Pharmacologic Treatment of Osteoporosis or Low Bone Mass to Prevent Fractures: Guidelines

 

Amir Qaseem, MD, PhD, MHA

,   

Lauri A. Hicks, DO

,   … View all authors 

DOI: https://doi.org/10.7326/M22-1034

Abstract

Description:

This guideline updates the 2017 American College of Physicians (ACP) recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults.

Methods:

The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of evidence and graded them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Audience and Patient Population:

The audience for this guideline includes all clinicians. The patient population includes adults with primary osteoporosis or low bone mass.

Recommendation 1a:

ACP recommends that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis (strong recommendation; high-certainty evidence).

Recommendation 1b:

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).

Recommendation 2a:

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).

Recommendation 2b:

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).

Recommendation 3:

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).

Recommendation 4:

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 fractures (conditional recommendation; low-certainty evidence).

Primary osteoporosis (osteoporosis that is not secondary to a separate condition or medication) is characterized by decreasing bone mass and density and reduced bone strength leading to a higher risk for fracture (Appendix Table 1) (1, 2). Fractures can occur in any bone, but hip and spine fractures are most common, accounting for 42% of all osteoporotic fractures. Fractures are associated with serious morbidity and mortality, and people with prevalent fractures are at much higher risk for future fractures (3–5). Overall, an estimated 10.2 million persons aged 50 years or older in the United States have osteoporosis, and about 43.3 million persons (>40% of older U.S. adults) have low bone mass associated with a high risk for progression to osteoporosis (6).

https://www.acpjournals.org/doi/10.7326/M22-1034