AACE releases updated guideline on osteoporosis treatment

22. Pharmacologic therapy is strongly recommended for patients with a T-score between −1.0 and −2.5 if the FRAX® (fracture risk assessment tool) (or if available, trabecular bone score [TBS]-adjusted FRAX®) 10-year probability for major osteoporotic fracture is ≥20% or the 10-year probability of hip fracture is ≥3% in the U.S. or above the country-specific threshold in other countries or regions.

23. Consider patients with a recent fracture (e.g., within the past 12 months), fractures while on approved osteoporosis therapy, multiple fractures, fractures while on drugs causing skeletal harm (e.g., long-term glucocorticoids), very low T-score (e.g., less than −3.0), high risk for falls or history of injurious falls, and very high fracture probability by FRAX® (fracture risk assessment tool) (e.g., major osteoporosis fracture >30%, hip fracture >4.5%) or other validated fracture risk algorithm to be at very high fracture risk. Consider patients who have been diagnosed with osteoporosis but are not at very high fracture risk, as defined above, to be high risk.

24. Approved agents with efficacy to reduce hip, nonvertebral, and spine fractures including alendronate, denosumab, risedronate, and zoledronate are appropriate as initial therapy for most osteoporotic patients with high fracture risk, as defined in R23.

25. Abaloparatide, denosumab, romosozumab, teriparatide, and zoledronate should be considered for patients unable to use oral therapy and as initial therapy for patients at very high fracture risk, as defined in R23.

26. Ibandronate or raloxifene may be appropriate initial therapy in some cases for patients requiring drugs with spine-specific efficacy.

27. Obtain a baseline axial (lumbar spine and hip; 1/3 radius if indicated) dual-energy X-ray absorptiometry (DXA) and repeat DXA every 1 to 2 years until findings are stable. The 1/3 radius may be considered as an alternate site when the lumbar spine/hip are not evaluable or as an additional site in patients with primary hyperparathyroidism. Continue with follow-up DXA every 1 to 2 years or at a less frequent interval, depending on clinical circumstances.

28. Monitor serial changes in lumbar spine, total hip, or femoral neck bone mineral density; if lumbar spine, hip, or both are not evaluable, monitoring with 1/3 radius site may be acceptable but is limited by a small area and a very large least significant change (LSC).

29. Follow-up of patients should ideally be conducted in the same facility with the same dual-energy X-ray absorptiometry (DXA) system, provided the acquisition, analysis, and interpretation adhere to International Society for Clinical Densitometry DXA best practices.

30. Consider using bone turnover markers (BTMs) for assessment of patient compliance and efficacy of therapy. Significant reductions in BTMs are seen with antiresorptive therapy and have been associated with fracture reduction, and significant increases indicate good response to anabolic therapy.

31. Consider stable or increasing bone mineral density, with no evidence of new fractures or vertebral fracture progression as a response to therapy for osteoporosis.

32. Consider bone turnover markers at or below the median value for premenopausal women as a target for response to therapy for patients taking antiresorptive agents.

33. Consider alternative therapy or reassessment for causes of secondary osteoporosis in patients who have recurrent fractures or significant bone loss while on therapy. Although a single fracture while on therapy is not necessarily evidence of treatment failure, consider two or more fragility fractures are evidence of treatment failure.

34. Limit treatment with abaloparatide and teriparatide to 2 years and follow abaloparatide or teriparatide therapy with a bisphosphonate or denosumab.

35. Limit treatment with romosozumab to 1 year and follow with a drug intended for long-term use, such as a bisphosphonate or denosumab.

36. For oral bisphosphonates, consider a bisphosphonate holiday after 5 years of treatment if fracture risk is no longer high (such as when the T score is greater than -2.5, or the patient has remained fracture free), but continue treatment up to an additional 5 years if fracture risk remains high.

37. For oral bisphosphonates, consider a bisphosphonate holiday after 6 to 10 years of stability in patients with very high fracture risk.

38. For zoledronate, consider a bisphosphonate holiday after 3 years in high-risk patients or until fracture risk is no longer high, and continue for up to 6 years in very-highrisk patients.

39. The ending of a bisphosphonate holiday should be based on individual patient circumstances such as an increase in fracture risk, a decrease in bone mineral density beyond the least significant change (LSC) of the dual-energy X-ray absorptiometry (DXA) machine, or an increase in bone turnover markers.

40. A holiday is not recommended for non-bisphosphonate antiresorptive drugs (Grade A; BEL 1), and treatment with such agents should be continued for as long as clinically appropriate.

41. If denosumab therapy is discontinued, patients should be transitioned to another antiresorptive.

42. Until the effect of combination therapy on fracture risk is better understood, AACE does not recommend concomitant use of these agents for prevention or treatment of postmenopausal osteoporosis

43. Follow treatment with an anabolic agent (e.g., abaloparatide, romosozumab, teriparatide) with a bisphosphonate or denosumab to prevent bone density decline and loss of fracture efficacy.

44. Vertebroplasty and kyphoplasty are not recommended as first-line treatment of vertebral fractures, given an unclear benefit on overall pain and potential increased risk of vertebral fractures in adjacent vertebrae.

45. Patients who experience fragility fractures should be evaluated and treated. Referral to an osteoporosis specialist or a fracture liaison team, if available, should be considered.

46. When a patient with normal bone mineral density sustains a fracture without major trauma, referral to a clinical endocrinologist or other osteoporosis specialists should be considered.

47. When recurrent fractures or continued bone loss occur(s) in a patient receiving therapy without obvious treatable causes of bone loss, referral to a clinical endocrinologist or other osteoporosis specialists should be considered.

48. When a patient has a condition that complicates management (e.g., decreased kidney function, hyperparathyroidism, or malabsorption), referral to a clinical endocrinologist or other osteoporosis specialists should be considered.

AACE Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis - 2020 Update