ACP Releases Guidance Update on Osteoporosis Treatment
Summary
Loss of bone mass and changes in bone microarchitecture leads to bone fragility and increased risk of fracture. Osteoporosis is common, with over 10 million older adults diagnosed with osteoporosis and over 40% diagnosed with osteopenia. Bone fractures due to osteoporosis are a substantial source of morbidity and mortality. In January of 2023 ACP has released an update on the treatment of osteoporosis to better aid clinicians in their practice.
Recommendations For Females
- Treat females with known osteoporosis to reduce hip and vertebral fractures with the following medications
- First line therapy bisphosphonates: Alendronate | Risedronate | Ibandronate | Zoledronate
- Second line therapy use RANK ligand inhibitor: Denosumab
- For females with primary osteoporosis and very high risk of fracture
- Sclerostin inhibitor (Romosozumab) or Recombinant PTH (Teriparatide) followed by
- Bisphosphanate therapy to prevent rebound fractures
- Treatment plan should include lifestyle changes such as regular exercise and adequate calcium and vitamin D intake
- Consider stopping bisphosphonate therapy after 5 years to reduce long term harm unless patient has a compelling indication for continued therapy
- Consider bisphosphonate therapy for patients ≥65 years with osteopenia based on patient’s individual circumstances
- Evidence regarding use of estrogen | treatment duration | drug discontinuation | serial bone mineral density not updated but there are plans to update these in the Living Clinical Guideline (see Learn More-Primary Sources below)
- Do not monitor bone density during 5-year treatment period
- Do not use menopausal estrogen therapy (with or without progestogen) or raloxifene
Recommendations For Males
- Treat males with known osteoporosis to reduce hip and vertebral fractures with the following medications
- First line therapy use bisphosphonates including: Alendronate | Risedronate | Ibandronate | Zoledronate
- Second line therapy use RANK ligand inhibitor: Denosumab
Note: There is no evidence suggesting differences in treatment benefits and harms between males and females. For transgender patients the risk of osteoporosis varies depending on age of gonadectomy and history of sex hormone therapy and should be taken into account when choosing treatments for secondary osteoporosis.
Risk Factors For Osteoporosis (Partial List):
- Clinical
- Increasing age
- Caucasian
- Female
- Low Dietary Calcium Intake
- Underweight
- Excessive Alcohol Intake (> 3 drinks/day)
- Smoking
- Fractures due to minimal trauma
- Family or personal history of fractures due to osteoporosis
- Medical History
- Rheumatoid arthritis
- HIV
- Immobilization
- Premature ovarian failure
- Postmenopausal
- Medications (partial list)
- Glucocorticoids
- Anticoagulants
- Anticonvulsants
- Aromatase inhibitors
- Gonadotropin-releasing hormone agonists
- Androgen deprivation therapy
- Clinical laboratory
- Vitamin D deficiency
Diagnosis:
- Occurrence of fragility fracture
- Decreased BMD
- Dual-energy x-ray absorptiometry (DXA)
- Will only predict less than 50% of fractures
- T score of –2 indicates a BMD that is 2 SDs below the comparative norm
- International reference standard in postmenopausal women and in men aged 50 years or older
- Neck BMD of 2.5 SD or more < the young female adult mean
