Development of clinical practice guidelines for prevention and treatment of osteoporosis

Clinical practice guidelines should be written for the physician who sees patients who already have or are at high risk for osteoporosis. They should also guide the physician in distinguishing between those at high and low risk and provide general guidelines for prevention of osteoporosis for the low-risk patient. Patients at high risk may require intervention to prevent further bone loss. The guidelines should be based on the strongest evidence available and be easy to comprehend and apply. Methods to identify individuals at high risk for osteoporosis must be described. Effective interventions also should be described, as should their benefits and risks. Elderly individuals who have a poor diet and little sun exposure may be vitamin D deficient unless a supplement is given. Factors that may be deleterious to the skeleton should be avoided. Weight-bearing exercise is important throughout life. Assessment of fracture risk is important in choosing candidates for intervention, especially interventions aimed at preventing osteoporosis. Measuring bone mass at any skeletal site is the necessary initial step for most individuals; measurement at the hip may best assess the risk of hip fracture. Some risk factors independent of bone mass may also aid in patient selection. The WHO has defined osteoporosis as a bone mass at least 2.5 standard deviations (SDs) below the mean of young normal. Such individuals and those with bone mass from 1 to 2.5 SDs below the mean of young normal may also be considered for intervention. The decision will depend on assessments of the risks, the costs of treatment, the desire of the patient, and the presence of other independent risk factors. The patient with an acute fracture may require an orthopedic intervention and should receive adequate analgesia. Physical therapy is an important adjunct that aids recovery. A number of therapeutic interventions, including adequate calcium intake throughout life and an adequate vitamin D intake, are available to high-risk individuals. These interventions may be recommended generally and do not require a diagnosis of osteoporosis. Similarly, a safe weight-bearing exercise program that helps to maintain muscle strength can be recommended to older patients. Other forms of therapy include hormone replacement, bisphosphonates, and calcitonin. Vitamin D analogs and selective estrogen receptor modulators may be helpful in the future. The risks and costs of each therapy should be weighed against its benefit in slowing bone loss or increasing bone mass and reducing fractures.