ACP strongly recommends generic bisphosphonates, denosumab to prevent fractures in women with osteoporosis

ACP strongly recommends that physicians prescribe generic bisphosphonates or denosumab for reducing fracture risk in women with osteoporosis and discuss medication adherence with their patients, especially for bisphosphonates, according to a new guideline.

ACP's guideline focuses on the comparative benefits and risks of short- and long-term drug treatments for low bone density or osteoporosis, including prescriptions, calcium, vitamin D, and estrogen. The guideline was published May 9 by Annals of Internal Medicine.

The six recommendations are as follows.

1. 1. Clinicians should 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 (Grade: strong recommendation; high-quality evidence). Clinicians should discuss the importance of adherence.
2. 2. Clinicians should treat osteoporotic women with pharmacologic therapy for five years (Grade: weak recommendation; low-quality evidence). Continuing treatment after the first five years may benefit some patients and may be appropriate after reassessing the risks and benefits of continuing therapy.
3. 3. Clinicians should offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinically recognized osteoporosis (Grade: weak recommendation; low-quality evidence). While data on men are sparse, no evidence suggests that treatment would differ between men and women.
4. 4. ACP recommends against bone density monitoring during the five-year pharmacologic treatment period for osteoporosis in women because the evidence does not show any benefit for monitoring during treatment (Grade: weak recommendation; low-quality evidence). The evidence also does not support frequent monitoring of women with normal bone density for osteoporosis, as most women with normal bone density measurements did not progress to osteoporosis within 15 years.
5. 5. ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women (Grade: strong recommendation; moderate-quality evidence). Estrogen treatment is associated with serious harms, such as increased risk for cerebrovascular accidents and venous thromboembolic events, that outweigh the potential benefits.
6. 6. 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 (Grade: weak recommendation; low-quality evidence). Clinicians can use their own judgment based on risk factors for fracture, or they can use a risk assessment tool.

According to an accompanying editorial, osteoporosis remains underdetected and undertreated and ACP's guideline provides a solid basis for informed clinical decision making.

“The ACP recommendations address difficult and controversial issues in the setting of insufficient evidence in some critical areas,” the editorial states. “Further, these guidelines are but one of several that exist. Clinicians must carefully examine the considerable differences among them.”