ACP issues new osteoporosis guidance
The new clinical guideline from the College updates its 2017 recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults.
Clinicians should use bisphosphonates for initial pharmacologic treatment to reduce the risk for fractures in postmenopausal females diagnosed with primary osteoporosis, ACP said in a strong recommendation based on high-certainty evidence.
The recommendation was included in a new ACP guideline published Jan. 3 by Annals of Internal Medicine. The guideline was based on a systematic review and network meta-analysis and updates the College's 2017 recommendations on this topic.
ACP's additional recommendations are as follows:
- ACP suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis (conditional recommendation; low-certainty evidence).
- ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; moderate-certainty evidence).
- ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; low-certainty evidence).
- ACP suggests that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant PTH (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture (conditional recommendation).
- ACP suggests that clinicians take an individualized approach regarding whether to start pharmacologic treatment with a bisphosphonate in females over the age of 65 with low bone mass (osteopenia) to reduce the risk of fracture(s) (conditional recommendation; low-certainty evidence).
The guideline, which was developed by ACP's Clinical Guidelines Committee, also included a section on clinical considerations. Among other suggestions, clinicians should prescribe generic medications if possible, encourage adherence to recommended treatments and healthy lifestyle modifications, and judge baseline risk for fracture based on individualized assessment of bone density, history of fractures, response to prior treatments for osteoporosis, and multiple risk factors for fractures, the guideline said. The guideline authors noted that more research is needed on comparative benefits and harms of treatment in premenopausal women, men, intersex persons, transgender persons after any transitioning treatment, residents of long-term care facilities, and people with multiple comorbid conditions and polypharmacy, among other evidence gaps.