Diagnosis and Treatment of Postmenopausal Osteoporosis
Publication Date: March 2, 2020
Last Updated: March 14, 2022
GUIDELINES
Fracture Risk
Evaluate all postmenopausal women aged ≥50 years for osteoporosis risk. (I, B)
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A detailed history, physical exam, and clinical fracture risk assessment with fracture risk assessment tool (FRAX®) or other fracture risk assessment tool should be included in the initial evaluation for osteoporosis. (I, B)
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Consider bone mineral density testing based on clinical fracture risk profile. (II, B)
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When bone mineral density is measured, axial dual-energy X-ray absorptiometry (DXA) measurement (lumbar spine and hip; 1/3 radius if indicated) should be used. (II, B)
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Osteoporosis is diagnosed based on presence of fragility fractures in the absence of other metabolic bone disorders and even with a normal bone mineral density (T-score). (II, B)
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Osteoporosis is also diagnosed based on a T-score of −2.5 or lower in the lumbar spine (antero-posterior), femoral neck, total hip, or 1/3 radius (33% radius), even in the absence of a prevalent fracture. (IV, B)
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When the initial diagnosis of osteoporosis is made according to a T-score of −2.5 or below, the diagnosis persists even when a subsequent dual-energy X-ray absorptiometry (DXA) measurement shows a T-score better than −2.5. (IV, B)
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Osteoporosis may also be diagnosed in patients with a T-score between −1.0 and −2.5 and increased fracture risk using FRAX® (fracture risk assessment tool) country-specific thresholds.
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Appropriate Evaluation
Evaluate for causes of secondary osteoporosis. (I, B)
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Evaluate for prevalent vertebral fractures. (II, B)
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Consider using bone turnover markers in the initial evaluation and follow-up of osteoporosis patients. Elevated levels can predict more rapid rates of bone loss and higher fracture risk. (I, A)
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Fundamental Measures for Bone Health
Measure serum 25-hydroxyvitamin D (25[OH]D) in patients who are at risk for vitamin D insufficiency, particularly those with osteoporosis. (II, B)
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Maintain serum 25-hydroxyvitamin D (25[OH]D) ≥30 ng/mL in patients with osteoporosis (preferable range, 30 to 50 ng/mL). (I, A)
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Supplement with vitamin D3 if needed, with a daily dose of 1,000 to 2,000 international units (IU) typically required to maintain an optimal serum 25(OH)D level. (I, A)
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Higher doses of vitamin D3 may be necessary in patients with present factors such as obesity, malabsorption, and older age. (I, A)
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Counsel patients to maintain adequate dietary intake of calcium, to a total intake (including diet plus supplement, if needed) of 1,200 mg/day for women age ≥50 years. (I, B)
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Counsel patients to limit alcohol intake to no more than 2 units per day. (II, B)
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Counsel patients to avoid or stop smoking. (I, B)
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Counsel patients to maintain an active lifestyle, including weight-bearing, balance, and resistance exercises. (I, A)
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Provide counseling on reducing risk of falls, particularly among the elderly. (I, B)
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Consider referral for physical therapy, which may reduce discomfort, prevent falls, and improve quality of life. (I, A)
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Pharmacologic Therapy
Pharmacologic therapy is strongly recommended for patients with osteopenia or low bone mass and a history of fragility fracture of the hip or spine. (I, A)
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Pharmacologic therapy is strongly recommended for patients with a T-score of −2.5 or lower in the spine, femoral neck, total hip, or 1/3 radius. (I, A)
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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. (I, A)
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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. (I, B)
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Medication
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 above. (I, A)
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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 above. (I, A)
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Ibandronate or raloxifene may be appropriate initial therapy in some cases for patients requiring drugs with spine-specific efficacy. (I, B)
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Treatment Monitoring
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. (II, B)
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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). (I, B)
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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. (II, C)
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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. (I, B)
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Successful Treatment
Consider stable or increasing bone mineral density, with no evidence of new fractures or vertebral fracture progression as a response to therapy for osteoporosis. (I, A)
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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. Consider significant increases in bone formation markers as a pharmacologic response to anabolic therapy. (I, B)
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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. (I, B)
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Treatment Duration
Limit treatment with abaloparatide and teriparatide to 2 years and follow abaloparatide or teriparatide therapy with a bisphosphonate or denosumab. (I, A)
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Limit treatment with romosozumab to 1 year and follow with a drug intended for long-term use, such as a bisphosphonate or denosumab. (I, B)
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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. (II, B)
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For oral bisphosphonates, consider a bisphosphonate holiday after 6 to 10 years of stability in patients with very high fracture risk. (II, B)
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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-high-risk patients. (I, A)
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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. (I, A)
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A holiday is not recommended for non-bisphosphonate antiresorptive drugs, and treatment with such agents should be continued for as long as clinically appropriate. (I, A)
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If denosumab therapy is discontinued, patients should be transitioned to another antiresorptive. (I, A)
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Concomitant Therapeutic Agents
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. (I, A)
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Sequential Therapeutic Agents
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. (I, A)
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Vertebral Augmentation for Compression Fractures
Vertebroplasty and kyphoplasty are not recommended as first-line treatment of vertebral fractures, given an unclear benefit on overall pain and a potential increased risk of vertebral fractures in adjacent vertebrae. (, )
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Referral
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. (II, C)
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When a patient with normal bone mineral density sustains a fracture without major trauma, referral to a clinical endocrinologist or other osteoporosis specialist should be considered. (II, C)
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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 specialist should be considered. (II, C)
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When bone mineral density is unexpectedly low or when osteoporosis has unusual features such as young age, unexplained artifacts on bone density, and unexplained laboratory studies, including high or low alkaline phosphatase and/or low phosphorus, referral to a clinical endocrinologist or other osteoporosis specialist should be considered. (II, C)
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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 specialist should be considered. (II, C)
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Recommendation Grading
Overview
Title
Diagnosis and Treatment of Postmenopausal Osteoporosis
Authoring Organization
American Association of Clinical Endocrinologists
Publication Month/Year
March 2, 2020
Last Updated Month/Year
June 10, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Treatment
Diseases/Conditions (MeSH)
D015663 - Osteoporosis, Postmenopausal, D058866 - Osteoporotic Fractures
Keywords
bone mineral density, postmenopausal osteoporosis
Source Citation
Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS- 2020 UPDATE EXECUTIVE SUMMARY. Endocr Pract. 2020 May;26(5):564-570. doi: 10.4158/GL-2020-0524. PMID: 32427525.