Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians

Abstract

Description: This guideline updates the 2017 American College of Physicians (ACP) recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults.

Methods: The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of evidence and graded them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Audience and patient population: The audience for this guideline includes all clinicians. The patient population includes adults with primary osteoporosis or low bone mass.

Recommendation 1a: ACP recommends that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis (strong recommendation; high-certainty evidence).

Recommendation 1b: ACP suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis (conditional recommendation; low-certainty evidence).

Recommendation 2a: ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; moderate-certainty evidence).

Recommendation 2b: ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; low-certainty evidence).

Recommendation 3: ACP suggests that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant PTH (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture (conditional recommendation).

Recommendation 4: ACP suggests that clinicians take an individualized approach regarding whether to start pharmacologic treatment with a bisphosphonate in females over the age of 65 with low bone mass (osteopenia) to reduce the risk of fractures (conditional recommendation; low-certainty evidence).

Appendix Figure.

Grading the certainty of evidence and strength of recommendations in ACP clinical guidelines using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. ACP = American College of Physicians.

Figure 1.

Treatments to reduce fractures in postmenopausal females with primary osteoporosis. ACP = American College of Physicians; PTH = parathyroid hormone; RANK = receptor activator of nuclear factor κB; RCT = randomized controlled trial.

Figure 1.

Treatments to reduce fractures in postmenopausal females with primary osteoporosis. ACP = American College of Physicians; PTH = parathyroid hormone; RANK = receptor activator of nuclear factor κB; RCT = randomized controlled trial.

Figure 2.

Treatments to reduce fractures in males with primary osteoporosis. ACP = American College of Physicians; RANK = receptor activator of nuclear factor κB; RCT = randomized controlled trial.

Figure 3.

Treatments to reduce fractures in postmenopausal females with low bone mass. ACP = American College of Physicians.