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Osteoporosis is preventable and treatable, but only a small proportion of people at risk for fractures are evaluated and treated, according to new osteoporosis guidelines published in the journal Endocrine Practice.

The guidelines recommend that all postmenopausal women aged 50 year and older be evaluated for osteoporosis risk. Such evaluation should include a detailed history, physical exam, and clinical fracture risk assessment.

The guidelines were developed by the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE).

The guidelines’ recommendations are graded from A to D. Most recommendations, including the recommendation to evaluate all women aged 50 years and older, are graded B, meaning they are based on at least 1 well-designed study.

Recommendations with an A grade are based on the most convincing evidence from multiple gold-standard clinical trials. A-grade recommendations include:

• Provide counselling on reducing risk of falls, particularly among the elderly.
• Strongly recommend medications for patients with osteopenia or low bone mass and a history of a fragility fracture of the hip or spine. Medications include alendronate (Fosamax), risedronate (Actonel), zoledronic acid (Zometa) and denosumab (Prolia and Xgeva).
• Treatment with teriparatide (Forteo) should be limited to 2 years.
• Successful treatment of osteoporosis is defined as stable or increasing bone mineral density with no evidence of new fractures or fracture progression.

The initial therapy should be guided by the patient’s fracture risk and the presence or absence of prior fragility fractures.

For patients with moderate fracture risk, the guidelines recommend that stable patients take a “drug holiday” after taking an oral bisphosphonate for 5 years or an intravenous (IV) bisphosphonate for 3 years. Patients at higher fracture risk should continue oral therapy for up to 10 years and IV therapy for up to 6 years. During the drug holiday in these higher risk patients, another drug such as raloxifene or teriparatide could be considered.

“Despite these significant costs, fewer than 1 in 4 women aged 67 years or older with an osteoporosis-related fracture undergoes bone density measurement or begins osteoporosis treatment,” the guidelines state.

Risk factors for osteoporosis include age 65 or older, low body weight, family history of osteoporosis or fractures, smoking, early menopause, and excessive alcohol intake (≥3 drinks per day).

“Further study is needed to determine the most effective means of communicating benefit and risk in osteoporosis management,” the guidelines state. “The best available evidence at this time suggests that communication skills can be learned, decision aids may be helpful and that shared decision-making may improve clinical outcomes.”

SOURCE: Loyola University Health System