Conflicting guidelines highlight controversies in osteoporosis management
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Discrepancies between clinical practice guideline documents highlight the over-arching controversies in osteoporosis management, according to a presenter at the 2021 Congress of Clinical Rheumatology-West.
“Anybody who sees rheumatology patients sees a lot of osteoporosis,” E. Michael Lewiecki, MD, director of New Mexico Clinical Research & Osteoporosis Center and clinical assistant professor of medicine at University of New Mexico Health Sciences Center. “And you cause a lot of osteoporosis.”
Lewiecki suggested that he was invited to speak at CCR-West for one key reason. “You do better than primary care at managing osteoporosis, but I think we could all improve what we do,” he said.
At least one reason for that is that there is a significant amount of uncertainty about how to manage osteoporosis, according to Lewiecki. Uncertainty, in turn, causes controversy at both the individual doctor-patient level and at the level of governing bodies that oversee the treatment of the condition. “Probably everything that we do in osteoporosis is controversial,” he said.
Ordinarily, clinicians turn to recommendation documents for guidance on treatment decisions and to resolve any controversies that they may experience in daily clinical practice. But Lewiecki showed why this can be problematic in the field of osteoporosis.
A graphic displaying some key recommendations from the American College of Physicians and the National Osteoporosis Foundation (NOF) demonstrated his point. “Here is a striking example of conflicting clinical practice guidelines,” he said. “[They] have come up with very different ideas about how we should manage osteoporosis.”
The ACP recommendations for women suggest that alendronate, risedronate, zoledronic acid (Reclast, Novartis) or denosumab (Prolia, Amgen) are acceptable, while estrogen or raloxifene (Evista, Eli Lilly & Co.) are not suggested. Conversely, the NOF recommends that all approved agents are acceptable.
For men, only bisphosphonates are recommended, while the NOF, again, suggests that any approved agents are acceptable.
Differences are also seen in duration of therapy, according to Lewiecki. “The ACP says to treat [women] for 5 years,” he said. “That’s it. This is a lifelong disease, they say to treat for 5 years. Does that make sense?”
For men, the ACP offers no recommendation for treatment duration. Lewiecki noted the outrage that these particular components yielded. “This document generated a firestorm of responses from osteoporosis-oriented organizations,” he said.
The NOF suggested that the drug’s label should be followed for instructions about treatment duration.
Turning to ongoing osteoporosis management, Lewiecki said that the ACP recommends that a dual-energy X-ray absorptiometry (DXA) should not be repeated in women, while guidance for DXA in men is not stated. “Would you take any drug for 5 years without any feedback of whether it was working or not?” he said.
The NOF recommends a DXA every 2 years or more frequently, as necessary, in both men and women.
“There are efforts about for guideline harmonization,” Lewiecki said, and acknowledged that other interested organizations are actively working toward this goal.
“I know that the ACP is working on new guidelines,” Lewiecki said. “I hope that they do better next time.”
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Lewiecki EM. Osteoporosis Controversies. Presented at: Congress of Clinical Rheumatology-West annual symposium; September 18-21, 2021 (hybrid meeting).
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