Rapid recommendations

Guideline updates

Both Osteoporosis Canada and the Canadian Task Force on Preventive Health Care (CTFPHC) now recommend a risk-based approach to fracture risk assessment and eligibility for bone mineral density (BMD) testing (conditional recommendation; very low-certainty evidence for men,³ low-certainty evidence for women^3,4). Osteoporosis Canada advocates a targeted approach, considering clinical risk factors such as age, prior fragility fractures, glucocorticoid steroid use, and parental hip fracture to determine eligibility for BMD assessment before age 70 in patients 50 years or older. The preferred tool is the Canada-specific Fracture Risk Assessment Tool (FRAX; https://osteoporosis.ca/frax).³ In contrast, the CTFPHC endorses a “risk assessment–first” approach, using the FRAX tool initially to calculate 10-year fracture risk without BMD measurement, and only recommends BMD testing if pharmacotherapy is being considered.⁴ The CTFPHC discourages screening women aged 40 to 64 and men aged 40 years and older.⁴

Osteoporosis Canada’s 2023 recommendations change the 10-year fracture risk threshold for initiating pharmacotherapy to 15% (strength of evidence varies from conditional recommendation, very low certainty; to strong recommendation, high certainty, depending on risk level and sex).³ For patients at very high risk with severe or multiple vertebral fractures and T-scores of −2.5 or lower, anabolic therapies such as teriparatide or romosozumab are recommended. For patients at high risk, including those with a 10-year fracture risk of 15% or greater, previous hip or spine fracture, T-score of −2.5 or lower, and age younger than 70, bisphosphonates are suitable initial treatment, with reassessment after 3 to 6 years before consideration of a 3-year drug holiday. If bisphosphonates are not tolerated, denosumab is an alternative option.

Osteoporosis Canada recommends a shift away from routine annual BMD monitoring in most patients (conditional recommendation, low-certainty evidence).³ Instead, BMD measurement is now recommended around 3 years after initiating pharmacotherapy, with flexibility for shorter intervals based on individual risk factors. Similarly, in those with a 10-year risk score of less than 15%, BMD can be repeated after 5 years. This change aims to reduce unnecessary testing while still allowing appropriate monitoring based on patient circumstances.

The Choosing Wisely Canada campaign recommends against routine imaging for patients with ankle sprains, Achilles tendon ruptures, and nontraumatic shoulder pain, recommending instead a focused history-taking and physical examination as the primary diagnostic approach (no evidence level provided).⁵ For patients with ankle sprains and Achilles tendon ruptures, early clinical diagnosis enables timely non-operative management, avoiding delays and potential complications from additional imaging. When imaging is required for foot and ankle conditions, weight-bearing radiographs are preferred over non–weight-bearing views to accurately assess the pathology and avoid unnecessary tests and expenses. In patients with nontraumatic shoulder pain, imaging with a 3-view x-ray scan series is only suggested if substantial movement restriction, persistent symptoms, or suspected traumatic pathology exists. In patients with shoulder pain, advanced imaging such as ultrasound and magnetic resonance imaging should be reserved for cases with potential malignancy.

The Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder (AUD) advises against prescribing selective serotonin reuptake inhibitors (SSRIs) for adults and youth with AUD who also have concurrent anxiety or depressive disorders (strong recommendation, moderate-certainty evidence).⁶ While SSRIs are commonly used as therapies for anxiety and depression, the guideline notes a lack of evidence for their efficacy in patients with comorbid AUD and advises their use might worsen alcohol use. Case studies and randomized controlled trials demonstrate SSRIs and trazodone are no more effective than placebo for depression in patients with AUD and were associated with higher alcohol use, a higher number of heavy drinking days, and poorer outcomes. Instead, the guideline recommends prioritizing evidence-based psychosocial interventions and approved AUD pharmacotherapies such as naltrexone, acamprosate, or gabapentin.

The Canadian Pediatric & Perinatal HIV/AIDS Research Group has provided guidance for postpartum women living with HIV who wish to breastfeed their infants.⁷ Exclusive formula feeding remains the preferred method to prevent postpartum HIV transmission to infants born to women living with HIV. Mothers living with HIV who choose to breastfeed should receive detailed multidisciplinary counselling and undergo frequent monitoring to ensure viral suppression. Antiretroviral prophylaxis for the infant should also be considered. Optimal breast health and avoidance of mixed feeding (ie, both breastfeeding and formula feeding) are crucial to minimize HIV transmission risk.

The Society of Obstetricians and Gynaecologists of Canada recommends screening all pregnant women with risk factors for vasa previa with transvaginal sonography starting at 18 weeks’ gestation (strong recommendation, moderate-quality evidence).⁸ Risk factors for vasa previa include previous placenta previa, bilobed or succenturiate placenta, velamentous cord insertion, low-lying placenta, twin or higher-order multiple pregnancy, and conception assisted by reproductive technology. Screening should primarily involve transvaginal sonography with colour flow mapping and pulsed-wave Doppler imaging, complemented by transabdominal sonography. Targeted screening protocols, which are especially important in patients with high-risk pregnancies, have been shown to be cost-effective and successful, with detection rates of greater than 97%.

For pregnant patients at risk of delivery between 34 weeks 0 days and 36 weeks 6 days’ gestation, the Society of Obstetricians and Gynaecologists of Canada recommends individualized consideration of antenatal corticosteroids, with decisions informed by a comprehensive discussion of potential benefits and risks with the patient (strong recommendation, moderate-quality evidence).⁹ For pregnancies in patients with pregestational diabetes, antenatal corticosteroids are generally not recommended during this period due to the increased risk of neonatal hypoglycemia. While these steroids can decrease the risk of neonatal respiratory morbidity in late preterm births, their absolute benefits decrease as gestation progresses, and their impact on neurodevelopment and long-term outcomes is unclear. Antenatal corticosteroid administration before 33 weeks 6 days’ gestation remains strongly recommended if delivery is anticipated within 7 days.