The National Osteoporosis Foundation (NOF) has issued recommendations for the prevention, risk factor assessment, diagnosis and treatment of osteoporosis, including specific guidelines on the use of bone mineral density tests. “The Physician's Guide to Prevention and Treatment of Osteoporosis” was developed by an expert committee of the NOF in collaboration with 10 multidisciplinary medical organizations. C. Conrad Johnston, Jr., M.D., Indiana University, Indianapolis, was chair of the development committee.
The recommendations are based on evidence from randomized clinical trials. The guide primarily addresses white postmenopausal women, because sufficient data are not available to formulate comparable recommendations for men, premenopausal women and women of other races. The NOF recommends that risk factors identified for white women be applied to other populations on an individual basis to help make therapeutic decisions. The guidelines also do not address secondary causes of osteoporosis but contain a list of medications and diseases that are associated with an increased risk of osteoporosis.
The NOF document includes an overview of osteoporosis and a discussion of the medical and economic impact of the disease in the United States. Other sections in the guide discuss basic pathophysiology, risk factor assessment (see table), diagnosis, universal recommendations for all adults concerning prevention of osteoporosis, pharmacologic options, and physical medicine and rehabilitation.
A single copy or bulk copies of the guide can be ordered by contacting the NOF, 1150 17th St., N.W., Ste. 500, Washington, DC 20036-4603; telephone: 202-223-2226; fax: 202-223-2237. Single copies are free of charge; packets of 10 are available for a small fee. The NOF is also producing a pocket guide and a patient guide to compliment the physician guidelines. The NOF Web address is http://www.nof.org.
The following information includes the key recommendations discussed in the NOF guidelines:
All women should be counseled about the risk factors for osteoporosis (see table). Risk factors for osteoporotic fracture include personal history of fracture as an adult, history of fracture in a first-degree relative, white race, advanced age, female sex, dementia, poor health/frailty, cigarette smoking, low body weight (under 127 lb [58 kg]), estrogen deficiency, lifelong low calcium intake, alcoholism, impaired eyesight despite adequate correction, recurrent falls and inadequate physical activity. According to the NOF, osteoporosis is a “silent” risk factor for fracture; one out of two white women will have an osteoporotic fracture at some point in her lifetime.
The NOF recommends that all postmenopausal women with a fracture be evaluated for osteoporosis using bone mineral density testing to determine if the woman has osteoporosis and to determine disease severity. According to the NOF, measurements of bone mineral density at any skeletal site can predict the risk of fracture, but a measurement of the hip is the best predictor of hip fractures, and hip measurement can predict fractures at other sites as well. The measurement of bone density can also be used to monitor changes in bone density associated with medical conditions or therapy.
The NOF recommends bone mineral density testing in all postmenopausal women under age 65 who have one or more additional risk factors for osteoporosis (in addition to menopause).
Bone mineral density testing is also recommended in all women aged 65 and older regardless of additional risk factors.
All adults should be advised to consume an adequate intake of dietary calcium (at least 1,200 mg per day, including supplements if necessary) and vitamin D (400 to 800 IU per day for persons at risk of deficiency).
All patients should be counseled to avoid smoking and to limit alcohol intake to moderate levels. All patients should be encouraged to participate in regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.
Physicians should consider osteoporosis treatment for all postmenopausal women who present with vertebral fractures or hip fractures. The NOF emphasizes that these sites are the most common sites for osteoporotic fractures.
Bone mineral tests provide physicians with a T score expressed in standard deviation; the more negative the number, the greater the risk of fracture. Each standard deviation represents a 10 to 12 percent bone loss, and a T score of -2.5 indicates osteoporosis. The NOF recommends therapy to reduce fracture risk in women with a bone mineral density T score below -2.0 in the absence of risk factors, and in women with a T score below -1.5 if other risk factors are present.
Approved pharmacologic options for osteoporosis prevention or treatment are hormone replacement therapy, alendronate, raloxifene and calcitonin. The guideline notes that hormone replacement therapy represents the greatest benefit relative to cost for all of the pharmacologic treatments. Evidence indicates a 50 to 80 percent decrease in vertebral fractures and a 25 percent decrease in nonvertebral fractures after five years of use of hormone replacement therapy. The NOF emphasizes that “all post-menopausal women should be counseled to consider hormone replacement therapy or estrogen replacement therapy and offered guidance in weighing its risks and benefits.”