Osteoporosis – prevention, diagnosis and treatment

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Aim

Osteoporosis results from a reduction in the quantity of bone tissue and the deterioration of bone microstructure, leading to a general loss in bone strength and greater fracture risk. While part of the natural aging process, osteoporosis doesnt affect everyone to the same degree. The condition is common in Sweden, the annual socioeconomic costs for osteoporosis and related fractures coming to 3.5 billion kronor. The scientific literature on prevention, diagnosis and treatment of osteoporosis was systematically reviewed.

Methods

Relevant questions were framed concerning the topics to be covered by the report. Systematic literature searches were performed in databases and other sources. For each topic, studies that met the inclusion criteria were reviewed, assessed for quality and correlated in order to reach general conclusions (which were then assigned evidence grades). The final manuscript was reviewed by the SBU scientific committee and board, as well as an external group.

Results

The available scientific evidence suggests that osteoporosis is only one of several risk factors for fractures. Bone density measurements has little likelihood of predicting hip fractures in individuals who are otherwise at small risk for fracture. Physical inactivity, low weight, tobacco smoking, high alcohol consumption, tendency to fall, impaired vision, low exposure to sunlight, and use of corticosteroids are other key risk factors over which patients have some control. Major risk factors over which patients have no control are advanced age, sex (women are at higher risk), previous fractures and heredity.

There is no scientific basis for using bone density measurements as a screening method in healthy, middle-aged people. But bone density plays an unequivocal role in studying individuals with multiple risk factors in order to predict their fracture risk and initiate prophylactic measures. No diagnostic method and no specific part of the body is optimal for measuring fracture risk throughout the skeleton. Measuring bone density in the hip is best for predicting the risk of hip fractures. Comparisons of the various measurement methods - DXA, ultrasound, and computed tomography - are less conclusive.

Physical activity has been shown to have a positive impact on bone density in all ages, particularly children and adolescents. Although greater intake of calcium appears to increase bone density in children and adolescents, the effect on maximum bone mass has been insufficiently studied.

When it comes to medication, calcium and vitamin D have been shown to reduce the risk of hip fractures and other non-spinal fractures in the elderly. Alendronate and risedronate (both of which are bisphosphonates) have been shown to reduce the incidence of fractures, particularly of the spine, in post-menopausal women with osteoporosis.

The following measures have been shown to reduce the incidence of falls in the elderly: individually tailored muscle strength and balance training, interventions to minimize fall risk in the home, and a combination of training and the modification of fall risks, including reduction of medication. Hip pads appear to reduce the risk of hip fracture when elderly persons in assisted living facilities fall.

Patients with osteoporosis-related fractures are an undertreated group in terms of drug therapies and other interventions for preventing new fractures. Hip fracture patients are rarely diagnosed with osteoporosis upon admission or discharge from the hospital.

Post-fracture rehabilitation at geriatric, orthopedic and multidisciplinary clinics appears to be equally effective with respect to mortality, institutional living and function. Assuming that primary care possesses sufficient resources and selects patients correctly, early mobilization and discharge to out-patient care matches the results of in-patient care.

Painful conditions related to spinal fractures can be relieved by conventional analgesics, as well as physical therapy in combination with muscle strength and balance training. There is not yet sufficient scientific evidence to support the use of vertebroplasty or kyphoplasty, two minimally invasive surgical procedures, for painful spinal fractures.

Hip fractures lead to protracted impairment of function and decreased quality of life, while multiple spinal fractures reduce quality of life.

Health economic assessments are very scarce because of the absence of information concerning the effect of various osteoporosis treatments on risks, mortality, quality of life and costs in different age and risk groups.

The treatment of osteoporosis patients appears to conform with accepted ethical standards. The one exception is the undertreatment of those who have suffered fractures. There is some doubt about the treatment of hip fracture patients with moderate to severe cognitive disorders.

How to cite this report: SBU. Osteoporosis – prevention, diagnosis and treatment. Stockholm: Swedish Council on Health Technology Assessment in Health Care (SBU); 2003. SBU report no 165/1 + 165/2 (in Swedish).

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SBU Assessment presents a comprehensive, systematic assessment of available scientific evidence. The certainty of the evidence for each finding is systematically reviewed and graded. Full assessments include economic, social, and ethical impact analyses.

SBU assessments are performed by a team of leading professional practitioners and academics, patient/user representatives and SBU staff. Prior to approval and publication, assessments are reviewed by independent experts, SBU’s Scientific Advisory Committees and Board of Directors.

Published: 10/14/2003
Report no: 165/1, 165/2