ACP Updates Clinical Recommendations on Treatment of Osteoporosis

Kenny Lin, MD, MPH
Posted on January 9, 2023

The American College of Physicians (ACP) has updated its 2017 clinical practice guideline on treatment of primary osteoporosis or low bone mass to prevent fractures in adults. The previous version, which was endorsed by the American Academy of Family Physicians, recommended treating women with osteoporosis for five years with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk of hip fractures and vertebral fractures. It also suggested that men with clinically recognized osteoporosis be offered bisphosphonates to reduce the risk of vertebral fractures. Treating older women with low bone mass (osteopenia) at high risk for fracture was deemed to be optional based on patient preferences and medication benefits, harms, and costs. The publication of additional studies on existing therapies and the availability of new therapies such as abaloparatide prompted this guideline update.

An independent evidence review team performed a systematic review and network meta-analysis of osteoporosis treatments that analyzed 34 randomized controlled trials and 36 observational studies. The review confirmed the effectiveness of bisphosphonates and denosumab in reducing hip, vertebral, and other clinical fractures. In older postmenopausal females at very high fracture risk, abaloparatide, teriparatide, and sequential romosozumab, then alendronate, appeared to be more effective at reducing clinical fractures over 24 months than bisphosphonates. Harms of therapies included an increased risk of adverse events with abaloparatide and teriparatide and a small absolute increased risk of atypical femoral fractures and osteonecrosis of the jaw for people taking bisphosphonates for 36 months or more.

In the updated guideline, the ACP now recommends that clinicians preferentially use bisphosphonates as first-line therapy in women and men with osteoporosis, with the exception of women at very high risk of fracture. In this group, either romosozumab or teriparatide can be used, followed by a bisphosphonate. Denosumab is endorsed as a second-line therapy for adults with contraindications to or who experience adverse effects from bisphosphonates. Similar to the 2017 guideline, the ACP suggests an individualized approach to prescribing bisphosphonates in women older than 65 years with low bone mass. Rather than revisiting the recommendations in a specific time frame, the ACP plans to perform quarterly literature surveillance and maintain this topic as a living guideline that will be updated periodically when new evidence becomes available.

The U.S. Preventive Services Task Force currently recommends screening for osteoporosis in all women 65 years and older and postmenopausal women younger than 65 years at increased risk using a clinical risk assessment tool. It found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men. The American College of Obstetricians and Gynecologists recently made similar screening recommendations. A 2020 report from the Women’s Health Initiative study found that repeating bone mineral density testing after three years did not provide more clinical information than a baseline measurement. Additional information on osteoporosis diagnosis and treatment is available in our AFP By Topic collection, including a Lown Right Care article on making decisions about fracture prevention in older adults.