Elsevier

Joint Bone Spine

Volume 79, Issue 3, May 2012, Pages 304-313
Joint Bone Spine

Recommendations
2012 update of French guidelines for the pharmacological treatment of postmenopausal osteoporosis

https://doi.org/10.1016/j.jbspin.2012.02.014Get rights and content

Abstract

Objectives

To update the evidence-based position statement published by the French National Authority for Health (HAS) in 2006 regarding the pharmacological treatment of postmenopausal osteoporosis, under the auspices of the French Society for Rheumatology and Groupe de Recherche et d’Information sur les Ostéoporoses (GRIO), and with the participation of several learned societies (Collège National des Gynécologues et Obstétriciens Français, Groupe d’Étude de la Ménopause et du Vieillissement hormonal, Société Française de Chirurgie Orthopédique, Société Française d’Endocrinologie, and Société Française de Gériatrie et de Gérontologie).

Methods

A multidisciplinary panel representing the spectrum of clinical specialties involved in managing patients with postmenopausal osteoporosis developed updated recommendations based on a systematic literature review conducted according to the method advocated by the HAS.

Results

The updated recommendations underline the need for osteoporosis pharmacotherapy in women with a history of severe osteoporotic fracture. In these patients, any osteoporosis medication can be used; however, zoledronic acid is the preferred first-line medication after a hip fracture. In patients with non-severe fractures or no fractures, the appropriateness of osteoporosis pharmacotherapy depends on the bone mineral density and FRAX® values; any osteoporosis medication can be used, but raloxifene and ibandronate should be reserved for patients at low risk for peripheral fractures. Initially, osteoporosis pharmacotherapy should be prescribed for 5 years. The results of the evaluation done at the end of the 5-year period determine whether further treatment is in order.

Conclusions

These updated recommendations are intended to provide clinicians with clarifications about the pharmacological treatment of osteoporosis.

Section snippets

Objectives and methods

These recommendations are intended for all physicians providing care to postmenopausal women who have osteoporosis or risk factors for osteoporosis. The objective is to discuss the principles of osteoporosis pharmacotherapy based on current data about indications, effectiveness, and safety. The content of these recommendations was discussed and drafted in accordance with the method propounded by the French National Authority for Health (Haute Autorité Sanitaire, HAS) then validated by a

Epidemiology and diagnosis of osteoporosis

Osteoporosis is a generalized bone disease characterized by diminished bone strength with an increased risk of fractures [2]. Osteoporosis is a major health concern, both because of the risk of potentially serious fractures and because its prevalence is increasing as the population ages. The present recommendations are intended only for postmenopausal patients who have none of the other metabolic, malignant, or genetic causes of decreased bone strength.

Evaluation of the fracture risk and treatment decision

The decision to initiate osteoporosis pharmacotherapy rests on the routine evaluation of three variables associated with fracture risk, namely, age, prior fractures, and fall risk, together with BMD values.

Therapeutic strategies for the prevention and treatment of postmenopausal osteoporosis

The treatment objective is to prevent fractures (professional consensus). The decision to initiate treatment rests on the estimated risk of having a fracture within the next 5 to 10 years, which is the duration for which efficacy data are available. Proof that osteoporosis medications prevent fractures was obtained in populations meeting specific BMD criteria or having a history of fractures (Table 4, Table 5, Table 6). When osteoporosis (with or without fractures) is diagnosed, the first step

Theoretical treatment duration

The following factors govern treatment duration (professional consensus):

  • patient age;

  • bone tissue response to treatment;

  • residual treatment effect after drug discontinuation; only low-level evidence is available about fracture rates after drug discontinuation, and studies of surrogate endpoints (BMD and biochemical markers) suggest considerable variability in the residual effect across drugs;

  • bone safety and general safety.

Controlled studies have established that the available osteoporosis

Adherence/persistence and safety

As with all drugs for chronic diseases, osteoporosis medications work best when taken as instructed. Several studies have documented decreased efficacy in the event of poor adherence. Clinical follow-up may be sufficient to monitor adherence and persistence (professional consensus). Patients should be informed of the very low risks of jaw osteonecrosis and atypical femoral fracture associated with bisphosphonate therapy. Any necessary dental procedures should be performed at the beginning of

Conclusion

This recommendation update is intended for all physicians providing care to women who have postmenopausal osteoporosis or who are at risk for the disease. Their objective is to review the principles of osteoporosis pharmacotherapy based on current data about the indications, efficacy, and safety of osteoporosis medications.

Literature review task force

Bachelot Anne (Endocrinologue, Paris), Brazier Michel (Pharmacien, Amiens), Benhamou Claude-Laurent (Rhumatologue, Orléans), Berrut Gilles (Gériatre, Nantes), Christin-Maitre Sophie (Endocrinologue, Paris), Cohen-Sohal Martine (Rhumatologue, Paris), Darai Emile (Gynécologue, Paris), Debiais Françoise (Rhumatologue, Poitiers), Drapier Faure Evelyne (Gynécologue, Lyon), Gompel Anne (Endocrinologue, Paris), Javier Rose-Marie (Rhumatologue, Strasbourg), Laroche Michel (Rhumatologue, Toulouse),

Disclosure of interest

Karine Briot: occasional interventions: consultancy or speaker fees from Amgen, Lilly, MSD, Novartis, and Servier. Indirect interests: financial support for research programs or investigator fees from Lilly.

Bernard Cortet: occasional interventions: consultancy or speaker fees from Amgen, Daiichi-Sankyo, Ferring, GSK, Lilly, MSD, Medtronic, Novartis, and Servier. Indirect interests: financial support for research programs or investigator fees from Amgen, Lilly, MSD, Novartis, and Roche.

Thierry

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