4. Review the basics of what osteoporosis is
Review key aspects of history taking and physical exam
related to osteoporosis
Be able to determine appropriate screening and
fracture risk stratification for different patient
demographics
Become familiar with basic management options for
osteoporosis (note: thorough discussion of
pharmacological management of osteoporosis is
beyond the scope of this learning module)
4
5. Skeletal disorder characterized by compromised bone
strength predisposing to an increased risk of fractures
(1)
WHO Definition:
BMD value at the spine, hip, or forearm of 2.5 or more
standard deviations below the young adult mean (i.e.
t-score ≤-2.5), with or without the presence of a
fragility fracture (2)
Fragility Fracture: no, or low trauma fracture (3)
1. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. Journal of Bone and Mineral
Research. 1994, 9:1137.
2. Kanis JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990, 5:209-11.
5
3. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting
intervention thresholds. Osteoporosis International. 2002, 12:417–24.
6. Normal: t-score ≥ -1
Osteopenia: -1 > t-score > -2.5
Osteoporosis: t-score < -2.5
3. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting
intervention thresholds. Osteoporosis International. 2002, 12:417–24. 6
7. Primary care physicians are often responsible for screening
and initiating management in patients with osteoporosis
Canada: 1 in 3 women and 1 in 5 men will experience a
fracture from osteoporosis
Approximately 80% of fractures in Canadians over 50 years
old are due to osteoporosis
The annual cost to the health care system from
Osteoporosis is estimated at $2.3 billion each year
Guidelines for management have changed several times
over the last few decades - most notably in 2002, 2004,
2010, 2011 and 2012(4)
4. Osteoporosis Canada. Osteoporosis Facts & Statistics [Internet]. Toronto, Ontario. Osteoporosis Canada. 2012 March.
Available from: http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-facts-and-statistics/. 7
8. Osteoporosis Guidelines can be found from several
different sources:
Canadian Task Force on LTC
SOGC/JOGC
CMA
Osteoporosis Canada
One of the main purposes of this online learning
module is to combine these guidelines into one
resource for use in Family Medicine practice
8
9. Fall Risk Assessment – Topics to ask patients about(5):
Previous history of falls
Alcohol intake (≥ 3 drinks per day)
Poor strength
Balance or gait issues
Dizziness
Poor vision
5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and
Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 9
1];[about 2 screens].
10. Main Risks for Developing Osteoporosis (5):
History of fragility fracture
Parent with a hip fracture
Rheumatoid Arthritis
Chronic (≥3 months) glucocorticoid use
Smoking (any amount has the potential to be
detrimental to bone health)
Chronic Liver/Kidney disease
Early Menopause (before age 45 years old – including
surgically induced menopause)
Caffeine intake (≥4 cups/day)
Androgen Deficiency (in men)
5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and
Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 10
1];[about 2 screens].
11. Physical Exam:
Check occiput-to-wall distance (look for >5cm)
Serial heights of patient – looking for >2cm loss of
height, or >6cm loss of height based on patient history
(6)
6. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada.
CMAJ 2002; 167(10 Suppl):S1-34. 11
12. Confirm Diagnosis with Dual-energy X-ray Absorptiometry
(DXA or DEXA) scan to determine BMD of the patient
In Ontario, OHIP (Ontario Health Insurance) will cover DEXA
scans:
-For patients at high risk for osteoporosis and future fractures,
annual scans are covered
-For patients at low/intermediate risk for osteoporosis and future
fractures, initial BMD testing is covered. A second test can be
ordered 3 years after the baseline (i.e. first) test. After those two
tests, OHIP will cover any further BMD testing up to every 5
years
7. Ontario Ministry of Health and Long-Term Care. BMD Testing [Internet]. Toronto, Ontario. Queen’s Printer for Ontario. July
2010 [updated June 28, 2012; cited 2013 March 2]. Available from:
http://www.health.gov.on.ca/en/public/publications/ohip/bone.aspx 12
13. Bloodwork is indicated to rule out secondary causes of
osteoporosis (8)
CBC – malabsorption or bone marrow malignancy
Creatinine – chronic renal disease
Calcium (+ Albumin) – hyperparathyroidism
TSH - hyperthyroidism
Alkaline Phosphatase – chronic liver disease
Vitamin D – malabsorption
Serum protein electrophoresis – multiple myeloma
8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of
Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 13
http://www.osteoporosis.ca
14. The Canadian Task Force on Preventative Health Care
made several screening recommendations in 2004(9):
There is fair evidence to recommend screening
postmenopausal women to prevent fragility fractures
(grade B)
There is no direct evidence that screening reduces fractures,
however, there is good evidence that screening is effective in
identifying postmenopausal women with low bone mineral
density and that treating osteoporosis can reduce the risk of
fractures in this population (grade A)
Screening is determined based on age and presence of
medical comorbidities
The most current osteoporosis screening guidelines used in
Ontario are from 2010 and are outlined in the following
slides
9. Wathen CN, Feig DS, Feightner JW, Abramson BL, Cheung AM. Hormone replacement therapy for the primary prevention
of chronic diseases: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2004 May, 14
170(10):1535-7.
15. DXA scans (to determine BMD and fracture risk) are
indicated for screening in all men and women over the
age of 65 years old (8)
8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of
Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 15
http://www.osteoporosis.ca
16. Screening is indicated in a patient between the age of
50-64 years old if they have a risk factor for developing
osteoporosis (discussed on slide #10)
In addition to the risk factors already mentioned,
consider screening in patients with:
primary hyperparathyroidism, type 1 diabetes,
osteogenesis imperfecta, hyperthyroidism,
hypogonadism, Cushing’s disease, malabsorption
syndrome, IBD, COPD (8)
8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of
Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 16
http://www.osteoporosis.ca
17. Screening is only indicated if patient has one of the
following risk factors (8):
history of fragility fracture
prolonged use of glucocorticoids (>3 months)
hypogonadism
premature menopause (<45 years old)
malabsorption syndrome
primary hyperparathyroidism
8.Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of
Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: 17
http://www.osteoporosis.ca
18. Assess 10-year fracture risk using BMD and one of two risk
assessment tools (available online)
FRAX score (10) (developed by the WHO – has settings that
can be set for the Canadian population specifically)
http://www.shef.ac.uk/FRAX/tool.aspx?country=19
CAROC (11) (Canadian Association of Radiologists and
Osteoporosis Canada Risk Assessment tool)
http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf
These tools enable risk stratification
10. World Health Organization Collaborating Centre for Metabolic Bone Diseases. FRAX [Internet]. Sheffield, UK: University of
Sheffield; 2013. Available from: http://www.shef.ac.uk/FRAX/tool.aspx?country=19.
11. Osteoporosis Canada. Assessment of 10-year Fracture Risk – Women and Men [Internet]. Canada. Canadian Association of
Radiologists and Osteoporosis Canada (CAROC); 2013. Available from: 18
http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.
19. Note – Entire Table can be found at: 12. The Foundation for Medical Practice Education. Osteoporosis: Applying the paradigm
shift from new guidelines. Practice Based Learning Program Educational Module. 2012 May;20(5)1-20. 19
20. The current 2010 guidelines recommend using the
CAROC tool (rather than FRAX) for assessing fracture
risk in patients in Canada
The same guidelines recommend using only the BMD
t-score for the femoral neck when calculating fracture
risk (with CAROC being the preferred tool)
13 Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM,
Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in
Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10. 20
21. In previous years, guidelines focussed on treating a
patient’s BMD t-score
Currently the focus has shifted to managing a patient’s
fracture risk level (rather than the t-score)
The main key point of the 2010 clinical practice
guidelines for osteoporosis in Canada states:
The management of osteoporosis should be guided by
an assessment of the patient’s absolute RISK OF
OSTEOPOROSIS RELATED FRACTURES (13)
13 Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM,
Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in
Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10. 21
22. Risk Categories based on 10-year fracture risk (14):
Low (< 10%)
Moderate (10 - 20%)
High (> 20%)
Risk categorization helps determine the most
appropriate (evidence based) treatment for each
patient
14. Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP, Feldman S, Hodsman AB,
Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K. Osteoporosis Canada 2010 Guidelines for the Assessment of
Fracture Risk. Can Assoc Radiol J. 2011 Nov;62(4):243-50 22
23. Thorough discussion of treatment options for
osteoporosis is beyond the scope of this learning
module but will briefly be discussed on the following
slides to introduce the learner to commonly used
medications for fracture reduction management
23
24. No evidence for benefit (i.e. prevention of future
fractures) from pharmacotherapy
May benefit from vitamin D and calcium
supplementation as well as conservative treatments
(see slide #25 and 26)
BMD should be repeated in 5 years to reassess risk
levels (5)
5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and
Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 24
1];[about 2 screens].
25. Recommend (13):
Weight bearing exercise such as walking or weights (grade B)
Balance training (such as Tai Chi ) (grade A evidence for those at
risk of falls)
Home safety assessments (PT/OT) (grade B)
Treating poor vision (i.e. glasses, cataract removal) (grade B)
Hip-protectors (for patients in long-term care facilities) (grade B)
Smoking cessation
Limiting alcohol intake (<2 drinks/day)
Consider Referral (if appropriate) to (5):
Geriatric medicine
Falls prevention program
Homecare
Occupational therapy or Physical therapy
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B,
Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary.
CMAJ. 2010
5.Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols 25
Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2
screens].
26. Daily Calcium Intake (from all sources):
1200mg (grade B) (discussed further on next slide)
Daily Vitamin D Intake:
<50 years old 400-1000IU (grade D)
>50 years old 800-2000IU (grade C)
Recheck Vitamin D levels 3 months after initiating
supplementation (OHIP will only cover Vitamin D
Testing for patients with Osteoporosis/Osteopenia)
Daily doses up to 2000 IU is safe and does not require
serial monitoring (grade C) (13)
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern
B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 26
summary. CMAJ 2010 Nov 23;182(17):1-10.
27. Recent article (June 2012) in the journal Heart suggests there
may be increase cardiovascular risk with taking calcium
supplements
Conclusion:
“this study suggests that increasing calcium intake from diet might
not confer significant cardiovascular benefits, while calcium
supplements, which might raise MI risk, should be taken with
caution” (15)
There has been no official change to guidelines in Canada for
calcium supplementation since this article was published
Anecdotally, many family doctors are avoiding use of calcium
supplements (and encouraging adequate calcium intake from
diet instead) until formal guidelines are released
15. Kuanrong Li, Rudolf Kaaks, Jakob Linseisen. Associations of dietary calcium intake and overall calcium supplementation with
myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective
Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012 98: 920-5. 27
28. May benefit from conservative management and
adequate supplementation of Calcium and Vitamin D
(see slide #27 for concerns around calcium
supplementation)
Use clinical judgement in considering that individuals
at increase risk for falls or fracture in particular may
benefit from treatment (5)
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and
Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct
1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html 28
29. Evidence for benefit from pharmacotherapy (5)
The following pharmacologic treatment options are
briefly discussed on the following slides:
Bisphosphonates
Selective Estrogen Receptor Modulators (SERMs)
Hormone Replacement Therapy (HRT)
Calcitonin
Miscellaneous
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and
Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct
1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html 29
30. Generally a bisphosphonate is used as first line treatments
for prevention of fracture for both men and women (Grade
A for women, Grade D for men) (13)
However, there are other first line options (with evidence in
post-menopausal women) for fracture prevention
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern
B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 30
summary. CMAJ 2010 Nov 23;182(17):1-10.
31. Raloxifene can be used as a first line therapy for
prevention of vertebral fractures in menopausal
women with osteoporosis (grade A) (13)
Raloxifene (Evista®) 60 mg daily
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern
B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 31
summary. CMAJ 2010 Nov 23;182(17):1-10.
32. Monoclonal Antibody
Denosumab (Prolia®) 60 mg subcutaneous injection every six months
Parathyroid Hormone (PTH) Analog
Teriparatide (Forteo®) 20 μg subcutaneously daily
In menopausal women with vasomotor symptoms and
osteoporosis, Hormone Replacement Therapy (HRT) can be
used to treat both
HRT is available as oral medication, patches applied to skin or as
a topical cream (13)
16. Papaioannou A. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet].
Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Oct]. Available from: http://www.osteoporosis.ca/health-care-
professionals/clinical-tools-and-resources/2010-clinical-guidelines-slideset/. Select Slide Deck 05 (Strategies for Fracture
Prevention).
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern 32
B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada:
summary. CMAJ 2010 Nov 23;182(17):1-10.
33. Second line therapies include calcitonin, and etidronate
(Grade B)
Calcitonin
Calcitonin (Miacalcin®) 200 IU intranasally daily
Etidronate
Cyclical therapy of daily 200 mg for 14 days
Etidronate (Didrocal®) followed by calcium supplements for 10
weeks
Testosterone is not recommended as a treatment in men
(Grade B)
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern
B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 33
summary. CMAJ 2010 Nov 23;182(17):1-10.
34. Consider referral to a specialist in patients who meet
one of the following criteria:
decrease in bone density while on therapy
new fracture while on therapy
poor drug tolerance to several first line agents
rare drug therapy complications such as osteonecrosis of
the jaw or atypical femoral fractures (13)
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern
B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: 34
summary. CMAJ 2010 Nov 23;182(17):1-10.
35. Osteoporosis corresponds to a BMD t-score < -2.5
Review falls risks and risk of developing osteoporosis when
concerned about a patient’s future risk of fracture
Screening for osteoporosis is appropriate in individuals over the
age of 65 years old, or younger patients at risk of developing
osteoporosis
Screening generally involves using a DEXA scan to determine
BMD, which is then used by a risk-assessment tool (CAROC is
preferred) to determine a patient’s fracture risk
Fracture risk level (low, intermediate or high) will determine
what type of management is appropriate to prevent future
fractures
Ultimately, the goal of osteoporosis management is fracture
risk reduction
35
36. 1. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The
diagnosis of osteoporosis. Journal of Bone and Mineral Research.
1994, 9:1137.
2. Kanis JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990, 5:209-11.
3. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The
burden of osteoporotic fractures: a method for setting intervention
thresholds. Osteoporosis International. 2002, 12:417–24.
4. Osteoporosis Canada. Osteoporosis Facts & Statistics [Internet].
Toronto, Ontario. Osteoporosis Canada. 2012 March. Available from:
http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-
facts-and-statistics/.
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British
Columbia Medical Association. Guidelines and Protocols Advisory
Committee. Osteoporosis: Diagnosis, Treatment and Fracture
Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens].
Available from:
http://www.bcguidelines.ca/guideline_osteoporosis.html
36
37. 6. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and
management of osteoporosis in Canada. CMAJ 2002; 167(10 Suppl):S1-34.
7. Ontario Ministry of Health and Long-Term Care. BMD Testing [Internet]. Toronto,
Ontario. Queen’s Printer for Ontario. July 2010 [updated June 28, 2012; cited 2013
March 2]. Available from:
http://www.health.gov.on.ca/en/public/publications/ohip/bone.aspx
8. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis
and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis
Canada. 2010 Oct [updated 2011 Sept]. Available from:
http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
9. Wathen CN, Feig DS, Feightner JW, Abramson BL, Cheung AM. Hormone replacement
therapy for the primary prevention of chronic diseases: recommendation statement from
the Canadian Task Force on Preventive Health Care. CMAJ 2004 May, 170(10):1535-7.
10. World Health Organization Collaborating Centre for Metabolic Bone Diseases. FRAX
[Internet]. Sheffield, UK: University of Sheffield; 2013. Available from:
http://www.shef.ac.uk/FRAX/tool.aspx?country=19.
37
38. 11. Osteoporosis Canada. Assessment of 10-year Fracture Risk – Women and Men [Internet]. Canada.
Canadian Association of Radiologists and Osteoporosis Canada (CAROC); 2013. Available from:
http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.
12. The Foundation for Medical Practice Education. Osteoporosis: Applying the paradigm shift from new
guidelines. Practice Based Learning Program Educational Module. 2012 May;20(5)1-20.
13. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal
SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and
management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
14. Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP,
Feldman S, Hodsman AB, Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K.
Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk. Can Assoc Radiol J. 2011
Nov;62(4):243-50
15. Kuanrong L, Rudolf K, Jakob L. Associations of dietary calcium intake and overall calcium
supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the
Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-
Heidelberg). Heart 2012 98: 920-5.
16. Papaioannou A. 2010 Clinical Practice Guidelines for the Diagnosis and Management of
Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct
[updated 2011 Oct]. Available from: http://www.osteoporosis.ca/health-care-
professionals/clinical-tools-and-resources/2010-clinical-guidelines-slideset/. Select Slide
Deck 05 (Strategies for Fracture Prevention).
38
Editor's Notes
Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. Journal of bone and mineral research. 1994, 9:1137.Kanis JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990, 5:209-11.
3. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporosis International. 2002, 12:417–24.
15. Osteoporosis Canada. Osteoporosis Facts & Statistics [Internet]. Toronto, Ontario. Osteoporosis Canada. 2012 March. Available from: http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-facts-and-statistics/.
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
6. Papaioannou A. Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Sept]. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf.
8. World Health Organization Collaborating Centre for Metabolic Bone Diseases. FRAX [Internet]. Sheffield, UK: University of Sheffield; 2013. Available from: http://www.shef.ac.uk/FRAX/tool.aspx?country=19.9. Osteoporosis Canada. Assessment of 10-year Fracture Risk – Women and Men [Internet]. Canada. Canadian Association of Radiologists and Osteoporosis Canada (CAROC); 2013. Available from: http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.
10. The Foundation for Medical Practice Education. Osteoporosis: Applying the paradigm shift from new guidelines. Practice Based Learning Program Educational Module. 2012 May;20(5)1-20.
11.Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP, Feldman S, Hodsman AB, Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K. Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk. Can Assoc Radiol J. 2011 Nov;62(4):243-50.
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
13. Kuanrong Li, Rudolf Kaaks, Jakob Linseisen. Associations of dietary calcium intake and overall calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012 98: 920-5.
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
5. Ministry of Health: BC Guidelines [Internet]. Victoria, BC. British Columbia Medical Association. Guidelines and Protocols Advisory Committee. Osteoporosis: Diagnosis, Treatment and Fracture Prevention. 2011 May 1 [updated 2012 Oct 1];[about 2 screens]. Available from: http://www.bcguidelines.ca/guideline_osteoporosis.html
12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
14. Papaioannou A. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada [Internet]. Toronto, Ontario. Osteoporosis Canada. 2010 Oct [updated 2011 Oct]. Available from: http://www.osteoporosis.ca/health-care-professionals/clinical-tools-and-resources/2010-clinical-guidelines-slideset/. Select Slide Deck 05 (Strategies for Fracture Prevention).
12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.
12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182(17):1-10.