International Journal of Rheumatic Diseases 2011; 14: 223–238

ORIGINAL ARTICLE

Consensus statements on osteoporosis diagnosis,

prevention, and management in the Philippines
Julie LI-YU,1 Emmanuel C. PEREZ,2 Arturo CAÑETE,3 Lauro BONIFACIO,3 Lyndon Q.
LLAMADO,1 Romil MARTINEZ,4 Allan LANZON5 and Mae SISON6 on behalf of the
Osteoporosis Society of the Philippines Foundation, Inc. (OSPFI) and Philippine Orthopedic
Association (POA) Clinical Practice Guidelines Task Force Committee on Osteoporosis*
1
Department of Medicine, University of Santo Tomas Hospital, Manila, 2De la Salle University Health Science Institute College
of Medicine, Cavite, 3Philippine Orthopedic Association (POA), Quezon City, 4Department of Rehabilitation Medicine,
Amang Rodriguez Medical Center, Manila, 5Department of Medicine, Mary Mediatrix Medical Center, Batangas, and
6
Department of Medicine, University of the Philippines, Phil. General Hospital, Manila, Philippines

Abstract
Objective: The consensus statements were developed to assist healthcare practitioners in providing optimal
care to postmenopausal individuals at risk for osteoporosis and fragility fractures in the local setting.
Methodology: The Technical Review Committee formed by the Osteoporosis Society of the Philippines Founda-
tion Inc. in cooperation with the Philippine Orthopedic Association drafted, retrieved available published evi-
dence, and appraised important issues on osteoporosis and fragility fractures. The Appraisal of Guidelines
Research and Evaluation instrument was used to appraise published guidelines while a systematic way of validat-
ing the quality of evidence and the level of recommendation was done using the GRADE system. A multidisci-
plinary panel of experts and stakeholders in an en banc meeting conferred and approved the recommendations.
Results and conclusion: There were five key issues on preventive, seven on diagnostic, nine on therapeutic
aspects of osteoporosis with four other surgical concerns on fragility fractures. All were approved by a panel
of stakeholders through a majority vote. These statements will best inform the clinicians and the specialists
including orthopedic surgeons and general care practitioners on issues of postmenopausal Filipino women at
risk for osteoporosis and fragility fractures.
Key words: osteoporosis, Philippines, position statements.

regional health care costs. Cost effective measures to

INTRODUCTION
The projected worldwide epidemic of osteoporosis in
Asia Pacific will entail a substantial impact to the
Correspondence: Associate Professor Julie Li-Yu, Section of
Rheumatology, Clinical Immunology, and Osteoporosis,
Department of Medicine, University of Santo Tomas
Hospital, España Manila, Philippines.
Email: julietanliyu@yahoo.com
*Members of on behalf of the Osteoporosis Society of the Philip-
pines Foundation, Inc. (OSPFI) and Philippine Orthopedic Asso-
ciation (POA) Clinical Practice Guidelines Task Force Committee
on Osteoporosis are in Appendix.
prevent the major complication of fragility fractures
including pain and disability are constantly being
improved. Clinical assessment of osteoporosis and
fracture risk is integral as part of careful evaluation
of individuals at greater risk. International practice
guidelines have been published to guide clinicians in
handling osteoporosis in certain regions around the
globe. However, for a developing country, priority
should be given to maximize utility of healthcare
resources and improve the quality of healthcare to
the underprivileged population. It is imperative that
general care practitioners and healthcare providers be

ª 2011 The Authors

International Journal of Rheumatic Diseases
ª 2011 Asia Pacific League of Associations for Rheumatology and Blackwell Publishing Asia Pty Ltd
J. Li-Yu et al.
guided on issues of prevention, diagnosis, and thera-
pies related to osteoporosis and fragility fractures in
the local setting. Hence, this evidence-based consen-
sus guideline was developed in order to best address
these pressing issues including surgical aspects of fra-
gility fractures.
GENERAL OBJECTIVE
To formulate clinical practice statements that focuses
on prevention, diagnosis, and treatment aspects of
osteoporosis and osteoporosis related fragility fractures
among postmenopausal women in the Philippines.
SPECIFIC OBJECTIVES
1 To formulate statements that emphasize on the role
of nutrition and exercise in the prevention of osteo-
porosis.
2 To formulate cost efficient ways in the diagnosis of
osteoporosis using bone densitometry technique,
Osteoporosis Screening Tool for Asians (OSTA),
spine radiographs, 10-year fracture risk assessment
(FRAX) tool.
3 To formulate evidence based recommendations on
pharmacologic and non-pharmacologic manage-
ment of osteoporosis and fracture prevention mea-
sures (in partnership with POA).
METHODOLOGY
Important clinical issues on prevention, diagnosis, and
therapy were discussed intently by the technical review
committee (TRC). Available published guidelines on
these issues were individually appraised for their valid-
ity using the Appraisal of Guidelines Research and
Evaluation (AGREE) instrument.1
Search terms for identification of guidelines
Clinical practice guidelines/practice guidelines/guide-
lines/prevention/therapy/primary and secondary pre-
vention of osteoporosis/fragility fractures/nutrition/
exercise.
Search methods for identification of
guidelines
Using different search engines like PUBMED, MED-
LINE, NICE, Cochrane, National Clearinghouse, avail-
able local and international guidelines including
position statements of organizations/societies on the
prevention, diagnosis, and management of postmeno-
224
pausal osteoporosis and fragility fractures published
between 2000 and 2008 were retrieved.
Types of participants
Postmenopausal women (regardless of age) were strati-
fied into low, medium, and high risk for osteoporosis
and fragility fractures. Low risk group included meno-
pausal women with low bone mass (osteopenia) with
no other clinical risk factors while medium risk
included those with osteoporosis with or without clin-
ical risk factors. Neither group ever had fragility frac-
tures. High risk group, on the other hand, included
menopausal women who had severe or established
osteoporosis.2
Types of outcomes
Increase in BMD on all sites measured, reduction in
incidence of clinical vertebral/hip/wrist/non-vertebral
fractures, reduction in incidence of new vertebral/hip/
wrist/non-vertebral fractures.
Types of interventions both medical and
surgical
1 Diagnostic tools – risk assessment tools, central and
peripheral bone density, radiographs, FRAX tool.
2 Non-pharmacologic – diet/nutrition, exercise.
3 Pharmacologic – anabolics, anti-resorptives, calcium
and vitamin D supplement.
4 Surgical – arthroplasty, fixation devices.
Data abstraction
For the initial data abstraction, there were 30 interna-
tional and one local guidelines retrieved. Each guide-
line was reviewed and appraised by three independent
reviewers using AGREE instrument. There were six
domains considered in the evaluation: scope and pur-
pose, stakeholder involvement, rigor of development,
clarity and presentation, applicability, and editorial
independence. The two most important domains given
highest credits were the ‘rigor of development’ and
‘clarity of presentation’ whereby each guideline should
score 60% and above in both domains for inclusion
into the final pool of evidence. Updated publications
on randomized controlled trials on therapy from Janu-
ary to December 2009 were separately searched for
and appraised as well as publications on diagnostics/
screening tools.
The TRC utilized Grades of Recommendation,
Assessment, Development and Evaluation (GRADES)3
in making judgment on both the overall quality of
International Journal of Rheumatic Diseases 2011; 14: 223–238
 Position statements on osteoporosis

evidence and the category of recommendations. As
suggested in GRADES, the approach took into
account study design, study quality, consistency, and
directness in judging the quality of evidence for each
important outcome. Definitions for grading the qual-
ity of evidence include ‘high’ if further research will
unlikely change the confidence in the estimate of the
effect, ‘moderate’ if further research is likely to have
an important impact on the confidence in the esti-
mate of the effect and may change the estimate,
‘low’ if further research is very likely to have an
important impact on the confidence in the estimate
of the effect and is likely to change the estimate,
and ‘very low’ if any estimate of effect is very uncer-
tain. The balance between benefits and harms, qual-
ity of evidence, applicability, and certainty of the
baseline risk were all considered in the judgments
on the category of recommendation. The category of
recommendation classified as: ‘do it’ or ‘don’t do it’
indicates judgment most well informed people would
make while ‘probably do it’ or ‘probably don’t do
it’ indicates judgment majority of well informed peo-
ple would make but a substantial minority would
not.
A multidisciplinary team of experts from various
specialty societies together with patient representatives
was invited to take part as panel members in the
guideline development. A consensus vote of more
than 75% using the Delphi technique during an en
banc meeting on all propositions was agreed upon. All
revisions underwent 2nd and final voting by the panel
using same technique. Issues and concerns were thor-
oughly discussed using global evidence translated to
local applicability.

RESULTS
Of the 30 international and one local guidelines retrieved, 16 guidelines were excluded. Reasons for exclusion
included: two guidelines were in men, one in pediatric patients, 13 guidelines fell short of the agreed score set in
either ‘rigor of development’ or ‘clarity of presentation’. The final list appraised included 15 guidelines.4–18 There
were three major divisions on which this guideline was developed: prevention, diagnosis, and treatment (medical
and surgical).

Preventive aspects
Q1. What is the role of calcium and vitamin D in bone health among PMW? How much calcium and vitamin
D supplement should a PMW woman receive? Can calcium and vitamin D supplementation reduce the risk
for fractures?
It is highly recommended that PMW should receive calcium in combination with vitamin D for optimal bone
health. (refer to Table 1 for 2002 Philippine Food and Nutrition Research Institute (FNRI) recommendation19 of
average daily requirement for calcium and vitamin D based on age group and Tables 2 and 3 for food sources
and food tips).

Recommendation Quality of Category of

evidence recommendation
It is recommended that PMW take at least 750–800 mg of calcium daily High Do it
for minimum of 2 years to prevent bone loss. The magnitude of reduction
in fracture risk with calcium supplementation alone remains unclear20
It is also recommended that dose of 10–20 lg of vitamin D3 be given
with 1000 mg calcium to reduce hip fracture risk of older individuals
especially those with limited sun exposure, i.e. housebound. However, it
is not routinely recommended to give vitamin D analogues21

International Journal of Rheumatic Diseases 2011; 14: 223–238 225

J. Li-Yu et al.

Q2. What forms of exercise can improve bone density?

Recommendation Quality of Category of

evidence recommendation
It is suggested that regular Tai Chi Chun (TCC) be done primarily for balance, Moderate Do it
muscle strength, fall prevention, flexibility, and performance of activities of daily
living. However, there is insufficient evidence to recommend Tai-Chi for the
prevention of osteoporosis22,23
Supervised high intensity resistance exercise such as muscular strength training Moderate to low Do it
loads consisting of single or multiple sets of 8–12 repetitions of exercises done
2–3 days/week is recommended. It is suggested that exercise therapy, e.g. aero-
bics, resistance* and weight bearing exercises, and walking be regularly done to
increase bone density at the lumbar spine and hip24,25
Both Tai Chi and resistance exercises maybe incorporated in regular community
center activities. Caution must be advised on the unfavorable effects of
high-resistance intensity training exercises in patients with knee osteoarthritis
and low back pain
*Resistance exercises: isotonic concentric and eccentric strengthening of upper and lower limbs and trunk: bench press, lateral pull
down, biceps curl, knee extension and flexion, hip extension/flexion/abduction/adduction, leg press, back extension, and abdominal
flexion.

Q3. Can lifestyle intervention reduce the risk of osteoporosis?

Recommendation Quality of Category of

evidence recommendation
It is suggested that individuals who need to lose weight should engage in Low Do it
weight bearing exercise and calcium supplementation to ameliorate bone
loss that occurs with weight loss26
It is recommended that individuals need to stop smoking cigarettes and Low Do it
suggested to limit moderate alcohol consumption27

Q4. Are there any forms of exercise that can reduce the risk of fractures?

Recommendation Quality of Category of

evidence recommendation
Moderate levels of walking* is suggested to increase lumbar spine bone Low Do it
density and to lower the risk of hip fracture in postmenopausal
women24,28,29
*Moderate levels of walking: 24 METs/week (metabolic equivalents per week) or equivalent to 8 h/week of walking at an average pace.

Q5. Are there natural food supplements that could prevent bone loss?

Recommendation Quality of Category of

evidence recommendation
The use of natural food supplements like isoflavones at a minimum dose Moderate Do it
of 80 mg/day can be considered in preventing bone loss during the early
postmenopausal period30,31

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 Position statements on osteoporosis

Screening tools
Q6. What is/are the screening tool/s that clinicians can use to identify risk of individuals for osteoporosis?

Recommendation Quality of Category of

evidence recommendation
In areas where central dual x-ray absorptiometry (DXA) is unavailable, it Moderate Do it
is recommended that Osteoporosis Screening Tool for Asians (OSTA) be
used to identify an individual’s risk for osteoporosis (refer to Fig. 1)32

Q7. How soon should PMW undergo bone density test?

Recommendation Quality of Category of

evidence recommendation
All postmenopausal women with at least one WHO risk factor should High Do it
have fracture probability assessed using the Fracture Risk Assessment Tool
(FRAX) tool before undergoing central DXA33

It is not cost-effective to do general population screening, case finding strategies (with or without BMD) in the
clinics should focus on the clinical and non-clinical risk factors that are known to put a patient at risk for osteo-
porosis and fragility fractures (refer to Tables 4–6). Considerations for secondary causes of osteoporosis that
warrant optional blood work-up should be pursued (refer to WHO list of secondary causes).

Diagnostic aspects
Q8. Should clinicians rely on radiograph in the diagnosis of osteoporosis?

Recommendation Quality of Category of

evidence recommendation
Spine radiograph without overt vertebral fractures should not be used in High Do it
the diagnosis of osteoporosis. However, in cases where incidental findings
of vertebral fractures are seen on radiographs, it is recommended that
thoracic and lumbar spine radiograph be done to document the presence
and extent of fracture/s or bone densitometry examination using VFA.34
Likewise, other causes of vertebral fractures should be ruled out.

Q9. What is the best way to assess vertebral fractures?

Recommendation Quality of Category of

evidence recommendation
In centers with densitometry capability, VFA using Genant’s visual semi- High Do it
quantitative method is recommended in the identification of vertebral
fractures (refer to Fig. 2)8
Remarks: Severity must be confirmed by morphometric measurement.

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J. Li-Yu et al.

Q10. How is osteoporosis diagnosed?

Recommendation Quality of Category of
evidence recommendation
It is recommended that diagnosis of osteoporosis be based on WHO High Do it
diagnostic classification criteria for bone mass using the dual energy x-ray
absorptiometry as the gold standard1 (refer to Table 7)
Presence of vertebral fractures on either radiograph or VFA examination High Do it
confirms clinical diagnosis of osteoporosis8,35

Q11. Can we use peripheral densitometry technologies and bone turnover markers in diagnosing osteoporo-
sis?

Recommendation Quality of Category of

evidence recommendation
Peripheral BMD technologies, such as quantitative ultrasound (QUS) and High Do it
CT scan (QCT), single X-ray absorptiometry done in sites like the
calcaneus, wrist, and metatarsals and bone turnover markers should not
be used in the diagnosis of osteoporosis. The T-scores generated from
these machines are not equivalent to the T-scores derived by DXA.
However, they can be used in fracture risk assessment
On the other hand, biochemical markers of bone turnover in clinical
practice can be used for assessing adherence to and effectiveness of
therapy8,36

Q12. What are the recommended sites for bone density measurement?

Recommendation Quality of Category of

evidence recommendation
It is recommended to measure bone density of femoral neck or total High Do it
femur and/or lumbar spine using the DXA. Bone density measurement of
the distal third of radius [33% (1/3) radius] can be recommended if
spine/hips cannot be evaluated8

Treatment options
Q13. When do we start treatment?

Recommendation Quality of Category of

evidence recommendation
Among those with BMD examination, it is recommended that treatment be
started if patient has:
a. vertebral compression fracture/s evident on VFA or confirmed High Do it
through radiograph (clinical osteoporosis);
b. BMD T-score of £ )2.5; High Do it

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 Position statements on osteoporosis

c. BMD T-score between )1 and )2.5 SD with any of the following:

c.1. history of previous fracture High Do it
c.2. secondary causes associated with high risk for fracture High Do it
c.3. 10-year probability of hip fracture ‡ 3% or any major osteo- Moderate Do it
porosis related fracture of ‡ 20% based on the FRAX estimates37
Among those without BMD measurement, it is suggested that treatment
be started if patient:
(i) belongs to the high risk category based on OSTA tool where central Low Do it
BMD cannot be done or not available
(ii) has a 10-year probability of hip fracture ‡ 3% or any major osteo- Moderate Do it
porosis related fracture of ‡ 20% based on the FRAX estimates37

Q14. Are calcium and vitamin D needed in patients with osteoporosis?

Recommendation Quality of Category of

evidence recommendation
Vitamin D or its analogue, in combination with calcium is used as High Do it
mandatory adjunct with pharmacological therapies for patients with
osteoporosis.21 Calcium supplement or Vitamin D and its analogues alone
are neither recommended to increase bone density nor to reduce risk of
fractures20

Q15. What are the treatment options available for low to intermediate risk PMW?

Recommendation Quality of Category of

evidence recommendation
It is recommended that low to intermediate risk PMW be given High Do it
pharmacologic options (e.g. bisphosphonates,38–45 selective estrogen
receptor modulator,46,47 strontium ranelate,48,49 hormonal replacement
therapy,50 calcitonin,51,52 or tibolone53 to increase BMD or reduce fracture
risks (refer to Table 8 for the grade of recommendation of each drug to
site-specific outcome and known adverse effects)

Osteoporosis related fragility fractures

(This part of the guideline aims to assist the orthopedic surgeons as the stakeholder as well).
When should one suspect osteoporosis related fragility fracture?
Definition: Fragility fracture is defined as a fracture that occurs spontaneously or following a minor trauma,
such as fall from standing height; a fall from sitting position; a fall from laying down on a bed or reclining deck
chair from less than a meter high; a fall after having missed 1–3 steps in a staircase; a fall after a movement from
outside of the typical plane of motion; or coughing.4
What are the basic work-up as part of assessment in a patient suspected to have fragility fracture?
A thorough history including the circumstances behind the fracture and a complete medical with drug history
as well as a focused physical examination should foremost be done. Radiograph needs to be performed to confirm
the presence and exact character of the fracture. In the interim before appropriate surgical therapy is rendered, sug-
gested basic laboratory parameters include complete blood count, hepatic and renal function tests, total calcium,
and 25(OH)D (vitamin D) assay. Considerations for secondary causes of osteoporosis that warrant optional blood
work-up should be pursued.

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J. Li-Yu et al.

Q16. Are there non-pharmacologic preventive measures that can be recommended to avoid falls or fragility
fractures?

Recommendation Quality of Category of

evidence recommendation
Other than exercise, provision of hip protectors can be considered to Low Probably do it
reduce incidence of hip fractures. However, acceptance and adherence by
the stakeholders are determinants of its maximal efficacy54

Q17. Can a special nutrition or diet improve functional outcome of high risk patients?

Recommendation Quality of Category of

evidence recommendation
Nutritional supplement to all elderly hip fracture patients is suggested on Low Probably do it
a case-to-case basis. Though providing supplements may decrease
complications during hospitalization, there’s paucity of data to confirm
any difference in improving functional recovery or reduction in
fracture-related mortality55–57

Q18. Can a special nutrition or diet decrease future fracture risk in high-risk patients? (no data).

Q19. What form of exercise should be recommended among the high risk individuals to increase their bone
mass and decrease risk for future fracture?

Recommendation Quality of Category of

evidence recommendation
It is suggested that exercise be encouraged among both the housebound Low Do it
elderly and those in the community due to its benefit on balance and
indirectly on fracture prevention58
A 3· a week, 6 month Tai Chi Chuan exercise program can be considered in
enhancing an individual’s balance and prevention of fall

Q20. What are the recommended treatment options to increase bone mass and decrease future fracture risk
among high risk group?

Recommendation Quality of Category of

evidence recommendation
It is recommended that high risk PMW be given pharmacologic options High Do it
(e.g. bisphosphonates, selective estrogen receptor modulator, hormonal
replacement therapy, calcitonin, tibolone, parathyroid hormone,59–61
strontium ranelate62–64 to increase BMD or reduce fracture risks. (refer to
Table 9 for the grade of recommendation of each drug to site-specific
outcome)

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 Position statements on osteoporosis

Q21. Is there a role for combination therapy or sequential therapy among high risk group?

Recommendation Quality of Category of

evidence recommendation
It is not routinely recommended to give combination65,66 or sequential Moderate Probably do it
therapy67–69 of antiresorptive and bone forming agents to increase bone
mass and/or reduce fracture risk.

The key issues for the succeeding part of the guidelines (Q22–25) were critically appraised by experts from the
Philippine Orthopedic Association (POA).
Q22. What specific surgical options will yield a better result in femoral neck fractures?

Recommendation Quality of Category of

evidence recommendation
It is recommended that for displaced femoral neck fracture, arthroplasty High Do it
be performed as compared to internal fixation in order to achieve better
result70,71

Q23. What specific surgical options will provide a better result in extracapsular hip fractures – fixation or
arthroplasty?

Recommendation Quality of Category of

evidence recommendation
It is recommended that extracapsular hip fractures be treated in Moderate Do it
accordance to what the surgeon chooses to be the most appropriate, either
arthroplasty or internal fixation72–75

Q24. What specific implant would provide a better result in extracapsular hip fractures – intramedullary or ex-
tramedullary devices?

Recommendation Quality of Category of

evidence recommendation
It is recommended that in extracapsular trochanteric fractures, a sliding Moderate Do it
hip screw be used instead of intramedullary devices to prevent complica-
tions72–75

Q25. What other benefits of bisphosphonates are considered in patients with fragility fractures?

Recommendation Quality of Category of

evidence recommendation
a. It is recommended that bisphosphonates be given to patients with distal Moderate Do it
radial and ankle fractures to prevent disuse osteoporosis76
b. It is recommended that alendronate be given to patients undergoing Moderate Do it
hip arthroplasty for fragility hip fractures in order to reduce early
periprosthetic bone loss77

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J. Li-Yu et al.

Table 1 2002 Food and nutrition research institute of the Table 3 Food tips
Philippines (FNRI) recommended energy and nutrients
Food based solutions are preferable to help ensure a
intake (RENI)
balanced diet and good eating habits
Population group Reference RNI mg/day RNI lg/day Two glasses of high calcium milk each day is a guaranteed
weight (kg) calcium vitamin D* way to meet all your calcium requirements. In addition,
milk provides large amounts of phosphorus and
Infants, month
components such as lactose and casein phosphopeptides
Birth – <6 6 200 5
which may enhance calcium absorption
6–12 9 400 5
Some fortified milks also supply adequate amounts of
Children, years
vitamin D, zinc, and magnesium for optimal bone health
1–3 13 500 5
Other sources of calcium include green leafy vegetables and
4–6 19 550 5
soy products, although calcium is less well absorbed from
7–9 24 700 5
these sources
Male, years
Eat green vegetables cooked, rather than raw, to boost their
10–18 1000 5
calcium content. Cooking releases some of the calcium
19–49 59 750 5
that’s bound to a compound called oxalic acid
50–64 59 750 10
Don’t take iron supplements with calcium-rich foods, since
‡65 and over 59 800 15
these minerals compete for absorption
Female, years
Drink tea and coffee between, rather than during meals.
10–18 1000 5
Natural compounds in these beverages inhibit calcium
19–49 51 750 5
absorption
‡50 and over 51 800 10–15
Pregnant 800 5
Lactating 750 5 Table 4 WHO clinical risk factors for osteoporosis
*5 lg of vitamin D is equivalent to 200 IU vitamin D. Low body mass index
Previous fragility fracture
Parental history of hip fracture
Glucocorticoid treatment
Current smoking
Alcohol intake (at least 3 units/day)
Rheumatoid arthritis
Table 2 Food sources Other secondary causes of osteoporosis, i.e. chronic renal
disease, liver disease, malabsorption, Crohn’s disease,
Calcium:
hypogonadism, hyperparathyroidism, hyperthyroidism,
The main source of dietary Ca in industrialized societies is
Cushing’s disease, chronic obstructive pulmonary disease,
milk which contains  1150 mg ca/L. Other good sources
organ transplantation, androgen deprivation therapy,
of calcium include milk products except butter and cream,
anorexia nervosa, malignancies
sardines, salmon, shellfish (oysters, tulya), dried dilis, green
vegetables that do not contain much phytates and oxalates
like mustasa, malunggay, petsay, saluyot, and gabi leaves Table 5 Other potentially modifiable risk factors for
calcium set tofu, some legumes, canned fish, seeds, nuts, osteoporosis
and fortified food products. Breads and cereals, although
relatively low in calcium, contribute significantly to total Sedentary lifestyle and prolonged immobilization
calcium intake because of the frequency of consumption. Poor health or frailty
Fish and other seafoods contain more calcium than pork, Low calcium intake
beef, or chicken. Excess drugs, i.e. thyroid replacement hormone,
Vitamin D: anticonvulsant, anticoagulant, corticosteroids (equivalent
Dietary vitamin D is provided by foods of animal origin to ‡ 7.5 mg daily for > 6 months)
especially beef, liver, veal, eggs, dairy products such as milk,
cheese, and butter, and some salt-water fish including
Table 6 Other risk factors independent of BMD for fractures
herring, salmon, and sardines. Selected foods such as milk
and margarine are usually the vehicle used for vitamin D Recurrent falls
fortification. Dietary vitamin D is a stable compound and is Poor balance and weak quadriceps muscle strength
not easily lost through cooking, storage, or other processing Impaired eyesight
methods. Environmental factors, i.e. slippery floors, poor lighting

232 International Journal of Rheumatic Diseases 2011; 14: 223–238

 Position statements on osteoporosis

Table 7 World Health Organization (WHO) diagnostic classification of bone density

BMD T-score Definition
‡ )1 SD Normal
Between )1 and )2.5 SD Low bone mass
£ )2.5 Osteoporosis
£ )2.5 and ‡ 1 fragility Severe (or established)
fracture/s osteoporosis

Table 8 Grade of recommendation on drug options in LOW to MODERATE risk PMW

Drug Inc BMD VFx reduction NVFx reduction HFx reduction Adverse effects
HRT A A A – Breast cancer, stroke, venous
thromboembolism, stroke,
coronary artery disease
Raloxifene A A – – Thromboembolic events,
vasomotor symptoms
Tibolone A A A – Stroke, gynecologic events
Alendronate A A A A Upper gastrointestinal events;
Risedronate A A A A transient flu-like sxs,
Ibandronate A A – – osteonecrosis of the jaw, atrial
fibrillation (AF)
Zoledronate A A – – AF, transient flu-like sxs
Calcitonin A – – – Nasal irritation
Parathyroid hormone No data No data No data No data Muscle cramps, hypercalcemia
Strontium ranelate A A A A Diarrhea
Calcium alone – – – No data
Vitamin D alone – – – –
–, No benefit demonstrated.

Table 9 Grade of recommendation on drug options in HIGH risk PMW

Drug Inc BMD VFx NVFx HFx New VFxs Multiple VFXs
reduction reduction reduction reduction reduction
HRT A A A B A –
Raloxifene A A – – – –
Tibolone A A A – A No data
Alendronate A A A A A A
Risedronate A A A A A A
Ibandronate A A A A A –
Zoledronate A A A A A A
Calcitonin A – – – A –
Parathyroid hormone A A A – A A
Strontium ranelate A A A A A A
Calcium/Vitamin D – – – A – –
Alphacalcidol – – – A – –
–, No benefit demonstrated.

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J. Li-Yu et al.

Weight 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94
(kg) 88–98 99–109 110–119 120–130 131–141 142–152 153–164 165–174 175–185 186–196 197–208
(lbs)
Age
40–44
45–49
50–54
55–59 LOW
60–64
65–69
70–74
75–79 MEDIUM
80–84
85–89 HIGH
90–94
95–99

Koh LKH, Sedine WB, Torralba TP et al A simple tool to identify Asian women at increased risk of osteoporosis Figure 1 Osteoporosis Screening Tool
Osteoporosis International 2001; 12:699-705 for Asians (OSTA).

Figure 2 Genant’s classification of ver-

tebral fractures.

should prevail over the clinician’s best clinical judg-

DISCUSSION
Incidence of osteoporosis as population ages is
expected to inflate in the coming decades. The enor-
mity of the socio-economic burden poses a great
challenge to medical practitioners. Maximal utiliza-
tion of healthcare resources will be inevitable. Cost-
effective and efficient measures to address osteoporo-
sis and its complications need to be drawn. This is
the first published guidelines that focused on both
medical and surgical facets of osteoporosis and fra-
gility fracture. Being such, all stakeholders are
encouraged to use them when sharing the same ide-
als of providing optimal care to individuals afflicted
with the condition. The above set of statements
should not be misconstrued as stringent rules that
ment. A reappraisal of evidence within the next
3 years will be done as new evidence are published
and reported.
ACKNOWLEDGMENT
This project was fully supported through a research
grant by OSPFI.
CONFLICT OF INTEREST
J Li-Yu serves as clinical trialist for Merck Sharp and
Dohme (MSD) and key opinion leader for Servier; E
Perez and R Martinez serve as key opinion leaders for
MSD. Others have nothing to declare.

234 International Journal of Rheumatic Diseases 2011; 14: 223–238


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APPENDIX
Other members of the technical review
committee
Dela Rosa M, Osteoporosis Society of the Philippines
Foundation, Inc. (OSPFI).
Fojas M, Philippine Society of Endocrine and
Metabolism (PSEM).
Habana A, Philippine Obstetrics and Gynecology
Society (POGS).
Sumpio J, Nutrition Dietician Association of the
Philippines (NDAP).
237
J. Li-Yu et al.
Tomacruz R, Philippine Obstetrics and Gynecology
Society (POGS).
Trinidad T, Food and Nutrition Research Institute of
the Philippines (FNRI).
Vista E, Philippine Rheumatology Association
(PRA).
Panel members
The following served as panel members during the en
banc meeting: Prof. LB Mercado-Asis and Dr. A Pineda
Jr for OSPFI, Dr. A Cañete for POA, Dr. C Jimeno for
PSEM/Philippine College of Physicians (PCP), Ms.
238
E Feliciano for Nutrition and Dietitian Association of
the Philippines (NDAP), Dr. C Arroyo for PRA,
Dr. MC Quevedo for PSCM, Dr. DD Decena for
POGS, Dr. R Sarmiento for PARM, Dr. T Bautista
for Phil. Academy of Family Physicians (PAFP), Dr. L
Jiloca for Phil Society of Geriatric Medicine (PSGM),
Ms. L Arguilla for Phil. Society of Hospital Pharmacists
(PSHP), Dr. C Bautista for Philippine Health Insur-
ance Corporation (PHIC), RZ Umali, patient with
osteoporosis, and HP Quemada, patient with osteopo-
rosis-related fragility fracture.
International Journal of Rheumatic Diseases 2011; 14: 223–238