The 2018 Guidelines for the diagnosis and treatment of osteoporosis in Greece



We report the updated guidelines for the management of osteoporosis in Greece, which include guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information, and national evidence from Greek clinical practice and the healthcare setting.


The purpose of this report was to update the Guidelines for the Management of Osteoporosis in Greece that was published in 2011.


In line with the GRADE system, the working group initially defined the main clinical questions that should be addressed when dealing with the diagnosis and management of osteoporosis in clinical practice in Greece. Following a literature review and discussion on the experience gained from the implementation of the 2011 Guidelines transmitted through the national electronic prescription network, the Hellenic Society for the Study of Bone Metabolism (HSSBM) uploaded an initial draft for an open dialogue with the relevant registered medical societies and associations on the electronic platform of the Greek Ministry of Health. After revisions, the Central Health Council approved the final document.


The 2018 Guidelines provide comprehensive recommendations on the issues of the timing of fracture risk evaluation and dual-energy X-ray absorptiometry (DXA) measurement, interpretation of the DXA results, the diagnostic work-up for osteoporosis, the timing as well as the suggested medications for osteoporosis treatment, and the follow-up methodology employed during osteoporosis treatment.


These updated guidelines were designed to offer valid guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information and national evidence from clinical practice and the healthcare setting. Clinical judgment is essential in the management of every individual patient for the purpose of achieving the optimal outcome in the safest possible way.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Svedbom A, Hernlund E, Ivergard M et al (2013) Epidemiology and economic burden of osteoporosis in Greece. Arch Osteoporos 8:83–90

    Article  Google Scholar 

  2. 2.

    Lyritis GP, Rizou S, Galanos A, Makras P (2013) Incidence of hip fractures in Greece during a 30-year period: 1977-2007. Osteoporos Int 24:1579–1585

    CAS  Article  Google Scholar 

  3. 3.

    Hernlund E, Svedbom A, Ivergard M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jonsson B, Kanis JA (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the international Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8:136

    CAS  Article  Google Scholar 

  4. 4.

    Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R, National Osteoporosis F (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25:2359–2381

    CAS  Article  Google Scholar 

  5. 5.

    Kanis JA, Cooper C, Rizzoli R, Reginster JY, Scientific Advisory Board of the European Society for C, Economic Aspects of O, the Committees of Scientific A, National Societies of the International Osteoporosis F (2018) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int.

  6. 6.

    Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD, for the Scientific Advisory Council of Osteoporosis Canada (2010) 2010 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 182:1864–1873

    Article  Google Scholar 

  7. 7.

    Makras P, Vaiopoulos G, Lyritis GP, Greek National Medicine A (2012) 2011 Guidelines for the diagnosis and treatment of osteoporosis in Greece. J Musculoskelet Neuronal Interact 12:38–42

    CAS  PubMed  Google Scholar 

  8. 8.

    Makras P, Athanasakis K, Boubouchairopoulou N, Rizou S, Anastasilakis AD, Kyriopoulos J, Lyritis GP (2015) Cost-effective osteoporosis treatment thresholds in Greece. Osteoporos Int 26:1949–1957

    CAS  Article  Google Scholar 

  9. 9.

    Compston J, Cooper A, Cooper C et al (2017) UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 12:43

    CAS  Article  Google Scholar 

  10. 10.

    Rodrigues AM, Canhao H, Marques A et al (2018) Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis—2018 update. Acta Reumatol Port 43:10–31

    CAS  PubMed  Google Scholar 

  11. 11.

    Kanis JA, Hans D, Cooper C et al (2011) Interpretation and use of FRAX in clinical practice. Osteoporos Int 22:2395–2411

    CAS  Article  Google Scholar 

  12. 12.

    Silverman SL, Calderon AD (2010) The utility and limitations of FRAX: a US perspective. Curr Osteoporos Rep 8:192–197

    Article  Google Scholar 

  13. 13.

    Kanis JA, Johansson H, Oden A, McCloskey EV (2011) Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int 22:809–816

    CAS  Article  Google Scholar 

  14. 14.

    Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA (2011) Spine-hip discordance and fracture risk assessment: a physician-friendly FRAX enhancement. Osteoporos Int 22:839–847

    CAS  Article  Google Scholar 

  15. 15.

    Lewiecki EM, Gordon CM, Baim S, Leonard MB, Bishop NJ, Bianchi ML, Kalkwarf HJ, Langman CB, Plotkin H, Rauch F, Zemel BS, Binkley N, Bilezikian JP, Kendler DL, Hans DB, Silverman S (2008) International Society for Clinical Densitometry 2007 Adult and Pediatric Official Positions. Bone 43:1115–1121

    Article  Google Scholar 

  16. 16.

    Silverberg SJ, Clarke BL, Peacock M, Bandeira F, Boutroy S, Cusano NE, Dempster D, Lewiecki EM, Liu JM, Minisola S, Rejnmark L, Silva BC, Walker MD, Bilezikian JP (2014) Current issues in the presentation of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab 99:3580–3594

    CAS  Article  Google Scholar 

  17. 17.

    Kanis JA, Melton LJ 3rd, Christiansen C, Johnston CC, Khaltaev N (1994) The diagnosis of osteoporosis. J Bone Miner Res 9:1137–1141

    CAS  Article  Google Scholar 

  18. 18.

    Genant HK, Cooper C, Poor G, Reid I, Ehrlich G, Kanis J, Nordin BEC, Barrett-Connor E, Black D, Bonjour JP, Dawson-Hughes B, Delmas PD, Dequeker J, Eis SR, Gennari C, Johnell O, Johnston Jr CC, Lau EMC, Liberman UA, Lindsay R, Martin TJ, Masri B, Mautalen CA, Meunier PJ, Miller PD, Mithal A, Morii H, Papapoulos S, Woolf A, Yu W, Khaltaev N (1999) Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporos Int 10:259–264

    CAS  Article  Google Scholar 

  19. 19.

    The International Society for Clinical Densitometry (2015) Official Positions of the International Society for Clinical Densitometry. Last access 15 Dec 2018

  20. 20.

    Ferrari S, Bianchi ML, Eisman JA, Foldes AJ, Adami S, Wahl DA, Stepan JJ, de Vernejoul MC, Kaufman JM, IOF Committee of Scientific Advisors Working Group on Osteoporosis Pathophysiology (2012) Osteoporosis in young adults: pathophysiology, diagnosis, and management. Osteoporos Int 23:2735–2748

    CAS  Article  Google Scholar 

  21. 21.

    Tannenbaum C, Clark J, Schwartzman K, Wallenstein S, Lapinski R, Meier D, Luckey M (2002) Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab 87:4431–4437

    CAS  Article  Google Scholar 

  22. 22.

    Rizzoli R, Boonen S, Brandi ML, Bruyere O, Cooper C, Kanis JA, Kaufman JM, Ringe JD, Weryha G, Reginster JY (2013) Vitamin D supplementation in elderly or postmenopausal women: a 2013 update of the 2008 recommendations from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Curr Med Res Opin 29:305–313

    CAS  Article  Google Scholar 

  23. 23.

    Papapoulos S, Makras P (2008) Selection of antiresorptive or anabolic treatments for postmenopausal osteoporosis. Nat Clin Pract Endocrinol Metab 4:514–523

    CAS  Article  Google Scholar 

  24. 24.

    Szulc P, Naylor K, Hoyle NR, Eastell R, Leary ET (2017) Use of CTX-I and PINP as bone turnover markers: National Bone Health Alliance recommendations to standardize sample handling and patient preparation to reduce pre-analytical variability. Osteoporos Int 28:2541–2556

    CAS  Article  Google Scholar 

  25. 25.

    Diez-Perez A, Adachi JD, Agnusdei D et al (2012) Treatment failure in osteoporosis. Osteoporos Int 23:2769–2774

    CAS  Article  Google Scholar 

  26. 26.

    Watts NB, Adler RA, Bilezikian JP, Drake MT, Eastell R, Orwoll ES, Finkelstein JS, Endocrine S (2012) Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 97:1802–1822

    CAS  Article  Google Scholar 

  27. 27.

    Cranney A, Wells GA, Yetisir E, Adami S, Cooper C, Delmas PD, Miller PD, Papapoulos S, Reginster JY, Sambrook PN, Silverman S, Siris E, Adachi JD (2009) Ibandronate for the prevention of nonvertebral fractures: a pooled analysis of individual patient data. Osteoporos Int 20:291–297

    CAS  Article  Google Scholar 

  28. 28.

    Silverman SL, Christiansen C, Genant HK, Vukicevic S, Zanchetta JR, de Villiers TJ, Constantine GD, Chines AA (2008) Efficacy of bazedoxifene in reducing new vertebral fracture risk in postmenopausal women with osteoporosis: results from a 3-year, randomized, placebo-, and active-controlled clinical trial. J Bone Miner Res 23:1923–1934

    CAS  Article  Google Scholar 

  29. 29.

    Diez-Perez A, Marin F, Eriksen EF, Kendler DL, Krege JH, Delgado-Rodriguez M (2018) Effects of teriparatide on hip and upper limb fractures in patients with osteoporosis: a systematic review and meta-analysis. Bone 120:1–8

    Article  Google Scholar 

  30. 30.

    Kanis JA, Cooper C, Rizzoli R et al (2017) Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting. Osteoporos Int 28:2023–2034

    CAS  Article  Google Scholar 

  31. 31.

    Hiligsmann M, Gathon HJ, Bruyere O, Ethgen O, Rabenda V, Reginster JY (2010) Cost-effectiveness of osteoporosis screening followed by treatment: the impact of medication adherence. Value Health 13:394–401

    Article  Google Scholar 

  32. 32.

    Adler RA, El-Hajj Fuleihan G, Bauer DC et al (2016) Managing osteoporosis in patients on long-term bisphosphonate treatment: report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res 31:16–35

    CAS  Article  Google Scholar 

  33. 33.

    Martino S, Cauley JA, Barrett-Connor E, Powles TJ, Mershon J, Disch D, Secrest RJ, Cummings SR, Investigators C (2004) Continuing outcomes relevant to Evista: breast cancer incidence in postmenopausal osteoporotic women in a randomized trial of raloxifene. J Natl Cancer Inst 96:1751–1761

    CAS  Article  Google Scholar 

  34. 34.

    European Medicines Agency (2013) Questions and answers on the review of calcitonin-containing medicines. EMA/731082/2012 Rev.1, EMEA/H/A-31/1291

  35. 35.

    Napoli N, Langdahl BL, Ljunggren O et al (2018) Effects of teriparatide in patients with osteoporosis in clinical practice: 42-month results during and after discontinuation of treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int.

  36. 36.

    Nevitt MC, Chen P, Dore RK, Reginster JY, Kiel DP, Zanchetta JR, Glass EV, Krege JH (2006) Reduced risk of back pain following teriparatide treatment: a meta-analysis. Osteoporos Int 17:273–280

    Article  Google Scholar 

  37. 37.

    Anastasilakis AD, Polyzos SA, Makras P (2018) Therapy of endocrine disease: denosumab vs bisphosphonates for the treatment of postmenopausal osteoporosis. Eur J Endocrinol 179:R31–R45

    CAS  Article  Google Scholar 

  38. 38.

    McClung MR, Wagman RB, Miller PD, Wang A, Lewiecki EM (2017) Observations following discontinuation of long-term denosumab therapy. Osteoporos Int 28:1723–1732

    CAS  Article  Google Scholar 

  39. 39.

    Brown JP, Roux C, Torring O et al (2013) Discontinuation of denosumab and associated fracture incidence: analysis from the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) trial. J Bone Miner Res 28:746–752

    CAS  Article  Google Scholar 

  40. 40.

    Anastasilakis AD, Polyzos SA, Makras P, Aubry-Rozier B, Kaouri S, Lamy O (2017) Clinical features of 24 patients with rebound-associated vertebral fractures after denosumab discontinuation: systematic review and additional cases. J Bone Miner Res 32:1291–1296

    CAS  Article  Google Scholar 

  41. 41.

    Cummings SR, Ferrari S, Eastell R, Gilchrist N, Jensen JEB, McClung M, Roux C, Törring O, Valter I, Wang AT, Brown JP (2018) Vertebral fractures after discontinuation of denosumab: a post hoc analysis of the randomized placebo-controlled FREEDOM trial and its extension. J Bone Miner Res 33:190–198

    CAS  Article  Google Scholar 

  42. 42.

    Tsourdi E, Langdahl B, Cohen-Solal M, Aubry-Rozier B, Eriksen EF, Guanabens N, Obermayer-Pietsch B, Ralston SH, Eastell R, Zillikens MC (2017) Discontinuation of denosumab therapy for osteoporosis: a systematic review and position statement by ECTS. Bone 105:11–17

    Article  Google Scholar 

  43. 43.

    Meier C, Uebelhart B, Aubry-Rozier B et al (2017) Osteoporosis drug treatment: duration and management after discontinuation. A position statement from the SVGO/ASCO. Swiss Med Wkly 147:w14484

    PubMed  Google Scholar 

  44. 44.

    Miller PD, Pannacciulli N, Brown JP, Czerwinski E, Nedergaard BS, Bolognese MA, Malouf J, Bone HG, Reginster JY, Singer A, Wang C, Wagman RB, Cummings SR (2016) Denosumab or zoledronic acid in postmenopausal women with osteoporosis previously treated with Oral bisphosphonates. J Clin Endocrinol Metab 101:3163–3170

    CAS  Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Polyzois Makras.

Ethics declarations

Conflict of interest

-PM has received lecture fees and research grants from Amgen and lecture fees from Glaxo, Eli-Lilly, Pfizer, Leo, Genesis, ELPEN, VIANEX, Rafarm, Galenica, and UniPharma.

-ADA has received lecture fees from Amgen, Eli-Lilly, ELPEN, ITF Hellas, Rafarm, and VIANEX.

-GA has nothing to disclose.

-EC has received lecture and/or advisory board fees from Eli-Lilly and Vianex.

-EGK has received lecture and/or advisory board fees or research grants from Amgen, ELPEN, MSD, Novartis, UCB, Vianex, and Inovis.

-AM has received lecture fees from Merck Sharp & Dohme, UCB, Eli-Lilly, Novartis, Roche, Amgen, Angelini, Janssen-Cilag, and Genesis.

-DKP has received lecture and/or advisory board fees from Abbvie, AENORASIS, Amgen, Eli-Lilly, Galenica, Genesis, Menarini Hellas, MSD, Novartis, Pfizer, Rafarm, Sandoz, UCB, and Vianex.

-KDS has received lecture fees and advisory board fees from Amgen Hellas and honoraria and lecture fees from Pharmaserve Lilly, Specifar a Teva, and VIANEX.

-ST has received lecture and/or advisory board fees from Amgen, Lilly, Vianex, ITF Hellas, Merck Biopharma Greece, Galenica, and Shire Hellas.

-GT has received lecture and advisory board fees from Farmaserv-Lilly, Amgen Hellas, Servier, Vianex, ITF Hellas, Merck Hellas, Astra Zeneca, GSK, and Valeant Bausch Health.

-CK has received lecture and/or advisory board fees from Amgen, Eli-Lilly, and VIANEX, and lecture fees from Galenica.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Authors are listed in alphabetical order, with the exception of first and senior author.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Makras, P., Anastasilakis, A.D., Antypas, G. et al. The 2018 Guidelines for the diagnosis and treatment of osteoporosis in Greece. Arch Osteoporos 14, 39 (2019).

Download citation


  • Osteoporosis
  • Treatment
  • Guidelines
  • Greece
  • FRAX