The American College of Physicians (ACP) recommends in an evidence–based clinical practice guideline published in Annals of Internal Medicine journal that physicians treat women with osteoporosis with bisphosphonates (alendronate, risedronate, or zoledronic acid) or denosumab, a biologic agent.

“Physicians should prescribe generic drugs to treat patients with osteoporosis whenever possible and they should discuss the importance of medication adherence, especially for bisphosphonates,” said Jack Ende, MD, MACP, president, ACP.

The American Academy of Family Physicians has endorsed ACP’s guideline.

ACP's guideline focuses on the comparative benefits and risks of short– and long–term drug treatments for low bone density or osteoporosis, including prescriptions, calcium, vitamin D, and estrogen.

The evidence suggests that physicians should treat women with osteoporosis with drug therapy for five years. Continuing treatment after the initial five years may be beneficial for some patients and may be appropriate after reassessing the risks and benefits of continuing therapy.

ACP recommends against bone density monitoring during the five–year treatment period because the evidence does not show any benefit for monitoring during treatment. ACP also recommends against using menopausal estrogen therapy or menopausal estrogen plus progestin therapy or raloxifene for the treatment of osteoporosis in women. Estrogen treatment is associated with serious harms such as increased risk for cerebrovascular accidents and venous thromboembolic events that outweigh the potential benefits.

Physicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences; fracture risk profile; and the benefits, harms, and costs of medications.

The evidence does not support frequent monitoring of women with normal bone density for osteoporosis; the data showed that most women with normal bone density measurements did not progress to osteoporosis within 15 years.

ACP recommends that physicians offer drug treatment with bisphosphonates to reduce the risk for vertebral fracture in men with osteoporosis.

“The evidence specifically for men is sparse,” Dr. Ende said. “However, the data did not suggest that outcomes associated with drug treatment would differ between men and women if based on similar bone mineral density, so treatment for men may be appropriate.”

“Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women” is based on a systematic review of randomized, controlled trials; systematic reviews; large observational studies (for adverse events); and case reports (for rare events). Clinical outcomes evaluated were fractures and adverse events.