AAOS Endorses Endocrinology Association CPG on Postmenopausal Osteoporosis

In December 2023, the AAOS Board of Directors approved an endorsement of a clinical practice guideline (CPG), “Diagnosis and Treatment of Postmenopausal Osteoporosis,” previously issued by the American Association of Clinical Endocrinology (AACE) and the American College of Endocrinology (ACE). The guideline, originally issued in 2016 and updated by AACE in 2020, was intended to serve as “a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of postmenopausal osteoporosis,” according to a summary statement issued by AACE.

Susan Bukata, MD, FAAOS, served as the content expert and reviewer in the process by which the AAOS Committee on Evidence-Based Quality and Value evaluates CPGs forwarded for AAOS endorsement. In her review, Dr. Bukata delineated the applicability of the guidelines across the practice of orthopaedic surgery, noting the high risk of fractures in women resulting from postmenopausal osteoporosis and the emphasis placed by the AACE guideline on the importance of treatment along with diagnostic criteria and treatment options. One in 10 women over the age of 60 years is affected by osteoporosis, and one in two postmenopausal women will have osteoporosis and suffer a fracture during their lifetime.

In the introduction to the CPG, AACE states, “Osteoporosis is a growing major public health problem, with an impact on quality and quantity of life that crosses medical, social, and economic lines.” The guideline notes, “Osteoporosis is preventable and treatable, but only a small proportion of those at increased risk for fracture are evaluated and treated.” Age, it states, “is an important risk factor for bone loss; by age 60 years, half of white women have low bone mass (osteopenia) or osteoporosis. It further notes that the average femoral neck T-score by dual-energy X-ray absorptiometry (DXA) for 75-year-old women is −2.5, meaning that more than half of women aged 75 and older meet the criterion for osteoporosis.” Furthermore, more than 20 percent of postmenopausal women have prevalent vertebral fractures. Although guidelines focus only on the evaluation and treatment of osteoporosis in postmenopausal women, the CPG notes that osteoporosis may affect men and women who have not yet undergone menopause.

AACE states that it developed the recommendations “with hopes of reducing the risk of osteoporosis-related fractures and thereby maintaining the quality of life for people with osteoporosis.” The guideline “uses the best evidence, taking into consideration the economic impact of the disease and the need for efficient and effective evaluation and treatment of postmenopausal women with osteoporosis.”

Key recommendations

The AACE CPG is organized within a framework of 12 questions, which serve to yield 49 total recommendations. The framing questions are as follows:

1. How is fracture risk assessed and osteoporosis diagnosed?
2. When osteoporosis is diagnosed, what is an appropriate evaluation?
3. What are the fundamental measures for bone health?
4. Who needs pharmacologic therapy?
5. What medication should be used to treat osteoporosis?
6. How is treatment monitored?
7. What is successful treatment of osteoporosis?
8. How long should patients be treated?
9. What is the role of concomitant use of therapeutic agents?
10. What is the role of sequential use of therapeutic agents?
11. What is the role of vertebral augmentation for compression fractures?
12. When should referral to a clinical endocrinologist or other osteoporosis specialist be considered?

In the diagnostic phase, the CPG advises evaluating postmenopausal women aged ≥50 years for osteoporosis risk using detailed history, physical exam, and clinical fracture risk-assessment tools in the initial evaluation (Fig. 1). The examiner should consider bone mineral density testing (Fig. 2) based on clinical fracture risk profile. A diagnosis of osteoporosis should be based on fragility fractures, T-score ≤–2.5, or T-score between –1.0 and –2.5 with increased fracture risk.

For diagnosed osteoporosis, the physician should evaluate for causes of secondary osteoporosis, assess for prevalent vertebral fractures, and consider bone turnover markers in initial and follow-up evaluations. Among the fundamental measures that should be taken to promote and enhance bone health are: measure serum 25-hydroxyvitamin D in at-risk patients, maintaining levels ≥30 ng/mL; supplement with vitamin D3 if needed, with a daily dose of 1,000 to 2,000 IU; and counsel the patient to achieve adequate calcium intake, limit alcohol, and practice an active lifestyle. The CPG recommends pharmacologic therapy for patients with osteopenia or low bone mass and a history of fragility fracture, and it strongly recommends pharmacologic therapy for T-score ≤–2.5 or T-score between –1.0 and –2.5 with high fracture risk.

In the selection of medication for osteoporosis treatment, the guideline advises initial therapy with alendronate, denosumab, risedronate, or zoledronate for most osteoporotic patients. The physician should consider alternative agents for patients unable to use oral therapy or at very high fracture risk. Overall, postmenopausal women with osteoporosis can be stratified according to high-risk and very high-risk features, which include prior fractures. “Stratification of the patient drives the choice of the initial agent as well as the duration of therapy,” the CPG states.

In monitoring treatment, the physician should obtain baseline DXA and repeat imaging every 1 to 2 years until the patient is stable, monitor changes in bone mineral density, and consider bone turnover markers for compliance and efficacy assessment. Indicators of successful treatment include stable or increasing bone mineral density with no new fractures. The physician may consider bone turnover markers as targets for response to therapy. The CPG advises limiting treatment duration for certain agents and considering bisphosphonate holidays based on fracture risk and stability.

Addressing the issue of concomitant and sequential therapeutic agents, the guideline discourages concomitant use of therapeutic agents until they are “better understood.” It also advises following up on anabolic therapy with bisphosphonate or denosumab to prevent bone density decline. On the role of vertebral augmentation, the guideline does not recommend vertebroplasty or kyphoplasty as first-line treatment for vertebral fractures.

Finally, the guideline recommends referral to osteoporosis specialists for patients with fragility fractures, unexplained fractures, or other complex conditions.

Terry Stanton is the senior medical writer at AAOS Now.