng/dl)

23. Intranasal calcitonin
• For temporary bone pain relief
• Only in women who cannot tolerate standard
T/t options

24. Combination therapies
• Denosumab + Teriparatide ( data’s
inadequate)

25. Sequential therapies
• Denosumab f/b BPN
• TP F/b Denosumab/BPN
• Unresponsive to anti-resorptive: TP + Anti-
Resorptives

26. Frequency of FU
• 3 months after initiation & then 3-6 monthly
• Annual thereafter

27. Check lists
• History : Falls; Bone/jaw pain
• Physical : Spine examination
• Vit D : 6 monthly f/b annually
• Ca: 12h after Teriparatide;
• DXA : 1-2 yearly- Increase above the LSC (changes
in LS robust than FN)
• BTM : For PINP, a threshold of > 20% or > 10 μg/L
and decrease in CTx by at least 30% or by at least
100 ng/L

28. Drug Holiday
• Matter of debate
• Only in Low/moderate risk groups

29. Existing other guidelines and
literatures

32. Difference with Endocrine society
guidelines
Endocrine Society Guidelines ISMBR guidelines
BMD DXA indications NOF
Female > 65, Male > 70
Female < 65 with RF for
fractures
Female > 60, Male > 65
Female < 65 with RF for
fractures
HRT Usage of Raloxifene,
Bazedoxifene , Tibolone
No mentioning of these
Classification Differentiates into Vertebral and
Non-vertebral
Differentiates into
prevalent and non-
prevalent fractures
Vit-D threshold At least 30 ng/ml At least 20 ng/ml

36. Reduced the risk of new radiographic vertebral fracture, with a cumulative
incidence of 2.3% in the denosumab group, versus 7.2% in the placebo group;
relative decrease of 68%
Reduced the risk of hip fracture, with a cumulative incidence of 0.7% in the
denosumab group, versus 1.2% in the
placebo group; relative decrease of 40%
Reduced the risk of non-vertebral fracture by 20%

37. Discontinuation increases bone turnover markers 3 months after a scheduled
dose is omitted, reaching above-baseline levels by 6 months, and decreases
bone mineral density (BMD) to baseline levels by 12 months
The vertebral fracture rate increased upon denosumab discontinuation to the
level observed in untreated participants
A majority of participants who sustained a vertebral fracture after
discontinuing denosumab had multiple vertebral fractures, with greatest risk in
participants with a prior vertebral fracture
Therefore, patients who discontinue denosumab should rapidly transition to an
alternative antiresorptive treatment

40. Women received 2-years of either teriparatide, denosumab or both medications
followed by 2- years of the alternate therapy (women who received combination
therapy initially received an additional 2-years of denosumab alone)
In the 22 women not receiving follow-up therapy, femoral neck, total hip, and
spine BMD decreased by −4.2±4.3%,−4.5±3.6%, and−10.0±5.4%, respectively,
while BMD was maintained in those who did receive follow-up antiresorptive
drugs
Among untreated women, femoral neck BMD decreased more in those
discontinuing denosumab (−5.8 ± 4.0%) than in those discontinuing teriparatide
(−0.8±2.6%, P=0.008)

41. Observational randomized comparative 1 year study was undertaken
to evaluate the adherence/compliance rates of most commonly prescribed daily alendronate (ALN),
weekly risedronate (RIS) and monthly ibandronate (IBN) BP regimens
Numerically maximum adherence rate of 56% was recorded in monthly
BP regimen followed by weekly (36%) and daily regimen (32%)
Concomitant treatment for co-morbid condition (57.14%), unawareness about osteoporosis (OP)
(50%), cost of treatment (45.33%), belief that drugs is for their general disability (39.28%),
physician’s failure to stress the need and necessary calcium + vitamin D daily requirement (23.80%)
each were the most prevalent factors responsible for non-adherence

42. Thank you……..