CLINICAL GUIDELINES |9
MAY 2017
;-Treatment of Low Bone Density or Osteoporosis to
Prevent Fractures in Men and Women: A Clinical Practice Guideline Update from
the American College of Physicians FREE
Amir Qaseem, MD, PhD, MHA; Mary Ann Forciea, MD; Robert M.
McLean, MD; Thomas D. Denberg, MD, PhD; for the Clinical Guidelines Committee
of the American College of Physicians (*)
:
This
guideline updates the 2008 American College of Physicians (ACP) recommendations
on treatment of low bone density and osteoporosis to prevent fractures in men
and women. This guideline is endorsed by the American Academy of Family
Physicians.
Q.1: What are the risk factors for
osteoporotic fracture? Ans: The risk
factors for osteoporotic fracture include (but are not limited to) 1) increasing age, 2) female sex, 3) postmenopausal
women, 4) hypogonadism or premature ovarian failure,5) low body weight,6) history of parental hip
fracture, 7) ethnic background (white persons are at higher risk than black
persons), 8) previous clinical or morphometric vertebral fracture,9) previous fracture due to minimal trauma (that
is, previous osteoporotic fracture), 10) rheumatoid arthritis, 11) current
smoking, 12) alcohol intake (3 or more drinks daily), 15( low bone mineral
density (BMD),16) vitamin D deficiency, 17)
low calcium intake, 18) hyperkyphosis, 19)
falling, and 20) immobilization . Another risk factor for osteoporotic
fracture is 21) long-term use of certain medications, the most commonly
implicated being glucocorticoids, anticoagulants, anticonvulsants, aromatase
inhibitors, cancer chemotherapeutic drugs, and gonadotropin-releasing hormone
agonists
How to diagnose osteoporosis?? Osteoporosis
can be diagnosed by the occurrence of fragility fracture. In patients without
fragility fracture, osteoporosis is often diagnosed by low BMD.
Q. 2: DXA : Method A:--DXA: Dual-energy x-ray absorptiometry (DXA) is the
current gold standard test for diagnosing osteoporosis in people without an
osteoporotic fracture. Results
of DXA are scored as SDs from a young, healthy norm (usually female) and
reported as T scores.
For
example, a T score of –2 indicates a BMD that is 2 SDs below the comparative
norm. The international reference standard for the description of osteoporosis
in postmenopausal women and in men aged 50 years or older is a femoral neck BMD
of 2.5 SD or more below the young female adult mean .
Low BMD as
measured by DXA is an imperfect predictor of fracture risk, identifying less
than one half of the people who go on to have an osteoporotic fracture.
Q. 3: Z score?? Method B:- Bone density can also be
classified according to the Z score, the number of SD above or below
the expected BMD for the patient's age and sex.
A Z score of –2.0 or lower is
defined as either “low BMD for chronological age” or “below the expected range
for age,” and those above –2.0 are “within the expected range for age” .
Q, 4: What is FRAX?? Risk scores that combine clinical risk factors
with BMD testing results, such as FRAX (the World Health Organization
Fracture Risk Assessment Tool), can be used to predict fracture risk among
people with low bone density.
Q. 5. What drug and how long to treat?? ACP recommends that clinicians
offer pharmacologic treatment with A) alendronate, B) risedronate, C) zoledronic
acid, or D) denosumab to reduce the risk for hip and vertebral fractures in
women who have known osteoporosis. (Grade: strong recommendation; high-quality
evidence) ACP recommends that clinicians treat osteoporotic women with
pharmacologic therapy for
5 year as per American College of Physicians (ACP)
ACP (American
College of Physicians )
This
guideline focuses on the comparative benefits and risks of short- and long-term
pharmacologic treatments for low bone density, including pharmaceutical
prescriptions, calcium, vitamin D, and
estrogen. Men and
women with low bone density and osteoporosis. ACP recommends that clinicians should make the decision whether to
treat osteopenic women 65 years of age or older who are at a high risk for
fracture based on a discussion of patient preferences, fracture risk profile,
and benefits, harms, and costs of medications.
What drugs??
Pharmacologic treatments for osteoporosis include A) bisphosphonates
(alendronate, risedronate, ibandronate, zoledronic acid), B) peptide hormones
(teriparatide [ 1,3,4 amino acid fragment of parathyroid hormone] and calcitonin), C) estrogen
(in the form of menopausal hormone therapy) for postmenopausal women, and D) selective estrogen receptor modulators (SERMs) (raloxifene for postmenopausal women).
Most of the treatments aim to prevent bone
resorption. E) Denosumab (a new biologic agent),
dietary and supplemental calcium, and vitamin D are also used for treatment. F) Bazedoxifene, a SERM, has recently been approved by the
U.S. Food and Drug Administration (FDA) with conjugated estrogen for prevention
of osteoporosis.
Osteoporosis
is a systemic skeletal disease characterized by decreasing bone mass and
microarchitectural deterioration of bone tissue that leads to an increased risk
for bone fragility and fracture. Although osteoporosis can be present in any
bone, the hip, spine, and wrist are most likely to be affected. Osteoporosis is
found in an estimated 200 million people worldwide and an estimated 54 million
men and women in the United States have osteoporosis or low bone density .Approximately
50% of Americans older than 50 years are at risk for osteoporotic fracture .
.
Recommendations:
ACP recommends that clinicians treat osteoporotic women with
pharmacologic therapy for 5 years. (Grade: weak recommendation; low-quality
evidence)
Recommendation
3:
ACP recommends that
clinicians offer pharmacologic treatment with bisphosphonates to reduce the
risk for vertebral fracture in men who have clinically recognized osteoporosis.
(Grade: weak recommendation; low-quality evidence)
Recommendation
4:
ACP recommends
against bone density monitoring during the 5-year pharmacologic treatment
period for osteoporosis in women. (Grade: weak recommendation; low-quality
evidence)
Recommendation
5:
ACP recommends
against using menopausal estrogen therapy or menopausal estrogen plus progestogen
therapy or raloxifene for the treatment of osteoporosis in women. (Grade:
strong recommendation; moderate-quality evidence)
Recommendation
6:
ACP recommends that clinicians should make the decision whether to
treat osteopenic women 65 years of age or older who are at a high risk for
fracture based on a discussion of patient preferences, fracture risk profile,
and benefits, harms, and costs of medications. (Grade: weak recommendation;
low-quality evidence)
Osteoporosis is a systemic skeletal
disease characterized by decreasing bone mass and microarchitectural
deterioration of bone tissue that leads to an increased risk for bone fragility
and fracture (1). Although osteoporosis can be present in any bone, the hip,
spine, and wrist are most likely to be affected. Osteoporosis is found in an
estimated 200 million people worldwide (2), and an estimated 54 million men and
women in the United States have osteoporosis or low bone density (3).
Approximately 50% of Americans older than 50 years are at risk for osteoporotic
fracture (4). The economic impact of osteoporosis on the health care system is
estimated to be $25.3 billion per year by 2025 (3). Courtsey: CLINICAL GUIDELINES |9
MAY 2017
;-Treatment of Low Bone Density or Osteoporosis to
Prevent Fractures in Men and Women: A Clinical Practice Guideline Update from
the American College of Physicians FREE
Amir Qaseem, MD, PhD, MHA; Mary Ann Forciea, MD; Robert M.
McLean, MD; Thomas D. Denberg, MD, PhD; for the Clinical Guidelines Committee
of the American College of Physicians (*))
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