Lessons learned with Bone Health TeleECHO: making treatment decisions when guidelines conflict.

Clinical practice guidelines provide helpful information for managing patients with metabolic bone disease. Good guidelines are based on the best available medical evidence; however, guidelines from different societies can conflict. Additionally, it is not possible for a guideline to anticipate the vast variability of circumstances, comorbidities, previous medical experiences, cultural differences, and preferences in real-world patients. Bone Health TeleECHO is a strategy for sharing knowledge on the care of patients with skeletal diseases through ongoing interactive videoconferences. We report three cases based on those presented at Bone Health TeleECHO, where, through discussion, treatment outside of commonly used guidelines was ultimately recommended. Guidelines developed by different organizations may provide "evidence-based" or "informed" recommendations which do not account for the variability of clinical circumstances encountered in the care of individual patients. This highlights the importance of Bone Health TeleECHO, where healthcare professionals can share knowledge, individualize treatment decisions, and improve patient care.Learning objectives At the end of this activity participants should be able to:• Distinguish between the onset and off of bisphosphonates versus other medications used in the prevention and treatment of osteoporosis and how this affects choice of a "drug holiday."• Understand the limitations of clinical practices guidelines in the care of an individual patient and how interactive video conferencing can assist with decision making.• Recognize that patients treated with glucocorticoids at high risk for fracture can benefit from more aggressive interventions for osteoporosis.