Clinical Edge

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Guidelines for Treatment of Osteoporosis

Ann Intern Med; ePub 2017 May 9; Qaseem, et al

The American College of Physicians (ACP) has updated its clinical practice guideline for the treatment of low bone density (LBD) or osteoporosis to prevent fractures in men and women. The guideline updates the 2008 ACP recommendations and is based on a systematic review of randomized controlled trials, systematic reviews, large observational studies, and case reports published between January 2, 2005, and June 3, 2011. The guideline focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for LBD. ACP recommendations include:

  • ACP recommends that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis.
  • ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years.
  • ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinically recognized osteoporosis.
  • ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women.
  • ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women.
  • ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications.

Citation:

Qaseem A, Forciea MA, McLean RM, Denberg TD, for the Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: A clinical practice guideline update from the American College of Physicians. [Published online ahead of print May 9, 2017]. Ann Intern Med. doi:10.7326/M15-1361.

Commentary:

Osteoporosis is defined by BMD at the hip or lumbar spine 2.5 standard deviations below the mean BMD of a young-adult reference population. It is best viewed not as a disease, but as a risk factor for fracture, similar to the way that hypertension is a risk factor for the development of coronary disease.¹ Approximately half of all Caucasian women and 20% of men will develop an osteoporosis-related fracture during their lifetime. The US Preventive Services Task Force recommends DEXA testing in all women aged 65 and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors.² This ACP guideline gives needed clarity and direction given the great deal of change over the last few years regarding therapy of osteoporosis. The guideline states that bisphosphonates or denosumab are first line agents for the treatment of osteoporosis. For women over the age of 65 with osteopenia, the guideline suggests using judgment and shared decision making, a recommendation that differs from the National Osteoporosis Foundation's recommendation that emphasizes use of the FRAX score to estimate risk of fracture and treat all those over a defined risk threshold.¹ The ACP guideline answers one of the most important recent questions of how long treatment should last. ACP says 5 years, except in women with severe osteoporosis in whom longer treatment may be indicated. —Neil Skolnik, MD

  1. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359-2381. doi:10.1007/s00198-014-2794-2.
  2. Nelson HD, Haney EM, Chou R, Dana T, Fu R, Bougatsos C. Screening for osteoporosis: Systematic review to update the 2002 US Preventive Services Task Force Recommendation. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Jul. Report No. :10-05145-EF-1. U.S. Preventive Services Task Force Evidence Synthesis.