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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">The present study is a summary of the clinical practice guidelines on postmenopausal&#44; glucocorticoid and male osteoporosis of the Spanish Society for Research on Bone and Mineral Metabolism &#40;SEIOMM&#41;&#44; performed using the methodology of evidence-based medicine&#46; This study focuses particular attention on the problems of treating osteoporosis that have arisen in recent years&#44; such as so-called therapeutic holidays&#44; sequential treatment&#44; controlling the therapeutic response and risk fracture assessment&#46; The levels of evidence reached have been translated into grades of recommendation and are summarized in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; The complete version is freely available at the SEIOMM website &#40;<a href="http://www.seiomm.org/">www&#46;seiomm&#46;org</a>&#41;&#46; All committee members have expressly declared any potential conflicts of interest in the preparation of the guide&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Risk factors for fracture</span><p id="par0010" class="elsevierStylePara elsevierViewall">There are numerous factors related to the risk of bone fractures&#46; The main risk factors are sex&#44; age&#44; bone mineral density &#40;BMD&#41;&#44; a personal history of fracture due to frailty&#44; a first-degree family history of fracture due to frailty and low body weight &#40;body mass index &#91;BMI&#93;<span class="elsevierStyleHsp" style=""></span>&#60;20<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Other known risk factors are various diseases and treatments &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion</span>&#58; Clinical assessment combined with BMD measurement is an effective method for assessing the risk of fracture &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Bone densitometry</span><p id="par0020" class="elsevierStylePara elsevierViewall">Among the various techniques available&#44; dual energy X-ray absorptiometry &#40;DXA&#41;&#44; which measures BMD&#44; is the commonly used procedure for determining the risk of fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">3</span></a> The results are expressed in terms of T-score&#44; which is the number of standard deviations &#40;SD&#41; by which the BMD value differs from that of the healthy youth population &#40;20&#8211;29 years&#41;&#46; The World Health Organization &#40;WHO&#41; has stated that a diagnosis of osteoporosis should be made when BMD is &#8804;&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">4&#44;5</span></a> The WHO later clarified that this value should correspond to a measurement performed in the femoral neck and using the NHANES III study as reference&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">6</span></a> The International Society for Clinical Densitometry&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">7</span></a> however&#44; considers that the diagnosis can be established when this value of &#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T is found in any of the following three locations&#58; lumbar spine&#44; total hip or femoral neck&#46; The WHO also defined the conditions of normality&#44; osteopenia &#40;low bone mass&#41; and established or severe osteoporosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> The measurement of BMD in the proximal femur and lumbar spine using DXA is a useful test for assessing the risk of fracture &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Bone remodeling markers</span><p id="par0030" class="elsevierStylePara elsevierViewall">Bone remodeling markers provide information on bone turnover dynamics&#46; Bone formation markers include osteocalcin&#44; bone alkaline phosphatase and type <span class="elsevierStyleSmallCaps">I</span> procollagen carboxy-terminal and amino-terminal propeptides &#40;PICP and P1NP&#41;&#46; Bone resorption markers include type <span class="elsevierStyleSmallCaps">I</span> collagen carboxy-terminal and amino-terminal telopeptides &#40;CTX in blood and urine&#44; and NTX in urine&#41; and tartrate-resistant acid phosphatase 5b &#40;TRACP 5b&#41;&#46; Various international organizations such as the International Federation of Clinical Chemistry have recommended the use of P1NP &#40;formation&#41; and s-CTX &#40;resorption&#41; for clinical studies&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Bone markers are not useful for diagnosing osteoporosis&#44; although they do help assess the risk of fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">9</span></a> Their change with treatment is useful for assessing the response to the treatment &#40;level of evidence 2a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">10</span></a> The change should be greater than the value of the so-called minimum significant change&#44; calculated at 20&#8211;25&#37; for P1NP&#44; 30&#37; for CTX and 37&#8211;54&#37; for NTX&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Systematic measurement of bone markers to diagnose patients with osteoporosis is not recommended but can be helpful in managing the therapeutic response &#40;grade B recommendation&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conventional radiology</span><p id="par0045" class="elsevierStylePara elsevierViewall">Conventional radiology is not a sensitive or specific method for assessing changes in bone mass&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">5</span></a> However&#44; the procedure is essential for identifying fractures&#46; For the vertebrae&#44; the diagnosis requires a reduction of at least 20&#8211;25&#37; in vertebral body height &#40;see the Genant method<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">11</span></a> in the complete version of the guidelines&#41;&#46; Slight reductions can be confused with deformities of other origins &#40;osteoarthritis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Conventional radiology should be indicated to detect vertebral fractures but should not be used as a method for assessing bone mass for the diagnosis of osteoporosis &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Study protocol</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study of female patients with osteoporosis should include a hemogram and a reading of elementary biochemical parameters&#46; It is advisable to measure 25-hydroxy vitamin D &#40;25OHD&#41; and thyrotropin levels and perform a proteinogram&#46; It is useful to quantify 24<span class="elsevierStyleHsp" style=""></span>h urinary calcium &#40;hypocalciuria indicates a lack of supply or malabsorption&#59; hypercalciuria contraindicates the administration of calcium&#41;&#46; The advisability of measuring parathyroid hormone &#40;PTH&#41; levels and bone remodeling markers is debated&#46; Patients should undergo both a BMD measurement and spinal radiography&#46; If specific diseases are suspected as the cause of the osteoporosis &#40;e&#46;g&#46;&#44; hypercortisolism&#44; celiac disease&#41;&#44; appropriate studies should be performed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Risk prediction tools</span><p id="par0060" class="elsevierStylePara elsevierViewall">Various scales have been developed to assess the risk of experiencing densitometric osteoporosis and osteoporotic fractures&#46; The scales for assessing the risk of densitometric osteoporosis do not include BMD&#44; although the tools are useful for deciding when to perform this test&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">13</span></a> These tools have similar abilities to predict low BMD&#46; The easiest of the tools &#40;the Osteoporosis Self-Assessment Tool &#91;OST&#93;&#41;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">14&#44;15</span></a> includes only age and weight&#44; factors present in all of the other tools&#46; To directly assess the risk of fractures&#44; other tools have been developed&#44; such as the Fracture Risk Assessment Tool &#40;FRAX&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">16</span></a> the Garvan Medical Research Institute tool<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">17</span></a> and the QFracture Index&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">18</span></a> The three tools have similar discriminatory capacity and offer moderate performance&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">19&#44;20</span></a> FRAX is also designed to decide when to perform a BMD reading&#46; Unfortunately&#44; its adaptation to Spain has been inadequate<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">21</span></a> and it should therefore not be used&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Therapeutic decision</span><p id="par0065" class="elsevierStylePara elsevierViewall">There is no one international consensus as to when treatment should start for osteoporosis&#46; SEIOMM considers that the following female patients should be treated&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Those who have a fracture due to frailty or a BMD<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T in the lumbar spine&#44; femoral neck or total hip&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Those with osteopenia &#40;particularly if the T is &#8804;&#8722;2&#46;0&#41; who also have factors strongly associated with a risk of fracture &#40;e&#46;g&#46;&#44; hypogonadism&#44; BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#44; a family history of fractures&#44; smoking and alcoholism&#44; rheumatoid arthritis&#44; type I diabetes and certain treatments such as antiestrogens&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Those on glucocorticoid therapy&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Regardless of the previously mentioned standards&#44; SEIOMM states that there are three conditions in which treatment is at the discretion of each physician&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Young women &#40;50&#8211;60 years&#41; with T values &#60;&#8722;3<span class="elsevierStyleHsp" style=""></span>T&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Young women with distal radius fractures who have some other risk factor&#44; especially if there are questions concerning the intensity of the trauma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Women with grade 1 vertebral deformities&#44; which are not always easy to interpret as fractures&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Performing densitometry</span><p id="par0105" class="elsevierStylePara elsevierViewall">There are no universally accepted criteria for its indication&#46; The procedure should be considered when there are risk factors strongly associated with osteoporosis or fractures&#46; FRAX is employed in other countries for this purpose&#44; but the inadequate Spanish version precludes its use in Spain and&#44; in any case&#44; records a low number of factors&#46; The criteria list is very long&#46; We therefore establish only a general classification&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Diseases and treatments frequently associated with osteoporosis &#40;e&#46;g&#46;&#44; rheumatoid arthritis&#44; early menopause&#44; hyperparathyroidism&#44; corticosteroids&#44; antiestrogens&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Diseases whose association with osteoporosis or osteoporotic fracture depends on their severity &#40;e&#46;g&#46;&#44; type 1 diabetes and poorly controlled hyperthyroidism&#44; malabsorption&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Other criteria&#44; especially if 2 of them are met&#58; age &#62;65 years&#44; BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hereditary component&#44; alcoholism&#47;smoking&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Nonpharmacological interventions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Patients should be advised to engage in physical activity&#44; stop smoking and avoid excessive alcohol consumption&#46; Preventing falls is important&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Calcium and vitamin D</span><p id="par0130" class="elsevierStylePara elsevierViewall">Patients treated with antiresorptive or anabolic drugs should take an appropriate amount of calcium and vitamin D &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">22&#8211;26</span></a> Serum 25OHD levels should be above 20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and preferably above 30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">27&#44;28</span></a> The recommended daily dose of vitamin D is 800&#8211;1000<span class="elsevierStyleHsp" style=""></span>IU&#47;d &#40;its fortnightly or monthly equivalent may also be administered&#41;&#46; The administration of large quantities of vitamin D in a single dose is not recommended &#40;e&#46;g&#46;&#44; 500&#44;000<span class="elsevierStyleHsp" style=""></span>IU&#47;year<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">29</span></a>&#41;&#46; In terms of calcium&#44; the daily intake should be 1000&#8211;1200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; Achieving this amount through diet is preferable&#59; however&#44; if this is not possible&#44; supplements should be added&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Calcitonin</span><p id="par0135" class="elsevierStylePara elsevierViewall">Its extended use is associated with an increased risk of cancer and is therefore not recommended&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Thiazides</span><p id="par0140" class="elsevierStylePara elsevierViewall">There are no data justifying their use in treating osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">30</span></a> Their use may be considered in patients with hypercalciuria&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Estrogen therapy</span><p id="par0145" class="elsevierStylePara elsevierViewall">Effective in preventing osteoporotic fractures &#40;level of evidence 2a&#41;&#46; Its secondary effects have meant that it is not recommended for osteoporosis&#44; except for women with a high risk of fracture who have no other therapeutic option&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">31&#44;32</span></a> For women who are treated with estrogens due to presenting a climacteric syndrome&#44; estrogens may be considered appropriate for treating the osteoporosis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Estrogen therapy is not recommended for treating postmenopausal osteoporosis &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Selective estrogen receptor modulators</span><p id="par0155" class="elsevierStylePara elsevierViewall">Raloxifene<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">33</span></a> &#40;level of evidence 1a&#41; and bazedoxifene<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">34</span></a> &#40;level of evidence 2b&#41; are useful for reducing vertebral fractures &#40;by approximately 40&#37;&#41; but not nonvertebral fractures&#46; Its main complication is an increased risk of deep vein thrombosis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Selective estrogen receptor modulators &#40;SERMs&#41; are indicated for treating osteoporosis by reducing vertebral fractures &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Tibolone</span><p id="par0165" class="elsevierStylePara elsevierViewall">Tibolone reduces fractures &#40;level of evidence 1b&#41;&#44; but its use is not recommended due to the risk of stroke &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">35</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Phytoestrogens and isoflavones</span><p id="par0170" class="elsevierStylePara elsevierViewall">Isoflavones can have a favorable effect on BMD&#44; but they are not recommended for treating osteoporosis due to a lack of data on their efficacy in fractures &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bisphosphonates</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Etidronate</span><p id="par0175" class="elsevierStylePara elsevierViewall">Reduces vertebral fractures by approximately 40&#37; but not nonvertebral fractures &#40;level of evidence 1a&#41; &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">36</span></a> The drug has fallen into disuse&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Alendronate</span><p id="par0180" class="elsevierStylePara elsevierViewall">At a dosage of 70<span class="elsevierStyleHsp" style=""></span>mg&#47;week&#44; alendronate decreases vertebral&#44; nonvertebral and hip fractures by approximately 45&#37;&#44; 25&#8211;30&#37; and 45&#8211;55&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">37&#44;38</span></a> According to an extension study&#44; patients for whom treatment is discontinued after 5 years have a greater risk of clinical vertebral fractures in the following 5 years than those who continue with the treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">39&#44;40</span></a> The risk of fracture&#44; including nonvertebral&#44; increases with increasing age and lower BMD in the femoral neck when discontinuing treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">41</span></a> Alendronate is usually well tolerated&#44; with adverse effects<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">42</span></a> that have been reported with the other bisphosphonates in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; alendronate has a grade A recommendation for treating osteoporosis&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Risedronate</span><p id="par0190" class="elsevierStylePara elsevierViewall">Weekly doses of 35<span class="elsevierStyleHsp" style=""></span>mg decrease vertebral&#44; nonvertebral and hip fractures by approximately 40&#37;&#44; 20&#37; and 25&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">44</span></a> The administration of 75<span class="elsevierStyleHsp" style=""></span>mg for two consecutive days a month is also effective&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">45</span></a> Risedronate is well tolerated&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; risedronate has a grade A recommendation for treating osteoporosis&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ibandronate</span><p id="par0200" class="elsevierStylePara elsevierViewall">This drug may be administered orally once a month &#40;150<span class="elsevierStyleHsp" style=""></span>mg&#41; or every 3 months intravenously &#40;3<span class="elsevierStyleHsp" style=""></span>mg&#41;&#46; Ibandronate decreases the risk of vertebral fracture by approximately 60&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">46&#44;47</span></a> but does not decrease nonvertebral fractures &#40;level of evidence 1b&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Ibandronate has a grade A recommendation for reducing vertebral fractures&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Zoledronate</span><p id="par0210" class="elsevierStylePara elsevierViewall">At a dosage of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;y&#44; zoledronate decreases vertebral&#44; nonvertebral and hip fractures by approximately 70&#37;&#44; 25&#37; and 40&#37;&#44; respectively &#40;level of evidence 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">48</span></a> Women who&#44; after 3 years of treatment&#44; continued with the treatment for another 3 years have a vertebral fracture rate below 50&#37; compared with those who discontinued the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">49</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; risedronate has a grade A recommendation for treating osteoporosis&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Denosumab</span><p id="par0220" class="elsevierStylePara elsevierViewall">This drug decreases the risk of vertebral&#44; nonvertebral and hip fractures by 70&#37;&#44; 20&#37; and 40&#37;&#44; respectively &#40;level of evidence 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">50</span></a> A <span class="elsevierStyleItalic">post hoc</span> analysis indicated that its efficacy in reducing hip fractures was 62&#37; greater when used at an age older than 75 years<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">51</span></a> than when used below this age &#40;level of evidence 2b&#41;&#46; In the 24 months following the discontinuation of the drug&#44; a loss of the gained bone mass is observed&#44; with subsequent stabilization at baseline values<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">52</span></a> &#40;level of evidence 1b&#41;&#46; Discontinuation also causes an increase in bone turnover markers to values greater than baseline&#44; which subsequently return to normal&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">52</span></a> When administered to patients who have previously undergone treatment with alendronate&#44; an increase in the intensity of the antiresorptive effect is observed &#40;level of evidence 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">53</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Denosumab is generally well tolerated&#44; although a slight increase in the incidence of infections has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">54</span></a> Cases of maxillary osteonecrosis and atypical femoral fractures have been reported&#44; although the incidence rates have been low&#46; The drug may be administered to patients with renal failure&#44; but patients should be monitored for the possible onset of hypocalcemia &#40;ensure an appropriate supply of calcium and vitamin D&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; denosumab has a grade A recommendation for treating osteoporosis&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Strontium ranelate</span><p id="par0235" class="elsevierStylePara elsevierViewall">The drug reduces the incidence of vertebral and nonvertebral fractures by approximately 40&#37; and 16&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">55&#44;56</span></a> A <span class="elsevierStyleItalic">post hoc</span> analysis indicated that the drug reduces the incidence of hip fractures &#40;36&#37;&#41; in high-risk patients &#40;level of evidence 2b&#41;&#46; The drug markedly increases BMD&#59; however&#44; part of the increase &#40;up to 50&#37;&#41; is due to the absorption of radiation by the strontium deposited in the bone&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The drug occasionally causes severe skin reactions&#46; The drug increases the incidence of vascular problems&#44; both venous &#40;deep vein thrombosis&#41; and arterial &#40;myocardial infarction&#41;&#46; The latter of these conditions means that the drug&#39;s indication is limited to patients with severe osteoporosis for whom there is no other therapeutic alternative&#44; in the absence of poorly controlled arterial hypertension&#44; a history of ischemic heart disease&#44; peripheral arterial disease or cerebrovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">57</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Strontium ranelate is effective in reducing vertebral and nonvertebral fractures &#40;grade A recommendation&#41;&#44; but its use is restricted to patients with a high risk of fracture and with no risk of cardiovascular disease&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">PTH 1-34 &#40;teriparatide&#41;</span><p id="par0250" class="elsevierStylePara elsevierViewall">This drug decreases the risk of vertebral and nonvertebral fractures by 65&#37; and 50&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">58</span></a> This is the only available bone formation drug&#46; The drug has not been studied in trials designed to assess its effect on hip fractures&#46; It is administered in a daily subcutaneous injection for 2 years&#46; The benefits achieved with the drug decrease after its discontinuation if it is not followed by the administration of an antiresorptive drug &#40;level of evidence 2b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">59</span></a> Its tolerance is good&#46; PTH &#40;1-84&#41; is still not commercially available&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Teriparatide reduces fractures&#44; both vertebral and nonvertebral &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Vertebroplasty and kyphoplasty</span><p id="par0260" class="elsevierStylePara elsevierViewall">These procedures are not recommended for patients with asymptomatic vertebral fractures or mild pain or in those with more than 1 year of progression&#46; The procedures may be considered for patients with fractures of less than 6 weeks of progression and intense pain despite medical treatment and for those patients with fractures of 6 weeks to 1 year of progression and persistent pain that respond poorly to analgesics&#44; if they present edema in magnetic resonance imaging&#46; They can also be of use for patients who are contraindicated or have poor tolerance of analgesics&#46; Given the cost-benefit ratio&#44; vertebroplasty is generally preferable to kyphoplasty &#40;grade B recommendation&#41;&#46;</p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Managing the therapeutic response</span><p id="par0265" class="elsevierStylePara elsevierViewall">Changing the treatment due to a possible inadequate response may be considered in the following circumstances<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">60</span></a>&#58; &#40;a&#41; development of two successive fractures and &#40;b&#41; two of the following three factors coinciding&#58; development of a new fracture&#44; a reduction in BMD greater than the minimum significant change and a reduction in bone turnover markers lower than the minimum significant change &#40;grade D recommendation&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Before changing the therapy&#44; the following conditions should be considered as possible causes of the inadequate response&#58; &#40;a&#41; lack of vitamin D&#44; &#40;b&#41; secondary forms of osteoporosis&#44; &#40;c&#41; inadequate compliance&#44; &#40;d&#41; tendency to fall&#44; &#40;e&#41; defects in the measurement techniques&#44; both BMD and remodeling markers&#44; and &#40;f&#41; the presence of severe bone deterioration&#44; which leads to an expectation of new fractures even though the drug is still active&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Treatment duration &#40;grade D recommendation&#41;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Treatment should last as long as necessary to decrease the risk of fractures to acceptable levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">61&#8211;63</span></a> Although there is no one official definition of what is considered an acceptable level&#44; it has been suggested that a BMD<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T in patients with no fractures or &#62;&#8722;2<span class="elsevierStyleHsp" style=""></span>T in patients with 1 previous fracture &#40;more than 3&#8211;5 years&#41; could be an acceptable level&#46; If the fracture is recent &#40;less than 3&#8211;5 years&#41;&#44; the situation is considered at risk&#44; even if the BMD is above &#8722;2<span class="elsevierStyleHsp" style=""></span>T&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">The achievement of objectives should be assessed every 3&#8211;5 years&#46; If the goals are considered achieved&#44; the treatment may be discontinued in the manner as described later in this document&#46; Otherwise&#44; treatment should be continued&#46; In this case&#44; if a number of years have passed &#40;approx&#46; 6 for zoledronate and approx&#46; 10 for alendronate&#44; risedronate and denosumab&#41; and it is deemed advisable to change to a drug with a different mechanism of action due to the risk of developing an atypical femoral fracture then teriparatide or&#44; if necessary &#40;and possible&#41;&#44; strontium ranelate should be used&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">If the decision is made to discontinue treatment&#44; then the increased risk of fracture this entails should be taken into account&#46; This risk is small with bisphosphonates&#44; which remain bound to the bone and can therefore be discontinued&#44; leaving the patient untreated for a few years&#46; The discontinuation of denosumab is followed by increased bone turnover&#46; A mild antiresorptive agent &#40;a SERM or a single injection of a half dose of zoledronate&#41; should therefore be administered&#44; at least temporarily&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Change of drug due to apparent lack of response &#40;grade D recommendation&#41;</span><p id="par0290" class="elsevierStylePara elsevierViewall">If the reason for the change is an apparent lack of response&#44; it is advisable<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">60&#44;64</span></a> to &#40;a&#41; choose a drug that is considered to have a greater capacity to reduce fractures&#44; &#40;b&#41; change an antiresorptive agent for a bone formation agent or &#40;c&#41; change an oral drug for an injectable one&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Clinical decision algorithms</span><p id="par0295" class="elsevierStylePara elsevierViewall">The following therapeutic scenarios should be considered for selecting the drug &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0300" class="elsevierStylePara elsevierViewall">A patient with a high vertebral fracture risk &#40;equivalent to two or more vertebral fractures&#41;&#46; The recommended treatment is teriparatide for 24 months&#44; followed by a bisphosphonate or denosumab&#46; If one does not wish to use teriparatide&#44; one of the latter can be administered from the start&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0305" class="elsevierStylePara elsevierViewall">A young patient with a moderate risk of vertebral fracture and a low risk of hip fracture &#40;no history of fractures and densitometric osteoporosis values exclusively in the spine&#41;&#46; It is advisable to administer a SERM&#46; This recommendation is reinforced by reports of atypical hip fracture as a long-term complication of bisphosphonates and denosumab&#44; whose use should be delayed&#46; Additionally&#44; the use of a SERM overcomes problems related to dental manipulation&#46; Alternatively&#44; if one does not wish to use a SERM&#44; alendronate or risedronate may be administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">A patient with other risk conditions&#46; There are 4 drugs for this situation&#58; alendronate&#44; risedronate&#44; zoledronate and denosumab&#46; The first two are less expensive and are administered orally &#40;zoledronate&#44; although available as a generic&#44; costs more due to the need for intravenous administration&#41;&#46; The last two are administered by injection &#40;intravenous in the case of zoledronate and subcutaneously for denosumab&#41;&#46; The selection between the first two and the last two should be made based on the presence or absence of a number of factors that can be labeled as a whole as &#8220;restrictive factors for administering oral bisphosphonates&#44;&#8221; such as oral intolerance&#44; polypharmacy &#40;comorbidity&#41;&#44; lack of adherence or advanced age&#46; The fewer of these factors that are present&#44; the more advisable it is to use alendronate or risedronate&#59; the more of these factors that are present&#44; the more zoledronate or denosumab are advisable&#46; The presence of a high risk of hip fractures&#44; which is common in the elderly&#44; can be another reason for preferring denosumab&#44; which has been shown to be highly effective in preventing this fracture in those older than 75 years&#46; Other circumstances that make the selection of denosumab advisable are a lack of availability of an outpatient center and a GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#8211;35<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0315" class="elsevierStylePara elsevierViewall">As second-line drugs for all situations&#44; we have ibandronate&#44; strontium ranelate and SERMs&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Finally&#44; the concept of sequential treatment refers to conditions defined by predictable changes in the drug to be employed&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows a sequential treatment algorithm&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Male osteoporosis</span><p id="par0325" class="elsevierStylePara elsevierViewall">The available evidence concerning treatment for male osteoporosis is scarce&#46; The primary objective of most studies has been BMD&#46; The results for BMD in men are similar to those observed in women&#44; which leads us to believe that its efficacy is probably similar in terms of fractures&#46; For this reason&#44; it is worth establishing a drug strategy for men that is similar to that for women&#58; &#40;a&#41; risedronate<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">65&#44;66</span></a> or alendronate<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">67&#44;68</span></a> &#40;although the latter is not approved in Spain for treating male osteoporosis&#41; for patients with no restrictive criteria for oral administration&#44; according to the reports on postmenopausal osteoporosis&#59; &#40;b&#41; zoledronate<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">69&#44;70</span></a> or denosumab<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">71</span></a> for patients with these criteria or more advanced age and therefore a greater risk of hip fractures&#59; &#40;c&#41; teriparatide<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">72&#44;73</span></a> for osteoporosis with a high risk of vertebral fractures&#46; Strontium ranelate<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">74</span></a> may be considered as a second-line drug&#44; taking into account its limitations &#40;grade D recommendation&#41;&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The administration of calcium and vitamin D is recommended&#46; Androgens are only justified if there is hypogonadism&#46; Even in this case&#44; one of the former drugs should probably be combined with androgens&#46; When hypercalciuria is detected&#44; the administration of thiazides should be assessed &#40;grade D recommendation&#41;&#46;</p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Glucocorticoid-induced osteoporosis</span><p id="par0335" class="elsevierStylePara elsevierViewall">The drugs of choice are bisphosphonates&#46;<a class="elsevierStyleCrossRefs" href="#bib0775"><span class="elsevierStyleSup">75&#8211;77</span></a> If the patient has several vertebral fractures&#44; treatment with teriparatide is justified&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">78&#44;79</span></a> Calcium and vitamin D should be administered&#46; The active metabolites of vitamin D have a certain preventive action on bone loss&#44; but there are no persuasive data on their effect in preventing fractures &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">80</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Postmenopausal women and men older than 50 years who take daily doses of prednisone equal to or greater than 5<span class="elsevierStyleHsp" style=""></span>mg &#40;or its equivalent&#41; for more than 3 months should be treated&#46; For premenopausal women and men younger than 50 years&#44; treatment is indicated only if there are previous fractures&#44; the BMD is very low or the corticosteroid dose is very high&#46; Treatment should be maintained while the patient takes prednisone at the listed dosages&#46; If this situation ceases but the patient meets the general criteria for undergoing antiosteoporotic treatment&#44; this treatment should be maintained&#46; For patients treated with corticosteroids&#44; a densitometric checkup at shorter intervals than for patients with postmenopausal osteoporosis may be justified &#40;grade D recommendation&#41;&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Conflict of interests</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2015-05-31"
    "fechaAceptado" => "2015-08-24"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">These guidelines update issues covered in previous versions and introduce new ones that have arisen in recent years&#46; The former refer mainly to the therapeutic developments that have been made during this time &#40;zoledronate&#44; denosumab&#44; bazedoxifene&#41;&#44; which have led to a change in the drug selection algorithm&#46; The latter deal with therapeutic management&#44; the description of new adverse effects &#40;which have led to changes in therapeutic behavior patterns&#44; as is the case with atypical fracture of the femur&#41;&#44; treatment duration &#40;with consideration for the so-called &#8220;therapeutic holidays&#8221;&#41;&#44; the so-called sequential treatment and changes in treatment imposed by certain circumstances&#46; A new algorithm has been introduced for sequential treatment&#46; Attention has also been paid to vertebroplasty and kyphoplasty&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La presente gu&#237;a actualiza aspectos tratados en versiones anteriores&#44; e introduce otros nuevos surgidos en los &#250;ltimos a&#241;os&#46; Los primeros se refieren fundamentalmente a las novedades terap&#233;uticas aparecidas en este tiempo &#40;zoledronato&#44; denosumab&#44; bazedoxifeno&#41;&#44; que han conducido a una modificaci&#243;n del algoritmo de elecci&#243;n del f&#225;rmaco&#46; Los segundos tienen que ver con el control terap&#233;utico&#44; la descripci&#243;n de nuevos efectos secundarios &#40;que han condicionado cambios en los patrones de conducta terap&#233;utica&#44; como es el caso de la fractura at&#237;pica de f&#233;mur&#41;&#44; la duraci&#243;n del tratamiento &#40;con la consideraci&#243;n de las denominadas &#171;vacaciones terap&#233;uticas&#187;&#41;&#44; los cambios de tratamiento que pueden imponer unas u otras circunstancias&#44; y el denominado tratamiento secuencial&#46; En relaci&#243;n con este &#250;ltimo se ha introducido un nuevo algoritmo&#46; Tambi&#233;n se han incluido consideraciones respecto a la vertebroplastia y la cifoplastia&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gonz&#225;lez-Mac&#237;as J&#44; del Pino-Montes J&#44; Olmos JM&#44; Nogu&#233;s X&#44; en nombre de la Comisi&#243;n de Redacci&#243;n de las Gu&#237;as de Osteoporosis de la SEIOMM&#46; Gu&#237;as de pr&#225;ctica cl&#237;nica en la osteoporosis posmenop&#225;usica&#44; glucocorticoidea y del var&#243;n&#46; Sociedad Espa&#241;ola de Investigaci&#243;n &#211;sea y del Metabolismo Mineral &#40;3&#46;&#170; versi&#243;n actualizada 2014&#41;&#46; Rev Clin Esp&#46; 2015&#59;215&#58;515&#8211;526&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The names of the members of the Drafting Committee of osteoporosis guidelines are listed in <a class="elsevierStyleCrossRef" href="#sec0180">Anexo A</a>&#46;</p>"
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            "apendice" => "<p id="par0350" class="elsevierStylePara elsevierViewall">Josep Blanch Rubi&#243;&#44; Jos&#233; Ram&#243;n Caeiro Rey&#44; Jorge B&#46; Cannata Andia&#44; Antonio Cano S&#225;nchez&#44; Cristina Carbonell Abella&#44; Luis Corral Gudino&#44; Javier del Pino Montes&#44; Luis del R&#237;o Barquero&#44; Manuel D&#237;az Curiel&#44; Bernardino D&#237;az L&#243;pez&#44; Adolfo D&#237;ez P&#233;rez&#44; Alberto Garc&#237;a Vadillo&#44; Carlos G&#243;mez Alonso&#44; Jes&#250;s Gonz&#225;lez Mac&#237;as&#44; Nuria Gua&#241;abens Gay&#44; Federico Hawkins Carranza&#44; Esteban J&#243;dar Gimeno&#44; Jorge Malouf Sierra&#44; Ana Monegal Branc&#243;s&#44; M&#46; Jes&#250;s Moro &#193;lvarez&#44; Manuel Mu&#241;oz Torres&#44; Xavier Nogu&#233;s Sol&#225;n&#44; Joan Miquel Nolla Sol&#233;&#44; Jos&#233; Manuel Olmos Mart&#237;nez&#44; Pilar Orozco L&#243;pez&#44; Ram&#243;n P&#233;rez Cano&#44; Jos&#233; Luis P&#233;rez Castrill&#243;n&#44; Pilar Peris Bernal&#44; J&#46; Manuel Quesada G&#243;mez&#44; Jos&#233; Antonio Riancho Moral&#44; Manuel Sosa Henr&#237;quez and Antonio Torrijos Eslava&#46;</p> <p id="par0355" class="elsevierStylePara elsevierViewall">Methodology&#58; Miguel Delgado&#46;</p> <p id="par0360" class="elsevierStylePara elsevierViewall">Literature search&#58; Jos&#233; Luis Hern&#225;ndez&#44; Mar&#237;a Rodr&#237;guez Sanz&#46;</p>"
            "etiqueta" => "Appendix A"
            "identificador" => "sec0180"
          ]
        ]
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2325
            "Ancho" => 3295
            "Tamanyo" => 420884
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Drug selection algorithm&#46; Abbreviations&#58; DS&#44; digestive system&#59; ALN&#44; alendronate&#59; Dmab&#44; denosumab&#59; BMD&#44; bone mineral density&#59; FN&#44; femoral neck&#59; RF&#44; renal failure&#59; PTH 1-34&#44; teriparatide&#59; SR&#44; strontium ranelate&#59; RIS&#44; risedronate&#59; SERMs&#44; selective estrogen receptor modulators&#59; ZOLE&#44; zoledronate&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2471
            "Ancho" => 3162
            "Tamanyo" => 454995
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Sequential treatment algorithm&#46; Abbreviations&#58; DS&#44; digestive system&#59; ALN&#44; alendronate&#59; BPN&#44; bisphosphonates&#59; Dmab&#44; denosumab&#59; BMD&#44; bone mineral density&#59; RF&#44; renal failure&#59; PTH 1-34&#44; teriparatide&#59; SR&#44; strontium ranelate&#59; RIS&#44; risedronate&#59; SERMs&#44; selective estrogen receptor modulators&#59; ZOLE&#44; zoledronate&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; RCT&#44; randomized clinical trial&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1a</span> Systematic reviews of RCTs with homogeneity among the individual studies or several RCTs with similar results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1b</span> Individual RCT with narrow confidence interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2a</span> Systematic review of cohort studies with homogeneity among the individual studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2b</span> Individual cohort study or RCT of low quality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2c</span> &#8220;Results&#8221; research&#59; ecological studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3a</span> Systematic review of case-control studies with homogeneity among the individual studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3b</span> Individual case-control study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4</span> Case series and low-quality cohort and case-control studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">5</span> Expert opinions without explicit critical assessment or based on physiology&#44; basic research or &#8220;first principles&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab971647.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Levels of evidence according to the Oxford Centre for evidence-based medicine for studies that assess therapy&#44; prevention or damage&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consistent level 1 studies &#40;randomized clinical trials&#41;&#46; Consistency is defined as homogeneity &#40;correlation&#41; in the results of the various individual studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consistent level 2 &#40;cohort&#41; or level 3 &#40;case-control&#41; studies or extrapolations of level 1 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Level 4 studies &#40;case series and low-quality cohort or case-control studies&#41; or extrapolations of level 2 or level 3 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Level 5 tests &#40;expert opinions&#44; inconclusive studies or inconsistency problems among them&#44; whatever their level&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab971643.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Levels of recommendation of the Oxford Centre for evidence-based medicine according to the levels of evidence&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1&#46; Factors associated with greater constancy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypogonadism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Early menopause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Amenorrhea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anorexia nervosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Malabsorption&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rheumatoid arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes &#40;particularly type 1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Immobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aromatase inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Gonadotropin-releasing hormone agonist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2&#46; Factors associated with lower regularity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hyperparathyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hyperthyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Selective serotonin reuptake inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Proton pump inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anticonvulsants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vitamin D deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab971645.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diseases and treatments that are risk factors for osteoporosis&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; SD&#44; standard deviation&#59; BMD&#44; bone mineral density&#59; T-score&#44; comparison with BMD value achieved in young reference population&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion for BMD &#40;T-score&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD T<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>&#8722;1 SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteopenia or low bone mineral density&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD T<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;1 and &#62;&#8722;2&#46;49 SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5 SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD T<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5 SD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fracture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab971646.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">WHO Diagnostic Criteria for Osteoporosis&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; NSAID&#44; nonsteroidal anti-inflammatory drugs&#59; ALN&#44; alendronate&#59; BP&#44; bisphosphonates&#59; FDA&#44; Food and Drug Administration&#59; GFR&#44; glomerular filtration rate&#59; IBAN&#44; ibandronate&#59; IV&#58; intravenous&#59; RIS&#44; risedronate&#59; ZOL&#44; zoledronate&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper gastrointestinal tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reported with oral bisphosphonates &#40;esophagitis and esophageal ulcers&#41;An increase in the incidence of esophageal cancer has not been confirmed&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Can be largely avoided if the drug is ingested properly &#40;with a glass of water and remaining upright for the next 30 &#91;ALN&#44; RIS&#93; or 60 &#91;IBAN&#93;<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; Oral BPs should be avoided for patients with upper gastrointestinal tract conditions &#40;e&#46;g&#46;&#44; difficulty swallowing and Barrett&#39;s esophagus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute phase reaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flu-like illness &#40;malaise&#44; myalgia&#44; fever&#41;&#46; Occurs mainly with IV BPs &#40;25&#8211;35&#37; of those who are treated with ZOL for the first time&#44; decreasing in successive doses&#41;&#46; Occurs at 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h and generally disappears in 3 days&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The administration of paracetamol &#40;but not NSAIDs&#41; is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Its association with BPs is debated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The FDA recommends that fear of its onset should not influence the prescription&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">For patients with normal GFR&#44; IV BPs can promote the development of renal failure if not administered with caution&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The excessively rapid administration of IV BPs &#40;&#60;15<span class="elsevierStyleHsp" style=""></span>min for ZOL&#41; should be avoided&#44; as well as the simultaneous use of potentially nephrotoxic agents &#40;diuretic NSAIDs&#41; and their use in dehydrated patients&#46;Renal function should be assessed in the days following the administration of ZOL&#46; BPs&#44; both IV and oral&#44; should be avoided if the GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#8211;35<span class="elsevierStyleHsp" style=""></span>mL&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypocalcemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV BPs can cause hypocalcemia&#44; especially when administered to patients with reduced GFR or vitamin D deficiency&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clinicians should ensure that vitamin D levels&#44; calcemia and renal function are appropriate before administering BP intravenously&#46;Calcemia should be assessed in the days following the administration of ZOL&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maxillary osteonecrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Its risk is very low with oral BPs &#40;1&#47;1500&#8211;1&#47;100&#44;000 patients per year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">43</span></a> This disease is related to oral health status and dental operations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discontinuing BPs when faced with a dental operation is not recommended&#46;The measurement of bone turnover markers is not recommended&#46;If a patient with BP requires a dental operation&#44; it should be performed&#44; ensuring that the procedure is as noninvasive as possible&#46;Patients with BPs should maintain good oral hygiene&#46;Teriparatide could be useful for treating osteonecrosis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atypical femur fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Its incidence increases with the BP exposure time &#40;high relative risk at 8&#8211;10 years of treatment&#44; but low absolute risk&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Requiring rest and&#44; if necessary&#44; surgery&#46;The contralateral femur should be examined&#46;Administering teriparatide may be considered for the treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adverse ocular effects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Various types of ocular inflammatory reactions have been reported with BPs&#46; Can appear hours to years after the start of its administration &#40;mean&#44; 3 weeks&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The use of BPs should be discontinued &#40;progression is usually favorable&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diffuse osteoarticular and muscle pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Is uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The use of BPs should be discontinued &#40;the spontaneous progression is usually favorable&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Adverse effects of bisphosphonates&#46;</p>"
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Clinical practice guidelines for postmenopausal, glucocorticoid-induced and male osteoporosis. Spanish Society for Research on Bone and Mineral Metabolism (3rd updated version 2014)
Guías de práctica clínica en la osteoporosis posmenopáusica, glucocorticoidea y del varón. Sociedad Española de Investigación Ósea y del Metabolismo Mineral (3.ª versión actualizada 2014)
J. González-Macíasa, J. del Pino-Montesb, J.M. Olmosa, X. Noguésc,
Corresponding author
Xnogues@hospitaldelmar.cat

Corresponding author.
, on behalf of the Comisión de Redacción de las Guías de Osteoporosis de la SEIOMM
a Departamento de Medicina Interna, Hospital Universitario Marqués de Valdecilla. IDIVAL, Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Universidad de Cantabria, Santander, Spain
b Servicio de Reumatología, Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad RETICEF), Universidad de Salamanca, Alfonso X el Sabio, Salamanca, Spain
c Servicio de Medicina Interna, Hospital del Mar, URFOA-IMIM (Institut Hospital del Mar d’Investigacions Mèdiques), Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Universidad Autónoma de Barcelona, Barcelona, Spain
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Clinical assessment combined with BMD measurement is an effective method for assessing the risk of fracture &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Bone densitometry</span><p id="par0020" class="elsevierStylePara elsevierViewall">Among the various techniques available&#44; dual energy X-ray absorptiometry &#40;DXA&#41;&#44; which measures BMD&#44; is the commonly used procedure for determining the risk of fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">3</span></a> The results are expressed in terms of T-score&#44; which is the number of standard deviations &#40;SD&#41; by which the BMD value differs from that of the healthy youth population &#40;20&#8211;29 years&#41;&#46; The World Health Organization &#40;WHO&#41; has stated that a diagnosis of osteoporosis should be made when BMD is &#8804;&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">4&#44;5</span></a> The WHO later clarified that this value should correspond to a measurement performed in the femoral neck and using the NHANES III study as reference&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">6</span></a> The International Society for Clinical Densitometry&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">7</span></a> however&#44; considers that the diagnosis can be established when this value of &#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T is found in any of the following three locations&#58; lumbar spine&#44; total hip or femoral neck&#46; The WHO also defined the conditions of normality&#44; osteopenia &#40;low bone mass&#41; and established or severe osteoporosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> The measurement of BMD in the proximal femur and lumbar spine using DXA is a useful test for assessing the risk of fracture &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Bone remodeling markers</span><p id="par0030" class="elsevierStylePara elsevierViewall">Bone remodeling markers provide information on bone turnover dynamics&#46; Bone formation markers include osteocalcin&#44; bone alkaline phosphatase and type <span class="elsevierStyleSmallCaps">I</span> procollagen carboxy-terminal and amino-terminal propeptides &#40;PICP and P1NP&#41;&#46; Bone resorption markers include type <span class="elsevierStyleSmallCaps">I</span> collagen carboxy-terminal and amino-terminal telopeptides &#40;CTX in blood and urine&#44; and NTX in urine&#41; and tartrate-resistant acid phosphatase 5b &#40;TRACP 5b&#41;&#46; Various international organizations such as the International Federation of Clinical Chemistry have recommended the use of P1NP &#40;formation&#41; and s-CTX &#40;resorption&#41; for clinical studies&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Bone markers are not useful for diagnosing osteoporosis&#44; although they do help assess the risk of fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">9</span></a> Their change with treatment is useful for assessing the response to the treatment &#40;level of evidence 2a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">10</span></a> The change should be greater than the value of the so-called minimum significant change&#44; calculated at 20&#8211;25&#37; for P1NP&#44; 30&#37; for CTX and 37&#8211;54&#37; for NTX&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Systematic measurement of bone markers to diagnose patients with osteoporosis is not recommended but can be helpful in managing the therapeutic response &#40;grade B recommendation&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conventional radiology</span><p id="par0045" class="elsevierStylePara elsevierViewall">Conventional radiology is not a sensitive or specific method for assessing changes in bone mass&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">5</span></a> However&#44; the procedure is essential for identifying fractures&#46; For the vertebrae&#44; the diagnosis requires a reduction of at least 20&#8211;25&#37; in vertebral body height &#40;see the Genant method<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">11</span></a> in the complete version of the guidelines&#41;&#46; Slight reductions can be confused with deformities of other origins &#40;osteoarthritis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Conventional radiology should be indicated to detect vertebral fractures but should not be used as a method for assessing bone mass for the diagnosis of osteoporosis &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Study protocol</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study of female patients with osteoporosis should include a hemogram and a reading of elementary biochemical parameters&#46; It is advisable to measure 25-hydroxy vitamin D &#40;25OHD&#41; and thyrotropin levels and perform a proteinogram&#46; It is useful to quantify 24<span class="elsevierStyleHsp" style=""></span>h urinary calcium &#40;hypocalciuria indicates a lack of supply or malabsorption&#59; hypercalciuria contraindicates the administration of calcium&#41;&#46; The advisability of measuring parathyroid hormone &#40;PTH&#41; levels and bone remodeling markers is debated&#46; Patients should undergo both a BMD measurement and spinal radiography&#46; If specific diseases are suspected as the cause of the osteoporosis &#40;e&#46;g&#46;&#44; hypercortisolism&#44; celiac disease&#41;&#44; appropriate studies should be performed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Risk prediction tools</span><p id="par0060" class="elsevierStylePara elsevierViewall">Various scales have been developed to assess the risk of experiencing densitometric osteoporosis and osteoporotic fractures&#46; The scales for assessing the risk of densitometric osteoporosis do not include BMD&#44; although the tools are useful for deciding when to perform this test&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">13</span></a> These tools have similar abilities to predict low BMD&#46; The easiest of the tools &#40;the Osteoporosis Self-Assessment Tool &#91;OST&#93;&#41;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">14&#44;15</span></a> includes only age and weight&#44; factors present in all of the other tools&#46; To directly assess the risk of fractures&#44; other tools have been developed&#44; such as the Fracture Risk Assessment Tool &#40;FRAX&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">16</span></a> the Garvan Medical Research Institute tool<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">17</span></a> and the QFracture Index&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">18</span></a> The three tools have similar discriminatory capacity and offer moderate performance&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">19&#44;20</span></a> FRAX is also designed to decide when to perform a BMD reading&#46; Unfortunately&#44; its adaptation to Spain has been inadequate<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">21</span></a> and it should therefore not be used&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Therapeutic decision</span><p id="par0065" class="elsevierStylePara elsevierViewall">There is no one international consensus as to when treatment should start for osteoporosis&#46; SEIOMM considers that the following female patients should be treated&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Those who have a fracture due to frailty or a BMD<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T in the lumbar spine&#44; femoral neck or total hip&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Those with osteopenia &#40;particularly if the T is &#8804;&#8722;2&#46;0&#41; who also have factors strongly associated with a risk of fracture &#40;e&#46;g&#46;&#44; hypogonadism&#44; BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#44; a family history of fractures&#44; smoking and alcoholism&#44; rheumatoid arthritis&#44; type I diabetes and certain treatments such as antiestrogens&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Those on glucocorticoid therapy&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Regardless of the previously mentioned standards&#44; SEIOMM states that there are three conditions in which treatment is at the discretion of each physician&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Young women &#40;50&#8211;60 years&#41; with T values &#60;&#8722;3<span class="elsevierStyleHsp" style=""></span>T&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Young women with distal radius fractures who have some other risk factor&#44; especially if there are questions concerning the intensity of the trauma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Women with grade 1 vertebral deformities&#44; which are not always easy to interpret as fractures&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Performing densitometry</span><p id="par0105" class="elsevierStylePara elsevierViewall">There are no universally accepted criteria for its indication&#46; The procedure should be considered when there are risk factors strongly associated with osteoporosis or fractures&#46; FRAX is employed in other countries for this purpose&#44; but the inadequate Spanish version precludes its use in Spain and&#44; in any case&#44; records a low number of factors&#46; The criteria list is very long&#46; We therefore establish only a general classification&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Diseases and treatments frequently associated with osteoporosis &#40;e&#46;g&#46;&#44; rheumatoid arthritis&#44; early menopause&#44; hyperparathyroidism&#44; corticosteroids&#44; antiestrogens&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Diseases whose association with osteoporosis or osteoporotic fracture depends on their severity &#40;e&#46;g&#46;&#44; type 1 diabetes and poorly controlled hyperthyroidism&#44; malabsorption&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Other criteria&#44; especially if 2 of them are met&#58; age &#62;65 years&#44; BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hereditary component&#44; alcoholism&#47;smoking&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Nonpharmacological interventions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Patients should be advised to engage in physical activity&#44; stop smoking and avoid excessive alcohol consumption&#46; Preventing falls is important&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Calcium and vitamin D</span><p id="par0130" class="elsevierStylePara elsevierViewall">Patients treated with antiresorptive or anabolic drugs should take an appropriate amount of calcium and vitamin D &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">22&#8211;26</span></a> Serum 25OHD levels should be above 20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and preferably above 30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">27&#44;28</span></a> The recommended daily dose of vitamin D is 800&#8211;1000<span class="elsevierStyleHsp" style=""></span>IU&#47;d &#40;its fortnightly or monthly equivalent may also be administered&#41;&#46; The administration of large quantities of vitamin D in a single dose is not recommended &#40;e&#46;g&#46;&#44; 500&#44;000<span class="elsevierStyleHsp" style=""></span>IU&#47;year<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">29</span></a>&#41;&#46; In terms of calcium&#44; the daily intake should be 1000&#8211;1200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; Achieving this amount through diet is preferable&#59; however&#44; if this is not possible&#44; supplements should be added&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Calcitonin</span><p id="par0135" class="elsevierStylePara elsevierViewall">Its extended use is associated with an increased risk of cancer and is therefore not recommended&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Thiazides</span><p id="par0140" class="elsevierStylePara elsevierViewall">There are no data justifying their use in treating osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">30</span></a> Their use may be considered in patients with hypercalciuria&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Estrogen therapy</span><p id="par0145" class="elsevierStylePara elsevierViewall">Effective in preventing osteoporotic fractures &#40;level of evidence 2a&#41;&#46; Its secondary effects have meant that it is not recommended for osteoporosis&#44; except for women with a high risk of fracture who have no other therapeutic option&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">31&#44;32</span></a> For women who are treated with estrogens due to presenting a climacteric syndrome&#44; estrogens may be considered appropriate for treating the osteoporosis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Estrogen therapy is not recommended for treating postmenopausal osteoporosis &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Selective estrogen receptor modulators</span><p id="par0155" class="elsevierStylePara elsevierViewall">Raloxifene<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">33</span></a> &#40;level of evidence 1a&#41; and bazedoxifene<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">34</span></a> &#40;level of evidence 2b&#41; are useful for reducing vertebral fractures &#40;by approximately 40&#37;&#41; but not nonvertebral fractures&#46; Its main complication is an increased risk of deep vein thrombosis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Selective estrogen receptor modulators &#40;SERMs&#41; are indicated for treating osteoporosis by reducing vertebral fractures &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Tibolone</span><p id="par0165" class="elsevierStylePara elsevierViewall">Tibolone reduces fractures &#40;level of evidence 1b&#41;&#44; but its use is not recommended due to the risk of stroke &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">35</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Phytoestrogens and isoflavones</span><p id="par0170" class="elsevierStylePara elsevierViewall">Isoflavones can have a favorable effect on BMD&#44; but they are not recommended for treating osteoporosis due to a lack of data on their efficacy in fractures &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bisphosphonates</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Etidronate</span><p id="par0175" class="elsevierStylePara elsevierViewall">Reduces vertebral fractures by approximately 40&#37; but not nonvertebral fractures &#40;level of evidence 1a&#41; &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">36</span></a> The drug has fallen into disuse&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Alendronate</span><p id="par0180" class="elsevierStylePara elsevierViewall">At a dosage of 70<span class="elsevierStyleHsp" style=""></span>mg&#47;week&#44; alendronate decreases vertebral&#44; nonvertebral and hip fractures by approximately 45&#37;&#44; 25&#8211;30&#37; and 45&#8211;55&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">37&#44;38</span></a> According to an extension study&#44; patients for whom treatment is discontinued after 5 years have a greater risk of clinical vertebral fractures in the following 5 years than those who continue with the treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">39&#44;40</span></a> The risk of fracture&#44; including nonvertebral&#44; increases with increasing age and lower BMD in the femoral neck when discontinuing treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">41</span></a> Alendronate is usually well tolerated&#44; with adverse effects<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">42</span></a> that have been reported with the other bisphosphonates in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; alendronate has a grade A recommendation for treating osteoporosis&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Risedronate</span><p id="par0190" class="elsevierStylePara elsevierViewall">Weekly doses of 35<span class="elsevierStyleHsp" style=""></span>mg decrease vertebral&#44; nonvertebral and hip fractures by approximately 40&#37;&#44; 20&#37; and 25&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">44</span></a> The administration of 75<span class="elsevierStyleHsp" style=""></span>mg for two consecutive days a month is also effective&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">45</span></a> Risedronate is well tolerated&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; risedronate has a grade A recommendation for treating osteoporosis&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ibandronate</span><p id="par0200" class="elsevierStylePara elsevierViewall">This drug may be administered orally once a month &#40;150<span class="elsevierStyleHsp" style=""></span>mg&#41; or every 3 months intravenously &#40;3<span class="elsevierStyleHsp" style=""></span>mg&#41;&#46; Ibandronate decreases the risk of vertebral fracture by approximately 60&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">46&#44;47</span></a> but does not decrease nonvertebral fractures &#40;level of evidence 1b&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Ibandronate has a grade A recommendation for reducing vertebral fractures&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Zoledronate</span><p id="par0210" class="elsevierStylePara elsevierViewall">At a dosage of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;y&#44; zoledronate decreases vertebral&#44; nonvertebral and hip fractures by approximately 70&#37;&#44; 25&#37; and 40&#37;&#44; respectively &#40;level of evidence 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">48</span></a> Women who&#44; after 3 years of treatment&#44; continued with the treatment for another 3 years have a vertebral fracture rate below 50&#37; compared with those who discontinued the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">49</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; risedronate has a grade A recommendation for treating osteoporosis&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Denosumab</span><p id="par0220" class="elsevierStylePara elsevierViewall">This drug decreases the risk of vertebral&#44; nonvertebral and hip fractures by 70&#37;&#44; 20&#37; and 40&#37;&#44; respectively &#40;level of evidence 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">50</span></a> A <span class="elsevierStyleItalic">post hoc</span> analysis indicated that its efficacy in reducing hip fractures was 62&#37; greater when used at an age older than 75 years<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">51</span></a> than when used below this age &#40;level of evidence 2b&#41;&#46; In the 24 months following the discontinuation of the drug&#44; a loss of the gained bone mass is observed&#44; with subsequent stabilization at baseline values<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">52</span></a> &#40;level of evidence 1b&#41;&#46; Discontinuation also causes an increase in bone turnover markers to values greater than baseline&#44; which subsequently return to normal&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">52</span></a> When administered to patients who have previously undergone treatment with alendronate&#44; an increase in the intensity of the antiresorptive effect is observed &#40;level of evidence 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">53</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Denosumab is generally well tolerated&#44; although a slight increase in the incidence of infections has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">54</span></a> Cases of maxillary osteonecrosis and atypical femoral fractures have been reported&#44; although the incidence rates have been low&#46; The drug may be administered to patients with renal failure&#44; but patients should be monitored for the possible onset of hypocalcemia &#40;ensure an appropriate supply of calcium and vitamin D&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> By reducing vertebral&#44; nonvertebral and hip fractures&#44; denosumab has a grade A recommendation for treating osteoporosis&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Strontium ranelate</span><p id="par0235" class="elsevierStylePara elsevierViewall">The drug reduces the incidence of vertebral and nonvertebral fractures by approximately 40&#37; and 16&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">55&#44;56</span></a> A <span class="elsevierStyleItalic">post hoc</span> analysis indicated that the drug reduces the incidence of hip fractures &#40;36&#37;&#41; in high-risk patients &#40;level of evidence 2b&#41;&#46; The drug markedly increases BMD&#59; however&#44; part of the increase &#40;up to 50&#37;&#41; is due to the absorption of radiation by the strontium deposited in the bone&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The drug occasionally causes severe skin reactions&#46; The drug increases the incidence of vascular problems&#44; both venous &#40;deep vein thrombosis&#41; and arterial &#40;myocardial infarction&#41;&#46; The latter of these conditions means that the drug&#39;s indication is limited to patients with severe osteoporosis for whom there is no other therapeutic alternative&#44; in the absence of poorly controlled arterial hypertension&#44; a history of ischemic heart disease&#44; peripheral arterial disease or cerebrovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">57</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Strontium ranelate is effective in reducing vertebral and nonvertebral fractures &#40;grade A recommendation&#41;&#44; but its use is restricted to patients with a high risk of fracture and with no risk of cardiovascular disease&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">PTH 1-34 &#40;teriparatide&#41;</span><p id="par0250" class="elsevierStylePara elsevierViewall">This drug decreases the risk of vertebral and nonvertebral fractures by 65&#37; and 50&#37;&#44; respectively &#40;level of evidence 1a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">58</span></a> This is the only available bone formation drug&#46; The drug has not been studied in trials designed to assess its effect on hip fractures&#46; It is administered in a daily subcutaneous injection for 2 years&#46; The benefits achieved with the drug decrease after its discontinuation if it is not followed by the administration of an antiresorptive drug &#40;level of evidence 2b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">59</span></a> Its tolerance is good&#46; PTH &#40;1-84&#41; is still not commercially available&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusion&#58;</span> Teriparatide reduces fractures&#44; both vertebral and nonvertebral &#40;grade A recommendation&#41;&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Vertebroplasty and kyphoplasty</span><p id="par0260" class="elsevierStylePara elsevierViewall">These procedures are not recommended for patients with asymptomatic vertebral fractures or mild pain or in those with more than 1 year of progression&#46; The procedures may be considered for patients with fractures of less than 6 weeks of progression and intense pain despite medical treatment and for those patients with fractures of 6 weeks to 1 year of progression and persistent pain that respond poorly to analgesics&#44; if they present edema in magnetic resonance imaging&#46; They can also be of use for patients who are contraindicated or have poor tolerance of analgesics&#46; Given the cost-benefit ratio&#44; vertebroplasty is generally preferable to kyphoplasty &#40;grade B recommendation&#41;&#46;</p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Managing the therapeutic response</span><p id="par0265" class="elsevierStylePara elsevierViewall">Changing the treatment due to a possible inadequate response may be considered in the following circumstances<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">60</span></a>&#58; &#40;a&#41; development of two successive fractures and &#40;b&#41; two of the following three factors coinciding&#58; development of a new fracture&#44; a reduction in BMD greater than the minimum significant change and a reduction in bone turnover markers lower than the minimum significant change &#40;grade D recommendation&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Before changing the therapy&#44; the following conditions should be considered as possible causes of the inadequate response&#58; &#40;a&#41; lack of vitamin D&#44; &#40;b&#41; secondary forms of osteoporosis&#44; &#40;c&#41; inadequate compliance&#44; &#40;d&#41; tendency to fall&#44; &#40;e&#41; defects in the measurement techniques&#44; both BMD and remodeling markers&#44; and &#40;f&#41; the presence of severe bone deterioration&#44; which leads to an expectation of new fractures even though the drug is still active&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Treatment duration &#40;grade D recommendation&#41;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Treatment should last as long as necessary to decrease the risk of fractures to acceptable levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">61&#8211;63</span></a> Although there is no one official definition of what is considered an acceptable level&#44; it has been suggested that a BMD<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T in patients with no fractures or &#62;&#8722;2<span class="elsevierStyleHsp" style=""></span>T in patients with 1 previous fracture &#40;more than 3&#8211;5 years&#41; could be an acceptable level&#46; If the fracture is recent &#40;less than 3&#8211;5 years&#41;&#44; the situation is considered at risk&#44; even if the BMD is above &#8722;2<span class="elsevierStyleHsp" style=""></span>T&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">The achievement of objectives should be assessed every 3&#8211;5 years&#46; If the goals are considered achieved&#44; the treatment may be discontinued in the manner as described later in this document&#46; Otherwise&#44; treatment should be continued&#46; In this case&#44; if a number of years have passed &#40;approx&#46; 6 for zoledronate and approx&#46; 10 for alendronate&#44; risedronate and denosumab&#41; and it is deemed advisable to change to a drug with a different mechanism of action due to the risk of developing an atypical femoral fracture then teriparatide or&#44; if necessary &#40;and possible&#41;&#44; strontium ranelate should be used&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">If the decision is made to discontinue treatment&#44; then the increased risk of fracture this entails should be taken into account&#46; This risk is small with bisphosphonates&#44; which remain bound to the bone and can therefore be discontinued&#44; leaving the patient untreated for a few years&#46; The discontinuation of denosumab is followed by increased bone turnover&#46; A mild antiresorptive agent &#40;a SERM or a single injection of a half dose of zoledronate&#41; should therefore be administered&#44; at least temporarily&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Change of drug due to apparent lack of response &#40;grade D recommendation&#41;</span><p id="par0290" class="elsevierStylePara elsevierViewall">If the reason for the change is an apparent lack of response&#44; it is advisable<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">60&#44;64</span></a> to &#40;a&#41; choose a drug that is considered to have a greater capacity to reduce fractures&#44; &#40;b&#41; change an antiresorptive agent for a bone formation agent or &#40;c&#41; change an oral drug for an injectable one&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Clinical decision algorithms</span><p id="par0295" class="elsevierStylePara elsevierViewall">The following therapeutic scenarios should be considered for selecting the drug &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0300" class="elsevierStylePara elsevierViewall">A patient with a high vertebral fracture risk &#40;equivalent to two or more vertebral fractures&#41;&#46; The recommended treatment is teriparatide for 24 months&#44; followed by a bisphosphonate or denosumab&#46; If one does not wish to use teriparatide&#44; one of the latter can be administered from the start&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0305" class="elsevierStylePara elsevierViewall">A young patient with a moderate risk of vertebral fracture and a low risk of hip fracture &#40;no history of fractures and densitometric osteoporosis values exclusively in the spine&#41;&#46; It is advisable to administer a SERM&#46; This recommendation is reinforced by reports of atypical hip fracture as a long-term complication of bisphosphonates and denosumab&#44; whose use should be delayed&#46; Additionally&#44; the use of a SERM overcomes problems related to dental manipulation&#46; Alternatively&#44; if one does not wish to use a SERM&#44; alendronate or risedronate may be administered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">A patient with other risk conditions&#46; There are 4 drugs for this situation&#58; alendronate&#44; risedronate&#44; zoledronate and denosumab&#46; The first two are less expensive and are administered orally &#40;zoledronate&#44; although available as a generic&#44; costs more due to the need for intravenous administration&#41;&#46; The last two are administered by injection &#40;intravenous in the case of zoledronate and subcutaneously for denosumab&#41;&#46; The selection between the first two and the last two should be made based on the presence or absence of a number of factors that can be labeled as a whole as &#8220;restrictive factors for administering oral bisphosphonates&#44;&#8221; such as oral intolerance&#44; polypharmacy &#40;comorbidity&#41;&#44; lack of adherence or advanced age&#46; The fewer of these factors that are present&#44; the more advisable it is to use alendronate or risedronate&#59; the more of these factors that are present&#44; the more zoledronate or denosumab are advisable&#46; The presence of a high risk of hip fractures&#44; which is common in the elderly&#44; can be another reason for preferring denosumab&#44; which has been shown to be highly effective in preventing this fracture in those older than 75 years&#46; Other circumstances that make the selection of denosumab advisable are a lack of availability of an outpatient center and a GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#8211;35<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0315" class="elsevierStylePara elsevierViewall">As second-line drugs for all situations&#44; we have ibandronate&#44; strontium ranelate and SERMs&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Finally&#44; the concept of sequential treatment refers to conditions defined by predictable changes in the drug to be employed&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows a sequential treatment algorithm&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Male osteoporosis</span><p id="par0325" class="elsevierStylePara elsevierViewall">The available evidence concerning treatment for male osteoporosis is scarce&#46; The primary objective of most studies has been BMD&#46; The results for BMD in men are similar to those observed in women&#44; which leads us to believe that its efficacy is probably similar in terms of fractures&#46; For this reason&#44; it is worth establishing a drug strategy for men that is similar to that for women&#58; &#40;a&#41; risedronate<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">65&#44;66</span></a> or alendronate<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">67&#44;68</span></a> &#40;although the latter is not approved in Spain for treating male osteoporosis&#41; for patients with no restrictive criteria for oral administration&#44; according to the reports on postmenopausal osteoporosis&#59; &#40;b&#41; zoledronate<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">69&#44;70</span></a> or denosumab<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">71</span></a> for patients with these criteria or more advanced age and therefore a greater risk of hip fractures&#59; &#40;c&#41; teriparatide<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">72&#44;73</span></a> for osteoporosis with a high risk of vertebral fractures&#46; Strontium ranelate<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">74</span></a> may be considered as a second-line drug&#44; taking into account its limitations &#40;grade D recommendation&#41;&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The administration of calcium and vitamin D is recommended&#46; Androgens are only justified if there is hypogonadism&#46; Even in this case&#44; one of the former drugs should probably be combined with androgens&#46; When hypercalciuria is detected&#44; the administration of thiazides should be assessed &#40;grade D recommendation&#41;&#46;</p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Glucocorticoid-induced osteoporosis</span><p id="par0335" class="elsevierStylePara elsevierViewall">The drugs of choice are bisphosphonates&#46;<a class="elsevierStyleCrossRefs" href="#bib0775"><span class="elsevierStyleSup">75&#8211;77</span></a> If the patient has several vertebral fractures&#44; treatment with teriparatide is justified&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">78&#44;79</span></a> Calcium and vitamin D should be administered&#46; The active metabolites of vitamin D have a certain preventive action on bone loss&#44; but there are no persuasive data on their effect in preventing fractures &#40;grade A recommendation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">80</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Postmenopausal women and men older than 50 years who take daily doses of prednisone equal to or greater than 5<span class="elsevierStyleHsp" style=""></span>mg &#40;or its equivalent&#41; for more than 3 months should be treated&#46; For premenopausal women and men younger than 50 years&#44; treatment is indicated only if there are previous fractures&#44; the BMD is very low or the corticosteroid dose is very high&#46; Treatment should be maintained while the patient takes prednisone at the listed dosages&#46; If this situation ceases but the patient meets the general criteria for undergoing antiosteoporotic treatment&#44; this treatment should be maintained&#46; For patients treated with corticosteroids&#44; a densitometric checkup at shorter intervals than for patients with postmenopausal osteoporosis may be justified &#40;grade D recommendation&#41;&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Conflict of interests</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2015-05-31"
    "fechaAceptado" => "2015-08-24"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">These guidelines update issues covered in previous versions and introduce new ones that have arisen in recent years&#46; The former refer mainly to the therapeutic developments that have been made during this time &#40;zoledronate&#44; denosumab&#44; bazedoxifene&#41;&#44; which have led to a change in the drug selection algorithm&#46; The latter deal with therapeutic management&#44; the description of new adverse effects &#40;which have led to changes in therapeutic behavior patterns&#44; as is the case with atypical fracture of the femur&#41;&#44; treatment duration &#40;with consideration for the so-called &#8220;therapeutic holidays&#8221;&#41;&#44; the so-called sequential treatment and changes in treatment imposed by certain circumstances&#46; A new algorithm has been introduced for sequential treatment&#46; Attention has also been paid to vertebroplasty and kyphoplasty&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La presente gu&#237;a actualiza aspectos tratados en versiones anteriores&#44; e introduce otros nuevos surgidos en los &#250;ltimos a&#241;os&#46; Los primeros se refieren fundamentalmente a las novedades terap&#233;uticas aparecidas en este tiempo &#40;zoledronato&#44; denosumab&#44; bazedoxifeno&#41;&#44; que han conducido a una modificaci&#243;n del algoritmo de elecci&#243;n del f&#225;rmaco&#46; Los segundos tienen que ver con el control terap&#233;utico&#44; la descripci&#243;n de nuevos efectos secundarios &#40;que han condicionado cambios en los patrones de conducta terap&#233;utica&#44; como es el caso de la fractura at&#237;pica de f&#233;mur&#41;&#44; la duraci&#243;n del tratamiento &#40;con la consideraci&#243;n de las denominadas &#171;vacaciones terap&#233;uticas&#187;&#41;&#44; los cambios de tratamiento que pueden imponer unas u otras circunstancias&#44; y el denominado tratamiento secuencial&#46; En relaci&#243;n con este &#250;ltimo se ha introducido un nuevo algoritmo&#46; Tambi&#233;n se han incluido consideraciones respecto a la vertebroplastia y la cifoplastia&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gonz&#225;lez-Mac&#237;as J&#44; del Pino-Montes J&#44; Olmos JM&#44; Nogu&#233;s X&#44; en nombre de la Comisi&#243;n de Redacci&#243;n de las Gu&#237;as de Osteoporosis de la SEIOMM&#46; Gu&#237;as de pr&#225;ctica cl&#237;nica en la osteoporosis posmenop&#225;usica&#44; glucocorticoidea y del var&#243;n&#46; Sociedad Espa&#241;ola de Investigaci&#243;n &#211;sea y del Metabolismo Mineral &#40;3&#46;&#170; versi&#243;n actualizada 2014&#41;&#46; Rev Clin Esp&#46; 2015&#59;215&#58;515&#8211;526&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The names of the members of the Drafting Committee of osteoporosis guidelines are listed in <a class="elsevierStyleCrossRef" href="#sec0180">Anexo A</a>&#46;</p>"
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            "apendice" => "<p id="par0350" class="elsevierStylePara elsevierViewall">Josep Blanch Rubi&#243;&#44; Jos&#233; Ram&#243;n Caeiro Rey&#44; Jorge B&#46; Cannata Andia&#44; Antonio Cano S&#225;nchez&#44; Cristina Carbonell Abella&#44; Luis Corral Gudino&#44; Javier del Pino Montes&#44; Luis del R&#237;o Barquero&#44; Manuel D&#237;az Curiel&#44; Bernardino D&#237;az L&#243;pez&#44; Adolfo D&#237;ez P&#233;rez&#44; Alberto Garc&#237;a Vadillo&#44; Carlos G&#243;mez Alonso&#44; Jes&#250;s Gonz&#225;lez Mac&#237;as&#44; Nuria Gua&#241;abens Gay&#44; Federico Hawkins Carranza&#44; Esteban J&#243;dar Gimeno&#44; Jorge Malouf Sierra&#44; Ana Monegal Branc&#243;s&#44; M&#46; Jes&#250;s Moro &#193;lvarez&#44; Manuel Mu&#241;oz Torres&#44; Xavier Nogu&#233;s Sol&#225;n&#44; Joan Miquel Nolla Sol&#233;&#44; Jos&#233; Manuel Olmos Mart&#237;nez&#44; Pilar Orozco L&#243;pez&#44; Ram&#243;n P&#233;rez Cano&#44; Jos&#233; Luis P&#233;rez Castrill&#243;n&#44; Pilar Peris Bernal&#44; J&#46; Manuel Quesada G&#243;mez&#44; Jos&#233; Antonio Riancho Moral&#44; Manuel Sosa Henr&#237;quez and Antonio Torrijos Eslava&#46;</p> <p id="par0355" class="elsevierStylePara elsevierViewall">Methodology&#58; Miguel Delgado&#46;</p> <p id="par0360" class="elsevierStylePara elsevierViewall">Literature search&#58; Jos&#233; Luis Hern&#225;ndez&#44; Mar&#237;a Rodr&#237;guez Sanz&#46;</p>"
            "etiqueta" => "Appendix A"
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            "Alto" => 2325
            "Ancho" => 3295
            "Tamanyo" => 420884
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Drug selection algorithm&#46; Abbreviations&#58; DS&#44; digestive system&#59; ALN&#44; alendronate&#59; Dmab&#44; denosumab&#59; BMD&#44; bone mineral density&#59; FN&#44; femoral neck&#59; RF&#44; renal failure&#59; PTH 1-34&#44; teriparatide&#59; SR&#44; strontium ranelate&#59; RIS&#44; risedronate&#59; SERMs&#44; selective estrogen receptor modulators&#59; ZOLE&#44; zoledronate&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2471
            "Ancho" => 3162
            "Tamanyo" => 454995
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Sequential treatment algorithm&#46; Abbreviations&#58; DS&#44; digestive system&#59; ALN&#44; alendronate&#59; BPN&#44; bisphosphonates&#59; Dmab&#44; denosumab&#59; BMD&#44; bone mineral density&#59; RF&#44; renal failure&#59; PTH 1-34&#44; teriparatide&#59; SR&#44; strontium ranelate&#59; RIS&#44; risedronate&#59; SERMs&#44; selective estrogen receptor modulators&#59; ZOLE&#44; zoledronate&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; RCT&#44; randomized clinical trial&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1a</span> Systematic reviews of RCTs with homogeneity among the individual studies or several RCTs with similar results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1b</span> Individual RCT with narrow confidence interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2a</span> Systematic review of cohort studies with homogeneity among the individual studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2b</span> Individual cohort study or RCT of low quality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2c</span> &#8220;Results&#8221; research&#59; ecological studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3a</span> Systematic review of case-control studies with homogeneity among the individual studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3b</span> Individual case-control study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4</span> Case series and low-quality cohort and case-control studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">5</span> Expert opinions without explicit critical assessment or based on physiology&#44; basic research or &#8220;first principles&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab971647.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Levels of evidence according to the Oxford Centre for evidence-based medicine for studies that assess therapy&#44; prevention or damage&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consistent level 1 studies &#40;randomized clinical trials&#41;&#46; Consistency is defined as homogeneity &#40;correlation&#41; in the results of the various individual studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consistent level 2 &#40;cohort&#41; or level 3 &#40;case-control&#41; studies or extrapolations of level 1 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Level 4 studies &#40;case series and low-quality cohort or case-control studies&#41; or extrapolations of level 2 or level 3 studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Level 5 tests &#40;expert opinions&#44; inconclusive studies or inconsistency problems among them&#44; whatever their level&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab971643.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Levels of recommendation of the Oxford Centre for evidence-based medicine according to the levels of evidence&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1&#46; Factors associated with greater constancy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypogonadism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Early menopause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Amenorrhea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anorexia nervosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Malabsorption&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rheumatoid arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes &#40;particularly type 1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Immobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aromatase inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Gonadotropin-releasing hormone agonist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2&#46; Factors associated with lower regularity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hyperparathyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hyperthyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Selective serotonin reuptake inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Proton pump inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anticonvulsants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vitamin D deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab971645.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diseases and treatments that are risk factors for osteoporosis&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; SD&#44; standard deviation&#59; BMD&#44; bone mineral density&#59; T-score&#44; comparison with BMD value achieved in young reference population&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion for BMD &#40;T-score&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD T<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>&#8722;1 SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteopenia or low bone mineral density&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD T<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#8722;1 and &#62;&#8722;2&#46;49 SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5 SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BMD T<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5 SD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fracture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab971646.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">WHO Diagnostic Criteria for Osteoporosis&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; NSAID&#44; nonsteroidal anti-inflammatory drugs&#59; ALN&#44; alendronate&#59; BP&#44; bisphosphonates&#59; FDA&#44; Food and Drug Administration&#59; GFR&#44; glomerular filtration rate&#59; IBAN&#44; ibandronate&#59; IV&#58; intravenous&#59; RIS&#44; risedronate&#59; ZOL&#44; zoledronate&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper gastrointestinal tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reported with oral bisphosphonates &#40;esophagitis and esophageal ulcers&#41;An increase in the incidence of esophageal cancer has not been confirmed&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Can be largely avoided if the drug is ingested properly &#40;with a glass of water and remaining upright for the next 30 &#91;ALN&#44; RIS&#93; or 60 &#91;IBAN&#93;<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; Oral BPs should be avoided for patients with upper gastrointestinal tract conditions &#40;e&#46;g&#46;&#44; difficulty swallowing and Barrett&#39;s esophagus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute phase reaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flu-like illness &#40;malaise&#44; myalgia&#44; fever&#41;&#46; Occurs mainly with IV BPs &#40;25&#8211;35&#37; of those who are treated with ZOL for the first time&#44; decreasing in successive doses&#41;&#46; Occurs at 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h and generally disappears in 3 days&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The administration of paracetamol &#40;but not NSAIDs&#41; is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Its association with BPs is debated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The FDA recommends that fear of its onset should not influence the prescription&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">For patients with normal GFR&#44; IV BPs can promote the development of renal failure if not administered with caution&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The excessively rapid administration of IV BPs &#40;&#60;15<span class="elsevierStyleHsp" style=""></span>min for ZOL&#41; should be avoided&#44; as well as the simultaneous use of potentially nephrotoxic agents &#40;diuretic NSAIDs&#41; and their use in dehydrated patients&#46;Renal function should be assessed in the days following the administration of ZOL&#46; BPs&#44; both IV and oral&#44; should be avoided if the GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#8211;35<span class="elsevierStyleHsp" style=""></span>mL&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypocalcemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV BPs can cause hypocalcemia&#44; especially when administered to patients with reduced GFR or vitamin D deficiency&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clinicians should ensure that vitamin D levels&#44; calcemia and renal function are appropriate before administering BP intravenously&#46;Calcemia should be assessed in the days following the administration of ZOL&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maxillary osteonecrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Its risk is very low with oral BPs &#40;1&#47;1500&#8211;1&#47;100&#44;000 patients per year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">43</span></a> This disease is related to oral health status and dental operations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discontinuing BPs when faced with a dental operation is not recommended&#46;The measurement of bone turnover markers is not recommended&#46;If a patient with BP requires a dental operation&#44; it should be performed&#44; ensuring that the procedure is as noninvasive as possible&#46;Patients with BPs should maintain good oral hygiene&#46;Teriparatide could be useful for treating osteonecrosis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atypical femur fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Its incidence increases with the BP exposure time &#40;high relative risk at 8&#8211;10 years of treatment&#44; but low absolute risk&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Requiring rest and&#44; if necessary&#44; surgery&#46;The contralateral femur should be examined&#46;Administering teriparatide may be considered for the treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adverse ocular effects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Various types of ocular inflammatory reactions have been reported with BPs&#46; Can appear hours to years after the start of its administration &#40;mean&#44; 3 weeks&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The use of BPs should be discontinued &#40;progression is usually favorable&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diffuse osteoarticular and muscle pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Is uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The use of BPs should be discontinued &#40;the spontaneous progression is usually favorable&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Original language: English
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