Jul 1, 2013

Osteoporosis Management Guidelines Updated for Women and Men

The National Osteoporosis Guideline Group (NOGG) has updated its 2009 guidelines on the diagnosis and management of osteoporosis in postmenopausal women and men at least 50 years of age in the United Kingdom. The new recommendations were published online June 17 in Maturitas.

“Since [2009] there has been a number of advances in the field, particularly with respect to glucocorticoid-induced osteoporosis, the role of calcium and vitamin D therapy, and the benefits and risks of long-term bisphosphonate therapy,” write J. Compston, MD, from the University of Cambridge School of Clinical Medicine, United Kingdom, and colleagues from the NOGG. “In addition new pharmacological interventions have been approved for the prevention of glucocorticoid-induced osteoporosis and the management of osteoporosis in postmenopausal women and men at increased risk.”

Selected Highlights of the 2013 Guidelines

  • Pharmacotherapies shown to lower the risk for vertebral fracture (and for hip fracture in some cases) include bisphosphonates, denosumab, parathyroid hormone peptides, raloxifene, and strontium ranelate.
  • Generic alendronate is usually first-line treatment because of its broad spectrum of antifracture efficacy and low cost.
  • Ibandronate, risedronate, zoledronic acid, denosumab, raloxifene, or strontium ranelate may be appropriate therapy when alendronate is contraindicated or poorly tolerated.
  • Because of the high cost, parathyroid hormone peptides should be used only for patients at very high risk, especially for vertebral fractures.
  • Postmenopausal women may benefit from calcitriol, etidronate, and hormone replacement therapy.
  • Approved treatments for men at increased fracture risk are alendronate, risedronate, zoledronic acid, and teriparatide.
  • Patients at increased risk for fracture should start alendronate or other bone-protective treatment at the onset of glucocorticoid therapy.
  • For postmenopausal women, approved pharmacotherapy for prevention and treatment of glucocorticoid-induced osteoporosis includes alendronate, etidronate, and risedronate; approved treatment options in both sexes are teriparatide and zoledronic acid.
  • Calcium and vitamin D supplementation is widely recommended for older persons who are housebound or live in residential or nursing homes and is often recommended as an adjunct to other treatments for osteoporosis.
  • Potential adverse cardiovascular effects of calcium supplementation are controversial, but it may be prudent to increase dietary calcium intake and use vitamin D alone rather than using both calcium and vitamin D supplementation.
  • Withdrawal of bisphosphonate treatment is associated with decreases in bone mineral density (BMD) and bone turnover after 2 to 3 years for alendronate and 1 to 2 years for ibandronate and risedronate.
  • Continuation of bisphosphonates without the need for further evaluation is recommended for high-risk individuals. When bisphosphonates are continued, treatment review, including renal function evaluation, is needed every 5 years.
  • If bisphosphonates are discontinued, fracture risk should be re-evaluated after every new fracture, or after 2 years if no new fracture occurs.
  • After 3 years of zoledronic acid treatment, the benefits on BMD density persist for at least another 3 years after discontinuation. Most patients should stop treatment after 3 years, and their physician should review the need for continuation of therapy 3 years later.
  • Persons with a previous vertebral fracture or a pretreatment hip BMD T-score of −2.5 SD or less may be at increased risk for vertebral fracture if zoledronic acid is discontinued.

“At present there is no universally accepted policy for population screening in the UK to identify individuals with osteoporosis or those at high risk of fracture,” the guideline authors write. “Patients are identified opportunistically using a case finding strategy on the finding of a previous fragility fracture or the presence of significant [clinical risk factors]. Some of these risk factors act independently of BMD to increase fracture risk whereas others increase fracture risk through their association with low BMD (e.g. some of the secondary causes of osteoporosis).”

An independent expert related the new UK guidelines to those used in Canada, released and published in 2010. “As with the current Canadian guidelines, the UK guidelines generally recommend fracture risk assessment in advance of making treatment recommendations,” said Joanna Sale, PhD, associate scientist, Mobility Program Clinical Research Unit, St. Michael’s Hospital, Toronto, Ontario, Canada, in an interview with Medscape Medical News.

“The recommendations in the guideline are intended to aid management decisions but do not replace the need for clinical judgment in the care of individuals in clinical practice,” the group contributors conclude.

These guidelines were developed without financial support from any commercial organization. Some NOGG members reported various disclosures with Servier, Consilient Health, Amgen, GSK, Shire, Eli Lilly. MSD, Novartis, Proctor & Gamble, ProStrakan, Roche, Medtronic, Tethys, Bayer, GE Lunar, Hologic, Merck, Pfizer, Warner-Chilcott, Innovus 3i, Alliance for Better Bone Health, Biointetica, Celtrix, D3A, General Electric, Kissel, Medimaps, Sanofi-Aventis, UBS, Warner-Chilcott, Nycomed, Acuitas, Olympus, Synthes, Stryker, Biomet, and Medtronic. Dr. Sale has disclosed no relevant financial relationships.

Maturitas. Published online June 17, 2013. Full text


— Laurie Barclay, MD


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