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.
“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.”
The 2010 edition of the NAMS statement, which was last updated in 2006, is available for free at www.menopause.org/aboutmeno/consensus.aspx
The statement recommends 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. FRAX integrates the fracture risks associated with clinical risk factors as well as bone mineral density at the femoral neck.
“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. Steven T. Harris, a member of the editorial board that updated the position statement, said in an interview.
Dr. Utian, who reviewed the position statement as a member of the 2008-2009 NAMS board of trustees, said that FRAX was endorsed 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.”
The statement says drug therapy is indicated for postmenopausal women with osteoporotic vertebral or hip fracture, bone mineral density consistent with osteoporosis (a T score of −2.5 or lower), or a T score from −1.0 to −2.5 plus a 10-year FRAX risk of at least 20% for a major osteoporotic fracture (hip, shoulder, wrist, and spine) or of at least 3% for a hip fracture.
Another new recommendation calls for postmenopausal women to obtain 800-1,000 IU/day of vitamin D3, up from 400-600 IU/day in the 2006 statement. “Even in temperate areas, there isn't enough sun exposure to guarantee vitamin D sufficiency,” said Dr. Harris of the University of California, San Francisco.
As for choice of osteoporosis therapy, the statement notes that no head-to-head trials have compared the effectiveness of medications in reducing fracture risk. Approved treatment options include bisphosphonates, selective estrogen-receptor modulators (SERMs), parathyroid hormone, estrogens, and calcitonin.
According to the statement, bisphosphonates “are the first-line drugs for treating postmenopausal women with osteoporosis. They have reduced the risk of vertebral fractures by 40%-70% and reduced the incidence of nonvertebral fracture, including hip fracture, by about half this amount.”
The SERM raloxifene “is most often considered for postmenopausal women with low bone mass or younger postmenopausal women with osteoporosis. It prevents bone loss and reduces the risk of vertebral fractures, but its effectiveness in reducing other fractures is uncertain.”
The statement notes that calcitonin “is not a first-line drug for postmenopausal osteoporosis treatment, as its fracture efficacy is not strong and its [bone mineral density] effects are less than those of other agents. However, it is an option for women with osteoporosis who are more than 5 years beyond menopause.”
Dr. Utian said that “we have a number of valuable therapies. Most of them are bone sparing, but gradually we're beginning to see the development of bone-developing therapies. Currently, prevention is a lot more effective than attempts at cure.”
Disclosures: The development of the 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 and Dr. Harris disclosed relationships with multiple pharmaceutical firms.
'Currently, prevention is a lot more effective than attempts at cure.'
Source DR. UTIAN