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ACP updates osteoporosis and low bone mass guidelines
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ACP updates osteoporosis and low bone mass guidelines

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Clarissa Chan, PharmD

Illustration of osteoporosis pain of the knee bones.

At the start of 2023, the American College of Physicians (ACP) released an update to their pharmacological guideline recommendations for the treatment of osteoporosis and low bone mass to prevent fractures in adults.

Bone health is one of the fastest growing areas of concern for individuals 50 years and older. Primary osteoporosis—osteoporosis not caused by conditions or medications—may not have any clinical manifestations or symptoms until there is a fracture, most commonly hip and spine fractures.

First-line treatment: bisphosphonates

In the new guidelines, ACP strongly urges clinicians to use bisphosphonates, such as alendronate, ibandronate, risedronate, and zoledronate, for initial pharmacologic treatment in postmenopausal females diagnosed with primary osteoporosis to reduce the risk of fractures. They also suggest a receptor activator of nuclear factor κB (RANK) ligand inhibitor (denosumab) for second-line use to prevent fractures in postmenopausal females who have contraindications or experience adverse effects from bisphosphonates.

For females with a very high risk of fractures, ACP suggests use of a sclerostin inhibitor (romosozumab) or recombinant human parathyroid hormone (PTH; teriparatide) followed by a bisphosphonate. Romosozumab has moderate-certainty evidence and teriparatide has low-certainty evidence.

“Females initially treated with an anabolic agent should be offered an antiresorptive agent after discontinuation to preserve gains and because of serious risk for rebound and multiple vertebral fractures,” said Amir Qaseem, MD, PhD, MHA, FACP, chief science officer of ACP and one of the authors of the recommendations.

ACP also suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis. A RANK ligand inhibitor is the suggested second-line option in males who have contraindications or experience adverse effects from bisphosphonate use.

In females over 65 with low bone mass (osteopenia), ACP suggests that clinicians take an individualized approach on whether to start pharmacologic treatment with bisphosphonates to reduce the risk of fractures. Decisions should be based on different factors, such as counseling and evaluation of fall risk.

Elective surgery considerations

“For those who have plans to undergo elective spine fusion and joint replacement surgeries, detecting osteoporosis is crucial to securing the best outcomes,” said Blossom P. Samuels, MD, attending physician at Westchester Medical Center and a clinical assistant professor of rehabilitation and bone health at New York Medical College in Hawthorne, NY. “As such, anabolic bone therapies are preferred during preoperative planning from their ability to enhance bone stock and thus reduce the risk of hardware failure.”

The main treatments that have been shown to increase bone stock in individuals with bone loss include PTH analogs teriparatide and abaloparatide (both anabolic), as well as the sclerostin inhibitor romosozumab (anabolic and antiresorptive).

“These bone therapies are the key to regenerating skeletal bone mass,” said Samuels. “Just as importantly, the sequential use of bone agents from different classes is key to achieving the largest bone density improvements.”

For example, after completion of a course of either of these anabolic therapies, patients should then transition to an antiresorptive drug that will help to lock in the bone gains. With this strategy, a patient’s fracture risk is reduced, and improved surgical outcomes at any age are more likely, Samuels said.

Long-term therapy precautions

Bisphosphonates and denosumab are generally considered safe and effective, but less common serious adverse effects include higher risk for osteonecrosis of the jaw and atypical femoral fractures. Romosozumab is also associated with jaw osteonecrosis and, more importantly, with adverse cardiovascular events like myocardial infarction and stroke. The long-term safety of teriparatide in humans is unknown and needs further research.

Other preventive considerations

ACP recommends that all adults with osteoporosis or those with low bone mass engage in regular weight-bearing exercise, limit alcohol intake, and quit smoking. Adequate intake of calcium and vitamin D is also crucial for maintaining good bone health. Adherence to recommended drug treatments is important as well for reducing fracture risk, said Qaseem, who is also an adjunct faculty member at Thomas Jefferson University, Philadelphia, PA.

Please visit to read the ACP guideline recommendations on the treatment of osteoporosis and low bone mass to prevent fractures in adults. ■



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