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Bisphosphonates for Postmenopausal Osteoporosis

Educational Objective
To understand how Bisphosphonates is used to treat postmenopausal osteoporosis
1 Credit CME

Bisphosphonates are the first-line pharmacologic treatment for postmenopausal osteoporosis and the most commonly prescribed medication for this condition.1 Bisphosphonates, classified as antiresorptive agents, have a very high affinity for bone mineral and bind to hydroxyapatite crystals on bony surfaces, where they inhibit osteoclast-mediated bone resorption.

The primary goal of osteoporosis drug treatment is to reduce risk of clinical fractures. Guidelines agree that pharmacologic therapy should be initiated in postmenopausal women with osteoporosis manifested by a hip or spine bone mineral density (BMD) T score less than or equal to −2.5 or personal history of fragility fracture (eg, hip, radiographic or clinical vertebral). Some organizations also recommend treatment initiation in postmenopausal women with osteopenia (BMD T score between −2.5 and −1.0) who have a 10-year fracture probability (calculated using the FRAX tool) at or above intervention thresholds proposed by the National Osteoporosis Foundation, but the benefit of treatment in patients selected on the basis of these criteria has not been assessed in clinical trials.

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Article Information

Corresponding Author: Kristine E. Ensrud, MD, MPH, Division of Epidemiology & Community Health, Department of Medicine, University of Minnesota, Minneapolis, One Veterans Dr (111-0), Minneapolis, MN 55417 (ensru001@umn.edu).

Published Online: October 17, 2019. doi:10.1001/jama.2019.15781

Conflict of Interest Disclosures: Dr Ensrud reported receiving grants from Merck & Co outside the submitted work. No other disclosures were reported.

References
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Sanderson  J, Martyn-St James  M, Stevens  J,  et al.  Clinical effectiveness of bisphosphonates for the prevention of fragility fractures.  Bone. 2016;89:52-58.PubMedGoogle ScholarCrossref
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Khan  AA, Morrison  A, Kendler  DL,  et al; International Task Force on Osteonecrosis of the Jaw.  Case-based review of osteonecrosis of the jaw (ONJ) and application of the international recommendations for management from the International Task Force on ONJ.  J Clin Densitom. 2017;20(1):8-24. doi:10.1016/j.jocd.2016.09.005PubMedGoogle ScholarCrossref
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Gedmintas  L, Solomon  DH, Kim  SC.  Bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture.  J Bone Miner Res. 2013;28(8):1729-1737.PubMedGoogle ScholarCrossref
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Black  DM, Abrahamsen  B, Bouxsein  ML, Einhorn  T, Napoli  N.  Atypical femur fractures: review of epidemiology, relationship to bisphosphonates, prevention, and clinical management.  Endocr Rev. 2019;40(2):333-368. doi:10.1210/er.2018-00001PubMedGoogle ScholarCrossref
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Dell  RM, Adams  AL, Greene  DF,  et al.  Incidence of atypical nontraumatic diaphyseal fractures of the femur.  J Bone Miner Res. 2012;27(12):2544-2550.PubMedGoogle ScholarCrossref
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Fink  HA, MacDonald  R, Forte  ML,  et al.  Long-term drug therapy and drug discontinuations and holidays for osteoporosis fracture prevention.  Ann Intern Med. 2019;171(1):37-50. doi:10.7326/M19-0533PubMedGoogle ScholarCrossref
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Adler  RA, El-Hajj Fuleihan  G, Bauer  DC,  et al.  Managing osteoporosis in patients on long-term bisphosphonate treatment: report of a task force of the American Society for Bone and Mineral Research.  J Bone Miner Res. 2016;31(1):16-35.PubMedGoogle ScholarCrossref
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Cummings  SR, Ferrari  S, Eastell  R,  et al.  Vertebral fractures after discontinuation of denosumab: a post hoc analysis of the randomized placebo-controlled FREEDOM Trial and its extension.  J Bone Miner Res. 2018;33(2):190-198.PubMedGoogle ScholarCrossref
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