Management of Osteoporosis in Postmenopausal Women: 2010 Position Statement

Recommendations

Management strategies for osteoporosis in postmenopausal women require assessment of risk factors for BMD-defined osteoporosis and osteoporotic fracture, followed by institution of measures that focus on reducing risk factors through lifestyle changes and, if indicated, pharmacologic therapy.

* All postmenopausal women should be encouraged to employ lifestyle practices that reduce the risk of bone loss and osteoporotic fractures: maintaining a healthy weight, eating a balanced diet, obtaining adequate calcium and vitamin D, participating in appropriate exercise, avoiding excessive alcohol consumption, not smoking, and utilizing measures to prevent falls. Periodic reviews of calcium and vitamin D intake and lifestyle behaviors are useful.
After menopause, a woman's risk of falls should be assessed annually and at any time her physical or mental status changes.
* The physical examination should include an annual measurement of height and weight, along with an assessment for chronic back pain, kyphosis, and clinical risk factors.
* BMD testing is indicated for:
o All postmenopausal women with medical causes of bone loss
o All women age 65 and over
* BMD testing should be considered for postmenopausal women age 50 and older who have one or more of the following risk factors:
o Previous fracture (other than skull, facial bone, ankle, finger, and toe) after menopause
o Thinness (body weight < 127 lbs [57.7 kg] or BMI < 21 kg/m2)
o History of hip fracture in a parent
o Current smoking
o Rheumatoid arthritis
o Excessive alcohol intake
* When BMD testing is indicated, DXA is the preferred technique. The total hip, femoral neck, and posterior-anterior lumbar spine should be measured, using the lowest of the three BMD scores.
* The routine use of biochemical markers of bone turnover in clinical practice is not generally recommended.
* Vertebral fracture must be confirmed by lateral spine radiographs or VFA visualization of fracture at the time of BMD testing. Vertebral fracture is confirmed by height loss >20% of the anterior, mid, or posterior dimension of a vertebra on imaging.
* An adequate intake of both calcium and vitamin D is important for bone health and is recognized as an important component of any osteoporosis prescription-drug regimen. NAMS follows the NOF recommendations of calcium intake of 1,200 mg/day for adults age 50 and older, and vitamin D3 of 800 to 1,000 IU/day.

* NAMS recommends osteoporosis drug therapy in the following populations:
o All postmenopausal women who have had an osteoporotic vertebral or hip fracture
o All postmenopausal women who have BMD values consistent with osteoporosis (ie, T-scores ≤−2.5) at the lumbar spine, femoral neck, or total hip region
o All postmenopausal women who have T-scores from −1.0 to −2.5 and a 10-year risk, based on the FRAX calculator, of major osteoporotic fracture (spine, hip, shoulder, and wrist) of at least 20% or of hip fracture of at least 3%
* It is important to encourage adherence to the treatment plan and to identify barriers to nonadherence. Providing clear information to women regarding their risk for fracture and the purpose of osteoporosis therapy may be the optimal way to improve adherence.
* During therapy, it is appropriate to reevaluate the treatment goals and the choice of medication on an ongoing basis through periodic medical examination and a follow-up BMD testing. Measurement of BMD has limited use in predicting the effectiveness of antiresorptive therapies for reducing fracture risk. Also, fracture risk reductions from therapy occur much more rapidly than BMD changes. An appropriate interval for repeat BMD testing is after 1 to 2 years of treatment. There appears to be little value in repeat testing if a woman is stable (within the precision error of the original instrument).
* For untreated postmenopausal women, repeat DXA testing is not useful until 2 to 5 years have passed.

* Bisphosphonates are the first-line drugs for treating postmenopausal women with osteoporosis. They have reduced the risk of vertebral fractures by 40% to 70% and reduced the incidence of nonvertebral fracture, including hip fracture, by about half this amount.
* The SERM raloxifene is most often considered for postmenopausal women with low bone mass or younger postmenopausal women with osteoporosis. It prevents bone loss and reduces the risk of vertebral fractures, but its effectiveness in reducing other fractures is uncertain. Extraskeletal risks and benefits are important when considering raloxifene therapy.
* Teriparatide (PTH 1–34) is best offered to postmenopausal women with osteoporosis who are at high risk for fracture. Daily subcutaneous injections have been shown to stimulate bone formation and improve bone density. Therapy is indicated for no more than 24 months.

* The primary indication for systemic ET/EPT is to treat moderate to severe menopause symptoms (eg, vasomotor symptoms). When symptoms are controlled or cease, continued hormone therapy can still be considered for bone effects, weighing its benefits and risks against those of alternative therapies.
* ET/EPT may be a treatment option for a few years of early postmenopause.
* Calcitonin is not a first-line drug for postmenopausal osteoporosis treatment, as its fracture efficacy is not strong and its BMD effects are less than those of other agents. However, it is an option for women with osteoporosis who are more than 5 years beyond menopause. Calcitonin therapy may reduce vertebral fracture risk in women with osteoporosis, although the evidence documenting fracture protection is not strong. It is not recommended for treating bone pain, except bone pain from acute vertebral compression fractures.
* Data are inadequate to make definitive recommendations regarding combination or serial anabolic and antiresorptive drug therapies.
* The treatment of osteoporosis needs to be long term in most women.
* If drug-related adverse effects occur, appropriate management strategies should be instituted. If adverse effects persist, switching to another agent may be required.
* Decisions to discontinue or suspend therapy are based on the woman's risk of fracture and her response to treatment. Given the uncertainties of long-term drug safety, careful monitoring is required. Fracture risk after discontinuing therapy has not been adequately evaluated.