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Osteoporosis is characterized by low bone mass and deterioration of bone tissue, which can lead to an increased risk of fracture. Bone deterioration can occur over a number of years without symptoms. By the time fractures occur, the disease is already advanced and less treatable. Most commonly, fractures occur in the hip, spine, wrist, and shoulder.

Here are some resources on osteoporosis selected by Joule’s Ask a Librarian team using a variety of tools included with CMA membership and freely available online.

Clinical summary from DynaMed

Access DynaMed online or through the mobile app to get concise overviews and detailed recommendations, medical graphics and images, drug information from Micromedex and more.

Osteoporosis (selected excerpts)

Background

  • Osteoporosis (compromised bone strength and bone quality) is common with prevalence of 20%-40% in postmenopausal women and 6%-8% men ≥ 50 years old.
  • Osteoporosis can occur as part of the aging process or secondarily due to nutritional deficiency, metabolic disorders, or medication side effects.
    • Certain endocrine, gastrointestinal, hematologic, autoimmune, and central nervous system (CNS) disorders increase the risk of osteoporosis.
    • Medications such as long-term anticoagulation, hormonal therapies, glucocorticosteroids, some immunosuppressants, lithium, thiazolidinediones (glitazones), and long-term proton pump inhibitor use may also cause osteoporosis.

Management

  • Encourage all patients with osteoporosis or increased risk of osteoporosis to initiate lifestyle changes including (Strong recommendation):
    • balanced diet with adequate calcium and vitamin D intake
    • regular weight-bearing and muscle-strengthening exercise to improve agility, strength, posture, balance, increase bone mineral density, and reduce risk of falls and fractures
    • smoking cessation
    • avoiding excess alcohol intake
  • Offer pharmacologic therapy to reduce fracture risk for (Strong recommendation):
    • postmenopausal women and men ≥ 50 years old with hip or vertebral fracture (including asymptomatic vertebral fracture)
    • postmenopausal women and men ≥ 50 years old with T-score ≤ -2.5 at femoral neck, total hip, or lumbar spine by dual-energy x-ray absorptiometry (DEXA)
    • patients taking long-term glucocorticoids
    • men with prostate cancer receiving androgen deprivation therapy who have high risk of fracture
  • Consider pharmacologic therapy to reduce fracture risk for postmenopausal women and men ≥ 50 years old with T-score -1 to -2.5 at femoral neck, total hip, or lumbar spine by DEXA and 10-year risk of hip fracture ≥ 3% or 10-year risk of major osteoporosis-related fracture ≥ 20% (using calculator such as FRAX).
  • Select a bisphosphonate as first-line therapy for most patients (Strong recommendation).
    • Bisphosphonates include alendronate 10 mg or risedronate 5 mg orally once daily, alendronate 70 mg or risedronate 35 mg orally once weekly, risedronate or ibandronate 150 mg orally once monthly, or zoledronic acid 5 mg IV once yearly.
    • Dosing is the same for those patients with asymptomatic osteoporosis and those who have had an osteoporotic fracture.
    • Consider discontinuation after 3-5 years to reduce adverse effects with minimal loss of efficacy.
  • Consider parathyroid hormone 1-34 (teriparatide 20 mcg subcutaneously once daily) as first-line therapy for patients at particularly high risk for fracture.
  • Consider denosumab 60 mg subcutaneously every 6 months as alternative first-line therapy (Weak recommendation).
  • Consider raloxifene 60 mg or lasofoxifene 0.5 mg orally once daily, but selective estrogen response modulators (SERMs) may be less effective than bisphosphonates and teriparatide, and may increase risk for venous thromboembolism.
  • Consider monitoring bone mineral density (BMD) with DEXA every 1-2 years after initiating treatment, but monitoring BMD may have little effect on predicting outcomes or changing treatment.

Related DynaMed summaries

Osteoporosis topic summary (CMA members can access full summaries for this and other topics via this link)

Clinical Summary from Essential Evidence Plus

Osteoporosis

Overall bottom line

  • The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women 65 years or older and and in postmenopausal women younger than age 65 years who are at increased risk of osteoporosis as determined by a formal clinical risk assessment tool (2018).B The USPSTF deemed data inconclusive for recommending screening in men. Other national organizations differ primarily in their recommendations for screening in men.
  • Consider a patient's absolute fracture risk assessed using the FRAX score or similar prior to the initiation of fracture-prevention therapy. B
  • Consider secondary causes of osteoporosis, especially in patients with a Z-score less than −2.0 SD. C
  • Calcium, C vitamin D, A and appropriate lifestyle changes C should be initiated in patients with osteoporosis and in patients at increased risk of fracture.
  • Medical therapy is recommended for those with osteoporosis. Alendronate has the strongest supporting evidence and prevents hip, vertebral, and nonvertebral fractures. A

Prevalence

  • Based on data from the National Health and Nutrition Examination Survey, 2005 to 2010, the prevalence of osteoporosis at either the femoral neck or lumbar spine was 16.2% of adults over age 65 years, ranging from 24.8% in women and 5.6% in men. Almost half (48.3%) of older adults have low bone mass at these sites.
  • Among adults over age 50 years, osteoporosis affects 10.3% of the US population which translates into an estimated 10.2 million adults according to data from the CDC.
  • Half of all postmenopausal women will have an osteoporosis-related fracture in their lifetime; 15% of postmenopausal women will have a hip fracture in their lifetime.
  • Five percent of 50-year-old women and 25% of 80-year-old women have had at least one vertebral fracture. 
  • About 1 in 5 older men are at risk of an osteoporosis-related fracture.
Risk Factor
Odds Ratio
Low body mass index (BMI) 1.95 (1.7-2.2)
Prior fracture after age 50 years 1.85 (1.6-2.2)
Parental history of hip fracture 2.3 (1.5-3.5)
Current smoking 1.8 (1.5-2.2)
Ever used systemic corticosteroids 2.3 (1.7-3.2)
Alcohol intake greater than 2 U/d 1.7 (1.2-2.4)
Rheumatoid arthritis 1.95 (1.1-3.4)
Peptic ulcer disease (independent of use of PPI) 1.85
Post gastrectomy HR 1.1 (1.04-1.16)

Read more via Essential Evidence Plus (CMA members only)

Synopsis of clinical studies in POEMs by Essential Evidence Plus

Clinical question

Does the benefit of reduced osteoporotic and hip fractures outweigh the increased risk of atypical femoral fracture in women who take a bisphosphonate?

Bottom line

For White, Black, and Hispanic women, the benefits of taking a bisphosphonate clearly outweigh the potential harm of atypical subtrochanteric fracture. Risk factors for atypical fracture include longer duration of bisphosphonate use, older age, Asian race, and previous glucocorticoid use. The risk rapidly returned to baseline after the discontinuation of bisphosphonates.

Reference: Black DM, Geiger EJ, Eastell R, et al. Atypical femur fracture risk versus fragility fracture prevention with bisphosphonates. N Engl J Med 2020;383(8):743-753.

Read the full POEM via this link  (CMA members only)

Clinical information via ClinicalKey

ClinicalKey drives better care by delivering fast, concise answers, and deep access to evidence whenever, wherever you need it. ClinicalKey includes access to 1,000+ textbooks, 600 full-text journals, images, videos and customizable patient handouts across 30+ medical specialties

Clinical Overviews

Postmenopausal osteoporosis. Updated September 9, 2020.

Osteoporosis. Ferri's Clinical Advisor 2021

Book chapters:

Bisphosphonates in Meyler's Side Effects of Drugs, 996-1001

Metabolic bone diseases of the spine in Spine Secrets, Chapter 64, 633-647.e1

Osteoporosis: Basic and Clinical Aspects in Williams Textbook of Endocrinology, 30, 1256-1297.e10

Free information sources

CMAJ

Ania Kania-Richmond, Jason Werle and Jill Robert; for the Bone and Joint Health Strategic Clinical Network. Bone and Joint Health Strategic Clinical Network. CMAJ December 04, 2019 191 (Suppl) S10-S12

Shannon M. Ruzycki and Nancy A. Nixon. Five things to know about …: Bone health after diagnosis of breast cancer. CMAJ December 10, 2018 190 (49) E1452

Christopher Symonds and Gregory Kline. Warning of an increased risk of vertebral fracture after stopping denosumab. CMAJ April 23, 2018 190 (16) E485-E486

Guidelines and other information

National

Osteoporosis in Menopause. Society of Obstetricians and Gynaecologists of Canada. 2014.

Choosing Wisely Canada recommendation - Don’t order DEXA (Dual-Energy X-ray Absorptiometry) screening for osteoporosis on low risk patients. College of Family Physicians of Canada. Published on: 2019-07

Choosing Wisely Canada recommendation - Don’t repeat dual energy X-ray absorptiometry (DEXA) scans more often than every 2 years. Canadian Rheumatology Association. Published on: 2019-06

Choosing Wisely Canada recommendation - Don’t repeat DEXA scans more often than every two years in the absence of high risk or new risk factors. Canadian Association of Nuclear Medicine. Published on: 2017-06

Diagnosis and management of osteoporosis. Toward Optimized Practice [Alberta]. Published on: 2016-02

International

Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update. American College of Physicians. Ann Intern Med. 2017 Jun 6;166(11):818-839

2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid‐Induced Osteoporosis. Arthritis Rheumatol. 2017 Aug;69(8):1521-1537.

Pre-formatted literature searches from Pubmed

Osteoporosis - Etiology

Osteoporosis - Diagnosis

Ostoporosis – Therapy

Patient education resources

Ostoporosis Canada – No date. Accessed October 30, 2020.

Osteoporosis – Government of Canada. Date modified 2018-01-12. Accessed October 30, 2020.

Osteoporosis – US NIH Osteoporosis and Related Bone Diseases National Resource Center. No date. Accessed October 30, 2020.

Osteoporosis prevention and treatment (Beyond the Basics) – Up To Date patient education – Updated July 18, 2019. Accessed October 30, 2020.

Need more information or have a clinical question on any other topic of interest? Contact the Ask a Librarian team to request a literature search.

This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  

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