2023 guidelines for osteoporosis care in older female patients

Clinical question

What are the most recent guidelines to optimize osteoporosis management in older female patients?

Bottom line

Osteoporosis is a skeletal disorder characterized by reduced bone strength and predisposition to fractures. It is defined as a bone mineral density (BMD) of 2.5 standard deviations below average peak bone density (ie, T-score ≤−2.5) at the lumbar spine, femoral neck, or total hip.¹ An article published in the Canadian Geriatrics Society Journal of CME² guides clinicians and interdisciplinary health care teams in the investigation, monitoring, and treatment of osteoporosis in older female patients and highlights changes from previous guidelines.

Evidence

Canadian osteoporosis guidelines were published in 2023 as an update to 2010 guidelines, reflecting new and emerging evidence in osteoporosis care.³ Treatment is now recommended for those aged 70 years or older with a T-score of −2.5 or lower. Most trials of osteoporosis therapy have enrolled postmenopausal females based on low T-scores and demonstrated reduction of fracture by 20% to 50%—depending on fracture site—indicating there is benefit to treating these groups (figure 1 in Morin et al³).⁴

Approach

The 2023 osteoporosis guidelines updated screening recommendations to start at age 70 years instead of 65 years, unless there is a clinical risk factor. Diagnosis of osteoporosis can be made clinically for those older than 50 years based on a history of fragility fracture (which includes low trauma hip, spine, humerus, or pelvic fractures occurring after the age of 40 years). Those with a 10-year probability of fracture greater than 20% based on a risk assessment tool, either the Fracture Risk Assessment Tool (FRAX; https://www.fraxplus.org) or the Canadian Association of Radiologists and Osteoporosis Canada (CAROC; https://osteoporosis.ca/wp-content/uploads/CAROC.pdf) system, or history of spine or vertebral fractures, or 2 or more fragility fractures are automatically deemed high risk for future fracture.⁵

Implementation

Exercise and nutrition are important for all postmenopausal females (not only those with osteoporosis), as well as balance and functional training, and adequate vitamin D and calcium in diet (with or without supplementation).

• The main update focuses on balance and functional training, which is recommended at least twice weekly. Functional training involves exercises to improve performance of regular activities (eg, repeat chair stands to improve sit-to-stand ability). Since the last guideline, 2 large-scale studies of calcium and vitamin D supplementation in community-dwelling adults have not demonstrated a reduction in fractures.^6,7 However, most of the individuals in these trials were not on pharmacotherapy for osteoporosis. For patients with osteoporosis, supplemental vitamin D should be provided to target a 25-hydroxy vitamin D level greater than 50 nmol/L before starting pharmacotherapy. Osteoporosis Canada has an online calculator to estimate daily calcium intake (https://osteoporosis.ca/calcium-calculator), which can be provided to patients to help them achieve a target of 1200 mg per day.

• Perform a fracture risk assessment for all postmenopausal females 50 years or older by inquiring about risk factors for osteoporosis and examining for signs of vertebral fracture. Use FRAX versus CAROC to estimate the 10-year probability of major osteoporotic fracture, which includes low-trauma fractures from standing height or lower of the hip, vertebrae, humerus, and distal forearm.

• Order a BMD scan for all individuals older than 70 years and select individuals younger than 70 years in the presence of risk factors (eg, parental hip fracture, glucocorticoid use, current smoking, high alcohol intake, falls in the past 12 months, body mass index <20 kg/m²).

• Order lateral spine radiograph tests for individuals 65 years or older with a T-score of −2.5 or less, major osteoporotic fracture risk of 15% to 19.9%, or clinical signs of vertebral fracture (provider-documented height loss >2 cm, patient-reported height loss >6 cm, rib-to-pelvis distance ≤2 finger-breadths in midaxillary line, occiput-to-wall distance >5 cm).

• Suggested investigations for secondary osteoporosis include calcium, albumin, phosphate, creatinine, alkaline phosphatase, and thyroid-stimulating hormone levels; serum protein electrophoresis (for patients with vertebral fracture); and 25-hydroxy vitamin D levels.

• Recommend treatment for osteoporosis in all individuals older than 70 years with T-scores −2.5 or less, a 10-year major osteoporotic fracture (MOF) risk of 20% or greater, history of hip or spine fracture, or more than 2 low-trauma fractures after age 40 years (excluding hands, feet, and craniofacial bones). Consider osteoporosis treatment for individuals younger than 70 years with a T-score of −2.5 or less, or with a 10-year MOF risk of 15% to 19.9%.

• First-line treatment includes bisphosphonates (alendronate, risedronate, zoledronic acid) for 3 to 6 years followed by a drug holiday; repeat BMD test 3 years after starting therapy. Patients with a severe vertebral fracture (vertebral body height loss >40%) within the past 2 years or those with more than 2 vertebral fractures should be referred to an osteoporosis specialist for consideration of anabolic therapy (teriparatide or romosozumab).