Journals club - Management of osteoporosis in postmenopausal women

Curriculum statement 15.9 Rheumatology and conditions of the musculoskeletal system.

Key trials

  • One trial has shown that treatment with alendronate has greater reductions in markers of bone turnover and also greater gains in bone mineral density compared with risedronate (J Clin Endocrinol Metab 2006; 91: 2,631-7).
  • However, the risedronate and alendronate (REAL) study showed that risedronate provides greater fracture protection than alendronate in the first year of treatment (Osteoporos Int 2007; 18: 25-34).
  • There are still no trials comparing relative efficacy or safety of drugs to prevent osteoporotic fractures (Ann Intern Med 2008; 148: 197-213).
  • Hip protectors do not prevent hip fracture among nursing home residents (JAMA 2007; 298: 413-22).
  • A once-yearly infusion of zoledronic acid over three years significantly reduced the risk of vertebral, hip and other fractures (N Engl J Med 2007; 356: 1,809-22).

Evidence base

  • A Cochrane review found evidence to support the efficacy of strontium ranelate in reducing fractures in postmenopausal osteoporotic women and increasing bone mineral density in postmenopausal women with or without osteoporosis (Cochrane Database Syst Rev 2006; (4): CD005326).
  • A Health Technology Assessment review showed that strontium ranelate was clinically effective in preventing osteoporotic fractures (Health Technol Assess 2007; 11: 1-134), but less cost-effective than alendronate.
  • A Cochrane review found both clinically and statistically significant reductions in vertebral, non-vertebral, hip and wrist fractures for secondary prevention with alendronate, it found no statistically significant results for primary prevention, with the exception of vertebral fractures (Cochrane Database Syst Rev 2008; (1): CD001155).

Guidelines

  • October 2008 NICE guidance recommends using alendronate in postmenopausal women with confirmed osteoporosis. Women over 75 years may not need a dual-energy X-ray absorptiometry scan.
  • The National Osteoporosis Guideline Group (NOGG) has updated guidelines from the Royal College of Physicians.
  • This guideline incorporates the use of FRAX (www.shef.ac.uk/FRAX), a simple online tool supported by the WHO to assess 10-year fracture risk.
  • However, NICE ruled out using FRAX as it did not accept that treatment advice should be based on FRAX-calculated absolute risk.
  • NICE states that if women cannot take alendronic acid, then risedronate sodium and disodium etidronate should be second-line treatments, with strontium ranelate third line.

Contributed by Dr Louise Newson, a GP in the West Midlands

Useful websites

Key points

  • Osteoporosis causes morbidity and mortality.
  • Alendronate should be the first-line therapy.
  • Strontium ranelate is effective but costly.
  • NICE and NOGG guidelines differ on use of FRAX.

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