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Osteoporosis

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General Information

Description

  • generalized skeletal disorder characterized by compromised bone strength and deterioration of bone quality, often leading to fragility fracture2
    • low bone mass frequently found, but not required, for diagnosis
    • regardless of bone mass, fragility fracture necessitates diagnosis

Definitions

  • osteomalacia - softening of bones, usually due to severe lack of vitamin D4
  • osteopenia1,2
    • low normal bone density, as defined by T-score between -1 and -2.5 when determined by lowest calculation from lumbar spine (at least 2 evaluable vertebrae), femoral neck, or total femur T-score, not low enough to be osteoporosis
    • preferred terms are "low bone mass" or "low bone density"
  • osteoporosis1,2
    • fragility fracture or T-score ≤ -2.5 when determined by lowest calculation from lumbar spine (at least 2 evaluable vertebrae), femoral neck, or total femur T-score
    • one-third radius site may be used if either lumbar spine or femur is nonevaluable
  • primary osteoporosis - deterioration of bone mass unassociated with other chronic illness, related to aging and decreased gonadal function (bone loss accelerated during sixth decade of life or perimenopausal period in women) (mnh11261866tcxh4191428tmdc11261866tAm Fam Physician 2001 Mar 1;63(5):897OpenInNewfull-textOpenInNew)
  • secondary osteoporosis - deterioration of bone mass associated with chronic conditions that contribute significantly to accelerated bone loss (mnh11261866tcxh4191428tmdc11261866tAm Fam Physician 2001 Mar 1;63(5):897OpenInNewfull-textOpenInNew)
  • severe osteoporosis - fragility fracture or fractures AND T-score ≤ -2.51,2
  • osteitis fibrosa - softening and deformity of bones, usually due to complications of hyperparathyroidism
  • fragility (low impact) fracture is fracture from minor trauma (for instance, fall from standing height or less)1,2
  • high-trauma fracture - fracture from high trauma (for instance, from car accident)1,2
  • clinical fracture - fracture suspected from signs on clinical exam1,2

References

General references used

  1. Cosman F, de Beur SJ, LeBoff MS, et al; National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014 Oct;25(10):2359-81OpenInNewfull-textOpenInNew, correction can be found in Osteoporos Int 2015 Jul;26(7):2045OpenInNew, commentary can be found in JAMA 2015 Apr 14;313(14):1467OpenInNew
  2. Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of osteoporosis, ninth edition. ICSI 2017 Jul PDFPictureAsPdf
  3. North American Menopause Society. Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010 Jan-Feb;17(1):25-54OpenInNew
  4. Watts NB, Adler RA, Bilezikian JP, et al; Endocrine Society. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012 Jun;97(6):1802-22OpenInNew
  5. International Society for Clinical Densitometry (ISCD). Skeletal health assessment in children from infancy to adolescence. ISCD 2013OpenInNew
  6. International Society for Clinical Densitometry (ISCD). Indications for bone mineral density (BMD) testing. ISCD 2013OpenInNew

Recommendation grading systems used

  • American College of Physicians (ACP) guideline grading system
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
      • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
      • Insufficient - balance of benefits and risks cannot be determined
    • quality of evidence
      • High - randomized trials without important limitations, or overwhelming evidence from observational studies
      • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
      • Low - observational studies or case series
      • Insufficient - evidence is conflicting, poor quality, or lacking
    • Reference - ACP guideline update on treatment of low bone density or osteoporosis to prevent fractures in men and women (mnh28492856pmdc28492856pAnn Intern Med 2017 Jun 6;166(11):818OpenInNew)
  • American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) criteria for grading recommendations
    • grades of recommendation
      • Grade A - ≥ 1 conclusive level 1 publications demonstrating benefit greater than risk
      • Grade B
        • no conclusive level 1 publication
        • ≥ 1 conclusive level 2 publications demonstrating benefit greater than risk
      • Grade C
        • no conclusive level 1 or 2 publication
        • ≥ 1 conclusive level 3 publications demonstrating benefit greater than risk or no risk at all and no benefit at all
      • Grade D
        • no conclusive level 1, 2, or 3 publication demonstrating benefit greater than risk, or
        • conclusive level 1, 2, or 3 publication demonstrating risk greater than benefit
    • levels of evidence
      • Level 1 - prospective, randomized, controlled trials - large
      • Level 2 - prospective with or without randomization - limited body of outcome data
      • Level 3 - other experimental outcome data and nonexperimental data
      • Level 4 - expert opinion
  • American College of Rheumatology (ACR) levels of recommendation
    • recommendations
      • Strong recommendation - confidence that desirable effects of following recommendation outweigh undesirable effects (or vice versa)
      • Conditional recommendation - uncertainty over balance of benefits and harms, low or very low evidence quality; patient preference or costs impact the decision
      • Good practice recommendation - supporting evidence is indirect, benefits of proceeding according to guidance far outweigh harms
    • grades of evidence
      • High-quality evidence - further research very unlikely to change confidence in estimate of effect
      • Moderate-quality evidence - further research likely to have important impact on confidence in estimate of effect; estimate may change
      • Low-quality evidence - further research very likely to have important impact on confidence in estimate of effect; estimate will likely change
      • Very low-quality evidence - any estimate of effect very uncertain
    • Reference - ACR 2017 guideline for the prevention and treatment of glucocorticoid-induced osteoporosis (cxh124315756t pmdc28585373pArthritis Rheumatol 2017 Aug;69(8):1521OpenInNew)
  • Institute for Clinical Systems Improvement (ICSI) grading system
    • strength of recommendation
      • Strong recommendation - benefits outweigh risks or harms, recommendation applies to most patients
      • Weak recommendation - benefits and harms are balanced or uncertainty exists about best estimates of benefits and harms; recommendation may depend on local circumstances, patient values, or preferences
    • quality of evidence
      • High-quality evidence - further research unlikely to change confidence in estimate of effect
      • Moderate-quality evidence - further research may impact recommendation and confidence in estimate of effect
      • Low-quality evidence - further research very likely to have important impact on confidence in estimate of effect and likely to change, so any estimate of effect is very uncertain
  • Endocrine Society uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • Strong recommendation - guideline panel members have high confidence that desirable effects of recommendation outweigh undesirable effects (or vice versa)
      • Weak recommendation - guideline panel members conclude with less confidence that desirable effects of recommendation probably outweigh undesirable effects, or benefits and harms are finely balanced, or appreciable uncertainty
    • quality of evidence
      • High-quality evidence - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate-quality evidence - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low-quality evidence - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low-quality evidence - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
  • Osteoporosis Canada (OC) level of evidence criteria
    • treatment and intervention
      • 1+ - systematic overview of meta-analysis of randomized controlled trials (RCTs)
      • 1 - RCT with adequate power
      • 2+ - systematic overview or meta-analysis of level 2 RCTs
      • 2 - randomized  controlled  trial  that  does  not  meet  level  1  criteria
      • 3 - nonrandomized  controlled  trial  or  cohort  study
      • 4 - before/after study, cohort study with noncontemporaneous controls, case-control study
      • 5 - case series without controls
      • 6 - case report or case series < 10 patients
    • grades of recommendation
      • Grade A - support level 1 or 1+ evidence plus consensus
      • Grade B - support level 2 or 2+ evidence plus consensus
      • Grade C - support level 3 evidence plus consensus
      • Grade D - any lower level of evidence supported by consensus
    • Reference - 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada (mnh20940232pmdc20940232pCMAJ 2010 Nov 23;182(17):1864OpenInNew)
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (June 2007 to June 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - clinicians may provide the service to select patients depending on individual circumstances; however, only small benefit is likely for most individuals without signs or symptoms
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Choosing Wisely Canada acknowledges dissemination of their recommendations through DynaMed Plus to reach the point of clinical decision-making.
  • The Canadian Association of Nuclear Medicine provides review for the incorporation of Choosing Wisely Canada recommendations.
  • The Canadian Medical Association provides review for the incorporation of Choosing Wisely Canada recommendations.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T113815, Osteoporosis; [updated 2018 Dec 03, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T113815. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Definitions

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes and risk factors

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Lungs

      • Abdomen

      • Back

      • Extremities

      • Genital exam

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Clinical prediction rules

    • KeyboardArrowRight

      Blood tests

      • Determining secondary causes of osteoporosis

      • Bone turnover markers for diagnosing osteoporosis

    • Urine studies

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      Imaging studies

      • KeyboardArrowRight

        Dual-energy x-ray absorptiometry (DEXA) scan

        • DEXA testing indications

        • Body site selection for DEXA scan

        • T-score and Z-score classification

        • DEXA scan in children

        • Peripheral dual-energy x-ray absorptiometry (pDEXA)

        • Vertebral fracture assessment (VFA)

      • Quantitative ultrasound (QUS)

      • Quantitative computed tomography-based absorptiometry (QCT)

      • Biomechanical analysis of computed tomography

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    Management

    • Management overview

    • Diet

    • Activity

    • Counseling

    • KeyboardArrowRight

      Medications

      • Medications licensed for osteoporosis treatment

      • Indications for pharmacologic therapy

      • Bisphosphonates

      • KeyboardArrowRight

        Parathyroid hormone (PTH)

        • Teriparatide

        • Abaloparatide

        • rhPTH (1-84)

      • KeyboardArrowRight

        Monoclonal antibodies

        • Denosumab

        • Romosozumab

      • KeyboardArrowRight

        Estrogen receptor modulators

        • Raloxifene

        • Lasofoxifene

        • Arzoxifene

        • Tibolone

      • Calcitonin

      • Strontium

      • KeyboardArrowRight

        Combination therapy

        • Bisphosphonate plus teriparatide

        • Bisphosphonate plus rhPTH (1-84)

        • Teriparatide plus denosumab

      • Comparative efficacy of bisphosphonates

      • KeyboardArrowRight

        Other medications

        • Fluoride

        • Odanacatib

        • Chinese herbal medicines

        • Growth hormone

    • KeyboardArrowRight

      Follow-up

      • KeyboardArrowRight

        Treatment monitoring

        • Bone mineral density (BMD) monitoring

        • Bone turnover markers (BTMs) in treatment monitoring

      • Treatment adherence

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Bone density testing for predicting fracture risk

      • Calculators for predicting fracture risk

      • Other factors for predicting fracture risk

      • Fractures associated with increased mortality

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • Prevention overview

      • Recommendations

      • Diet

      • Exercise

      • Behavioral interventions and counseling

      • KeyboardArrowRight

        Vitamins and supplements

        • Calcium and vitamin D

        • Vitamin K

        • Isoflavones

        • Potassium salts

      • KeyboardArrowRight

        Medications for prevention of osteoporosis

        • Bisphosphonates

        • Thiazide diuretics

        • Selective estrogen receptor modulators (SERMs)

        • Estrogen

        • Testosterone and dehydroepiandrosterone (DHEA)

        • Strontium ranelate

        • Romosozumab

    • KeyboardArrowRight

      Screening

      • Recommendations

      • Risk assessment

      • Screening evidence

      • Screening intervals

      • Screening tests

      • Increasing screening uptake

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

    • Choosing Wisely

    • Choosing Wisely Canada

    • Choosing Wisely Australia

    • Quality indicators

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Mexican guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

      • Middle Eastern guidelines

    • Review articles

    • MEDLINE search

  • Patient Decision Aids

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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