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1
Adam Samosh
PGY-2 Family Medicine
Schulich School of Medicine
University of Western Ontario
Guidelines for Screening and Diagnosis of
Osteoporosis:A Review of Current Guidelines and
Recent Changes
2
A learning resource for Residents in Family Medicine Residency Programs
Online Learning Module
Osteoporosis
3
DefinitionsFamily MedicineAssessmentInvestigationsScreeningRisk AssessmentTreatment SummaryReferences
Outline
4
Review the basics of what osteoporosis isReview key aspects of history taking and
physical exam related to osteoporosisBe 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)
Learning Objectives
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)
Osteoporosis
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.
6
Normal: t-score ≥ -1
Osteopenia: -1 > t-score > -2.5
Osteoporosis: t-score < -2.5
Bone Density (3)
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.
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)
Relevance for Family Medicine
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/.
8
Osteoporosis Guidelines can be found from several different sources:Canadian Task Force on LTCSOGC/JOGCCMAOsteoporosis 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
Family Medicine
9
Fall Risk Assessment – Topics to ask patients about(5):Previous history of fallsAlcohol intake (≥ 3 drinks per day)Poor strengthBalance or gait issuesDizzinessPoor vision
History – Fall Risk
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].
10
Main Risks for Developing Osteoporosis (5):History of fragility fractureParent with a hip fractureRheumatoid ArthritisChronic (≥3 months) glucocorticoid useSmoking (any amount has the potential to be
detrimental to bone health)Chronic Liver/Kidney diseaseEarly Menopause (before age 45 years old –
including surgically induced menopause)Caffeine intake (≥4 cups/day)Androgen Deficiency (in men)
History
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].
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)
Physical Exam
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.
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
Investigations – DEXA(7)
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
13
Bloodwork is indicated to rule out secondary causes of osteoporosis (8)CBC – malabsorption or bone marrow
malignancyCreatinine – chronic renal diseaseCalcium (+ Albumin) – hyperparathyroidismTSH - hyperthyroidismAlkaline Phosphatase – chronic liver diseaseVitamin D – malabsorption Serum protein electrophoresis – multiple
myeloma
Investigations - Bloodwork
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
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
Screening
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.
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)
Screening (>65 year olds)
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
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)
Screening (50-64 year olds)
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
17
Screening is only indicated if patient has one of the following risk factors (8):history of fragility fractureprolonged use of glucocorticoids (>3 months)hypogonadismpremature menopause (<45 years old)malabsorption syndromeprimary hyperparathyroidism
Screening (<50 year olds)
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
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
Fracture Risk
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: http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf.
19
FRAX vs CAROC(12)
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.
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)
CAROC(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
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)
Fracture Risk
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.
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
Risk Stratification
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
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
Treatment
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)
Treatment – Low Risk
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].
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
Conservative 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. 20105.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].
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)
Supplementation
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.
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
Calcium
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.
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)
Treatment – Moderate Risk
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
Evidence for benefit from pharmacotherapy (5)
The following pharmacologic treatment options are briefly discussed on the following slides:BisphosphonatesSelective Estrogen Receptor Modulators (SERMs)Hormone Replacement Therapy (HRT)CalcitoninMiscellaneous
Treatment – High Risk
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
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
Bisphosphonates
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.
31
Raloxifene can be used as a first line therapy for prevention of vertebral fractures in menopausal women with osteoporosis (grade A) (13)
SERMs
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: summary. CMAJ 2010 Nov 23;182(17):1-10.
32
Monoclonal Antibody
Parathyroid Hormone (PTH) Analog
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)
Other Treatments (16)
Teriparatide (Forteo®) 20 μg subcutaneously daily
Denosumab (Prolia®) 60 mg subcutaneous injection every six months
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 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
Etidronate
Testosterone is not recommended as a treatment in men (Grade B)
Second-Line Treatments (13)
Calcitonin (Miacalcin®) 200 IU intranasally daily
Etidronate (Didrocal®)Cyclical therapy of daily 200 mg for 14 days followed by calcium supplements for 10 weeks
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.
34
Consider referral to a specialist in patients who meet one of the following criteria:decrease in bone density while on therapynew fracture while on therapypoor drug tolerance to several first line agentsrare drug therapy complications such as
osteonecrosis of the jaw or atypical femoral fractures (13)
Referrals
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.
35
Osteoporosis corresponds to a BMD t-score < -2.5Review falls risks and risk of developing osteoporosis when
concerned about a patient’s future risk of fractureScreening 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
Summary
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
References
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.
References
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).
References