By Bianca Nogrady
New guidelines on fracture prevention from the American College of Physicians strongly recommend pharmacological fracture prevention in women with known osteoporosis.
The guidelines, published in the Annals of Internal Medicine, cite ‘high-quality’ evidence for the prescription of alendronate, risedronate, zoledronic acid or denosumab to reduce the risk of hip and vertebral fractures in women. There was also a separate recommendation to offer bisphosphonates to men with clinically-recognised osteoporosis, to reduce their risk of vertebral fracture.
The third recommendation, which was graded as weak/supported by low-quality evidence, suggested that women with osteoporosis use pharmacological treatment for five years.
‘Low-quality evidence showed that the appropriate duration of treatment is uncertain, although high-risk patients may benefit from more than five years of treatment,’ the guideline authors wrote.
Commenting on this recommendation, Professor Peter Ebeling, Medical Director of Osteoporosis Australia and Head of the Department of Medicine at Monash University in Melbourne, said it was a little too prescriptive, particularly with a drug such as denosumab which generally required longer treatment duration.
The US guidelines also recommended against bone density monitoring during the five-year pharmacological treatment period – a recommendation Professor Ebeling also said should be approached with caution. ‘We would probably recommend checking bone density again after patients start treatment,’ he told Endocrinology Today, pointing out that the recommendation may relate to changes in the US regarding reimbursement for bone densitometry.
‘Certainly if people stop therapy we would recommend checking bone density after two or three years.’
The authors of the US guidelines also addressed the role of hormone replacement therapy (HRT), saying there was moderate-quality evidence to support a recommendation against using menopausal oestrogen therapy, menopausal oestrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women.
However, Professor Ebeling said this disagreed with the recent guidelines from the Royal Australian College of General Practitioners.
‘In women who were less than 59 years of age and had menopausal symptoms and low bone density, we would recommend considering using HRT,’ Professor Ebeling said. He said raloxifene should particularly be considered in women at risk of spinal osteoporosis who also have an elevated background risk of breast cancer, because that might have the added benefit of reducing their risk of breast cancer.
The final recommendation of the US guidelines was that clinicians should consider patient preference, fracture risk profile and the benefits, harms and cost of medications when making a decision about whether to treat osteopenic women aged 65 years or older.
Ann Intern Med 2017; 166: 818-839.