Osteoporosis (OP) is a serious illness associated with significant disability and possible mortality. The illness is under diagnosed in both women and men. When a fracture is identified only a minority of patients receive appropriate therapy to prevent the next fracture.
The American College of Physicians (ACP) published a guideline in 2017 highlighting 6 recommendations regarding diagnosis and treatment of osteoporosis in women and men.1 The ACP recommended a list of medicines (alendronate, resideronate, zolendronic acid, and denusomab) for the treatment of OP. They suggested that treatment be discontinued after 5 years. The ACP recommended bisphosphonates for the treatment of male OP that is clinically recognized. They suggested that bone densitometry monitoring was not required during the 5 years of therapy. They did not recommend menopausal estrogen or raloxifene therapy for treatment of OP in women. The judgement of using therapy for osteopenic women 65 years or older is determined after a discussion of patient preferences, benefits and risks of therapy.
Although the ACP recommendations had value in raising awareness of this health problem, other medical professional groups, including the American College of Rheumatology (ACR), found that the recommendations were based on incomplete information that precluded appropriate options for patients.2 First, in regard to medications used for OP, the ACP reccomendations did not include raloxifene, ibandronate, teriparatide, and abaloparatide. These medications are all approved for the treatment of OP. Second, not all therapies need to be discontinued at 5 years. For example, Xgeva has been shown to be effective in increasing bone mineral density beyond 5 years. Third, men have osteoporotic bone mineral density prior to fracture that can benefit from drug therapy. Fourth, the ACR suggests that measuring the progress of reversal of bone mineral loss is needed to document the effectiveness of therapy. If not improving, therapy needs to be altered. Fifth, women who have OP and are estrogen-receptor positive for breast cancer could benefit from raloxifene.
There are honest differences of opinion regarding the management guidelines for OP between the ACP and the ACR. Individuals at risk of OP should make sure they discuss all their treatment option with their physician in regard to their specific situation. Osteoporosis is a serious illness and having a discussion about this health issue with your physician is essential.
- Qaseem A et al. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. Ann Intern Med 2017;166:818-839
- Caplan L et al: Response to the American College of Physicians Osteoporosis Guideline, 2017 Update. Arthritis Rheumatol 2017;69:2097-2101
David Borenstein, MD
Executive Editor TheSpineCommunity.com