Osteoporosis increases fracture risk due to reduced bone mass. Explore the updated treatment recommendations including pharmacologic treatments & screening guidelines, from the American College of Physicians. Learn about the latest approaches to managing this condition & reducing fracture risk.

Definition

Osteoporosis that is primary (i.e., not due to another ailment or medicine) is defined by a decline in bone mass and density as well as a reduction in bone strength, which increases the risk of fracture. Fractures may happen in any bone, although hip and spine fractures are the most prevalent, accounting for 42% of all osteoporotic fractures. People who have many fractures are at a much-increased risk of developing new fractures in the future. Fractures are connected with considerable morbidity and death.

Screening recommendations and guidelines

The American College of Physicians (ACP) has released updated treatment recommendations for osteoporosis. The US Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women over 65 and in younger women who are at elevated risk based on a risk assessment instrument (often the FRAX tool) in their 2018 statement. There is not enough data to support or refute the practice of screening males.

The Bone Health & Osteoporosis Foundation is another significant body that offers screening recommendations. It concurs with the USPSTF but adds that males beyond the age of 70 and men who are younger (age 50 to 69) but have risk factors should be screened. Additionally, everyone who gets a fracture after little or no stress should be screened.

Now we will discuss the ACP treatment guidelines. Bone mineral density at the femoral neck or the lumbar spine, or both, with a T score less than -2.5 is considered osteoporosis.

ACP treatment guidelines

Bisphosphonate should be used as the first line of therapy for postmenopausal women with osteoporosis in order to lower the risk of future fractures. Based on solid evidence with a high degree of confidence, this is strongly advised.

Over a period of three years, the use of bisphosphonates reduces the number of hip fractures per 150 patients treated and the number of vertebral fractures per 50 patients treated.

The rest of the guidelines' suggestions are all regarded as "conditional recommendations" that are true for the majority of individuals. However, whether they are appropriate for a certain patient will depend on other factors, including their values and preferences.

A conditional recommendation, for example, is offered for the treatment of osteoporosis in men—not because the data says it is less beneficial, but rather because there is less of it.

Bisphosphonates are the first line of therapy for males with osteoporosis. Men get osteoporosis, and they are responsible for 30% of hip fractures. Any person who provides care for senior people is not surprised by this.

Treatment options and considerations

1. Use of a RANK ligand inhibitor is advised for postmenopausal women or men who need treatment but cannot take a bisphosphonate.
2. As a second-line therapy, denosumab may help to lower the risk of fractures. Keep in mind that denosumab and bisphosphonates are antiresorptive medications, which means they halt the development of osteoporosis.
3. The anabolic medications, on the other hand, such as recombinant human parathyroid hormone (PTH) teriparatide and the sclerostin inhibitor romosozumab, improve bone density.
4. The use of anabolic agents must always be followed by the use of an antiresorptive agent to prevent rebound osteoporosis and increased risk for vertebral fractures. These agents should only be used in women with primary osteoporosis who are at very high risk for fractures.

Approach to osteopenia

What about osteopenia now? The recommendations advise using a tailored strategy for women over 65 with osteopenia depending on their degree of fracture risk, which may include their age, low body weight, current smoking status, parent's history of hip fracture, risk of falling, and personal fracture history.

According to the recommendations, continuing bisphosphonate medication for more than three to five years lowers the chance of developing new vertebral fractures, but not other fractures and it raises the risk of atypical hip fractures and osteonecrosis of the jaw.

Therefore, unless a person is at exceptionally high risk, the recommendations state that we should only take bisphosphonates for 3-5 years. The likelihood of atypical femoral fractures is five times greater in Asian women, which is particularly significant to note.

Clinical considerations

1. If feasible, doctors should recommend generic drugs rather than more costly brand-name drugs.
2. Clinicians caring for persons with osteoporosis should promote adherence to prescribed medications, healthy lifestyle changes including exercise, and counselling for fall assessment and prevention.
3. All individuals with low bone density or osteoporosis should consume enough calcium and vitamin D as a part of their overall fracture prevention strategy.
4. Clinicians should determine an individual's baseline risk for fracture based on their evaluation of their bone density, history of fractures, response to previous osteoporosis therapies, and various fracture risk factors. Numerous risk assessment methods are available with variable predictive values; these tools were not assessed in the systematic review or in this recommendation.
5. According to recent research, bisphosphonate medication that lasts longer than 3 to 5 years lowers the incidence of new vertebral fractures but not other fractures. However, there is a higher chance of long-term damage. Therefore, unless the patient has a good rationale for therapy continuation, doctors should think about terminating bisphosphonate medication after 5 years.
6. The choice to temporarily stop taking a bisphosphonate medicine (for a holiday) and how long it will last should be made individually based on the patient's baseline risk of fracture, the medication's kind and bone half-life, benefits, and harms (greater risk of fracture due to drug withdrawal).
7. To maintain gains and due to the high danger of rebound and numerous vertebral fractures, females who had been first treated with an anabolic agent should be provided with an antiresorptive agent after termination.
8. Due to polypharmacy or medication interactions, older persons (for instance, those over 65 years old) with osteoporosis may be more susceptible to falls and other serious effects. Based on comorbidities and concurrent medicines, individualised therapy selection should take into account contraindications and warnings for pharmaceuticals recommended to treat osteoporosis as well as a reevaluation of other drugs linked to a greater risk for falls and fractures.
9. Based on the age of gonadectomy, sex hormone treatment, distribution of comorbidities, and behavioural risk factors for osteoporosis and fractures, transgender people are at varying risk for low bone mass. Treatment choices for secondary osteoporosis should take into account the history of gonadectomy (including age) and sex steroid medication when evaluating the possible risk for fractures.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.