New guidelines released for preventing fragility fractures

Osteoporosis Canada — an organization for those who have or are at risk for osteoporosis — has released comprehensive new guidelines aimed at preventing fragility fractures in women and men older than 50 years.

The guidelines have been published in the Canadian Medical Association Journal and include information on exercise, pharmacological therapies, risk management, and calcium and vitamin D supplementation.

“Fragility fractures — the consequence of osteoporosis — are responsible for excess mortality, morbidity, chronic pain, institutionalization and economic costs,” Alexandra Papaioannou, MD, MSc, an author of the guideline, and colleagues wrote. “They represent 80% of all fractures in menopausal women over age 50, and those with hip or vertebral fractures have substantially increased risk of death post-fracture.”

According to the authors, fewer than 20% of women and 10% of men with fragility fractures receive interventions to prevent future fractures.

Take-home messages

Key points of the guidelines include:

an assessment of a patient’s “absolute risk” of osteoporosis-related fractures should guide the management of osteoporosis;
fragility fracture should be considered in this assessment, as it increases the risk of further fractures; and
pharmocologic therapy and lifestyle modification should be individualized in the effort to enhance adherence to each patient’s treatment plan.

To assess for osteoporosis and fracture risk, the guidelines recommend that physicians take a detailed history and perform a focused physical examination of each patient. This can help identify risk factors such as low bone mineral density (BMD), falls and fractures — including undiagnosed vertebral fractures. The guidelines recommend dual-energy X-ray absorptiometry to measure BMD in certain patients.

Biochemical tests

The guidelines also note that height should be measured annually and, if a fall has occurred in the past year, a multifactorial risk assessment of patients should be conducted. This should include patients’ ability to get out of a chair without using their arms.

The guidelines also recommend certain biochemical tests to help assess patients for osteoporosis, including:

calcium, which should be corrected for albumin;
a complete blood count;
creatinine;
alkaline phosphatase;
thyroid-stimulating hormone;
serum protein electrophoresis, for patients with vertebral fractures; and
25-Hydroxyvitamin D.

Since the publication of previous guidelines in 2002, Osteoporosis Canada reported that “focus has shifted” to preventing fragility fractures and their negative outcomes. Current data, the group noted, indicates that many fracture patients are not appropriately assessed or treated. The new guidelines focus on identification and management of these fractures to help clinicians better manage fractures and osteoporosis in patients.

Reference:
Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010. DOI:10.1503/cmaj.100771.

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