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Is Too Much Intervention Recommended in the ACP Osteoporosis Treatment Guidelines?
- Amir Qaseem, MD, PhD, MHA;
- Paul Shekelle, MD, PhD; and
- Douglas K. Owens, MD, MS
- From American College of Physicians, Philadelphia, PA 19106; Veterans Affairs Greater Los Angeles Healthcare System and RAND, Santa Monica, CA 90401; and Stanford University, Stanford, CA 94305.
IN RESPONSE:
We thank Dr. Alonso-Coello and colleagues for their comments regarding the ACP's recent guideline on pharmacologic treatment of osteoporosis. The Fracture Risk Assessment Tool (FRAX) may be a useful instrument for estimating an individual patient's risk for fracture, and we noted in our guideline that physicians may use such models to help guide their decisions. However, evidence from randomized, controlled trials showing the benefits of treatment in patients who were selected on the basis of their scores from FRAX is currently lacking. Almost all trials demonstrating benefit of treatment enrolled patients on the basis of BMD-determined osteoporosis, as defined by T-score and/or the presence of existing fragility fractures. For example, Liberman and colleagues (1) enrolled postmenopausal women solely on the basis of a BMD T-score of −2.5 or less. This trial showed that treatment with alendronate was associated with a 48% reduction in the proportion of women with new vertebral fractures (3.2% vs. 6.2% in the placebo group; P = 0.03), a decreased progression of vertebral deformities (33% vs. 41% in the placebo group; P = 0.028), and a reduced loss of height (P = 0.005) and was well tolerated. Similarly, Reid and colleagues (2) showed benefits of zoledronic acid in a study population that included women with BMD at the lumbar spine of at least 2.0 SD below the mean value for young adults (a T-score less than −2.0). Thus, our guideline statements define the populations to be considered for treatment to be consistent with the enrollment criteria in the clinical trials that reported benefits. We await evidence from clinical trials showing the benefits of using the FRAX score to make decisions on treatment.
Paul Shekelle, MD, PhD
Veterans Affairs Greater Los Angeles Healthcare System and RAND
Santa Monica, CA 90401
Article and Author Information
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Potential Financial Conflicts of Interest: None disclosed.
