The ACP recommends bisphosphonates for men and postmenopausal women with primary osteoporosis

January 04, 2023

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Ayers and Kasem report no relevant financial disclosures. Please see the guideline and systematic review for all relevant third author disclosures.

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In an update to its guidance on primary osteoporosis, the ACP recommended bisphosphonates as a first line of defense to reduce fracture risk in postmenopausal men and women.

The new guide published in Annals of Internal Medicine, It is based on an updated systematic review of evidence that included 34 randomized clinical trials and 36 observational studies to evaluate the comparative effectiveness of different treatments.

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Data from: Qasim A et al. Ann is a med trainee. 2023; doi: 10.7326/M22-1034.

Chelsea Ayers, MPH, A senior research associate at the Center for Improving Veteran’s Participation in Care, VA Portland Health Care System, and colleagues found that, in postmenopausal men and women with primary osteoporosis, “bisphosphonates were the best balance of benefits and harms and patient values ​​and preferences,” according to a press release for ACP.

Notably, the ACP said that bisphosphonates also confer benefits in that they are “much cheaper than other drug therapies and available in generic oral and injectable formulations.”

“Bone fractures from osteoporosis are associated with serious morbidity and mortality, and people with a history of bone fractures from osteoporosis are at increased risk of future fractures,” Ryan D. Meyer, MD, MACP, ACP chief, per the statement. “This guideline will help clinicians determine the best course of treatment for their patients to better prevent bone fractures.”

The bisphosphonate recommendation for postmenopausal women is a strong recommendation based on high certainty evidence, while the recommendation for men is conditional, with low certainty evidence, according to the ACP.

The organization noted that extending bisphosphonate therapy beyond 3 to 5 years may reduce the risk of new vertebral fractures but not others, although “there is an increased risk of long-term damage”. Therefore, caregivers should consider stopping treatment after 5 years “unless there is a strong indication to continue treatment,” says the ACP.

The guide stresses the importance of adults with osteoporosis adhering to “recommended drug therapies and healthy lifestyle modifications,” which includes exercises and counseling for fall assessment and prevention, according to Release.

In addition, the ACP has recommended that physicians use the RANK ligand inhibitor denosumab as a second-line treatment to reduce the risk of fractures in men and postmenopausal women who have contraindications or have experienced adverse events from bisphosphonates.

In women with a high risk of fractures, the ACP recommended recombinant human thyroid hormone teriparatide (low certainty evidence) or the sclerostin eventy inhibitor (romosuzumab, Amgen; moderate certainty evidence), followed by a bisphosphonate.

Finally, the ACP has recommended that doctors use an “individualized approach” when deciding whether to start bisphosphonate therapy in women over 65 with low bone mass.

In an accompanying editorial, Susan M Ott, MD, Of the Bone and Joint Center and Professor of Medicine at the University of Washington in Seattle, the evidence for bisphosphonates “may seem overwhelmingly positive, leading to strong recommendations for their use in treating osteoporosis, but the decision to start using bisphosphonates is actually not that easy.”

“A strong recommendation should only be made when future studies are unlikely to change it. However, the data do suggest that in patients with serious osteoporosis, treatment should be started with anabolic medication because previous treatment with either bisphosphonates or denosumab will block the anabolic response.” for new drugs,” wrote Ott. “Fewer fractures appear when the initial treatment is an anabolic drug, which increases bone volume and not just bone density.”

Ott also writes that it is “unfortunate that the review and recommendations do not address estrogen,” because it is “one of the most effective medications for preventing osteoporotic fractures.”

Both observational studies and clinical trials show beneficial effects on the skeletal system of estrogens. Ott writes that those with sufficient strength show reduced fractures. In 1991, I reviewed all the clinical and preclinical studies of estrogen for a Federal Drug Administration conference and was astonished to find that they all showed positive effects. It was the least controversial topic. Since then, observational studies have shown benefits of estrogen for the skeleton, until After three decades of using it.”


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