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(Meredith to add text here, including any applicable footnotes)
Assess/address low bone density/fx risk factors1,2 - Eval for dz/meds3 assoc w/ bone loss (NOF3)
- If at risk of vit D deficiency,4 ✓serum 25(OH)D levels (NOF5)
- Assess/manage fall risk factors (NOF6)
- ✓ht annually (wall-mount stadiometer preferred) (NOF5)
If risk factors for osteoporosis/fx:1,2 ✓BMD +/- vertebral imaging - ✓BMD w/ DXA @ hip + spine (ES,7 NOF,3 ISCD8); ✓DXA @ forearm needed in selected pts (ISCD,8 ES9)
- If specific risk factors (low trauma fx, long-term glucocorticoid tx,10 ht loss11), also consider vertebral imaging (NOF,12 ISCD13)
- Use FRAX® tool to estimate osteoporosis-assoc fx risk (NOF14)
Recommend measures to ↓osteoporosis/fx risk in all pts - Ca++ intake: 1,000 mg/day; supplement if needed (NOF5); 1,000-1,200 mg/day if risk factors (ES15)
- Vit D intake: 800–1,000 IU/day; supplement if needed to correct deficiency (ES,16 NOF5)
- Regular wt-bearing/muscle-strengthening exercise (NOF17)
- Smoking cessation, avoid excessive EtOH intake (NOF5)
Footnotes 1 ES 2012. Risk factors include hx of low-trauma fx at/after age 50, hx of falls w/in past yo, delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, COPD, RA, dementia, stroke hx, DM, alcoholism, smoking, glucocorticoid tx, GnRH tx. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
2 ISCD 2015. Risk factors include low body wt, prior fx, high-risk medication use, dz or condition assoc w/ bone loss. 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
3 NOF 2014. Dz assoc w/ bone loss include: RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia/bulimia, osteogenesis imperfecta, multiple myeloma.
Meds assoc w/bone loss include: aluminum (antacids), anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for 3mo), GnRH agonists, Li, PPI, SSRIs, TZDs.
Other factors assoc w/bone loss include: smoking, alcohol (≥3 drinks/day) immobilization, nutritional deficiencies, inadequate physical activity, frequent falls, parenteral nutrition, thinness. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
4 NOF 2014. Vit D-deficiency risks include: malabsorption (eg, celiac dz, IBD, gastric bypass), chronic renal dz, meds that ↑vit D breakdown (eg, some antiseizure drugs), ↓sun exposure, very dark skin, obesity. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
5 NOF 2014. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
6 NOF 2014. Assess for/manage: previous falls/fear of falling, home safety (loose rugs, low lighting, slippery conditions, obstacles), orthostatic hypotension, arrhythmias, poor vision, dehydration, CNS depressants, excessive EtOH, BP meds, impaired balance/mobility/proprioception, deconditioning, malnutrition, vit-D deficiency, urgent urinary incontinence, cognitive issues. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
7 ES 2012 [1] [L]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
8 ISCD 2015. If over wt limit for DXA table, cannot interpret spine/hip DXA, or hyperparathyroidism. 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
9 ES 2012 [1] [L]. If cannot interpret spine/hip DXA, hyperparathyroidism or on anti-androgens for prostate CA. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
10 NOF 2014. ≥5 mg prednisone or equivalent daily for ≥3mo. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
11 NOF 2014. Historical ht loss=peak ht @ 20 yo–current ht. Prospective ht loss=any previously documented ht–current ht. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
12 NOF 2014. Consider lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray if any of:
• hx of low-trauma fx at/after age 50
• long-term glucocorticoid tx
• historical ht loss ≥1.5” (4 cm)
• prospective ht loss ≥0.8” (2 cm)
Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
13 ISCD 2015. Lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray indicated if BMD T-score <-1 plus ≥ one of:
• historical ht loss >1.5” (4 cm)
• self-reported (undocumented) vertebral fx
• glucocorticoid tx equivalent to ≥5 mg prednisone daily for ≥3mo
2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
14 NOF 2014. USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors and BMD; femoral neck preferred; nonhip sites not recommended. Underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑fall risk. Most useful in low femoral-neck BMD. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
15 ES 2012 [1] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
16 ES 2012 [2] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
17 NOF 2014. Wt-bearing: walking, jogging, Tai Chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
Assess/address osteoporosis/fx risk factors1,2 in all pts, ✓BMD +/- vertebral imaging - Eval for dz/meds3 assoc w/ bone loss (NOF3)
- If at risk of vit D deficiency,4 ✓serum 25(OH)D levels (NOF5)
- ✓DXA @ hip + spine (ES,6 NOF,5 ISCD7); ✓DXA @ forearm needed in selected pts (ISCD,8 ES9)
- If specific risk factors (age ≥80 yo + BMD T-score <-1, low trauma fx, long-term glucocorticoid tx,10 ht loss11), also consider vertebral imaging (NOF,12 ISCD13)
- Use FRAX® tool to estimate osteoporosis-assoc fx risk (NOF14)
- Assess/manage fall risk factors (NOF15)
- ✓ht annually (wall-mount stadiometer preferred) (NOF5)
Recommend measures to ↓osteoporosis/fx risk for all pts - Ca++ intake: 1,000 mg/day; supplement if needed (NOF5); 1,000-1,200 mg/day if risk factors (ES16)
- Vit D intake: 800–1,000 IU/day; supplement if needed to correct deficiency (ES,17 NOF5)
- Regular wt-bearing/muscle-strengthening exercise (NOF18)
- Smoking cessation, avoid excessive EtOH intake (NOF5)
Footnotes 1 ES 2012. Risk factors include hx of low-trauma fx at/after age 50, hx of falls w/in past yo, delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, COPD, RA, dementia, stroke hx, DM, alcoholism, smoking, glucocorticoid tx, GnRH tx. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
2 ISCD 2015. Risk factors include low body wt, prior fx, high-risk medication use, dz or condition assoc w/ bone loss. 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
3 NOF 2014. Dz assoc w/ bone loss include: RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia/bulimia, osteogenesis imperfecta, multiple myeloma.
Meds assoc w/ bone loss include: aluminum (antacids), anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for 3mo), GnRH agonists, Li, PPI, SSRIs, TZDs.
Other factors assoc w/ bone loss include: smoking, alcohol (≥3 drinks/day) immobilization, nutritional deficiencies, inadequate physical activity, frequent falls, parenteral nutrition, thinness. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
4 NOF 2014. Vit D-deficiency risks include: malabsorption (eg, celiac dz, IBD, gastric bypass), chronic renal dz, meds that ↑vit D breakdown (eg, some antiseizure drugs), ↓sun exposure, very dark skin, obesity. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
5 NOF 2014. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
6 ES 2012 [1] [L]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
7 ISCD 2015. 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
8 ISCD 2015. If over wt limit for DXA table, cannot interpret spine/hip DXA, or hyperparathyroidism. 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
9 ES 2012 [1] [L]. If cannot interpret spine/hip DXA, hyperparathyroidism or on anti-androgens for prostate CA. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
10 NOF 2014. ≥5 mg prednisone or equivalent daily for ≥3mo. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
11 NOF 2014. Historical ht loss=peak ht @ 20 yo–current ht. Prospective ht loss=any previously documented ht–current ht. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
12 NOF 2014. Consider lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray if any of:
• age ≥80 yo plus BMD T-score <-1
• age 70-79 yo plus BMD T-score <-1.5
• hx of low-trauma fx at/after age 50
• long-term glucocorticoid tx
• historical ht loss ≥1.5” (4 cm)
• prospective ht loss ≥0.8” (2 cm)
Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
13 ISCD 2015. Lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray indicated if BMD T-score <-1 plus ≥ one of:
• age ≥ 80 yo
• historical ht loss >1.5” (4 cm) 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
14 NOF 2014. USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors and BMD; femoral neck preferred; nonhip sites not recommended. Underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑fall risk. Most useful in low femoral-neck BMD. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
15 NOF 2014. Assess for/manage: previous falls/fear of falling, home safety (loose rugs, low lighting, slippery conditions, obstacles), orthostatic hypotension, arrhythmias, poor vision, dehydration, CNS depressants, excessive EtOH, BP meds, impaired balance/mobility/proprioception, deconditioning, malnutrition, vit D deficiency, urgent urinary incontinence, cognitive issues. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
16 ES 2012 [1] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
17 ES 2012 [2] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
18 NOF 2014. Wt-bearing: walking, jogging, Tai Chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
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Assess/address osteoporosis/fx risk factors1-3 in all pts; consider vertebral imaging if specific risk factors - If specific risk factors (low trauma fx, long-term glucocorticoid tx,4 ht loss5), consider vertebral imaging (NOF6)
- Ca++ intake: men 50-70 yo=1,000 mg/day; men ≥71 yo=1,200 mg/day; supplement if needed (NOF7)
- Vit D intake: 800–1,000 IU/day; supplement if needed to correct deficiency (NOF,7 ES8)
- Use FRAX® tool to estimate osteoporosis-assoc fx risk (NOF9)
- Smoking cessation, avoid excessive EtOH intake (NOF7)
- Assess/manage fall risk factors10
- Regular wt-bearing/muscle strengthening exercise (NOF,11 ES12)
- ✓ht annually (wall-mount stadiometer preferred) (NOF7)
Footnotes 1 ES 2012. Risk factors include hx of low-trauma fx at/after age 50, hx of falls w/in past yo, delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, COPD, RA, dementia, stroke hx, DM, alcoholism, smoking, glucocorticoid tx, GnRH tx. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
2 ISCD 2015. Risk factors include low body wt, prior fx, high-risk medication use, dz or condition assoc w/bone loss. 2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
3 NOF 2014. Dz assoc w/ bone loss include: RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia/bulimia, osteogenesis imperfecta, multiple myeloma.
Meds assoc w/ bone loss include: aluminum (antacids), anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for 3mo), GnRH agonists, Li, PPI, SSRIs, TZDs.
Other factors assoc w/ bone loss include: smoking, alcohol (≥3 drinks/day) immobilization, nutritional deficiencies, inadequate physical activity, frequent falls, parenteral nutrition, thinness. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
4 NOF 2014. ≥5 mg prednisone or equivalent daily for ≥3mo. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
5 NOF 2014. Historical ht loss=peak ht @ 20 yo–current ht. Prospective ht loss=any previously documented ht–current ht. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
6 NOF 2014. Consider lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray if any of:
• hx of low-trauma fx at/after age 50
• long-term glucocorticoid tx
• historical ht loss ≥1.5” (4 cm)
• prospective ht loss ≥0.8” (2 cm)
Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
7 NOF 2014. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
8 ES 2012 [2] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
9 NOF 2014. USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors and BMD; femoral neck preferred; nonhip sites not recommended. Underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑fall risk. Most useful in low femoral-neck BMD. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
10 NOF 2014. Assess/manage: previous falls/fear of falling, home safety (loose rugs, low lighting, slippery conditions, obstacles), orthostatic hypotension, arrhythmias, poor vision, dehydration, CNS depressants, excessive EtOH, BP meds, impaired balance/mobility/proprioception, deconditioning, malnutrition, vit D deficiency, urgent urinary incontinence, cognitive issues. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
11 NOF 2014. Wt-bearing: walking, jogging, Tai Chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
12 ES 2012 [2] [VL]. Wt-bearing activities recommended in sessions of 30-40min, 3-4x/wk. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
Abnormal BMD (T-score <-1): tx-naive Eval osteoporosis/osteopenia; consider vertebral imaging if specific risk factors, consider pharmacologic tx, and f/u - Eval for secondary causes of osteoporosis1,2
- If specific risk factors (low trauma fx, long-term glucocorticoid tx,3 ht loss4), consider vertebral imaging (NOF,5 ISCD,6 ES7)
- Use FRAX® tool to estimate osteoporosis-assoc fx risk (NOF8)
- If low trauma hip/vertebral fx, T-score ≤−2.5, or other indications (NOF,9 ES10), consider drug tx11,12 on case-by-case basis
- If starting tx, ✓biochemical markers of bone turnover13 at 3-6mo + ✓BMD w/ DXA @ hip + spine q1-2y (ES14)
- ✓ht annually (wall-mount stadiometer preferred) (NOF15)
Recommend nonpharmacologic measures for all pts - Ca++ intake: men 50-70 yo=1,000 mg/day; men ≥71 yo=1,200 mg/day; supplement if needed (NOF15)
- Vit D intake: 800–1,000 IU/day; supplement if needed to correct deficiency (ES,14 NOF15)
- Assess/manage fall risk factors16,17
- Regular wt-bearing/muscle-strengthening exercise (NOF,18 ES19)
- Smoking cessation, avoid excessive EtOH intake (NOF15)
Footnotes 1 NOF 2014. Dz assoc w/ bone loss include: RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia/bulimia, osteogenesis imperfecta, multiple myeloma.
Meds assoc w/ bone loss include: aluminum (antacids), anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for 3mo), GnRH agonists, Li, PPI, SSRIs, TZDs.
Other factors assoc w/ bone loss include: smoking, alcohol (≥3 drinks/day) immobilization, nutritional deficiencies, inadequate physical activity, frequent falls, parenteral nutrition, thinness. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
2 NOF 2014. Consider in all pts: CBC, Ca++, phos, magnesium, renal/hepatic fxn, 25(OD)D, total testosterone, TSH, bone turnover markers, PTH, 24-h urinary Ca++ excretion Consider in selected pts: serum/urine protein electrophoresis, tissue transglutaminase abs, Fe studies, homocysteine, prolactin, tryptase, urinary free cortisol, urinary histamine. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
3 NOF 2014. ≥5 mg prednisone or equivalent daily for ≥3mo. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
4 NOF 2014. Historical ht loss=peak ht @ 20 yo–current ht. Prospective ht loss=any previously documented ht–current ht. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
5 NOF 2014. Consider lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray if any of:
• age ≥ 80 yo plus BMD T-score <-1
• age 70-79 yo plus BMD T-score <-1.5
• hx of low-trauma fx at/after age 50
• long-term glucocorticoid tx
• historical ht loss ≥1.5” (4 cm)
• prospective ht loss ≥0.8” (2 cm)
Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
6 ISCD 2015. Lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray indicated if BMD T-score <-1 plus ≥ one of:
• age ≥ 80 yo
• historical ht loss >1.5” (4 cm)
• self-reported (undocumented) vertebral fx
• glucocorticoid tx equivalent to ≥5 mg prednisone daily for ≥3mo
2015 ISCD Official Positions–Adult. The International Society for Clinical Densitometry. Accessed online 9/19/16
7 ES 2012 [1] [L]. Assess w/ lateral vertebral fx assessment (VFA) on DXA equipment or lateral T + L-spine x-ray if osteoporosis or osteopenia + possibly undx vertebral fx. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
8 NOF 2014. USA-adapted FRAX® tool intended for postmenopausal women + men ≥50 yo; calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors and BMD; femoral neck preferred; nonhip sites not recommended. Underestimates fx risk in pts w/ recent fx, multiple osteoporosis-related fx, and those w/ ↑fall risk. Most useful in low femoral-neck BMD. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
9 NOF 2014. Indications for pharmacologic tx:
• hip/vertebral fx
• T-score ≤−2.5
• T-score −1.0 to−2.5 (osteopenia) + FRAX® 10-yr hip fx probability ≥3%, or 10-yr major osteoporosis-related fx probability ≥20%
Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
10 ES 2012. Indications for pharmacologic tx:
• low-trauma hip/vertebral fx [1] [M]
• T-score ≤−2.5 [1] [L]
• T-score −1.0 to−2.5 (osteopenia) + FRAX® 10-yr hip fx probability ≥3%, or 10-yr major osteoporosis-related fx probability ≥20% [1] [L]
• long-term glucocorticoid tx (prednisone or equivalent >7.5mg/d) [1] [L]
• androgen-deprivation tx for prostate CA [1] [M]
Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
11 ES 2012. FDA-approved options for men (individualize based on fx hx, severity, comorbid conditions, cost):
• bisphosphonates (alendronate, risedronate, zoledronic acid); zoledronic acid preferred in men w/ recent hip fx
• PTH (1-34) (teriparatide); suggest use w/ antiresorptive tx
• RANKLi (denosumab); for men on anti-androgens for prostate CA
Meds not approved for osteoporosis in men (eg, calcitonin, ibandronate, strontium ranelate, etc) should only be used if above agents can’t be given. Testosterone tx suggested for men w/ high fx risk + testosterone level <200 ng/dl (6.9 nmol/L) w/o standard indications for testosterone if unable to take approved meds. Testosterone tx suggested for men w/ borderline fx risk if testosterone level <200 ng/dl (6.9 nmol/L) + s/sx of androgen deficiency/hypogonadism; stop if no improvement in s/sx after 3-6mo. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
12 NOF 2014. FDA-approved options for men:
• bisphosphonates (alendronate, risedronate, zoledronic acid)
• PTH (1-34) (teriparatide)
• RANKLi (denosumab)
Most efficacy data obtained in studies on women. Non-FDA-approved meds are not recommended. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
13 NOF 2014. Includes bone resorption markers (CTX, NTX) + bone formation markers (BSAP, OC, PINP). Obtain samples in early AM after overnight fast. In treated pts, markers may predict extent of fx risk reduction (when repeated after 3–6 mo of tx), + predict magnitude of BMD increase w/ tx. Helps assess adequacy of tx compliance/persistence. In untreated pts, markers predict fx risk independently of bone density + rapidity or bone-loss. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
14 ES 2012 [2] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
15 NOF 2014. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
16 NOF 2014. Assess for/manage: previous falls/fear of falling, home safety (loose rugs, low lighting, slippery conditions, obstacles), orthostatic hypotension, arrhythmias, poor vision, dehydration, CNS depressants, excessive EtOH, BP meds, impaired balance/mobility/proprioception, deconditioning, malnutrition, vit D deficiency, urgent urinary incontinence, cognitive issues. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
17 NOF 2014. Lack of evidence that hip protectors ↓hip/pelvis fx risk/fall rate in community-dwellers. Some studies in long-term care/residential care show marginally significant ↓hip fx risk. Adherence is poor, most marketed products not tested in RCTs. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
18 NOF 2014. Wt-bearing: walking, jogging, Tai Chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
19 ES 2012 [2] [VL]. Wt-bearing activities recommended in sessions of 30-40min, 3-4x/wk. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
Abnormal BMD (T-score <-1): tx-experienced F/U at least annually while on meds, ✓bone turnover markers1 3-6mo after tx initiation, ✓BMD q1-2y (NOF,2 ES3); individualize tx duration - Assess tx adherence, diet/supplements (Ca++, vit D),4 exercise,5,6 smoking/EtOH, fall risk factors annually (NOF7,8)
- ✓BMD w/ DXA @ hip + spine q1-2y (NOF,2 ES3)
- If new ht loss, back pain/posture change, suspicious CXR finding, or if considering d/c’ing meds: ✓vertebral imaging (NOF9)
- ✓ht annually (wall-mount stadiometer preferred) (NOF10)
After 3-5y of initial tx, individualize ongoing tx based on comprehensive risk assessment11 (NOF,9 ASBMR12) - If hip/spine/multiple other osteoporotic fx before/during tx: Consider continued bisphosphonate tx or change to alternative tx (ASBMR12)
- If hip BMD T-score ≤-2.5/high fx risk:13 Consider continued bisphosphonate tx for up to 10y or change to alternative tx (ASBMR12)
- If no fx before/during tx w/ hip BMD T-score >-2.5/no high fx risk: Consider d/c meds (drug holiday) (NOF,14 ASBMR12)
- Reassess BMD in all pts q2-3y (NOF,9 ASBMR15)
Footnotes 1 NOF 2014. Includes bone resorption markers (CTX, NTX) + bone formation markers (BSAP, OC, PINP). Obtain samples in early AM after overnight fast. In treated pts, markers may predict extent of fx risk reduction (when repeated after 3–6mo of tx), + predict magnitude of BMD increase w/ tx. Helps assess adequacy of tx compliance/persistence. In untreated pts, markers predict fx risk independently of bone density + rapidity or bone-loss. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
2 NOF 2014. ✓BMD 1-2y after initiating tx, then q2y thereafter; more or less frequently if clinically indicated. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
3 ES 2012 [2] [M]. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
4 NOF 2014. Adequate Ca++ intake: men 50-70 yo=1,000 mg/day; men ≥71 yo=1,200 mg/day. Adequate vit D intake: 800–1,000 IU/day; vit D-deficient adults: tx w/ 50,000 IU vit D2 or D3 once/wk (or 7,000 IU vit D2 or D3 daily) x8–12wk to achieve 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,500–2,000 IU/day or as required for target blood levels. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
5 NOF 2014. Wt-bearing: walking, jogging, Tai Chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Eval by clinician before starting new vigorous program (eg, running, heavy wt-lifting). Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
6 ES 2012 [2] [VL]. Wt-bearing activities recommended in sessions of 30-40min, 3-4x/wk. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-22. PDF
7 NOF 2014. Assess/manage: previous falls/fear of falling, home safety (loose rugs, low lighting, slippery conditions, obstacles), orthostatic hypotension, arrhythmias, poor vision, dehydration, CNS depressants, excessive EtOH, monitor BP meds, impaired balance/mobility/proprioception, deconditioning, malnutrition, vit D deficiency, urgent urinary incontinence, cognitive issues. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
8 NOF 2014. Lack of evidence that hip protectors ↓hip/pelvis-fx risk/fall rate in community-dwellers. Some studies in long-term care/residential care show marginally significant ↓hip-fx risk. Adherence is poor, most marketed products not tested in RCTs. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
9 NOF 2014. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
10 NOF 2014. Historical ht loss=peak ht @ 20 yo–current ht. Prospective ht loss=any previously documented ht–current ht. If pt loses ≥2 cm (0.8”) acutely or cumulatively, repeat vertebral imaging for fx. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
11 NOF 2014. Consists of hx, incl intercurrent fxs and new chronic dz/meds, ✓ht (if ht ↓, then ✓vertebral imaging,) ✓BMD. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
12 ASBMR 2016. Approach outlined for postmenopausal women considered generally applicable to men. Adler RA, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016;31:16-35. PDF
13 ASBMR 2016. High fx risk defined as older age (>70 yo), other strong fx risk factors, FRAX® score above country-specific threshold. Adler RA, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016;31:16-35. PDF
14 NOF 2014. Bisphosphonates may have residual effects, at least for several yrs after d/c. Nonbisphosphonate effects wane rapidly. If considering drug holiday: re-√vertebral imaging, as d/c not recommended if recent vertebral fx. If d/c meds: Monitor serially for fx/falls/new chronic dz/meds; consider serial BMD, bone turnover markers, vertebral imaging. Bone turnover markers may help determine drug-holiday duration. Cosman F, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int. 2014;25:2359-2381. PDF
15 ASBMR 2016. Shorter interval if new fx or anticipate accelerated bone loss (eg, glucocorticoid/aromatase inhibitor tx). Adler RA, et al. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2016;31:16-35. PDF
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