ACP issues guidelines for osteoporosis, low BMD in men and women

Recommendations include pharmacologic therapies to prevent fractures in men and women with osteoporosis and in those at high risk.

The American College of Physicians has released the second section of its two-part clinical practice guidelines for low bone density and osteoporosis in an effort to prevent fractures. The guidelines were published in the Annals of Internal Medicine.

“Essentially, osteoporosis is an important public health issue. Forty-four million people in the United States are affected by osteoporosis, and the economic burden is still large and growing,” Amir Qaseem, MD, PhD, MHA, senior medical associate in the American College of Physicians Clinical Programs and Quality of Care Department, told Endocrine Today.

Using Medline, the Cochrane database and other databases, the researchers from various U.S. sites identified clinical trials and meta-analyses that examined pharmacologic therapies to prevent fractures among patients with osteoporosis or low bone density. The researchers compared the data on available therapies for fracture reduction against placebo, within classes, and for different risk groups. They also analyzed adverse effects and summarized their findings into four recommendations.

“We developed recommendations to help clinicians when they’re making decisions in terms of whether to start treatment or not,” Qaseem said.

Offering treatment

The American College of Physicians strongly recommended that clinicians offer pharmacologic treatment to men and women with known osteoporosis and to those who have had fragility fractures. According to the organization, sufficient evidence exists to support treatment in such patients to prevent additional bone loss and to decrease the risk for initial or subsequent fractures.

The organization recommended treatment with bisphosphonates, as supported by clinical trial data, and recommended adding calcium and vitamin D to treatment regimens.

Treatment consideration was also recommended for men and women at high risk for osteoporosis, though not as strongly as for those with confirmed osteoporosis, according to the American College of Physicians. Risk factors for men include old age, low body weight, weight loss, physical inactivity, steroid use, use of androgen deprivation therapy and fracture without trauma, according to Qaseem. In women, risk factors include low body weight, smoking, weight loss, decreased physical activity, alcohol or caffeine use and low calcium and vitamin D intake.

Considering treatment regimens

The American College of Physicians also strongly recommended choosing pharmacologic treatments based on the assessment of risks, benefits and adverse effects of drugs for each individual. The researchers added that patients at high risk for hip fracture are candidates for bisphosphonate therapy, as evidenced by quality data.

“Bisphosphonates are reasonable pharmacologic options, as they reduce the risk for vertebral, non-vertebral and hip fractures,” Qaseem said. However, there is a lack of evidence and head-to-head trials to show superiority of one bisphosphonate over another, he said.

More data needed

According to the researchers, further research is necessary to evaluate treatment for osteoporosis in both men and women. The researchers recommended head-to-head trials comparing the efficacy of therapies in the prevention of fractures, and are particularly interested in additional patient populations, including men.

The American College of Physicians also called for data on the relationship between osteonecrosis of the jaw and bisphosphonate use, prevention strategies, and the appropriate duration of treatment for osteoporosis.

The first set of guidelines, which addressed the importance of screening for osteoporosis in men, were published in the May 6 issue of Annals of Internal Medicine (Endocrine Today, June 25, 2008). – by Stacey L. Adams

Ann Intern Med. 2008;149:404-415.