In a conditional recommendation with low-certainty evidence, the group also suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis.
The new guideline updates the 2017 ACP recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults.
In a conditional recommendation with moderate-certainty evidence, the ACP suggested that clinicians use the RANK (receptor activator of nuclear factor kappa-B) ligand inhibitor (denosumab) as a second-line pharmacologic treatment for postmenopausal females diagnosed with osteoporosis but who have contraindications to or experience adverse effects of bisphosphonates. A similar, but weaker, recommendation is made for males with osteoporosis who have difficulty taking bisphosphonates.
In a condition recommendation, the guidelines advised that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant parathyroid hormone (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture.
For females aged older than 65 years with osteopenia, the guideline panel suggested that clinicians take an individualized approach on whether to start pharmacologic treatment with a bisphosphonate to reduce the risk of fracture. That is a conditional recommendation with low-certainty evidence, the panel said.
“Primary osteoporosis (osteoporosis that is not secondary to a separate condition or medication) is characterized by decreasing bone mass and density and reduced bone strength leading to a higher risk for fracture,” the guideline document pointed out. “Fractures can occur in any bone, but hip and spine fractures are most common, accounting for 42% of all osteoporotic fractures. Fractures are associated with serious morbidity and mortality, and people with prevalent fractures are at much higher risk for future fractures.”
The authors noted that an estimated 10.2 million persons aged 50 years or older in the United States have osteoporosis, and about 43.3 million persons have low bone mass associated with a high risk for progression to osteoporosis.
The guideline states that the increase in clinical and economic burdens of osteoporotic fractures is not equal across the board but occurs more in certain racial and ethnic groups compared with white Americans, although differences in treatment effects for these populations remain unclear.
“Over the past decade, the prevalence of osteoporosis in the United States increased in females but not males,” the authors wrote. “However, males with osteoporotic hip fractures have greater morbidity and mortality than females with hip fractures and receive treatments aimed at fracture prevention less often than females. There is a substantial burden for working patients due to absenteeism and loss of productivity.”
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