Diagnosis and Management of Osteoporosis: A Comprehensive Review of Guidelines
Authors: Rentzeperi Elpiniki , Pegiou Stavroula , Tsakiridis Ioannis , Kalogiannidis Ioannis , Kourtis Anargyros , Mamopoulos Apostolos , Athanasiadis Apostolos , Dagklis Themistoklis 
Published: November 2023

Importance
Osteoporosis causes increased morbidity and mortality, and thus poses a significant economic burden to the health systems worldwide.

Objective
The aim of this study was to review and compare the most recently published major guidelines on diagnosis and management of this common medical entity.

Evidence Acquisition
A thorough comparative review of the most influential guidelines from the RACGP (Royal Australian College of General Practitioners), the ESCEO-IOF (European Society for Clinical and Economic Aspects of Osteoporosis–International Osteoporosis Foundation), the NOGG (National Osteoporosis Guideline Group), the NAMS (North American Menopause Society), the ES (Endocrine Society), and the ACOG (American College of Obstetricians and Gynecologists) was conducted.

Results
The reviewed guidelines generally agree on the definition, the criteria, and investigations used to diagnose osteoporosis. They also concur regarding the risk factors for osteoporosis and the suggested lifestyle modifications (calcium and vitamin D intake, normal body weight, reduction of alcohol consumption, and smoking cessation). However, there is lack of consensus on indications for fracture risk assessment in the general population and the exact indications for bone mineral density assessment. Referral to a bone specialist is reserved for complex cases of osteoporosis (NOGG, NAMS, and ACOG) or in case of inadequate access to care (RACGP). The use of hip protectors to reduce the risk of fractures is supported by RACGP, NOGG, and NAMS, solely for high-risk elderly patients in residential care settings. All guidelines reviewed recognize the efficacy of the pharmacologic agents (ie, bisphosphonates, denosumab, hormone therapy, and parathyroid hormone analogs). Nonetheless, recommendations regarding monitoring of pharmacotherapy differ, primarily in the case of bisphosphonates. The proposed intervals of repeat bone mineral density testing after initiation of drug therapy are set at 2 years (RACGP), 1–3 years (NAMS, ES, and ACOG), or 3–5 years (ESCEO-IOF and NOGG). All guidelines agree upon the restricted use of bone turnover markers only in bone specialist centers for treatment monitoring purposes. Finally, the definition of treatment failure varies among the reviewed guidelines.

Conclusions
Osteoporosis is a distressing condition for women, mainly those of postmenopausal age. Thus, it seems of paramount importance to develop consistent international practice protocols for more cost-effective diagnostic and management techniques, in order to improve women's quality of life.

Target Audience
Obstetricians and gynecologists, family physicians.

Learning Objectives
After participating in this activity, the physician should be able to identify early risk factors for osteoporosis; describe the appropriate diagnostic techniques for osteoporosis; and explain available drug agents for the management of osteoporosis, as well as the difference in approach regarding their use.