To treat osteoporosis, focus on breaks, doctors told

Never mind how much calcium is in your bones as you age; concentrate instead on preventing and treating tiny fractures that can cause tremendous pain. That is the message emerging from new guidelines for the diagnosis and management of osteoporosis, published Tuesday in the Canadian Medical Association Journal.

"This is a major shift in approach to target patients at highest risk," said Alexandra Papaioannou, a professor of geriatric medicine at McMaster University in Hamilton, Ont., and lead author of the guidelines, in an interview.

Until now, the key strategy for tackling osteoporosis - a condition that affects two million Canadians - has been testing for bone mineral density (the levels of minerals such as calcium in the bones) and using drugs to bolster BMD.

But the new guidelines take an entirely different tack, placing emphasis on detecting and treating fragility fractures - tiny breaks of the spine, hips and wrists that occur during minor falls.

"When you break a bone after the age of 50, that needs to be taken seriously," Dr. Papaioannou said.

She noted that many fractures, particularly in the spine, are undiagnosed or untreated because aches and pains are often dismissed as a normal part of aging. But those small breaks are a key clue that the bones are weakening, and are often a precursor to a more severe, disabling injury.

"A broken hip can lead to a downward spiral of disability and death," Dr. Papaioannou said. "But we can prevent a lot of those problems if we intervene early."

The new guidelines state that the best way to prevent fractures and their recurrence is with exercise, specifically resistance training and weight-bearing aerobic exercise. For those at highest risk, balance exercises such as Tai Chi are recommended.

The guidelines also emphasize the importance of two nutrients, vitamin D and calcium. It is recommended that everyone over the age of 50 take vitamin D supplements - 1,000 international units daily for healthy adults and 2,000 for those who have already suffered fractures.

Adults should also consume 1,200 milligrams a day of calcium from dietary sources or supplements. (In earlier guidelines, much higher doses were recommended but those have not proved beneficial.)

The new guidelines strongly play down the need for BMD testing before the age of 65, except in high-risk individuals.

Similarly, it is no longer recommended that drugs be prescribed for the treatment of low BMD alone (a condition called osteopenia). "We don't recommend that women at low risk be on medication," Dr. Papaioannou said.

Instead, the guidelines call for patients to be screened using tools that predict their 10-year fracture risk based on family medical history, what fractures they've had in the past, and a host of factors that could place them at high risk for weak bones.

Those at high risk include smokers, heavy drinkers, people suffering from conditions that increase their risk of falling, , such as dementia, people on medications that can weaken the bones, patients with bowel disorders such as Crohn's disease, and people with diabetes and prostate cancer.

Those high-risk individuals should be treated aggressively to prevent breaks, the guidelines say.

"When there was a break, we used to heal the bone, but we didn't take the next step of strengthening the bone to prevent future fractures," Dr. Papaioannou said. "That's what has to change."

There is now a host of prescription drugs for the treatment of osteoporosis and the pain associated with it. The guidelines recommend they be used differently for various patient groups:

- For postmenopausal women, alendronate (brand name Fosomax), risedronate (Actonel), zoledronic acid (Zometa) and denosumab (Prolia) can prevent hip and spine fractures, and raloxifene (Evista) can prevent spine fractures;

- For women seeking relief of menopause symptoms, hormone replacement therapy can be used as it also helps prevent hip and spine fractures;

- For men, alendronate (Fosomax), risedronate (Actonel) and zoledronic acid (Zometa) can be used to prevent fractures. Testosterone is not considered an effective treatment.

Osteoporosis, which is characterized by the deterioration of the micro-architecture of the bone - affects about one in 10 women over the age of 60 and increases steadily with age, striking two in three women over 90.

While osteoporosis is viewed principally as a condition of postmenopausal women, it is also common in older men. However, men tend to be diagnosed only after they suffer a severe fracture.