The North American Menopause Society's updated position statement on the management of osteoporosis in postmenopausal women includes the FRAX tool to calculate the risk of major osteoporotic fracture and recommends increasing vitamin D3 intake.
Last updated in 2006, the statement released last month is meant to serve as a guide for clinicians regarding the diagnosis, prevention, and treatment of postmenopausal osteoporosis. The statement can be accessed at www.menopause.org/aboutmeno/consensus.aspx
“It's the most current and practice-oriented, evidence-based statement that's out at the moment,” Dr. Wulf H. Utian, honorary founding president and executive director emeritus of NAMS, said in an interview. “It's taken all of the current evidence into account and has come out with some key recommendations––not a lot of which are absolutely new––but it summarizes [the evidence] extremely well and deals with all the issues.”
Among the new recommendations is the use of the World Health Organization's FRAX (Fracture Risk Assessment) tool to calculate a patient's 10-year risk of major osteoporotic fracture (hip, shoulder, wrist, and spine). Developed by researchers led by Dr. John A. Kanis of the University of Sheffield (England), FRAX is based on individual patient models that integrate the fracture risks associated with clinical risk factors as well as bone mineral density at the femoral neck.
“People have been intimidated by the language associated with bone density reports over the years,” Dr. Steven T. Harris, a member of the editorial board that drafted the updated position statement, said in an interview. “It's distressing to be told that you have osteopenia or osteoporosis. To be able to use the FRAX tool to reduce that to a number—some reasonable estimate of fracture risk—is very helpful.”
Dr. Utian, who was a member of the 2008–2009 NAMS Board of Trustees and as such reviewed the position statement, said that FRAX was included in the statement because clinicians have come to realize “some of the limitations of DXA [dual-energy x-ray absorptiometry] and the overuse of DXA, which could lead to inappropriate therapies. While DXA is a valuable tool, the FRAX gives you an ability to speak to individuals and actually give them an idea of what their risk is. It also gives health care organizations the ability to set parameters at what level of risk they would consider therapy to be indicated.”
According to the statement, drug therapy is indicated for postmenopausal women with osteoporotic vertebral or hip fracture; bone mineral density values consistent with osteoporosis (a T score of −2.5 or lower); or a T score from −1.0 to −2.5 and a 10-year FRAX risk of major osteoporotic fracture (hip, shoulder, wrist, and spine) of at least 20% or hip fracture of at least 3%.
Another new part of the NAMS statement recommends that postmenopausal women obtain 800–1,000 IU/day of vitamin D3, up from the recommended dosage of 400–600 IU/day contained in the 2006 statement.
As for choosing a specific osteoporosis therapy, the statement emphasizes that no head-to-head trials comparing the effectiveness of pharmacologic therapies to reduce fracture risk have been conducted. Current approved treatment options include bisphosphonates, selective estrogen-receptor modulators (SERMs), parathyroid hormone, estrogens, and calcitonin.
The development of this position statement was supported by an unrestricted educational grant from the Alliance for Better Bone Health, a collaboration between Warner Chilcott and its affiliates and Sanofi-Aventis US.
Dr. Utian disclosed that he is a consultant or a member of the advisory board for Bionovo, Depomed, Duramed, Eli Lilly, KV Pharmaceuticals, Merck & Co., Novartis, Orcas Therapeutics, and QuatRx. Dr. Harris disclosed that he is a consultant or a member of the speakers bureau for Amgen, GlaxoSmithKline, Eli Lilly, Merck, Novartis, Procter & Gamble, Roche, Sanofi-Aventis, and Wyeth.