Goal-directed osteoporosis treatment: ASBMR/BHOF task force position statement 2024

Abstract

The overarching goal of osteoporosis management is to prevent fractures. A goal-directed approach to long-term management of fracture risk helps ensure that the most appropriate initial treatment and treatment sequence is selected for individual patients. Goal-directed treatment decisions require assessment of clinical fracture history, vertebral fracture identification (using vertebral imaging as appropriate), measurement of bone mineral density (BMD), and consideration of other major clinical risk factors. Treatment targets should be tailored to each patient's individual risk profile and based on the specific indication for beginning treatment, including recency, site, number and severity of prior fractures, and BMD levels at the total hip, femoral neck, and lumbar spine. Instead of first-line bisphosphonate treatment for all patients, selection of initial treatment should focus on reducing fracture risk rapidly for patients at very high and imminent risk, such as in those with recent fractures. Initial treatment selection should also consider the probability that a BMD treatment target can be attained within a reasonable period of time and the differential magnitude of fracture risk reduction and BMD impact with osteoanabolic versus antiresorptive therapy. This position statement of the ASBMR/BHOF Task Force on Goal-Directed Osteoporosis Treatment provides an overall summary of the major clinical recommendations about treatment targets and strategies to achieve those targets based on the best evidence available, derived primarily from studies in older postmenopausal women of European ancestry.

Keywords: DXA, analysis/quantitation of bone; anabolics, therapeutics; antiresorptives, therapeutics; osteoporosis, diseases and disorders of/related to bone; practice/policy-related issues.

Figure 1

One-year risk of recurrent fracture in women > 65 years of age, based on site of initial fracture, from Medicare database of 377,561 women with first fracture. Adapted from reference .

Figure 2

Relationship between T-score attained after one year of treatment with either alendronate or romosozumab and subsequent risk of nonvertebral (left) or vertebral fracture (right) for the total hip (A and B), femoral neck (C and D) and lumbar spine (E and F).

Figure 3

Relationship between T-score attained on denosumab and subsequent risk of nonvertebral fracture in full population (A), by age < 75 vs. > 75 yr (B), and by prior history of fracture (C).

Figure 4

Probability of attaining T-score above −2.5 for TH (A) and LS (B) over 3 yr during treatment with alendronate, romosozumab followed by alendronate, or romosozumab followed by denosumab, based on starting T-score.

Figure 5

Goal directed therapy algorithm. Treatment targets and initial treatment selection, guided by fracture history (site, number and recency) and BMD. ¹Risk likely differs based on fractures that occurred a few years earlier vs. very remote events (eg 15 yr earlier). ²Many, but not all, patients with multiple fractures are at imminent risk, based on fracture sites and time from fracture occurrence. ³In some countries, T-score intervention thresholds are lower; T-score targets should be adjusted accordingly. ⁴There is no consensus about which recent fracture sites should be recommended for osteoanabolic treatment vs. BP or DMAB or what T-score should prompt use of osteoanabolic treatment in patients with recent “other fractures.” ⁵BP or DMAB might be first choice in some patients with no other risk factors, especially in countries where T-score intervention thresholds are lower. ⁶Choosing osteoanabolic agents provides a higher probability of achieving treatment targets, achieving treatment targets faster, and achieving higher T-score targets. Abbreviations: TH, total hip; FN, femoral neck; LS, lumbar spine; BP, bisphosphonates; DMAB, denosumab.