Osteoporosis Update

New ACP guidelines have improved the specificity of criteria for diagnosis of osteoporosis.^1,2 The current standard of low BMD (femoral neck BMD of ≥2.5 SD below the young female adult mean) is recognized as an “imperfect” predictor of fracture risk, with < 50% accuracy, and the presence of fragility fractures has been added to diagnostic criteria. The guidelines also expanded the target population of patients from post-menopausal women to include premenopausal women and men with clinical signs of osteoporosis.

The mechanism of most established treatments is to prevent bone loss by reducing resorption. Calcitonin has declined in use for osteoporosis, although it is still available. Etidronate and pamidronate were removed from the guidelines, as neither has FDA-approval for the prevention of fractures or treatment of osteoporosis. Bazedoxifene, a SERM, was recently approved for use with conjugated estrogen for the prevention of osteoporosis. The guidelines note that calcium and vitamin D may be added as dietary supplements to osteoporosis treatment regimens, but their effectiveness on fracture prevention is unclear. ©Patricia Chumillas/ Shutterstock.com

High quality evidence showed that, compared to placebo, treatment with bisphosphonates (including alendronate, risidronate, and zoledronic acid) reduced vertebral, nonvertebral, and hip fractures in postmenopausal osteoporotic women.

Sub-Q abaloparatide (80 µg/day) (ABL) for 18 mo followed by alendronate PO for 6 mo (70 mg/week) (ALN) produced greater gains in BMD and fewer vertebral and non-vertebral fractures compared to 6 mo of ALN alone.

A review by Eiken and Vestergaard⁵ showed benefits of switching from first-line therapies alendronate or residronate. More investigation of these combinations is needed.