clinical topic updates

Updated Osteoporosis Treatment Recommendations Begin Consensus Building

by Tom Iarocci, MD

Overview

A multistakeholder coalition assembled by the American Society for Bone and Mineral Research reached agreement in key areas after recognizing a lack of harmony among specialty guidelines on osteoporosis. Existing guidelines note the benefits of bone mineral density (BMD) testing in the post-fracture setting.

Expert Commentary

Tom Iarocci, MD

Editor-in-Chief, Expert Perspectives in Medicine
University of Maryland School of Medicine
Baltimore, MD

“The multistakeholder coalition recommended that providers convey 3 simple messages to patients aged 65 years or older with a hip or vertebral fracture that highlight risks for additional fractures, immobility, and losing independence, as well as actionable options for risk reduction.”

Tom Iarocci, MD

The undertreatment of osteoporosis stems from a number of factors, including concerns regarding the rare side effects of osteoporosis medications and, importantly, discrepancies among treatment guidelines and ongoing controversies in the field.

Noting the lack of a unified front on osteoporosis, the American Society for Bone and Mineral Research assembled a multistakeholder coalition with representation from an impressive array of additional organizations, including the American Academy of Orthopedic Surgeons, the American Association of Clinical Endocrinologists, the American College of Endocrinology, the American College of Rheumatology, the Endocrine Society, and Geisinger Health, among others. Recommendations were laser-focused on patients aged 65 years or older with a hip or vertebral fracture, which represents an area of strong agreement. The coalition recommended that providers convey the following 3 simple messages to patients aged 65 years or older with a hip or vertebral fracture that highlight risks for additional fractures, immobility, and losing independence, as well as actionable options for risk reduction:

  1. The presence of a fracture likely means that they have osteoporosis and are at high risk for additional fractures, especially over the next 1 to 2 years.
  2.  Fractures result in declines in mobility or independence—potentially leading to a patient having to use a walker, cane, or wheelchair; to move from their home to a residential facility; or to stop participating in favorite activities—and they will be at higher risk of dying prematurely.
  3.  There are actions that can be taken to reduce their risk, including regular follow‐up with their usual health care provider as for any other chronic medical condition.

The coalition acknowledged that optimal duration of pharmacotherapy is unknown, but stated that, because the risk for second fractures is highest in the early post‐fracture period, prompt treatment is recommended. A fragility fracture has been defined variously as one that occurs after a fall from the standing position or one that is associated with low BMD and increases in incidence with age. The coalition also recommended that practitioners should not wait for BMD testing to offer treatment to patients with fragility fractures. Other widely agreed upon practices included assuring adequate vitamin D and calcium intake; routine reevaluation for fracture risk in those being treated for osteoporosis; monitoring for adverse treatment effects; and strongly encouraging patients to avoid tobacco, to consume alcohol in moderation at most, and to engage in regular exercise and fall prevention strategies.

“BMD testing in the post-fracture setting has a number of benefits. Such testing every 1 to 2 years can identify patients who continue to lose bone despite treatment. These individuals may have secondary causes of osteoporosis, may need changes to their medication regimens, or may have adherence issues such as not taking their medication correctly.”

Tom Iarocci, MD

In a nod to future consensus building, the coalition authors noted that their recommendations are not intended to address the clinical management of acute fractures or how to optimize recovery, nor did they enter the debate regarding the value of BMD testing. As the coalition emphasized, a clinical diagnosis of osteoporosis may be made in the presence of a fragility fracture, regardless of BMD. However, the appropriateness of osteoporosis treatment in the context of a fragility fracture does not negate the benefits of BMD testing. Contemporary guidelines recommend repeat BMD testing for patients being treated for osteoporosis, whereby stability or improvement in BMD is considered to be consistent with a favorable response to therapy, favoring a reduced frequency of BMD measurements thereafter. BMD testing in the post-fracture setting has a number of benefits. Such testing every 1 to 2 years can identify patients who continue to lose bone despite treatment. These individuals may have secondary causes of osteoporosis, may need changes to their medication regimens, or may have adherence issues such as not taking their medication correctly.

Finally, as is also noted in several contemporary guidelines, referral to endocrinologists, rheumatologists, or other osteoporosis specialists may be warranted for patients who experience repeated fracture or bone loss and for those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).

References

Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis - 2016. Endocr Pract. 2016;22(suppl 4):1-42.

Conley RB, Adib G, Adler RA, et al. Secondary fracture prevention: consensus clinical recommendations from a multistakeholder coalition. J Bone Miner Res. 2020;35(1):36-52.

Cosman F, de Beur SJ, LeBoff MS, et al; National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis [published correction appears in Osteoporos Int. 2015;26(7):2045-2047]. Osteoporos Int. 2014;25(10):2359-2381.

Cosman F. The evolving role of anabolic therapy in the treatment of osteoporosis. Curr Opin Rheumatol. 2019;31(4):376-380.

Lagari V, Gavcovich T, Levis S. The good and the bad about the 2017 American College of Physicians osteoporosis guidelines. Clin Ther. 2018;40(1):168-176.

The International Society for Clinical Densitometry. 2019 ISCD official positions ‐ adult. https://www.iscd.org/official-positions/2019-iscd-official-positions-adult/. Accessed January 30, 2020.

Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822.

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