Osteoporosis guideline tackles optimal treatments, monitoring in postmenopausal women
NEW ORLEANS — A new guideline from the Endocrine Society outlines current evidence for treating osteoporosis in postmenopausal women and provides recommendations on the newest, most effective medication options, monitoring and more.
One of the key points for providers, according to Clifford J. Rosen, MD, is the recommendation to treat high-risk individuals — particularly those with a history of fracture — with pharmacologic therapies, as the benefits outweigh the risks.
“Multiple pharmacologic therapies are capable of reducing fracture rates in postmenopausal women at risk, with acceptable risk-benefit and safety profiles,” Rosen, director of the Center for Clinical and Translational Research at Maine Medical Center Research Institute in Scarborough and chair of the guideline writing committee, said during a press conference at the Endocrine Society Annual Meeting.
Bisphosphonates are the recommended first-line therapy to reduce fracture risk in high-risk postmenopausal women, with the exception of ibandronate, which is not recommended to reduce nonvertebral or hip fracture risk, according to the guideline, simultaneously published in The Journal of Clinical Endocrinology & Metabolism. Denosumab (Prolia, Amgen) is recommended as an alternative initial treatment in women with high risk for fractures.
An important point with bisphosphonate treatment, according to Rosen, is the need to reassess fracture risk in women who have been on bisphosphonates for 3 to 5 years. Women taking bisphosphonates who have low to moderate risk for fractures should be considered for a bisphosphonate holiday after reassessment, he said.
The guideline also provides recommendations for other treatments. Teriparatide (Forteo, Eli Lilly) or abaloparatide (Tymlos, Radius Health) can be used for up to 2 years in postmenopausal women with very high fracture risk to reduce vertebral and nonvertebral fractures. In specific patients, such as those with high risk for breast cancer, those with low risk for deep vein thrombosis and those for whom bisphosphonates or denosumab are not appropriate, treatment with the selective estrogen receptor modulators raloxifene or bazedoxifene can be considered. Estrogen treatment is advised only for women with hysterectomy at high risk for fracture who have a variety of special characteristics, such as younger age, increased risk for deep vein thrombosis, bothersome vasomotor symptoms and no history of prior myocardial infarction, stroke or breast cancer. Nasal spray calcitonin is recommended only for women who cannot tolerate the aforementioned therapies or for whom these therapies are not considered appropriate, according to the guideline.
Calcium and vitamin D can be considered as an adjunct to osteoporosis therapies for postmenopausal women. Dietary intake is preferred, Rosen said, but supplements can be used.
Continued monitoring of this population is recommended, with bone mineral density monitoring via DXA at the spine and hip every 1 to 3 years to assess treatment response in postmenopausal women with low BMD and high risk for fractures.
Recommendations in the guideline were derived from two evidence-based reviews and a meta-analysis. One of the reviews evaluated values and preferences related to the management of osteoporosis in postmenopausal women. The factors most important to women regarding osteoporosis treatment were effectiveness and adverse events, followed by convenience and impact on daily routine.
“Less important [to women] is the cost, which was a bit surprising to us. Obviously, safety was deemed important, but how they take the drug [was just as important],” Rosen said, noting that women generally preferred oral administration, but an injection was preferred if administered less frequently.
For providers, Rosen said, “patient preferences should be incorporated into treatment planning.”
Taken together, the guideline authors recommend overall using country-specific assessment tools to guide decision-making.
Rosen noted, however, that in recent years, “the number of prescriptions has gone down for bisphosphonate therapies, as has [BMD screening],” coupled with an increase in the rate of hip fractures.
“We hope our guideline will not only improve patient care, but provide confidence in treatment,” he said in a press release. – by Katie Kalvaitis
Rosen CJ, et al. Pharmacological Management of Osteoporosis in Post-Menopausal Women: An Endocrine Society Clinical Practice Guideline. Presented at: The Endocrine Society Annual Meeting; March 23-26, 2019; New Orleans.
Eastell R, et al. J Clin Endocrinol Metab. 2019;doi:10.1210/jc.2019-00221.
Disclosure: Rosen reports no relevant financial disclosures.