Endocrine Society Clinical Practice Guideline: Management of Postmenopausal Osteoporosis (2019) (Summary)

This clinical practice guideline can be applied to a postmenopausal woman when considering the management of her osteoporosis. In addition to women with low-moderate fracture risk, women at high risk as being eligible for drug therapy are also considered in this.

 

*Risk of Fracture

 

 

 

 

 

 

 

 

 

Lifestyle and nutritional optimization especially

Calcium & Vitamin D

1st Line Treatment

2nd Line Treatment

Reassessment

Drug Holiday

Low

 

 

 

Reassess fracture risk in 2-4 yrs

 

 

Moderate

 

Calcium & Vitamin D

±

Bisphosphonates (BPs)

 

 

Reassess fracture risk –

  • In 2-4 yrs if no treatment given
  • In 3-5 yrs during BPs therapy (5yrs for oral, 3yrs for IV)
  1. For patients on BPs therapy-
  • Low-moderate risk – consider drug holiday (reassess every 2-4 yrs for restarting therapy in patients with high risk/ increased bone loss)
  • High risk- continue/ switch to another therapy

 

  1. For patients on Denosumab therapy-
  • Low-moderate risk – consider BPs treatment then drug holiday (reassess every 1-3 yrs for restarting therapy in patients with high risk/ increased bone loss/fracture)
  • High risk- continue/ switch to another therapy

 

 

High

 

BPs/ Denosumab/ Teriparatide (for 2 years, followed by BPs/denosumab)

+

Calcium & Vitamin D

If intolerant/inappropriate to BPs/ Denosumab therapy

  • Age <60yrs, <10 yrs menopause, low VTE risk -
    • No vasomotor symptoms, high breast cancer risk - SERM
    • Vasomotor symptoms - HT / Tibolone
  • Age >60yrs (in order)-
    • SERM
    • HT/ Tibolone
    • Calcitonin
    • Calcium + Vitamin D
  1. Reassess fracture risk in-
  • 3-5 yrs during BPs therapy
  • 5-10 yrs during denosumab therapy

 

 

Very high

 

*Low- no prior hip or spine fracture, T-score at the hip and spine > -1.0, hip fracture FRAX <3% and major osteoporotic fracture FRAX <20%,

Moderate- no prior hip or spine fracture, T-score at the hip and spine > -2.5, hip fracture FRAX <3% and major osteoporotic fracture FRAX <20%,

High- a prior hip or spine fracture, T-score at the hip and spine ≤ -2.5, hip fracture FRAX ≥3% and major osteoporotic fracture FRAX ≥20%,

Very high- multiple prior hip or spine fracture, T-score at the hip and spine ≤ -2.5;

#No uterusàEstrogen; with uterus à Estrogen+ Progestin

SERM- Selective Estrogen Receptor Modulator; HT- Hormone Therapy; VTE – Venous Thromboembolism

Reference:

Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3).

 

 

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