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      European guidance for the diagnosis and management of osteoporosis in postmenopausal women

      research-article

      , 1 , 2 , 3 , 4 , 5 , 6 , 7 , on behalf of the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) and the Committees of Scientific Advisors and National Societies of the International Osteoporosis Foundation (IOF)

      Osteoporosis International

      Springer London

      Bone mineral density, Diagnosis of osteoporosis, Fracture risk assessment, FRAX, Health economics, Treatment of osteoporosis

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          Abstract

          Summary

          Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

          Introduction

          The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

          Methods

          Systematic reviews were updated.

          Results

          The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

          Conclusions

          A platform is provided on which specific guidelines can be developed for national use.

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          Most cited references 267

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          Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis.

          Once-daily injections of parathyroid hormone or its amino-terminal fragments increase bone formation and bone mass without causing hypercalcemia, but their effects on fractures are unknown. We randomly assigned 1637 postmenopausal women with prior vertebral fractures to receive 20 or 40 microg of parathyroid hormone (1-34) or placebo, administered subcutaneously by the women daily. We obtained vertebral radiographs at base line and at the end of the study (median duration of observation, 21 months) and performed serial measurements of bone mass by dual-energy x-ray absorptiometry. New vertebral fractures occurred in 14 percent of the women in the placebo group and in 5 percent and 4 percent, respectively, of the women in the 20-microg and 40-microg parathyroid hormone groups; the respective relative risks of fracture in the 20-microg and 40-microg groups, as compared with the placebo group, were 0.35 and 0.31 (95 percent confidence intervals, 0.22 to 0.55 and 0.19 to 0.50). New nonvertebral fragility fractures occurred in 6 percent of the women in the placebo group and in 3 percent of those in each parathyroid hormone group (relative risk, 0.47 and 0.46, respectively [95 percent confidence intervals, 0.25 to 0.88 and 0.25 to 0.861). As compared with placebo, the 20-microg and 40-microg doses of parathyroid hormone increased bone mineral density by 9 and 13 more percentage points in the lumbar spine and by 3 and 6 more percentage points in the femoral neck; the 40-microg dose decreased bone mineral density at the shaft of the radius by 2 more percentage points. Both doses increased total-body bone mineral by 2 to 4 more percentage points than did placebo. Parathyroid hormone had only minor side effects (occasional nausea and headache). Treatment of postmenopausal osteoporosis with parathyroid hormone (1-34) decreases the risk of vertebral and nonvertebral fractures; increases vertebral, femoral, and total-body bone mineral density; and is well tolerated. The 40-microg dose increased bone mineral density more than the 20-microg dose but had similar effects on the risk of fracture and was more likely to have side effects.
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            Diagnosis of osteoporosis and assessment of fracture risk.

             J Kanis (2002)
            The diagnosis of osteoporosis centres on the assessment of bone mineral density (BMD). Osteoporosis is defined as a BMD 2.5 SD or more below the average value for premenopausal women (T score < -2.5 SD). Severe osteoporosis denotes osteoporosis in the presence of one or more fragility fractures. The same absolute value for BMD used in women can be used in men. The recommended site for diagnosis is the proximal femur with dual energy X-ray absorptiometry (DXA). Other sites and validated techniques, however, can be used for fracture prediction. Although hip fracture prediction with BMD alone is at least as good as blood pressure readings to predict stroke, the predictive value of BMD can be enhanced by use of other factors, such as biochemical indices of bone resorption and clinical risk factors. Clinical risk factors that contribute to fracture risk independently of BMD include age, previous fragility fracture, premature menopause, a family history of hip fracture, and the use of oral corticosteroids. In the absence of validated population screening strategies, a case finding strategy is recommended based on the finding of risk factors. Treatment should be considered in individuals subsequently shown to have a high fracture risk. Because of the many techniques available for fracture risk assessment, the 10-year probability of fracture is the desirable measurement to determine intervention thresholds. Many treatments can be provided cost-effectively to men and women if hip fracture probability over 10 years ranges from 2% to 10% dependent on age.
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              Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis.

                (1993)
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                Author and article information

                Contributors
                w.j.Pontefract@shef.ac.uk
                Journal
                Osteoporos Int
                Osteoporos Int
                Osteoporosis International
                Springer London (London )
                0937-941X
                1433-2965
                15 October 2018
                15 October 2018
                2019
                : 30
                : 1
                : 3-44
                Affiliations
                [1 ]GRID grid.11835.3e, ISNI 0000 0004 1936 9262, Centre for Metabolic Bone Diseases, , University of Sheffield Medical School, ; Beech Hill Road, Sheffield, S10 2RX UK
                [2 ]GRID grid.411958.0, ISNI 0000 0001 2194 1270, Mary McKillop Health Institute, , Australian Catholic University, ; Melbourne, Australia
                [3 ]GRID grid.5491.9, ISNI 0000 0004 1936 9297, MRC Lifecourse Epidemiology Unit, , University of Southampton, ; Southampton, UK
                [4 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, NIHR Musculoskeletal Biomedical Research Unit, , University of Oxford, ; Oxford, UK
                [5 ]GRID grid.150338.c, ISNI 0000 0001 0721 9812, University Hospitals and Faculty of Medicine of Geneva, ; Geneva, Switzerland
                [6 ]GRID grid.4861.b, ISNI 0000 0001 0805 7253, Department of Public Health, Epidemiology and Health Economics, , University of Liège, ; Liège, Belgium
                [7 ]GRID grid.56302.32, ISNI 0000 0004 1773 5396, Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, , King Saud University, ; Riyadh, Kingdom of Saudi Arabia
                Article
                4704
                10.1007/s00198-018-4704-5
                7026233
                30324412
                327811d5-eea7-4169-987b-677e7e1680ee
                © International Osteoporosis Foundation and National Osteoporosis Foundation 2018, corrected publication 2020

                Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

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                © International Osteoporosis Foundation and National Osteoporosis Foundation 2019

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