Two different medical groups have separately released recommendations for patients who have osteoporosis – or are at high risk of developing it – outlining the best evidence-based treatment practices to prevent and manage the disease.
Osteoporosis is a condition in which bones lose mass and become thin and brittle, increasing the risk of a fracture. Often, osteoporosis is a result of aging and the hormonal changes that accompany it. But it also can be a result of disease (including rheumatoid and psoriatic arthritis) or the use of certain medications, including corticosteroids (also called glucocorticoids). The U.S. Department of Health and Human Services (HHS) estimates 50 percent of Americans over the age of 50 are at risk for an osteoporotic fracture.
The first set of recommendations comes from the American College of Rheumatology (ACR), which updated its 2010 guidelines for preventing and treating glucocorticoid-induced osteoporosis. This condition happens as a result of prolonged use of medications like prednisone, which is often prescribed long-term for patients with inflammatory types of arthritis, like rheumatoid arthritis (RA).
“Many patients with arthritis are, at times, going to need to take prednisone and other steroid-type medicines, and it is always important for physicians and patients to have some sense of what the evidence shows,” says Kenneth G. Saag, MD, vice chair of the department of medicine at the University of Alabama at Birmingham School of Medicine and president of The National Osteoporosis Foundation’s board of trustees.
Lenore M. Buckley, MD, professor of medicine at the Yale School of Medicine, in New Haven, Connecticut, and the principal investigator on the committee that authored the updated ACR guidelines, says they offer general recommendations for those who use glucocorticoid therapy for more than three months at a dose equal to or greater than 2.5 mg a day.
For these patients, ACR now recommends:
- Assessing fracture risk within 6 months of starting long-term glucocorticoid therapy
- Reassessing fracture risk every 12 months throughout treatment
- Treating patients found to be at moderate to high risk of a fracture with specific therapies (detailed in the guidelines), depending on age, sex, level of risk and other factors
- For adult patients, optimizing intake of calcium (800 to 1,000 mg/day) and vitamin D (600 to 800 IU/day), and making lifestyle changes consistent with good bone health, including not smoking, not drinking excessively, maintaining a healthy weight and exercising (weight bearing or resistance training) regularly
ACR’s updated guidelines, published in June in both Arthritis & Rheumatology and Arthritis Care & Research, also contain specific recommendations for special populations, including women of childbearing potential, adults treated with very high-dose glucocorticoids, adults with organ transplants, and children 4 to 17 years of age. Dr. Buckley points out the guidelines also discuss the possibility of bone-mass recovery among those who have taken but discontinued glucocorticoids.
But, because few studies of osteoporosis therapies look specifically at people with glucocorticoid-induced osteoporosis, the committee notes that most of the recommendations are “conditional.” That is, “the desirable effects of following [a particular] recommendation probably outweigh the undesirable effects, so the course of action would apply to the majority of the patients, but some may not want to follow the recommendation.”
A second, more general set of updated osteoporosis treatment guidelines has been released by the American College of Physicians (ACP) – a national organization of internal medicine doctors. These were published in May in Annals of Internal Medicine.
“A number of things have changed since the last guidelines in 2008. There is more data on newer medications, studies with more long-term outcomes and more inclusion of men in research,” explains guideline co-author, Robert McLean, MD, a rheumatologist with Northeast Medical Group of the Yale New Haven Hospital, in Connecticut.
ACP now strongly recommends:
- Treatment with the bisphosphonates alendronate (Binosto, Fosamax, generic), risedronate (Actonel, Atelvia, generic), zoledronic acid (Reclast, Zometa), or the biologic denosumab (Prolia) to reduce risk of hip and vertebral fractures in women with existing osteoporosis
- Against using menopausal estrogen therapy or menopausal estrogen plus progesterone therapy or the selective estrogen receptor modulator (SERM) raloxifene (Evista) for the treatment of existing osteoporosis in women
Although ACP found that the evidence isn’t as strong, it issued weaker recommendations that clinicians:
- Treat women with osteoporosis with pharmacologic therapy for five years
- Offer bisphosphonates to reduce the risk for vertebral fracture in men with osteoporosis
Dr. McLean says there isn’t enough data to issue a broad recommendation beyond a five-year time period, so the guidelines suggest treatment and assessment after five years should be decided by a patient and his or her physician.
ACP also recommends against bone density monitoring during the five-year period women are treated for osteoporosis, which Dr. McLean says has drawn some questions.
“That isn’t to say there aren’t exceptions,” he explains. “But these are broad-stroke recommendations. There may be some who might benefit, but the data in large studies doesn’t show it makes a big difference across large groups of people.”
The bottom line, say experts: If you are on prednisone or other medications that put you at risk for osteoporosis or if you already have osteoporosis or a history of previous fractures, you should talk with a doctor to devise or review your treatment plan.
“We know a lot of patients are not getting treated who should be treated,” says Dr. Saag. “The vast majority of patients with osteoporosis don’t see a specialist so it is very important that we have guidelines to help generalists and to identify gaps in our evidence.”
Author: Jennifer Davis for the Arthritis Foundation
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