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Questions and Answers
What is the aim of the guideline mentioned in the content?
What is the aim of the guideline mentioned in the content?
to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk
Which approach is described in Figure 1 of the guideline?
Which approach is described in Figure 1 of the guideline?
Fractures of the hands and feet are considered major osteoporotic fractures.
Fractures of the hands and feet are considered major osteoporotic fractures.
False
Fractures of the hip, vertebra, humerus, and distal forearm are categorized as major osteoporotic _____.
Fractures of the hip, vertebra, humerus, and distal forearm are categorized as major osteoporotic _____.
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What does the systematic review of randomized controlled trials suggest about resistance training and quality of life?
What does the systematic review of randomized controlled trials suggest about resistance training and quality of life?
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How can the recommendations be grouped under in the article?
How can the recommendations be grouped under in the article?
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Impact exercise may improve BMD and physical functioning and may reduce mortality.
Impact exercise may improve BMD and physical functioning and may reduce mortality.
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Yoga and Pilates have direct evidence supporting their effects on health-related outcomes.
Yoga and Pilates have direct evidence supporting their effects on health-related outcomes.
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What is the abbreviation BMD stand for?
What is the abbreviation BMD stand for?
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What was the association of calcium and vitamin D supplementation with fracture reduction?
What was the association of calcium and vitamin D supplementation with fracture reduction?
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Protein supplementation has a significant impact on reducing hip fracture rates.
Protein supplementation has a significant impact on reducing hip fracture rates.
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Assessment of adherence and tolerance is recommended before starting ______________ therapy.
Assessment of adherence and tolerance is recommended before starting ______________ therapy.
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Match the following guidelines with their recommendations:
Match the following guidelines with their recommendations:
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What is defined as 'recent fracture' in the context of osteoporosis?
What is defined as 'recent fracture' in the context of osteoporosis?
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Which osteoporosis medication may be preferred when there is a high burden of oral medications or gastrointestinal intolerance?
Which osteoporosis medication may be preferred when there is a high burden of oral medications or gastrointestinal intolerance?
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What is the Health Canada recommended dietary allowance for calcium for males aged 51-70 years?
What is the Health Canada recommended dietary allowance for calcium for males aged 51-70 years?
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Bone turnover markers are clinically proven to predict fracture risk in individuals on a bisphosphonate drug holiday.
Bone turnover markers are clinically proven to predict fracture risk in individuals on a bisphosphonate drug holiday.
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Denosumab is a RANK-ligand inhibitor given __________.
Denosumab is a RANK-ligand inhibitor given __________.
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What is the Health Canada recommended dietary allowance for calcium for females older than 50 years and males older than 70 years?
What is the Health Canada recommended dietary allowance for calcium for females older than 50 years and males older than 70 years?
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What is the Health Canada recommended dietary allowance for vitamin D for individuals older than 50 years?
What is the Health Canada recommended dietary allowance for vitamin D for individuals older than 50 years?
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Which supplement should be provided for people at risk of vitamin D deficiency?
Which supplement should be provided for people at risk of vitamin D deficiency?
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FRAX is the preferred tool for fracture risk estimation in Canada.
FRAX is the preferred tool for fracture risk estimation in Canada.
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According to the guidelines, what is the suggested initial therapy duration for people on bisphosphonates?
According to the guidelines, what is the suggested initial therapy duration for people on bisphosphonates?
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What is the recommended course of action for people with inadequate response or substantial concerns during bisphosphonate therapy?
What is the recommended course of action for people with inadequate response or substantial concerns during bisphosphonate therapy?
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Monitoring using bone turnover markers is recommended for deciding on resumption of therapy in people who have stopped bisphosphonates.
Monitoring using bone turnover markers is recommended for deciding on resumption of therapy in people who have stopped bisphosphonates.
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After discontinuing denosumab, transitioning to a bisphosphonate therapy is suggested ________.
After discontinuing denosumab, transitioning to a bisphosphonate therapy is suggested ________.
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What tool is suggested for fracture risk estimation in Canada?
What tool is suggested for fracture risk estimation in Canada?
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What are some topics of high relevance to skeletal health mentioned in the text?
What are some topics of high relevance to skeletal health mentioned in the text?
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Which type of therapy inhibits osteoclastic activity?
Which type of therapy inhibits osteoclastic activity?
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Why were primary health care osteoporosis and multiple comorbidities excluded from the guideline?
Why were primary health care osteoporosis and multiple comorbidities excluded from the guideline?
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Postmenopausal females and males aged 50 years and older with recent fractures should have access to a Fracture Liaison Service for osteoporosis identification and treatment.
Postmenopausal females and males aged 50 years and older with recent fractures should have access to a Fracture Liaison Service for osteoporosis identification and treatment.
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Patient values and preferences are considered in fall prevention interventions for older community-dwelling adults.
Patient values and preferences are considered in fall prevention interventions for older community-dwelling adults.
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What was the framework used by the working groups to formulate recommendations?
What was the framework used by the working groups to formulate recommendations?
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How were the recommendations strength categorized according to the GRADE system?
How were the recommendations strength categorized according to the GRADE system?
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The Canadian Task Force on Preventive Health Care guideline recommends against screening younger females for the primary prevention of fragility fractures.
The Canadian Task Force on Preventive Health Care guideline recommends against screening younger females for the primary prevention of fragility fractures.
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The development of certain recommendations was supported by the results of analyses from a large observational Canadian cohort registry called the Manitoba _______ _______ Density registry.
The development of certain recommendations was supported by the results of analyses from a large observational Canadian cohort registry called the Manitoba _______ _______ Density registry.
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Study Notes
Osteoporosis and Fracture Prevention Guidelines
- In Canada, over 2 million people live with osteoporosis, a disease that increases the risk of fractures, resulting in excess mortality, morbidity, and loss of autonomy.
- The guideline update is intended to assist Canadian healthcare professionals in delivering care to optimize skeletal health and prevent fractures in postmenopausal females and males aged 50 years and older.
Background
- Osteoporosis is often considered a disease of older females, but males are remarkably under-evaluated and under-treated despite suffering worse outcomes following fractures.
- Every year in Canada, about 150 people per 100,000 suffer a hip fracture, which is considered one of the most serious fractures associated with osteoporosis.
Definition and Diagnosis
- Osteoporosis is defined as a bone mineral density (BMD) of 2.5 or more standard deviations below the peak bone mass (i.e., T-score ≤ –2.5).
- A clinical diagnosis of osteoporosis can be made in people aged 50 years and older if they have sustained a low-trauma hip, vertebral, humerus, or pelvis fracture after the age of 40 years, or if they have an absolute fracture risk of 20% or more over the next 10 years using a fracture risk assessment tool (FRAX or the Canadian Association of Radiologists and Osteoporosis Canada [CAROC]).
Risk Factors
- Age, sex, and other factors modify the risk of fracture.
- Fracture risk increases with advancing age, as a result of declining skeletal strength and increased risk of falling.
Exercise
- Exercise is a key element of the management strategy for fracture prevention and should be individualized.
- The recommendations on exercise for fall and fracture prevention in postmenopausal females and males aged 50 years and older are outlined in Table 2.
- Functional and balance training in adults older than 50 years can reduce the number of falls and the number of people who fall.
- Resistance training may improve quality of life, physical functioning, and BMD, and may reduce the number of falls and number of people who fall.
Nutrition
- The recommendations on nutrition for postmenopausal females and males aged 50 years and older to prevent falls and fracture are summarized in Table 2.
- A balanced diet (https://food-guide.canada.ca/en/food-guide-snapshot/) is recommended for people who are not receiving supplements.
Guideline Recommendations
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The guideline formulated 25 recommendations and 10 good practice statements using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
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The recommendations are grouped under the sections of exercise, nutrition, fracture risk assessment, and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring.### Osteoporosis Guidelines
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Postmenopausal females and males aged ≥ 50 years:
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Recommend balance and muscle-strengthening exercises ≥ twice weekly
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Suggest eating foods rich in calcium and protein
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Suggest a minimum vitamin D supplement of 400 IU daily
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Perform clinical assessment to identify risk factors and signs of undiagnosed vertebral fracture
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Consider lateral spine imaging to identify vertebral fracture(s)
Risk Factors
- Previous fracture, after age 40 years
- Glucocorticoids (> 3 mo in the last year, prednisone dose > 5 mg daily)
- Falls, ≥ 2 in the last year
- Parent fractured hip
- Body mass index < 20 kg/m2
- Secondary osteoporosis
- Current smoking
- Alcohol ≥ 3 drinks/d
- Prospective height loss > 2 cm or historical > 6 cm
- Rib-to-pelvis distance ≤ 2 finger-breadths in midaxillary line
- Occiput-to-wall distance > 5 cm
Approach to Management
- Age < 70 yr and no risk factors: No pharmacotherapy
- Age 50–64 yr with previous fracture or ≥ 2 risk factors: Suggest pharmacotherapy
- Age 65–69 yr with 1 risk factor: Suggest pharmacotherapy
- Age ≥ 70 yr with no risk factors: No pharmacotherapy
- Obtain BMD and calculate 10-yr fracture risk with BMD using FRAX (preferred) or CAROC tool
- Reassess BMD and fracture risk in 3 years if pharmacotherapy initiated
Pharmacotherapy
- Recent severe vertebral fracture or ≥ 2 vertebral fractures and T-score ≤ –2.5: Anabolic therapy (teriparatide or romosozumab)
- Bisphosphonates (alendronate, risedronate, zoledronic acid) or denosumab: Antiresorptive therapy
- Raloxifene or menopausal hormone therapy: Alternative therapies
- Initial treatment for 3–6 years, followed by reassessment
Exercise and Nutrition
- Recommend balance and functional training ≥ twice weekly to reduce the risk of falls
- Suggest progressive resistance training ≥ twice weekly
- Suggest activities like walking, impact exercise, yoga, or Pilates for enjoyment and other benefits
- Encourage a variety of types and intensities of physical activity in accordance with the Canadian 24-Hour Movement Guidelines
- Suggest calcium-rich foods and vitamin D supplement of 400 IU daily
- No supplementation of protein, vitamin K, or magnesium to prevent fractures### Fracture Risk Assessment and Treatment Initiation
- Individualize intake of calcium and vitamin D according to risk factors for insufficiency.
- Fracture risk assessment tools include FRAX and CAROC, with FRAX preferred for fracture risk estimation.
- Clinical assessment for osteoporosis and fracture includes identifying risk factors and assessing for signs of undiagnosed vertebral fracture(s).
- BMD testing is suggested in postmenopausal females and males who meet specific criteria (e.g., previous osteoporosis-related fracture or ≥ 2 clinical risk factors).
Pharmacotherapy
- Bisphosphonates (alendronate, risedronate, or zoledronic acid) are recommended for people who meet criteria for initiation of pharmacotherapy.
- Menopausal hormone therapy may be an alternative option for postmenopausal females aged < 60 yr or within 10 yr of menopause who prioritize alleviation of substantial menopausal symptoms.
- Denosumab is suggested for people meeting criteria for initiation of pharmacotherapy who have contraindications, substantial intolerance, or barriers to bisphosphonates.
Fracture Liaison Service
- Fracture Liaison Service programs increase appropriate use of fracture risk assessment and antifracture treatment, and are cost-effective.
Monitoring
- Monitoring is recommended for patients who initiate pharmacotherapies or stop bisphosphonates.
- Monitoring includes assessing for secondary causes of osteoporosis and potential limitations when considering specific osteoporosis pharmacotherapy.
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Description
Clinical practice guideline for management of osteoporosis and fracture prevention in Canada, updated in 2023. This guideline is for healthcare professionals and provides recommendations for osteoporosis management and fracture prevention.
