Guideline recommends pharmacologic treatment of osteoporosis in postmenopausal women at high fracture risk

Postmenopausal women at high risk for fractures should be treated initially with bisphosphonates, according to new recommendations from the Endocrine Society.

The clinical practice guideline was supported by two systematic reviews commissioned by the writing committee, one examining 107 randomized controlled trials of osteoporosis treatment in postmenopausal women and one evaluating women's values and preferences. It was published online March 25 by the Journal of Clinical Endocrinology and Metabolism and will appear in the May issue.

Postmenopausal women at high risk for fracture, especially those who have had a fracture recently, should receive bisphosphonates as initial treatment, although ibandronate is not recommended for reducing nonvertebral or hip fracture risk, the guideline said. The guideline recommends reassessment of fracture risk after three to five years of treatment; those still at high risk should continue therapy, while a bisphosphonate holiday should be considered in those who are at low to moderate risk.

Denosumab is recommended as an alternative treatment, 60 mg subcutaneously every six months. Because the effects of denosumab reverse after six months if the drug is not taken as scheduled, a drug holiday is not recommended. Fracture risk in patients taking denosumab should be reassessed after five to 10 years, and those who remain at high risk should continue denosumab or start treatment with other osteoporosis therapies, the guideline said. Of note, denosumab should not be delayed or withdrawn without administration of antiresorptive or other therapy to prevent a rebound in bone turnover or rapid bone loss.

The guideline recommends that postmenopausal women with osteoporosis who are at very high risk for fracture should be treated with teriparatide or abaloparatide for up to two years. Those who complete a course of treatment with either drug should be treated with antiresorptive therapies to maintain gains in bone density, the guideline said. Patients at high risk who have a low risk of deep venous thrombosis or a high risk of breast cancer or in whom bisphosphonates or denosumab is not appropriate should be treated with raloxifene or bazedoxifene, the guideline recommends.

The guideline also includes recommendations on menopausal hormone therapy and tibolone, calcitonin, and calcium and vitamin D, as well as more advice on choice of treatment, optimal duration of treatment and drug holidays, and monitoring. The guideline writing committee determined that the risk of future fractures in postmenopausal women should be determined by using country-specific assessment tools to guide decision-making, that patient preferences should be considered when planning treatment, that nutritional and lifestyle interventions and fall prevention should accompany all pharmacologic regimens to reduce fracture risk, and that multiple pharmacologic therapies can reduce fracture rates in at-risk postmenopausal women with acceptable risk-benefit and safety profiles.

The guideline authors also noted that ACP's guideline on treatment of low bone mineral density or osteoporosis to prevent fractures in women and men differs from the current guideline, for example, by recommending treatment with drug therapy for five years and recommending against monitoring bone mineral density during that time. ACP's guideline was published by Annals of Internal Medicine on May 9, 2017.