MJA: Osteoporosis consensus statement, Australia 1997

The prevention and management of osteoporosis
Consensus statement

8. What are the goals of treatment and how do you choose an appropriate management strategy for individual patients?

THE KEY OBJECTIVES in managing osteoporosis are to:

restore and maintain bone strength to prevent fractures; and
reduce the overall morbidity and mortality associated with the condition.

Encouraging adequate calcium and vitamin D intakes and modification of other lifestyle factors such as smoking, excessive alcohol intake, inactive lifestyle or excessive exercise is appropriate in all individuals, from childhood to old age.

Younger hypogonadal females

Hypogonadism in young women needs to be appropriately investigated and treated. This condition often results from excessive exercise or anorexia and may benefit from appropriate sex hormone replacement, if modification of contributing lifestyle factors is unsuccessful.

Early postmenopausal women

In women within 15 years of menopause, hormone replacement therapy has been shown to prevent bone loss and should be offered to symptomatic menopausal women and those at increased risk based on bone density measurement and other factors. In women without oestrogen deficiency symptoms, there is debate about the level of bone density reduction at which treatment with hormone therapy is required. However, as up to 60% of women experience osteoporotic fractures during their lifetime, any postmenopausal woman with a T score for bone density less than -1 and/or with risk factors for bone loss should be considered for hormone replacement therapy.

Older postmenopausal women

In women who are more than 15 years past menopause, clinical risk factors may provide additional information about the risk of fracture (e.g., those related to falling). Bone density measurement remains the best method of assessing fracture risk. The proximal femur may be the most reliable site for measurement because of the greater incidence of osteoarthritis of the lumbar spine in older patients. Hormone replacement therapy is first line treatment in older postmenopausal women. To improve compliance, continuous combined regimens should be used, starting with a low dose and increasing slowly over several months to the full replacement dose. In women for whom hormone replacement therapy is unsuitable, the available evidence suggests the order of choice is alendronate, followed by etidronate or calcitriol.[note]

Housebound or institutionalised patients

In these patients vitamin D deficiency should be considered and treated when present, in addition to the strategies outlined above.

Men

In men, causes of secondary osteoporosis, including hypogonadism, need to be excluded or treated. If no such causes are found, treatments (other than oestrogen) which have been shown to increase bone mineral density in women are likely to be effective in men. Calcitriol is available for the treatment of male osteoporosis in Australia. Excessive use of alcohol and multiple myeloma are important risk factors for osteoporosis in men.

Glucocorticoid-treated patients

Glucocorticoid treatment represents a major iatrogenic cause of osteoporosis and fractures, especially vertebral and rib fractures. In patients starting glucocorticoid therapy, bone loss is most rapid in the first one to two years, and randomised controlled trials have shown it is possible to prevent spinal bone loss with calcitriol or etidronate. Some restoration of bone mass has also been reported with these agents and other bisphosphonates in patients undergoing long-term glucocorticoid therapy. Therefore, these agents are appropriate to consider in patients starting glucocorticoid therapy or treated with long-term high dose therapy. Patients should be given the lowest dose of glucocorticoids possible, local administration (e.g., inhalation) is preferred, and sex hormones should be replaced where deficient (in both men and women).

Next: What is the optimal approach to follow-up and monitoring of treatment of the patient with osteoporosis?

Revision note: These guidelines were originally published with an editorial error, which was corrected on 20 April 1998. The sentence "In women for whom hormone replacement therapy is unsuitable, the available evidence suggests the order of choice a bisphosphonate, followed by calcitriol" has been corrected to read "In women for whom hormone replacement therapy is unsuitable, the available evidence suggests the order of choice is alendronate, followed by etidronate or calcitriol." [Back to text]

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