The National Osteoporosis Foundation (NOF) has recently released Clinical Guidelines for the Prevention and Treatment of Osteoporosis, which emphasize risk assessment, diagnostic criteria for osteoporosis, and pharmacologic treatment in high-risk groups. The main contents are summarized below.
Risk assessment
All postmenopausal women and older men should be clinically assessed for risk of osteoporosis to determine the need for a bone mineral density (BMD) test. In general, the greater the risk factors, the greater the risk of fracture. Osteoporosis is preventable and treatable, but because there are no warning signs before a fracture, many people are not diagnosed and receive effective treatment in the early stages of the disease. Many factors can increase the risk of osteoporosis-associated fractures.
Since most osteoporosis-related fractures are caused by falls, it is also important to assess risk factors for falls. In addition to muscle weakness, gait, balance and vision deficits, the most important appears to be a personal history of falls.
In the WHO 10-year fracture risk model, risk factors include current age, sex, history of fracture, femoral neck BMD, low body mass index, and use of oral glucocorticoids, as well as the presence of secondary osteoporosis, parental history of hip fracture, smoking, and heavy alcohol consumption, and the WHO states that this group of risk factors can be combined with BMD measurements to assess a patient’s fracture risk.
In addition to osteoporosis, metabolic bone diseases (such as hyperparathyroidism or osteochondrosis) may also reduce BMD. Many of these conditions have very specific treatments, and history taking and physical examination should be completed before diagnosing osteoporosis based solely on BMD.
If a patient is considered to have a treatable secondary cause of osteoporosis, appropriate blood and urine tests (e.g., serum calcium, urine calcium, serum thyrotropin, protein electrophoresis, antibodies related to cortisol or gluten-sensitive enteropathy) should be performed before initiating treatment. In elderly patients with recent fractures, secondary causes should be evaluated, and if osteochondrosis or vitamin D deficiency is considered, serum 25(OH)D levels should be measured. In general, biochemical tests (e.g., serum calcium and creatinine) should be considered before starting treatment in patients with confirmed osteoporosis.
Diagnostic criteria
Osteoporosis is diagnosed based on BMD measurements. A preliminary or clinical diagnosis of osteoporosis can often be made in patients at high risk of having a low trauma fracture.
Bone mineral density measurement and classification
Mesial DXA Dual-energy X-ray absorptiometry (DXA) of the hip and spine is now used to establish or confirm the diagnosis of osteoporosis, to predict future fracture risk, and to monitor patients through a series of measurements.
According to the WHO diagnostic classification, the diagnosis of BMD is classified as normal: BMD within 1 standard deviation (SD) of BMD in “normal young” adults (T score ≥ -1.0); low bone mass (“osteopenia”): BMD within 1 standard deviation (SD) of BMD in “normal young” adults (T score ≥ -1.0); and low bone mass (“osteopenia”): BMD within 1 standard deviation (SD) of BMD in “normal young” adults. 1.0 to 2.5 SD lower than BMD in “normal young” adults (T score -1.0 to -2.5); osteoporosis: BMD ≥ 2.5 SD lower than BMD in “normal young” adults (T score ≤ -2.5); severe or definite Osteoporosis: this group of patients with one or more fractures.
In postmenopausal women and men ≥50 years of age, the T-score criteria (normal, low bone mass, and osteoporosis) used by the WHO for diagnosis were applied to BMD measurements in the mid-axis DXA (lumbar spine, total hip, and femoral neck). If BMD cannot be measured at the hip or spine, DXA BMD measurements at the 1/3 radial site can be used to diagnose osteoporosis. In premenopausal women or men and children <50 years of age, do not use the WHO BMD diagnostic classification criteria. In this group, osteoporosis should not be diagnosed based on densitometry criteria alone. The International Society for Clinical Densitometry (ISCD) recommends that instead of a T-score, a race- or ethnicity-corrected Z-score should be used, with a Z-score ≤-2.0 defined as "lower bone mineral density than at full age" or "lower than the expected range for that age"; a Z-score >– 2.0 defined as “lower than at full age”; and a Z-score >- 2.0 defined as “lower than at full age”. 2.0 was defined as “within the expected range for that age”.
Indications for BMD screening
1. Women ≥ 65 years of age and men ≥ 70 years of age, regardless of clinical risk factors.
2, Younger postmenopausal women and men aged 50-70 years with risk factors.
3, Transmenopausal women with specific risk factors for increased fracture risk, such as low body weight, history of minimally invasive fractures, or on high-risk medications.
4. Adults with fractures after age 50.
5, Adults with diseases that cause low bone mass or bone loss (e.g., rheumatoid arthritis) or with medications that cause low bone mass or bone loss (e.g., glucocorticoids ≥ 5 mg/d for ≥ 3 months).
6, Anyone considering treatment with osteoporosis medications.
7.Anyone who is being treated with osteoporosis to monitor the effects of treatment.
8.Anyone who is not currently on treatment but has evidence of bone loss and will receive treatment.
9.Postmenopausal women who have stopped using estrogen should consider having a BMD test.
Prevention
1. It is recommended that all patients consume adequate amounts of calcium and vitamin D.
2. It is recommended that women over 50 years of age consume at least 1200 mg of elemental calcium daily. NOF recommends that adults >50 years of age consume 800-1000 international units (IU) of vitamin D3 per day, which will raise the mean serum 25(OH)D concentration to an ideal level of ≥30 ng/ml (75 nmol/L).
3. Engage in regular weight-bearing exercise.
4.Prevent falls.
5.Do not smoke, do not drink alcohol excessively.
Indications for drug treatment
Postmenopausal women and men ≥ 50 years of age with the following symptoms need treatment:
1. Hip or vertebral (clinical or morphometric) fractures.
2. Previous fractures at other sites and low bone mass (femoral neck, total iliac or spinal T score -1.0 to -2.5).
3. Femoral neck, total iliac or spine T-score ≤ -2.5 after appropriate evaluation except for secondary causes.
4.Low bone mass (T-score -1.0~-2.5 for femoral neck, total hip or spine) and secondary causes that increase the risk of fracture (e.g., hormonal use or complete braking).
5, low bone mass (femoral neck, total iliac or spine T-score -1.0 to -2.5) and a 10-year hip fracture lament rate of ≥ 3% or a 10-year lament rate of ≥ 20% for any significant osteoporosis-related fracture according to the US modified WHO absolute fracture risk model.