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AACE/ACE Guidelines AMERICAN ASSOCIATION of CLINICAL AACE/ACE Guidelines AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS — 2016 Pauline M. Camacho, MD, FACE; Steven M. Petak, MD, MACE, FACP, FCLM, JD; Neil Binkley, MD; Bart L. Clarke, MD, FACP, FACE; Steven T. Harris, MD, FACP Daniel L. Hurley, MD, FACE; Michael Kleerekoper, MBBS, MACE; E. Michael Lewiecki, MD, FACP, FACE; Paul D. Miller, MD; Harmeet S. Narula, MD, FACP, FACE; Rachel Pessah-Pollack, MD, FACE; Vin Tangpricha, MD, PhD, FACE; Sunil J. Wimalawansa, MD, PhD, MBA, FCCP, FACP, FRCP, DSc, FACE; Nelson B. Watts, MD, FACP, MACE The American Association of Clinical Endocrinologists/American College of Endocrinology Medical Guidelines for Practice are systematically developed statements to assist healthcare professionals in medical decision-making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. From 1Professor of Medicine, Loyola University Medical Center, Director, Loyola University Osteoporosis and Metabolic Bone Disease Center, Chicago, IL; 2Associate Clinical Professor Weill-Cornell Medical College, Division Head Endocrinology and Chief of Endocrinology, Houston Methodist Hospital, Houston, TX; 3School of Medicine and Public Health, University of Wisconsin, Madison, WI; 4Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN; 5Clinical Professor of Medicine, University of California, San Francisco; 6Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN; 7University of Toledo Medical School, Toledo, OH; 8New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM; 9Distinguished Clinical Professor of Medicine, University of Colorado Health Sciences Center, Medical Director, Colorado Center for Bone Research at Centura Health, Lakewood, CO; 10Banner Health, Phoenix, AZ; 11Assistant Clinical Professor, Mount Sinai School of Medicine, NY, NY, ProHealth Care Associates, Division of Endocrinology, Lake Success, NY; 12Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, GA; 13Professor of Medicine, Endocrinology & Nutrition; 14Director, Mercy Health Osteoporosis and Bone Health Services, Cincinnati OH. Address correspondence to American Association of Clinical Endocrinologists, 245 Riverside Ave, Suite 200, Jacksonville, FL 32202. E-mail: [email protected]. DOI:10.4158/EP161435.GL To purchase reprints of this article, please visit: www.aace.com/reprints. Copyright © 2016 AACE. A complete list of the Reviewers of the AACE/ACE Postmenopausal Osteoporosis Clinical Practice Guidelines can be found in the Acknowledgment. ENDOCRINE PRACTICE Vol 22 (Suppl 4) September 2016 1 2 AACE/ACE Postmenopausal Osteoporosis CPG, Endocr Pract. 2016;22(Suppl 4) was used to evaluate the available literature and to grade Abbreviations: references relative to evidence level (EL) (Table 1), evi- AACE = American Association of Clinical dence analysis, and subjective factors (Table 2), based on Endocrinologists; AFF = atypical femur fracture; the ratings of 1 through 4 from the 2010 and 2014 AACE ASBMR = American Society for Bone and Mineral protocols for standardized production of clinical practice Research; BEL = best evidence level; BMD = bone guidelines (available online at https://www.aace.com/files/ mineral density; BTM = bone turnover marker; CBC = checklists_july_2014_ep.pdf) (1 [EL 4; CPG NE], 2 [EL complete blood count; CI = confidence interval; DXA 4; CPG NE]). Best evidence level (BEL) for evidence = dual-energy X-ray absorptiometry; EL = evidence presented in the discussion of the evidence base is given level; FDA = U.S. Food and Drug Administration; for each recommendation in the Executive Summary. In FLEX = Fracture Intervention Trial (FIT) Long-term addition, recommendations were graded A through D, in Extension; FRAX® = Fracture Risk Assessment Tool; accordance with methods established by the AACE in 2004 GFR = glomerular filtration rate; GI = gastrointestinal; and clarified in 2010 (Table 3) (1 [EL 4; CPG NE], 3 [EL HORIZON = Health Outcomes and Reduced Incidence 4; CPG NE]). Information pertaining to cost-effectiveness with Zoledronic Acid Once Yearly; IOF = International was included when available. Examples of qualifiers that Osteoporosis Foundation; ISCD = International Society are appropriate to append to recommendations include for Clinical Densitometry; IU = international units; IV risk-benefit analyses, evidence gaps, alternative physician = intravenous; LSC = least significant change; NBHA preferences (dissenting opinions), alternative recommen- = National Bone Health Alliance; NOF = National dations (e.g., based on resource availability and cultural Osteoporosis Foundation; 25(OH)D = 25-hydroxy vita- factors), expert consensus and relevance (i.e., patient-ori- min D; ONJ = osteonecrosis of the jaw; PINP = serum ented evidence that matters) (1 [EL 4; CPG NE]). (Endocr carboxy-terminal propeptide of type I collagen; PTH = Pract. 2016;22:Suppl4;1-42) parathyroid hormone; R = recommendation; RANK = receptor activator of nuclear factor kappa-B; RANKL 3. EXECUTIVE SUMMARY = receptor activator of nuclear factor kappa-B ligand; RCT = randomized controlled trial; RR = relative risk; To guide readers, recommendations are organized into the S-CTX = serum C-terminal telopeptide; SQ = subcuta- following questions: neous; VFA = vertebral fracture assessment; WHO = • Q1. How is fracture risk assessed and osteoporosis World Health Organization. diagnosed? • Q2. When osteoporosis is diagnosed, what is an appropriate evaluation? 1. INTRODUCTION • Q3. What are the fundamental measures for bone health? Osteoporosis is a growing major public health prob- • Q4. Who needs pharmacologic therapy? lem with impacts on quality and quantity of life that cross • Q5. What medication should be used to treat medical, social, and economic lines. These guidelines osteoporosis? were developed by the American Association of Clinical • Q6. How is treatment monitored? Endocrinologists (AACE) with hopes of reducing the risk • Q7. What is successful treatment of osteoporosis? of osteoporosis-related fractures and thereby maintaining • Q8. How long should patients be treated? the quality of life for people with osteoporosis. The guide- • Q9. Is combination therapy better than treatment lines use the best evidence, taking into consideration the with a single agent? economic impact of the disease and the need for efficient • Q10. Should sequential use of therapeutic agents be and effective evaluation and treatment of postmenopausal considered? women with osteoporosis. The intent is to provide evi- • Q11. Should vertebral augmentation be considered dence-based information about the diagnosis, evaluation, for compression fractures? and treatment of postmenopausal osteoporosis for endocri- • Q12. When should referral to a clinical endocrinolo- nologists, physicians in general, regulatory bodies, health- gist or osteoporosis specialist be considered? related organizations, and interested laypersons. 3.Q1. How Is Fracture Risk Assessed and 2. METHODS FOR DEVELOPMENT OF AACE Osteoporosis Diagnosed? CLINICAL PRACTICE GUIDELINES FOR POSTMENOPAUSAL OSTEOPOROSIS • R1. Evaluate all postmenopausal women aged ≥50 years for osteoporosis risk (Grade B; BEL 1, down- Evidence was obtained through MEDLINE searches graded due to gaps in evidence). and other designated reference sources. Expert opinion • R2. A detailed history, physical exam, and clinical AACE/ACE Postmenopausal Osteoporosis CPG, Endocr Pract. 2016;22(Suppl 4) 3 Table 1 2010 AACE Protocol for Production of Clinical Practice Guidelines Step 1: Evidence Rating 1 Meta-analysis of randomized controlled trials (MRCT) 1 Randomized controlled trial (RCT) 2 Meta-analysis of nonrandomized prospective or case-controlled trials (MNRCT) 2 Nonrandomized controlled trial (NRCT) 2 Prospective cohort study (PCS) 2 Retrospective case-control study (RCCS) 3 Cross-sectional study (CSS) 3 Surveillance study (registries, surveys, epidemiologic study) (SS) 3 Consecutive case series (CCS) 3 Single case reports (SCR) 4 No evidence (theory, opinion, consensus, or review) (NE) 1 = strong evidence; 2 = intermediate evidence; 3 = weak evidence; 4 = no evidence. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283.(1 [EL 4; CPG NE]) fracture risk assessment with the Fracture Risk 3.Q3. What Are the Fundamental Measures for Assessment Tool (FRAX®) should be included in the Bone Health? initial evaluation for osteoporosis (Grade B; BEL 2). • R3. Consider bone mineral density (BMD) testing based • R9. Measure serum 25-hydroxyvitamin D (25[OH]D) on clinical fracture risk profile(Grade B; BEL 2). in patients who are at risk for vitamin D insufficiency, • R4. When BMD is measured, axial dual-energy X-ray particularly those with osteoporosis
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