NEW ORLEANS – New Endocrine Society guidelines for the pharmacological treatment of osteoporosis in postmenopausal women are designed to encourage clinicians to increase screening and treatment rates for this condition.
The paper, entitled "Pharmacological Management of Osteoporosis in Postmenopausal Women," was presented here at ENDO 2019 on March 25: The Endocrine Society Annual Meeting and simultaneously online in the Journal of Clinical Endocrinology & Metabolism [19459006ThedocumentisendorsedbytheEuropeanEndocrinologySociety
Clifford J. Rosen, Director of the Center for Clinical and Translational Research at the Maine Medical Research Institute at Scarborough, summarizes the key points of the guideline
"We need to be aggressive." on treating individuals who had a previous fracture, he said Medscape Medical News .
First, lifestyle and nutritional optimization for the Bone health ̵
Bisphosphonates and denosumab are still recommended as first-line therapies. However, the Endocrine Society now recommends anabolic treatments – teriparatide or abaloparatide ( Tymlos Radius Health) – as first-line therapy for patients with very severe osteoporosis, multiple fractures, and / or very low bone density.  This new recommendation, Rosen says, "means that we intervene early because the effects are faster than with bisphosphonates."
In women who have been treated with bisphosphonates for 3 to 5 years, the fracture risk should be evaluated.
Following a reassessment, women who have a low to moderate fracture risk should be prescribed a "bisphosphonate leave".
All women taking osteoporosis therapies, with the exception of anabolic steroids, should take calcium and vitamin D supplements in their diet or at one time.
Bone mineral density (BMD) monitoring for high-risk patients with low BMD should be done every 1 to 3 years, according to the guidelines.
Were the risks of osteoporosis treatment exaggerated?
During the briefing on the risks associated with some of these osteoporosis treatments, Rosen was given special concern about atypical femur fractures associated with bisphosphonates and found that patients often wonder why they are taking a medicine should, in order to prevent possible fractures cause a fracture.
"We are very concerned about this, and some recent data suggest that the risk of atypical fractures with bisphosphonates is still relatively low," he said.
But he also noted that certain factors increase this risk, especially prolonged therapy duration. "That's one of the reasons why we've been on a drug holiday for many people who have been successfully treated with bisphosphonate for three years." The other adverse events, including osteonecrosis of the jaw, are less common, he said.
"Femoral fracture has attracted the most attention and was most disturbing to individuals," Rosen added. "From a medical point of view, it is difficult because you have to spend time discussing the absolute risk and relative risk differences for a single patient, and you need to receive signals from the person you want to treat for risk perception and how anxious It takes time and it is difficult in our healthcare system, so many providers are reluctant to treat it. "
For this reason, he said," Osteoporosis therapies and the number of screening DEXAs. "That's one of the reasons Why we are worried, because this is a very good risk predictor for predicting the 10-year fracture risk. "
At the same time, the use of DEXA has occurred partly because of declining reimbursement costs – the hip fracture rates have dropped while they have been for many years had gone down.
"We think we do not treat enough people, we start with medications, but 70% are not on therapy within a year of initiation, we think this is due to fractures, and I think sometimes it is It is a real dilemma for us and it is important to treat. "
Comparison with the 2017 ACP Guidelines
In the introduction to According to the guidelines, the Endocrine Society Panel notes some differences between these new guidelines and those of the American College of Physicians (ACP) in 2017 for the treatment of women with low BMD or osteoporosis in women and men.
"Certain recommendations in these guidelines have raised new questions and raised much discussion, particularly with regard to duration of therapy and monitoring," according to the Endocrine Society Notes.
The ACP, for example, recommends that women with osteoporosis should be on medication for five years, and monitoring of BMD during this period is not recommended. The duration of therapy is not different between bisphosphonates and denosumab despite different differences between pharmacokinetic profiles of the two classes.
The ACP Guidelines also do not include recommendations for the use of Abaloparatide, whi I was approved by the US Food and Drug Administration shortly before the publication of these guidelines. In severely affected patients, the use of teriparatide is not recommended.
The ACP Guideline, co-author Robert McLean, a practicing rheumatologist in New Haven, Connecticut, and the elected president of the ACP states, said  to Medscape Medical News : "The ACP guidelines tend to make broader recommendations with full recognition that clinical recommendations may not apply to every patient or to all clinical situations. "
McLean also said," The ACP policy process is very strong evidence-based when deciding which recommendations This can of course lead to limitations because there are simply no adequately designed studies to answer the clinical questions that arise in certain patient situations. "
He noted that the guidelines The Endocrine Society are more detailed than the ACPs in certain sections. "I think the ACP guidelines are broader, more general, and based on the evidence-based process that we follow."
Overall, McLean said, "What information can be understood and understood by our patients? be declared by each clinician to help make joint decision-making most helpful. "
Rosen and McLean have not reported any relevant financial relationships.
ENDO 2019. Presented on Mar. 25, 2019.
Eastell R. et al. J Clin Endocrinol Metab. 2019; 104: 1-28. Full text
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