Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Recommendations

Pharmacologic management in the elderly

Evidence statement

Despite the high absolute fracture risk in the older adult population, there is a paucity of evidence-based literature, randomised controlled trials (RCTs) and head-to-head studies with fractures as an outcome in older patients. Elderly is defined as over 75 years for the purpose of this recommendation. This group is at the highest risk of fracture, with hip fracture the most common fracture type.1,2 Few studies include patients older than 75 years of age and, if they do, the numbers are often small and infrequently analysed as sub-groups. Most of the evidence is based on a systematic review.3 A review of the published literature on the clinical efficacy and safety of specific osteoporosis treatments in reducing fracture risk in women 75 years of age and older confirms the benefit of treatment.4,5–15 Denosumab and strontium ranelate are the only agents in which RCTs have been specifically designed and powered to demonstrate a benefit in reduction of the risk of hip fracture in females older than 75 years of age.4,12–14 Risedronate has been demonstrated to be beneficial in a mixed cohort of patients from the age of 70 to 100 years with demonstrated osteoporosis, but not in those over 80 years with risk factors only.6–8 For non-vertebral fracture, there is evidence for fracture risk reduction with the use of strontium ranelate12,13 and zoledronic acid11 in the 75 years-plus cohort, and in the cohort of patients 70 to 79 years of age for risedronate.6 There are inadequate conclusive data for most other agents in terms of non-vertebral fracture risk reduction in older populations.4,15 All currently available agents (antiresorptives and teriparatide) are considered effective for vertebral fracture-risk reduction in older female populations.3–16 Only one study, which specifically included residents of a long-term-care facility treated with alendronate, reported an improvement in bone mineral density at two years.17 There is only one RCT subgroup analysis suggesting benefit of teriparatide in reducing vertebral fracture risk only in older cohorts.18

Grade: A

Recommendation 29
Anti-resorptive therapy is recommended for reduction of fracture risk in people over 75 years of age with osteoporosis.

Grade: C

Recommendation 30
Anabolic therapy with teriparatide may be considered for reduction of vertebral fracture risk in people over 75 years of age with osteoporosis.

  1. Sanders KM, Seeman E, Ugoni AM, et al. Age- and gender-specific rate of fractures in Australia: A population-based study. Osteoporos Int 1999;10(3):240–47.
  2. Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA. Symptomatic fracture incidence in elderly men and women: The Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 1994;4(5):277–82.
  3. Inderjeeth CA, Foo AC, Lai MM, Glendenning P. Efficacy and safety of pharmacological agents in managing osteoporosis in the old old: Review of the evidence. Bone 2009;44(5):744–51.
  4. Inderjeeth CA, Poland KE. Management of osteoporosis in older people. J Pharm Pract Res 2010;40(3):226–31.
  5. Ensrud KE, Black DM, Palermo L, et al. Treatment with alendronate prevents fractures in women at highest risk: Results from the Fracture Intervention Trial. Arch Intern Med 1997;157(22):2617–24.
  6. Boonen S, McClung MR, Eastell R, El-Hajj Fuleihan G, Barton IP, Delmas P. Safety and efficacy of risedronate in reducing fracture risk in osteoporotic women aged 80 and older: Implications for the use of antiresorptive agents in the old and oldest old. J Am Geriatr Soc 2004;52(11):1832–39.
  7. McClung MR, Geusens P, Miller PD, et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 2001;344(5):333–40.
  8. Masud T, McClung M, Geusens P. Reducing hip fracture risk with risedronate in elderly women with established osteoporosis. Clin Interv Aging 2009;4:445–49.
  9. Boonen S, Black DM, Colon-Emeric CS, et al. Efficacy and safety of a once-yearly intravenous zoledronic acid 5 mg for fracture prevention in elderly postmenopausal women with osteoporosis aged 75 and older. J Am Geriatr Soc 2010;58(2):292–99.
  10. Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 2007;356(18):1809–22.
  11. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007;357:1799–809.
  12. Reginster JY, Seeman E, De Vernejoul MC, et al. Strontium ranelate reduces the risk of nonvertebral fractures in postmenopausal women with osteoporosis: Treatment of Peripheral Osteoporosis (TROPOS) study. J Clin Endocrinol Metab 2005;90(5):2816–22.
  13. Seeman E, Vellas B, Benhamou C. Strontium ranelate reduces the risk of vertebral and nonvertebral fractures in women eighty years of age and older. J Bone Miner Res 2006;21(7):1113–20.
  14. Boonen S, Adachi JD, Man Z, et al. Treatment with denosumab reduces the incidence of new vertebral and hip fractures in postmenopausal women at high risk. J Clin Endocrinol Metab 2011;96(6):1727–36.
  15. McClung MR, Boonen S, Torring O, et al. Effect of denosumab treatment on the risk of fractures in subgroups of women with postmenopausal osteoporosis. J Bone Miner Res 2012;27(1):211–18.
  16. Boonen S, Marin F, Mellstrom D, et al. Safety and efficacy of teriparatide in elderly women with established osteoporosis: Bone anabolic therapy from a geriatric perspective. J Am Geriatr Soc 2006;54(5):782–89.
  17. Greenspan SL, Schneider DL, McClung MR, et al. Alendronate improves bone mineral density in elderly women with osteoporosis residing in long-term care facilities. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2002;136(10):742–46.
  18. Inderjeeth CA, Chan K, Glendenning P. Teriparatide: Its use in the treatment of osteoporosis. Clin Med Insights Ther 2010:2:1–14.

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