SAN FRANCISCO — Evidence-based osteoporosis guidelines now being developed by the World Health Organization will evaluate treatment cost-effectiveness and help individual nations tailor management of the disease based on their resources, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.
Several speakers at the UCSF conference said that they expect these guidelines to appear later in 2006 or sometime in 2007. Dr. Bauer, of UCSF, said he hopes that the WHO guidelines can be adapted for use on a personal digital assistant or a Web-based program. The clinician would plug in the patient's bone mineral density (BMD) and other risk factors, and the software would calculate the patient's probability of suffering a fracture within the next 10 years.
Until the WHO guidelines are finished, however, “clinicians are sort of left out dangling by themselves” with currently available guidelines, which contain many gaps, said Dr. Bauer. “There are absolutely no good evidence-based guidelines for nonpostmenopausal women populations,” or for men and ethnic minorities. “There are no good evidence-based guidelines to help you decide how long you should treat people.”
The five available guidelines are:
▸ The 1994 WHO guidelines. These were highly influential because they defined osteoporosis and osteopenia based on T-scores, resulting in the widespread use of densitometry. “This was never meant to be a treatment guideline or to identify treatment thresholds, although in the medical community they were largely identified as such,” Dr. Bauer said.
▸ The American Association of Clinical Endocrinologists (AACE) guidelines. Although AACE conducted a review of the literature, the AACE guidelines ultimately were based on a consensus of experts rather than a quantitative, evidence-based review (Endocr. Pract. 2003;9:544–64), Dr. Bauer noted.
These guidelines state that women with postmenopausal osteoporosis should be treated if they've experienced a fracture and have a low BMD, or if their T-score is less than −2.5. Women with osteopenia should also be treated if they have risk factors, and the list of risk factors is longer than in the National Osteoporosis Foundation (NOF) guidelines. Patients should also be treated if nonpharmacologic therapy—vitamin D and calcium supplementation—proves ineffective as evidenced by bone loss or fracture.
▸ U.S. Preventive Services Task Force guidelines. These guidelines, published in 2002, addressed only screening for osteoporosis, not treatment, Dr. Bauer said.
▸ Canadian Task Force on Preventive Health Care guidelines. Issued in 2004 (CMAJ 2004;170:1665–7), these guidelines were developed using a rigorous evidence-based approach and state that patients who are classified as normal under WHO guidelines should receive no treatment. Those classified as having WHO osteopenia should be considered for a bisphosphonate or raloxifene if they are older than 65 years and have a T-score below −2.0. Patients classified as having WHO osteoporosis should be treated with a bisphosphonate and raloxifene, and parathyroid hormone should also be considered.
▸ National Osteoporosis Foundation guidelines. Dr. Bauer reserved his greatest praise for these guidelines, first published in 1999, revised in 2003, and available through the foundation's Web site (www.nof.org
Centered on an unbiased, evidence-based review of the literature, the NOF guidelines state that patients should be treated if their T-scores are less than −2.0 without any additional risk factors or less than −1.5 in the presence of certain risk factors. Treatment was also indicated even in the absence of a BMD score for patients with previous vertebral or hip fractures.
A drawback is that the NOF guidelines don't apply to ethnic minorities, premenopausal women, or men.