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NEW ORLEANS – The new Endocrine Society guidelines on the pharmacological treatment of osteoporosis in postmenopausal women are intended to encourage clinicians to increase the rates of screening and treatment for this disease.
The document titled "Pharmacological Management of Osteoporosis in Postmenopausal Women" was presented on March 25th at ENDO 2019: Annual Meeting of the Society of Endocrinology and published concurrently online in the Journal of Clinical Endocrinology & Metabolism with other online resources. The document is co-sponsored by the European Society of Endocrinology.
The Chair of the Editorial Board, Clifford J. Rosen, MD, Director of the Center for Clinical and Translational Research at the Maine Medical Research Institute in Scarborough, summarized the key points of the guideline at a press conference .
"We have to be aggressive in treating people who have already had a fracture," he said. Medscape Medical News.
For starters, lifestyle and nutrition optimization for bone health – especially calcium and vitamin D – is recommended for all postmenopausal women, as well as an badessment of fracture risk over 10 years in accordance with country specific guidelines.
As in the past, bisphosphonates and denosumab are still recommended as first-line treatments. But the Endocrine Society now recommends anabolic treatments – teriparatide or abaloparatide (Tymlos, Radius Health) – as a first-line treatment for patients with very severe osteoporosis, multiple fractures and / or very low bone density.
This new recommendation, said Rosen, "means we need to intervene quickly because the effects are faster than with bisphosphonates".
For women taking bisphosphonates for 3 to 5 years, the risk of fracture should be badessed.
After rebadessment, women at low to moderate risk of fracture should be prescribed "bisphosphonate leave".
All women taking osteoporosis treatments – with the exception of anabolic steroids – should consume calcium and vitamin D in their diet or by taking supplements.
Monitoring of bone mineral density (BMD) for high-risk patients with low BMD should occur every 1-3 years, as directed.
Have the risks of treatments for osteoporosis been overestimated?
Asked at the risk briefing for some of these osteoporosis treatments, Rosen acknowledged the concern over atypical fractures of the femur badociated with bisphosphonates, noting that patients often ask why they need to take a medication to prevent fractures that can cause a fracture. .
"We are very concerned about this, and some of the recent data suggest that the risk of atypical fractures of the femur by bisphosphonates remains quite low," he said.
But he also noted that some factors increase this risk, including a longer duration of treatment. "This is one of the reasons we have advocated drug leave for many people who have been successfully treated for three years by means of a bisphosphonate." Other adverse events, including osteonecrosis of the jaw, are less common, he noted.
"The fracture of the femur has attracted the most attention and has been the most disconcerting for individuals," added Rosen. "As a doctor, it is difficult because you have to spend time discussing the absolute risk and the relative risk differences for a given patient." You also need to receive signals from the person you want What is your perception of risk? It takes time, and in our health care system it is difficult, so many providers are reluctant to treat. "
For this reason, he said, "the number of prescriptions for anti-osteoporosis treatments has decreased significantly, as has the number of screenings at DEXA.This is one of the reasons we worry, because it's a very good predictor of risk to predict 10-year fracture risk. "
At the same time, the use of DEXA decreased – partly because of the decline in reimbursement – hip fracture rates have stabilized, while they have been declining for many years.
"We think it is because we do not treat enough patients.We start taking medication, but 70% of them do not receive treatment in the year following the start. We think this is due to the concern for fractures.I sometimes think it's a lack of communication from providers about the importance of staying in therapy … It's a real dilemma for us.It's important to treat. "
Comparison with the 2017 guidelines of the ACP countries
In the introduction to the guidelines, the Endocrine Society Group highlights some of the differences between these new guidelines and those published by the American College of Physicians (ACP) in 2017 for the treatment of low BMD or Osteoporosis in women and men.
"Some of the recommendations in these guidelines have raised new questions and generated a lot of discussion, especially regarding treatment time and surveillance," says the Endocrine Society's paper.
For example, the ACP recommends that women with osteoporosis receive medication for five years and recommends not to monitor their BMD during this period. No differentiation is made for the duration of treatment between bisphosphonates and denosumab, despite the different pharmacokinetic profiles of the two clbades.
The ACP guidelines also do not contain recommendations regarding the use of abaloparatide, which was approved by the US Food and Drug Administration just before the publication of these guidelines. And they do not advise the use of teriparatide for severely affected patients.
Asked about the comments, co-author of the ACP recommendations, Robert McLean, MD, acting rheumatologist in New Haven, Connecticut, and the elected president of the ACP, said Medscape Medical News"ACP guidelines tend to provide broader recommendations while recognizing that clinical guidelines may not be applicable to all patients and clinical situations."
In addition, McLean said, "The ACP guidelines process is very strictly evidence-based when it decides what recommendations it can make and what recommendations it can not make, which clearly leads to some limitations because There are simply no sufficiently designed trials issues that arise in certain specific patient situations. "
He noted that the guidelines of the Society of Endocrinology are more detailed than those of the ACP in some sections. "I think ACP guidelines are broader and more general, based on the evidence-based process we follow."
Overall, McLean said, the important question regarding the recommendations is "what information can be understood and explained by our patients by our clinicians to make shared decision making conversations more useful".
Rosen and McLean have not reported any relevant financial relationship.
ENDO 2019. Presented on March 25, 2019.
Eastell R, et al. J Clin Endocrinol Metab. 2019; 104: 1-28. Full Text
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