2022 ACOG Management of Postmenopausal Osteoporosis
2022 ACOG Management of Postmenopausal Osteoporosis
2022 ACOG Management of Postmenopausal Osteoporosis
Number 2
REPLACES PRACTICE BULLETIN NUMBER 129, SEPTEMBER 2012
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Continued
approved agents, results from systematic reviews and Bisphosphonates prevent and treat osteoporosis by
meta-analyses show that bisphosphonates (ie, alendro- inhibiting osteoclast-mediated bone resorption. Four
nate, risedronate, zoledronic acid) and denosumab effec- bisphosphonates are approved for use in the United
tively reduce the risk of vertebral, nonvertebral, and hip States (alendronate, risedronate, ibandronate, and zole-
fractures (1, 32, 34). Given their broad-spectrum antifrac- dronic acid). The bisphosphonates differ in binding
ture efficacy, these antiresorptive agents are considered affinity, dose frequency, and route of administration. They
as first-line therapy for most patients with osteoporosis all have been studied extensively in large RCTs that have
and elevated fracture risk (32). demonstrated antifracture benefit (1, 32, 40, 41). A net-
In patients with severe bone loss, very high fracture work meta-analysis of studies on bisphosphonates found
risk, or both (eg, a T-score of -3 or lower, T score of less that they significantly reduce vertebral fractures: zole-
than 2.5 and a fracture within the past 12 months, or a dronic acid (relative risk [RR] 0.38; 95% CI 0.25–0.58),
history of severe or multiple vertebral fractures), it may be risedronate (RR 0.61; 95% CI 0.48–0.78), alendronate
appropriate to choose an anabolic agent as initial (RR 0.57; 95% CI 0.45–0.71), and ibandronate (RR 0.67;
therapy (11, 24, 35) because they have been shown to 95% CI 0.48–0.93) (32). Similarly, a systemic review and
be more effective than antiresorptive therapies for meta-analysis showed that bisphosphonates were asso-
increasing BMD and bone formation and decreasing ciated with an overall 50% reduction in vertebral fractures
the risk of vertebral fractures (33, 36, 37). Raloxifene in postmenopausal women with osteoporosis or osteo-
may be appropriate in select patients who need spine- penia (41). Alendronate, risedronate, and zoledronic acid
specific therapy and are at elevated risk of breast cancer also significantly reduce nonvertebral fractures and hip
(24). Because of the risks associated with hormone ther- fractures (32). In addition, zoledronic acid (42) and risedr-
apy and the low efficacy of calcitonin, these treatments onate (43) have been shown to reduce the incidence of
generally are reserved for use in patients who cannot vertebral and nonvertebral fragility fractures in postmen-
tolerate other osteoporosis therapies. opausal women with osteopenia. Ibandronate improves
In addition to efficacy, mode of administration (inject- bone density and reduces vertebral fractures, but evi-
able vs oral), dosing frequency, and cost are important dence is lacking for its prevention of hip and nonvertebral
considerations for patients who are deciding among the fractures (32).
various osteoporosis treatments (Table 1) (38). A system-
atic review of studies on patient decision making regard- Implementation and Safety Considerations
ing osteoporosis medications found that oral therapies Lack of adherence to taking oral bisphosphonates as
generally are preferable to injectable agents unless oral directed is an issue and limits their effectiveness in
treatments require more frequent dosing (38). The most preventing fracture (44). Bisphosphonates are poorly ab-
cost-effective initial therapy for postmenopausal osteopo- sorbed orally; therefore, oral therapies need to be taken
rosis is generic oral alendronate or generic parenteral in the early morning on an empty stomach with water 30–
zoledronic acid (39). Additional important considerations 60 minutes before eating, and patients need to stay
for shared decision making about osteoporosis pharma- upright to avoid esophageal irritation. Other adherence
cotherapy include drug contraindications and adverse issues are attributed to the need for weekly instead of
effects, ease and convenience of administration, and monthly dosing and adverse effects of the medication
duration of treatment. (44, 45).
Adverse effects of oral bisphosphonates include
Bisphosphonates musculoskeletal aches and pains, gastrointestinal irrita-
tion, and esophageal reflux and ulceration (1). Potential
ACOG recommends bisphosphonates as ini- rare risks identified in postmarketing surveillance include
tial therapy for most postmenopausal patients osteonecrosis of the jaw, atypical fractures of the femoral
at increased risk of fracture. (STRONG RECOMMEN- shaft, and esophageal cancer (1). Patients should be
DATION, HIGH-QUALITY EVIDENCE) cautioned that pain in the thigh or groin may be a
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