Conference Update

Guideline update: Pharmacological management of osteoporosis in postmenopausal women

4 months ago, OP Editor

Treatment guidelines for the management of osteoporosis in postmenopausal women were updated by the Endocrine Society. The updated guidelines recommended to include or alter treatments with romosozumab, selective estrogen receptor modulators, menopausal hormone therapy, tibolone, calcitonin, calcium, and vitamin D.

The guidelines for the management of postmenopausal osteoporosis are designed to provide the clinicians with an evidence-based approach. Several therapeutic options are available for the treatment of osteoporosis, and this framework presents evidence from clinical trials for the efficacy and safety of these interventions. And an algorithm was presented to guide the clinicians on choosing the most appropriate therapeutic choices for their patients (Figure 1).

Since the development of the last guidelines, several regulatory agencies have approved romosozumab, a new type of anabolic agent for the treatment of osteoporosis that differs from teriparatide and abaloparatide in its mechanism of action. Unlike the latter drugs which work directly through the parathyroid hormone (PTH) type 1 receptor, romosozumab works by blocking the actions of sclerostin, an inhibitor of bone formation that binds to the low-density lipoprotein receptor-related protein (LRP)5/6 component of the LRP5/6-frizzled co-receptor complex that mediates Wnt/β-Catenin pathway. The introduction of romosozumab to the clinical armamentarium necessitates this update to the osteoporosis guidelines. This development gives providers an additional osteoporosis treatment option to consider, particularly in women with multiple vertebral fractures and low bone mineral density (BMD), as indicated by the above algorithm and also in the approval documents from the United States Food and Drug Administration and Health Canada. Discussion about the efficacy and safety of this drug is contained within the guideline update and is based on a systematic review of the clinical trials for romosozumab.

Other updates for this high-risk group include:

  • Selective estrogen receptor modulators raloxifene or bazedoxifene are recommended to reduce the risk of vertebral fractures in patients who are (1) at low risk of deep vein thrombosis; (2) women in which bisphosphonates or denosumab are not appropriate; (3) women with a high risk of breast cancer
  • Menopausal hormone therapy, using estrogen-only therapy in women with hysterectomy, to prevent all types of fractures for: (1) women under 60 years of age or less than 10 years past menopause; (2) women at low risk of deep vein thrombosis; (3) women in which bisphosphonates or denosumab are not appropriate; (4) women with vasomotor symptoms; (5) women with climacteric symptoms, and (6) women without contraindications, prior myocardial infarction or stroke, or breast cancer
  • The nasal spray calcitonin is recommended for women who cannot tolerate raloxifene, bisphosphonates, estrogen, denosumab, tibolone, abaloparatide or teriparatide
  • Calcium and vitamin D are recommended as add-on therapy for postmenopausal women with low BMD and at high risk of fractures with osteoporosis
  • Postmenopausal women with a low BMD who are at high risk of fractures should undergo monitoring for BMD by dual-energy X-ray absorptiometry at the spine and hip every 1 to 3 years to assess treatment response
  1. Shoback D et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020;105(3):587-594.


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