Clinical guidelines for the diagnosis and treatment of osteoporosis

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The latest recommendations from the Institute for Clinical Systems Improvement

The aging of the population is expected to increase the frequency, cost, and burden of fractures associated with age-related bone loss. Guidelines on prevention, screening, diagnosis, and treatment of osteoporosis are available from several organizations.

In July, 2013, the Institute for Clinical Systems Improvement (ICSI) released an update to its Health Care Guideline for the Diagnosis

and Treatment of Osteoporosis (Available at:

This is the eighth edition of the evidence-based guideline. For the first time, ICSI used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

The guideline group considered systematic reviews and randomized controlled trials published between January, 2010 and January, 2013, that evaluated frequency of dual-energy X-ray absorptiometry (DXA), primary and secondary workups, fracture risk assessment (FRAX), calcium as it pertains to cardiovascular risk, osteoporosis in men, vitamin D, and denosumab.

The guideline focuses on adults only and discusses prevention, diagnosis and treatment. To achieve these aims, the guideline provides two recommendations:

  • Clinicians should discuss risk factors for osteoporosis and primary prevention with all patients presenting for preventive/wellness health visits, and

  • address options for prevention and treatment of osteoporosis, including pharmacologic intervention if appropriate, and engage the patient in shared decision-making to facilitate discussions on treatment options.


Screening is recommended for osteoporosis in women aged 65 years and older and in younger women whose fracture risk by FRAX analysis is ≥9.3 percent or who are considered to be at fracture risk.

Male risks

The guidelines recommend identifying men in whom bone mineral density measurement is justified. They include men 70 years and older or aged 50-69 years and who, based on risk factor profile, are deemed as being at sufficiently high risk for low bone mass and future fracture

Estrogen therapy

Estrogen therapy is not recommended as a first-line agent for prevention or management of osteoporosis and should be used for preventing postmenopausal osteoporosis only in women at significant risk who cannot take non-estrogen therapies.

Other updates

Other updates pertain to recommendations for dietary/supplement intake of calcium and vitamin D, duration of bisphosphonate therapy and drug holidays, data on denosumab treatment frequency and safety, and the frequency of follow-up DXA testing.