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Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age
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
Anti-resorptive therapy is recommended for reduction of fracture risk in people over 75 years of age with osteoporosis.
Anabolic therapy with teriparatide may be considered for reduction of vertebral fracture risk in people over 75 years of age with osteoporosis.
Osteoporosis-flowchart.pdf (PDF 0.98 MB)