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Archives of Osteoporosis
Published in: Archives of Osteoporosis 1/2023

01-12-2023 | Osteoporosis | Original Article

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management—a Pakistani context

Authors: Sarah Nadeem, Alina Pervez, Muhammad Abbas Abid, Rehab Naeem Khalid, Nashia Ali Rizvi, Salima Saleem Aamdani, Bushra Ayub, Mohsin Ali Mustafa, Sibtain Ahmed, Mehmood Riaz, Khadija Irfan, Shahryar Noordin, Lena Jafri, Hafsa Majid, Masood Umer, Nawazish Zehra, Aisha Sheikh, Adil H. Haider, Aysha Habib Khan

Published in: Archives of Osteoporosis | Issue 1/2023

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Abstract

Summary

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000–4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.

Purpose

Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.

Methods

The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)—clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2020 update from American Association of Clinical Endocrinology (AACE).

Results

The SG was “adoloped” to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000–4000 IU of vitamin D in patients with obesity, malabsorption, and old age.

Conclusion

The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000–4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.
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Literature
1.
Lorentzon M, Johansson H, Harvey NC, Liu E, Vandenput L, McCloskey EV, Kanis JA (2022) Osteoporosis and fractures in women: the burden of disease. Climacteric 25:4–10CrossRefPubMed
2.
3.
Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY (2013) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 24:23–57CrossRefPubMed
4.
Anupama D, Noronha J, Acharya K, Prabhu M, Shetty J, Shankar R, Nayak B (2022) Burden of osteopenia and osteoporosis among postmenopausal women in India: a systematic review and meta-analysis. J Mid-life Health 13:107–114CrossRef
5.
Handa R, Ali Kalla A, Maalouf G (2008) Osteoporosis in developing countries. Best Pract Res Clin Rheumatol 22:693–708CrossRefPubMed
6.
Keramat A, Patwardhan B, Larijani B, Chopra A, Mithal A, Chakravarty D, Adibi H, Khosravi A (2008) The assessment of osteoporosis risk factors in Iranian women compared with Indian women. BMC Musculoskelet Disord 9:28CrossRefPubMedPubMedCentral
7.
Camacho PM, Petak SM, Binkley N et al (2020) American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2020 update. Endocr Pract 26:1–46CrossRefPubMed
8.
Chandran M, Mitchell PJ, Amphansap T et al (2021) Development of the Asia Pacific Consortium on Osteoporosis (APCO) framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region. Osteoporos Int 32:1249–1275CrossRefPubMedPubMedCentral
9.
Khan AH, Jafri L, Ahmed S, Noordin S (2018) Osteoporosis and its perspective in Pakistan: a review of evidence and issues for addressing fragility fractures. Ann Med Surg (Lond) 29:19–25CrossRefPubMed
10.
Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA (2000) Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am 82:1063–1070CrossRefPubMed
11.
12.
13.
Chan SP YS, Lee EGM, Chee W, Hew FL, Lee JK, Lim HH, Damodaran P, Mumtaz M (2015) Clinical guidance on management of osteoporosis, 2nd edn. Malaysian Osteoporosis Society, Academy of Medicine & Ministry of Health, Malaysia, Petaling Jaya
14.
Li-Yu J, Perez E, Cañete A, Bonifacio L, Llamado L, Martinez R (2011) Osteoporosis Society of Philippines Foundation, Inc. (OSPFI); Philippine Orthopedic Association (POA) Clinical Practice Guidelines Task Force Committee on Osteoporosis. Consensus statements on osteoporosis diagnosis, prevention, and management in the Philippines. Int J Rheum Dis 14:223–238CrossRefPubMed
15.
Schünemann HJ, Wiercioch W, Brozek J et al (2017) GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol 81:101–110CrossRefPubMed
16.
17.
Johansson H, Naureen G, Iqbal R et al (2022) FRAX-based intervention thresholds for Pakistan. Osteoporos Int 33:105–112CrossRefPubMed
18.
19.
Bordelon P, Ghetu MV, Langan RC (2009) Recognition and management of vitamin D deficiency. Am Fam Physician 80:841–846PubMed
20.
Riaz H, Finlayson AE, Bashir S, Hussain S, Mahmood S, Malik F, Godman B (2016) Prevalence of vitamin D deficiency in Pakistan and implications for the future. Expert Rev Clin Pharmacol 9:329–338CrossRefPubMed
21.
Akhtar S, Jan R (2013) Prevalence of vitamin D inadequacy among postmenopausal women. Medical Forum Monthly 24:96–99
22.
Shamsi U, Azam I, Shamsi A, Shamsi D, Callen D (2021) Frequency and determinants of vitamin D deficiency among premenopausal and postmenopausal women in Karachi Pakistan. BMC Womens Health 21:194CrossRefPubMedPubMedCentral
23.
Habiba U, Ahmad S, Hassan L (2002) Predisposition to osteoporosis in postmenopausal women. J-Coll Phys Surg Pak 12:297–301
24.
Carmel AS, Shieh A, Bang H, Bockman RS (2012) The 25(OH)D level needed to maintain a favorable bisphosphonate response is ≥33 ng/ml. Osteoporos Int 23:2479–2487CrossRefPubMedPubMedCentral
25.
Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B (2004) Positive association between 25-hydroxy vitamin D levels and bone mineral density: a population-based study of younger and older adults. Am J Med 116:634–639CrossRefPubMed
26.
Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM (2011) Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 96:1911–1930CrossRefPubMed
27.
Kalra S, Aggarwal S (2015) Vitamin D deficiency: diagnosis and patient centred management. J Pak Med Assoc 65:569–573PubMed
28.
Bischoff-Ferrari HA, Dawson-Hughes B, Orav EJ, Staehelin HB, Meyer OW, Theiler R, Dick W, Willett WC, Egli A (2016) Monthly high-dose vitamin D treatment for the prevention of functional decline: a randomized clinical trial. JAMA Intern Med 176:175–183CrossRefPubMed
29.
30.
Khan MN, Masood MQ, Siddiqui MA, Naz S, Islam N (2017) Vitamin-D toxicity and other non-malignant causes of hypercalcemia: a retrospective study at a tertiary care hospital in Pakistan. J Ayub Med Coll Abbottabad 29:436–440PubMed
31.
Masood MQ, Khan A, Awan S, Dar F, Naz S, Naureen G, Saghir S, Jabbar A (2015) Comparison of vitamin d replacement strategies with high-dose intramuscular or oral cholecalciferol: a prospective intervention study. Endocr Pract 21:1125–1133CrossRefPubMed
32.
Muneer S, Siddiqui I, Majid H, Zehra N, Jafri L, Khan AH (2022) Practices of vitamin D supplementation leading to vitamin D toxicity: experience from a low-middle income country. Ann Med Surg (Lond) 73:103227PubMed
33.
Khan AH (2018) Seven decades of vitamin D research in Pakistan: too little, too much or just right! J Pak Med Assoc 68:1742–1743PubMed
34.
Tariq A, Khan SR, Basharat A (2020) Assessment of knowledge, attitudes and practice towards vitamin D among university students in Pakistan. BMC Public Health 20:355CrossRefPubMedPubMedCentral
35.
Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B (2005) Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 293:2257–2264CrossRefPubMed
36.
Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B (2006) Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-year randomized controlled trial. Arch Intern Med 166:424–430PubMed
37.
Broe KE, Chen TC, Weinberg J, Bischoff-Ferrari HA, Holick MF, Kiel DP (2007) A higher dose of vitamin d reduces the risk of falls in nursing home residents: a randomized, multiple-dose study. J Am Geriatr Soc 55:234–239CrossRefPubMed
38.
39.
Hussain T, Eimal Latif AH, Malik S et al (2021) Vitamin D deficiency and associated risk factors in Muslim housewives of Quetta, Pakistan: a cross-sectional study. Cureus 13:e17643PubMedPubMedCentral
40.
Holick MF, Siris ES, Binkley N, Beard MK, Khan A, Katzer JT, Petruschke RA, Chen E, de Papp AE (2005) Prevalence of vitamin D inadequacy among postmenopausal North American women receiving osteoporosis therapy. J Clin Endocrinol Metab 90:3215–3224CrossRefPubMed
41.
Jackson RD, LaCroix AZ, Gass M et al (2006) Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med 354:669–683CrossRefPubMed
42.
Wadoo O, Ouanes S, Ahmed MAS, Saeid ISA, AlAbdulla SA, AlAbdulla M (2021) Improving referrals from primary care to secondary mental health services through an educational intervention: experience from Qatar. BJPsych Int 18:70–74CrossRefPubMedPubMedCentral
43.
LeBoff MS, Murata EM, Cook NR, Cawthon P, Chou SH, Kotler G, Bubes V, Buring JE, Manson JE (2020) VITamin D and OmegA-3 TriaL (VITAL): effects of vitamin D supplements on risk of falls in the US population. J Clin Endocrinol Metab 105:2929–2938CrossRefPubMedPubMedCentral
44.
45.
Abid MA, Majid H, Khan AH (2020) Vitamin-D supplementation in COVID-19: existing evidence and gap in literature. RCT 36:40
46.
Institute of Medicine Committee on standards for developing trustworthy clinical practice G (2011) In Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E (eds) Clinical practice guidelines we can trust. National Academies Press (US) Copyright 2011 by the National Academy of Sciences. All rights reserved., Washington (DC)
Metadata
Title
GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management—a Pakistani context
Authors
Sarah Nadeem
Alina Pervez
Muhammad Abbas Abid
Rehab Naeem Khalid
Nashia Ali Rizvi
Salima Saleem Aamdani
Bushra Ayub
Mohsin Ali Mustafa
Sibtain Ahmed
Mehmood Riaz
Khadija Irfan
Shahryar Noordin
Lena Jafri
Hafsa Majid
Masood Umer
Nawazish Zehra
Aisha Sheikh
Adil H. Haider
Aysha Habib Khan
Publication date
01-12-2023
Publisher
Springer London
Published in
Archives of Osteoporosis / Issue 1/2023
Print ISSN: 1862-3522
Electronic ISSN: 1862-3514
DOI
https://doi.org/10.1007/s11657-023-01258-2

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