Vancouver IM LMR

This Tuesday the long awaited update to the 2010 Osteoporosis Canada clinical practice guidelines for osteoporosis were released: https://www.cmaj.ca/content/cmaj/195/39/E1333.full.pdf

Slides from this presentation

Summary of the 2023 Osteoporosis guidelines

Similar to 2010, emphasis on a targeted approach to patients to identify those at high risk and target them for screening and intervention. The new guidelines set out to avoid over-screening and over-treating those patients who are unlikely to see benefit.

Exercise

• New expanded recommendations for specific forms of exercise for reduced risk of falls – balance and functional training twice weekly or more, progressive resistance training twice weekly or more, encouraging patients to participate in other activities (eg walking, impact exercise, yoga, pilates) if they can be done safely.

Nutrition

• For patients with a regular diet, patients will likely not require calcium supplementation but still need to supplement Vitamin D (recommend 400 IU daily for patients over 50) as it can be difficult to achieve recommended level of intake (600 IU/day age 51-70, 800 IU/day age > 70).

• By the way, how do we get Vitamin D?
  • Food: egg yolk, soft margarine, fatty fish (salmon, rainbow trout, arctic char), milk, fortified plant-based beverages
  • Sunlight exposure: Older people synthesize less Vitamin D!

Fracture assessment and initiation of treatment

• Decision to measure BMD and calculation of fracture risk with FRAX/CAROC based on clinical assessment of age and risk factors, previous fractures.
• Lateral spine XR to assess for asymptomatic vertebral fracture previously indicated “for clinical evidence suggestive of vertebral fracture”, now indicated for those over 60 with an osteoporotic BMD T-score or 10-year fracture risk 15-19.9% (middle category)
• Prednisone dose considered to be high risk decreased from 7.5 mg daily to 5 mg daily (average dose for 3 months of the past year)
• Moving the main age threshold for screening patients without risk factors to 70 years old (previously 65)
• Loosening of criteria for initiating pharmacotherapy to avoid overtreatment (eg “suggest” group was previously 10-20% fracture risk, now 15-19.9%)

Pharmacotherapy

• Bisphosphonates remain first line, but denosumab has been dethroned as first line therapy over concern with rapid increase of vertebral fracture risk and BMD decrease when abruptly stopped.
• Denosumab is now considered as an alternative choice for patients with CI or intolerance/barriers to bisphosphonate use (similar guidance in other guidelines – 1 2 3).
• Anabolics (teriparatide, romosozumab) are good but expensive options for patients with recent severe vertebral fracture or 2+ vertebral fractures.

Duration and sequence of therapy

• Initial treatment for 3-6 years (closer to 6 years for people with higher risk), followed by drug holiday for 3 years (avoid atypical femur fractures, osteonecrosis of the jaw).
• Long trials of oral bisphosphonates (5+ years) vs shorter durations do not appear to make a difference in the fractures and harms appear ~3-6 years into treatment.
• Denosumab benefits do not appear to wane at 10 years of therapy and incidence of AFF and ONJ is relatively stable.
• Any assessment for inadequate response to treatment but be accompanied by looking for secondary causes of osteoporosis, considering imprecision in BMD (use the same DEXA scanner for repeat BMD).

*Denosumab is complicated when stopped, as there is risk of rapid bone loss after discontinuation. If 4 or less doses of denosumab given (duration of therapy 2 years or less, with the q6month dosing), can put on bisphosphonate 6 months after last dose. If over 4 doses, need to involve an osteoporosis expert to advise on transition.

*Anabolic drugs (teriparatide, romosozumab) require transition to antiresorptive therapy (bisphosphonates, denosumab, raloxifene, menopausal hormone therapy) after discontinuation to preserve BMD gains, and patients need to be counselled about the need for transition.

Monitoring

• Recommendation for BMD measurement 3 years after starting pharmacotherapy (sooner if secondary causes of OP, new fracture, new risk factors associated with rapid bone loss)
• Three years into drug holiday, repeat BMD measurement and re-risk stratify to determine need for resumption of therapy
• New time intervals for BMD reassessment if not a candidate for or chose not to take pharmacotherapy (previous guidance was to check in 1-3 years for those on treatment, and 5 years if low risk and did not start medications)