What are the Canadian guidelines for osteoporosis screening and treatment?

From the Guidelines

Canadian guidelines recommend screening women 65 years or older for fracture risk with the Canadian FRAX tool, and ordering DXA testing if pharmacotherapy is considered. According to the Canadian Task Force on Preventive Health Care recommendations in 2023, as reported by the US Preventive Services Task Force 1, this approach facilitates shared decision-making about pharmacotherapy. The guidelines recommend against screening men 40 years or older and women younger than 65 years.

Key Recommendations

• Screening for osteoporosis is recommended for women 65 years or older using the Canadian FRAX tool to assess fracture risk.
• DXA testing is recommended to reestimate fracture risk with BMD input to the FRAX if pharmacotherapy is considered.
• The guidelines do not recommend screening for men 40 years or older and women younger than 65 years.
• Treatment decisions should be based on fracture risk assessment and BMD testing results, with consideration of individual patient factors and preferences.

Treatment Considerations

• Treatment is typically recommended for individuals with a high fracture risk, based on the results of the FRAX tool and DXA testing.
• First-line medications and lifestyle modifications, such as calcium and vitamin D supplementation, weight-bearing exercise, smoking cessation, and limiting alcohol consumption, may be recommended as part of a comprehensive treatment plan, although specific details on treatment are not provided in the referenced guideline 1.

From the Research

Canadian Guidelines for Osteoporosis Screening

• The Canadian guidelines for osteoporosis screening recommend that individuals with an increased risk of fracture should undergo screening with central dual-energy x-ray absorptiometry (DEXA) 2.
• The diagnosis of osteoporosis can be confirmed by DEXA, but this should only be performed in patients who have an increased risk of fracture on the basis of clinical risk factors 3.
• Strategies for identifying those at increased risk, such as those with at least one major or two minor risk factors, and screening with central DEXA at age 65 years are recommended 2.

Risk Factors and Screening Recommendations

• Risk factors for osteoporosis include increasing age, female gender, long-term corticosteroid therapy, chronic inflammatory disease, malabsorption, and untreated premature menopause 3.
• Screening with DEXA should be considered if the 10-year risk of major osteoporotic fracture is > 10% 3.
• Vertebral fractures are generally taken as diagnostic of osteoporosis, even if spine BMD values are not in the osteoporotic range 3.

Treatment Recommendations

• Oral bisphosphonates are the first-line treatment for osteoporosis 3.
• If oral bisphosphonates are contraindicated or not tolerated, parenteral therapy should be considered 3.
• Bisphosphonates and raloxifene are first-line therapies in the prevention and treatment of postmenopausal osteoporosis 2.

Comparison with International Guidelines

• The Canadian guidelines are similar to international guidelines, such as those from the American College of Preventive Medicine (ACPM), which recommend screening with BMD testing for osteoporosis in women aged ≥65 years and in men aged ≥70 years 4.
• The International Society for Clinical Densitometry also recommends DXA in postmenopausal women younger than 65 years and men 50-69 years only in the presence of clinical risk factors for low bone mass 5.