Osteoporosis Clinical Guideline. South African Medical Association—Osteoporosis Working Group

S Hough
South African Medical Journal 2000, 90 (9 Pt 2): 907-44

OBJECTIVE: This Guideline aims to improve the efficacy of both diagnostic and therapeutic interventions for osteoporosis. All health care workers are targeted in the Guideline. A rather detailed summary, which is cross-referenced to the full guideline, is provided to cater for the busy general practitioner. The motivation for the development of this Guideline is based on the facts that: Osteoporosis is a common, costly disease which carries a significant morbidity and mortality, yet is still too often regarded as an inescapable part of normal ageing. Early detection and intervention will be more cost-effective than the treatment of advanced disease. Much confusion exists regarding diagnostic criteria, the assessment of fracture risk, and therapeutic intervention thresholds. A rational approach to drug selection is seldom considered. No consensus guideline on the diagnosis and management of osteoporosis has been published in this country.

OUTCOMES: Prevention of fracture and a reduction in morbidity and mortality were the major considerations in the development of this Guideline. Although no formal economic analysis was undertaken, the cost-effectiveness of diagnostic and therapeutic interventions was considered in all recommendations.

EVIDENCE: A combination of descriptive, boundary (minimum standards) and algorithmic guidelines was employed. The highest level of evidence (meta-analyses, randomised and controlled studies) was used as far as possible and isolated descriptive studies and expert opinions were largely ignored. A draft guideline was developed, debated at a consensus meeting and finalised on the basis of written comments following the distribution of a second draft.

METHODOLOGY: See Annexure B.

RECOMMENDATIONS: In the absence of a sound health economic justification for a screening policy, it is recommended that the prevention and treatment of osteoporosis is best managed using a case-finding approach. It is recommended that clinical risk factors--related to bone mineral density (BMD), bone strength or falls--provide indications for further assessment, in particular bone mass measurement. Axial, dual energy X-ray absorptiometry (DEXA) is the preferred technique to assess BMD, to diagnose osteoporosis and to assess rates of bone loss/gain. While the four diagnostic categories proposed by the World Health Organisation (WHO, 1994) provide a practical basis to identify those at risk of fracture, cognisance should be taken of its limitations. We recommend that the BMD of both spine and hip should be measured, that the NHANES III reference data for Caucasians be used for subjects of all races (until local reference ranges for different ethnic groups are established), and that the same absolute thresholds be employed to diagnose osteoporosis in men and women. Recommendations are also made regarding indications for bone mass measurement and selected routine laboratory tests. The differences between diagnostic criteria and intervention thresholds are emphasised. The need to treat should not depend on a BMD value alone, but should also be determined by the patient's age, general health and willingness to consider treatment; the presence of clinical risk factors; prevalent vertebral fractures; and the rate of bone loss/turnover; as well as the cost-effectiveness and side-effects of available treatment. Non-pharmacological measures to improve bone strength include a balanced diet, physical exercise, limiting alcohol consumption, the avoidance of smoking and bone toxic drugs and the prevention of falls. No ideal drug can be recommended for the prevention and treatment of osteoporosis in all patients. The choice of drug is largely determined by the nature of the disease (e.g. antiresorptive agents like calcium (+/- vitamin D) for mild osteopenia, hormone replacement therapy (HRT) or bisphosphonates for moderate bone loss and the addition of a bone formation-stimulating agent in patients with more severe osteoporosis) and the pati

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