Osteoporosis Guidelines

Updated: May 10, 2017
  • Author: Monique Bethel, MD; Chief Editor: Herbert S Diamond, MD  more...
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Guidelines

Guidelines Summary

The National Osteoporosis Foundation (NOF) recommends that pharmacologic therapy should be reserved for postmenopausal women and men aged 50 years or older who present with the following [2] :

  • A hip or vertebral fracture (vertebral fractures may be clinical or morphometric [ie, identified on a radiograph alone])
  • T-score of –2.5 or less at the femoral neck or spine after appropriate evaluation to exclude secondary causes
  • Low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture of 3% or greater or a 10-year probability of a major osteoporosis-related fracture of 20% or greater based on the US-adapted WHO algorithm

A clinical practice guideline from the American College of Physicians (ACP) recommends offering pharmacologic treatment to women with known osteoporosis, to reduce the risk of hip and vertebral fractures. [122] The ACP recommends use of any of the following agents:

  • Alendronate
  • Risedronate
  • Zoledronic acid
  • Denosumab

The ACP recommends against the use of estrogen or estrogen plus progestogen or raloxifene for the treatment of osteoporosis in postmenopausal women. Additional recommendations, based on low-quality evidence, include the following:

  • In women with osteoporosis, pharmacologic treatment should last for 5 years; generic drugs should be used when possible.
  • Monitoring of bone mineral density (BMD) during the 5 years of treatment in women with osteoporosis is not advised, as evidence suggests that fracture risk may be reduced regardless of BMD changes
  • For women aged 65 and older who have osteopenia and are at high fracture risk, decisions to treat should take into account patient preference, fracture-risk profile, benefits, harms, and price of medications
  • In men with clinically recognized osteoporosis, clinicians should offer bisphosphonate therapy to reduce the risk of vertebral fracture; evidence is lacking on BMD monitoring in men.

Guidelines from the American Association of Clinical Endocrinologists (AACE), published in 2010, include the following recommendations for choosing drugs to treat osteoporosis [11] :

  • First-line agents: alendronate, risedronate, zoledronic acid, denosumab
  • Second-line agent: ibandronate
  • Second- or third-line agent: raloxifene
  • Last-line agent: calcitonin
  • Treatment for patients with very high fracture risk or in whom bisphosphonate therapy has failed: teriparatide

Combination therapy with two or more agents has not been shown to have a greater effect on fracture reduction than single therapy. The AACE guidelines advise against the use of combination therapy, until the effect of combination therapy on fracture is better understood.

In June 2013, the National Osteoporosis Guideline Group (NOGG) updated its guidelines on the diagnosis and management of osteoporosis in men and postmenopausal women, aged 50 years or older, in the United Kingdom. Recommendations include the following [213] :

  • 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 anti-fracture efficacy and low cost
  • Ibandronate, risedronate, zoledronic acid, denosumab, raloxifene, or strontium ranelate may be appropriate therapy if alendronate is contraindicated or poorly tolerated
  • Because of their 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
  • Treatments for men at increased fracture risk include alendronate, risedronate, zoledronic acid, and teriparatide
  • Patients at increased risk for fracture should start alendronate or other bone-protective treatment when beginning glucocorticoid therapy
  • For postmenopausal women, pharmacotherapy for prevention and treatment of glucocorticoid-induced osteoporosis includes alendronate, etidronate, and risedronate; treatment options for 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 BMD and bone turnover after 2-3 years for alendronate and 1-2 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 reevaluated 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
  • Treatment review is recommended after 5 years for alendronate, risedronate, or ibandronate and after 3 years for zoledronic acid
  • 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