ACP Guideline Recommends Generic Bisphosphonates But Limits DEXA Use Save

The American College of Physicians (ACP) has updated its 2008 clincial practice guideline on the treatment of low bone density and osteoporosis to prevent fractures in men and women.  The new guideline is in favor of generic bisphosphonate use and recommends against using menopausal estrogen therapy and against DEXA monitoring during the first 5 years.

Guidelines was developed using the GRADE system, based on a systematic literature review, and focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density, including pharmaceutical prescriptions, calcium, vitamin D, and estrogen.

The American College of Physicians (ACP) strongly recommends bisphosphonates (alendronate, risedronate, zoledronic acid) or denosumab for reducing fracture risk in women with osteoporosis. ACP advises physicians to prescribe generics over brand name drugs whenever possible and to discuss medication adherence with their patients, especially for bisphosphonates. 

ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestin therapy or raloxifene for the treatment of osteoporosis in women. Estrogen treatment is associated with serious harms such as increased risk for cerebrovascular accidents and venous thromboembolic events that outweigh the potential benefits.

The evidence suggests that physicians should treat women with osteoporosis with drug therapy for five years. Continuing treatment after the initial five years may be beneficial for some patients and may be appropriate after reassessing the risks and benefits of continuing therapy.

ACP's states the evidence suggests that physicians should treat women with osteoporosis with drug therapy for 5 years. ACP recommends against bone density monitoring during the 5-year treatment period because the evidence does not show any benefit for monitoring during treatment. The evidence also does not support frequent monitoring of women with normal bone density for osteoporosis, as most women with normal bone density measurements did not progress to osteoporosis within 15 years.

Physicians should offer bisphosphonates to reduce the risk for vertebral fractures in men with known osteoporosis. The decision to treat osteopenic women 65 years of age or older who are at a high risk for fracture should be based on a discussion of patient preferences; fracture risk profile; and the benefits, harms, and costs of medications.

Osteoporosis is an enormous public health problem affecting about half of all Americans over the age of 50. The author of an editorial from Oregon Health and Science University in Portland writes that ACP’s recommendation to offer bisphosphonates or denosumab to women with osteoporosis is particularly important because, despite the wealth of evidence, osteoporosis remains underdetected and undertreated. ACP’s guideline provides a solid basis for informed clinical decision-making.

There is an accompanying video from the  ACP’s president discussing treatment of low bone density or osteoporosis are available to download at http://www.dssimon.com/MM/ACP-osteoporosis-guideline/