Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Executive summary

This guideline is an evidence update of Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men, published in 2010 by The Royal Australian College of General Practitioners (RACGP).1 The accumulation of high-quality evidence supporting changes to clinical practice over the last six years, the need for expert consensus in areas of conflicting evidence or variable practice, and new developments in the pharmacological management of osteoporosis were important factors in the decision to undertake this revision.

The publication of new data on the prevalence of osteoporosis in Australia and the health and economic impacts of this disease has also highlighted the need to clarify and re-enforce clinical guidance for health professionals at the front line of osteoporosis management. A burden of disease analysis recently published by Osteoporosis Australia estimates that in 2012, 4.74 million Australians older than 50 years of age (66%) had poor bone health, including more than one million with osteoporosis.2 By 2022, it is estimated that 6.2 million Australians older than 50 years of age will have osteoporosis or osteopenia, a rise of 31% from 2012. A similar increase in the rate of fracture, from 140,882 in 2012 to 183,105 in 2022, is anticipated if action is not taken to improve the diagnosis and management of osteoporosis.2

In addition to its significant health and social burden, osteoporosis exerts considerable economic pressures on government. The total direct and indirect costs of osteoporosis and osteopenia in Australia were $2.75 billion in 2012.2 This total annual cost is predicted to reach $3.84 billion by 2022. Hip fractures constitute the major burden, costing nearly $800 million in 2012.2 Evidence shows that timely diagnosis and appropriate pharmacological management reduces fracture rates. However, osteoporosis remains significantly underdiagnosed and inadequately managed in Australia. Less than 20% of patients presenting to healthcare services with minimal trauma fractures are investigated or treated for osteoporosis.3,4

This guideline is designed to provide clear, evidence-based recommendations to assist general practitioners and other health professionals in managing older patients with osteoporosis. The purpose of the guideline is to support clinical judgement, not to replace it.

A 12-member expert Working Group has developed 42 recommendations for this guideline, constituting Australian best practice in the identification, diagnosis, treatment and management of osteoporosis in the following populations:

  • Postmenopausal women and men older than 50 years of age who may be at risk of minimal trauma fracture.
  • Postmenopausal women and men older than 50 years of age diagnosed as having at least one fracture following minimal trauma (equivalent to a fall from standing height or less).
  • Postmenopausal women and men older than 50 years of age diagnosed with osteoporosis, defined as a T-score of –2.5 or less, but without evidence of a minimal trauma fracture.

The majority of the recommendations are based on critical analysis of the body of published, peer-reviewed evidence that has accumulated from September 2006 to February 2016, following a systematic review of the available evidence to support these recommendations. Where insufficient evidence is available, or where the quality of the evidence does not meet minimum requirements (as described in Appendix A), recommendations have been developed through Working Group consensus. Details on the guideline development process and Working Group membership can be found in Appendices A and B.

Certain areas of osteoporosis management have developed significantly since the publication of the first guideline in 2010, and evidence has accumulated in other areas that supports change to clinical practice. Several new recommendations have been developed for the update to reflect this changing landscape. Recommendations on the use of denosumab, the only new medication approved since the publication of the 2010 guideline, have been added. Comprehensive information on the evaluation of absolute fracture risk and guidance on the use of fracture risk calculators is included, and new recommendations on exercise and the appropriate use of calcium and vitamin D supplements have been developed. A ‘special issues’ section makes several recommendations in the areas of osteoporosis management in the elderly, including minimising falls risk, as well as fracture risk reduction in patients undergoing androgen deprivation therapy for prostate cancer or aromatase inhibitor therapy for breast cancer.

Professor Peter R Ebeling AO MBBS MD FRACP
Chair, Osteoporosis Australia Guidelines Working Group

  1. The Royal Australian College of General Practitioners. Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. 1st edn. South Melbourne, Vic: RACGP, 2010.
  2. Watts JJ, Abimanyi-Ochom J, Sanders K. Osteoporosis costing all Australians: A new burden of disease analysis – 2012 to 2022.Glebe, NSW: Osteoporosis Australia, 2013.
  3. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: A systematic review. Osteoporos Int 2004;15:767–78.
  4. Eisman J, Clapman S, Kehow L. Osteoporosis prevalence and levels of treatment in primary care: The Australian BoneCare Study. J Bone Miner Res 2004;19(12):1969–75.
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