Updated statement on managing osteoporosis in postmenopause

Successfully managing osteoporosis in postmenopausal women revolves around risk factors and risk-assessment tools for identifying women who are candidates for pharmacologic therapy, according to an updated position statement from the North American Menopause Society (NAMS).

The 2021 statement in the journal Menopause is an update of a 2010 statement in the same journal.

“The update incorporates many new developments in our field, including delineation of additional risk factors for fracture, which result in better strategies for assessing fracture risk,” said Michael R. McClung, MD, co-lead of the editorial panel for the statement and director emeritus of the Oregon Osteoporosis Center in Portland. “There is also much more information about the long-term safety of therapies and the availability of 3 new drugs with unique mechanisms of action. Expanded clinical experience informs us of the effects of using different treatments in various sequences.”

McClung noted that osteoporosis is a very common clinical problem, affecting at least half of postmenopausal women, causing significant morbidity and mortality, especially among older women.

“However, patients with osteoporosis and high fracture risk are infrequently recognized and treated,” McClung told Contemporary OB/GYNÒ. “General measures such as good nutrition and regular physical activity are important and useful, but are not sufficient to treat patients with osteoporosis.”

Among the key take-home messages of the statement, none of which should come as a surprise to clinicians, are that patients with osteoporosis need long-term if not lifelong management; the pivotal role of hormone therapy (estrogen) for preventing osteoporosis in young postmenopausal women; and that a recent fracture in a postmenopausal woman is the strongest risk factor for another fracture.

“Having a fracture should be thought of and assessed as a ‘bone attack,’” McClung said.

Other salient points of the statement are that bone density levels measured while on osteoporosis therapy correlate with current fracture risk; the concept of "drug holidays" does not pertain to non-bisphosphonate drugs; and that for patients at very high risk of fracture, osteoanabolic or bone-building agents are more effective than bisphosphonates and are recommended as initial therapy.

Because there are no new drugs in late-stage clinical development, “current research is focused on how to use the treatments we have more effectively and to address and overcome the many factors contributing to patients being reluctant to receive therapy to reduce fracture risk,” said McClung, who also is a professorial fellow in health research at Australian Catholic University in Melbourne, Australia. “With an increasing number of older women, the number of fractures that occur each year continues to rise, increasing the burden of osteoporosis on our health care system. All physicians and nurse practitioners caring for postmenopausal women should be knowledgeable about the prevention and treatment of osteoporosis.”

McClung anticipates that the updated statement will be the resource used most frequently by menopause practitioners. “It is our hope that these updated recommendations will encourage physicians and advanced health practitioners who care for postmenopausal women to identify patients in their practices who are at high risk for fracture and will give them confidence to discuss bone health with their patients,” he said.

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Disclosure

McClung receives consulting fees and honorarium from Amgen. He also serves on the boards of trustees of NAMS and the International Osteoporosis Foundation.

Reference

The North American Menopause Society (NAMS). Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi:10.1097/GME.0000000000001831.