From the Guidelines
Fractures in postmenopausal women should be treated as part of a chronic disease rather than isolated events, with a focus on long-term management of underlying osteoporosis to prevent subsequent fractures and improve quality of life. This approach is supported by high-quality evidence from recent studies, including a 2023 living clinical guideline from the American College of Physicians 1, which recommends a comprehensive evaluation and treatment plan for postmenopausal women with osteoporosis.
Key Components of Treatment
- First-line medications include bisphosphonates such as alendronate (70mg weekly), risedronate (35mg weekly), or zoledronic acid (5mg IV annually) 1
- For higher-risk patients or those who cannot tolerate bisphosphonates, alternatives include denosumab (60mg subcutaneously every 6 months) or anabolic agents like teriparatide or abaloparatide (daily subcutaneous injections for up to 24 months) 1
- All patients should receive adequate calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) 1
- Comprehensive management should address fall prevention, lifestyle modifications, and regular monitoring of treatment response, typically with bone density testing every 1-2 years and bone turnover markers when appropriate 1
Importance of Chronic Disease Approach
The chronic disease approach is essential because a fracture significantly increases the risk of subsequent fractures, creating a "fracture cascade" if the underlying condition remains untreated. By treating fractures as part of a chronic disease, clinicians can help prevent subsequent fractures, improve quality of life, and reduce morbidity and mortality in postmenopausal women with osteoporosis. This approach is supported by evidence from studies such as the 2017 clinical practice guideline update from the American College of Physicians 1, which recommends pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis.
Individualized Treatment
Treatment should be individualized based on baseline risk for fractures, type of medication and its half-life in bone, duration of discontinuation, benefits and harms of discontinuation, and higher risk for fracture due to temporary treatment discontinuation (holidays) 1. Clinicians should also consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication for treatment continuation, and offer an antiresorptive agent after discontinuation of anabolic agents to preserve gains and prevent rebound and multiple vertebral fractures 1.
From the FDA Drug Label
In postmenopausal women with osteoporosis, Prolia reduces the incidence of vertebral, nonvertebral, and hip fractures [see Clinical Studies (14.1)]. The FDA drug label does not answer the question.
From the Research
Treatment of Fractures in Postmenopausal Women
- Fractures in postmenopausal women should be treated as part of a chronic disease, rather than isolated events, as osteoporosis is a progressive condition that increases the risk of fractures 2, 3, 4, 5.
- The management of osteoporosis in postmenopausal women involves assessing risk factors for fracture, reducing modifiable risk factors through dietary and lifestyle changes, and the use of pharmacologic therapy for patients at significant risk of osteoporosis or fracture 5.
- A comprehensive treatment plan should include nonpharmacologic measures such as good nutrition, regular physical activity, and avoiding smoking and excessive alcohol consumption, as well as pharmacologic therapy to increase bone density and improve bone strength 2, 3, 5.
Pharmacologic Therapy
- Bisphosphonates are considered first-line therapy for patients with established osteoporosis at high risk of fracture, and can reduce vertebral fractures by 40% to 70% and non-vertebral fractures by 20% to 35% 2, 3.
- Other pharmacologic options include denosumab, teriparatide, and selective estrogen receptor modulators (SERMs), which have been shown to reduce the risk of fractures in postmenopausal women with osteoporosis 2, 3, 4, 5.
- The choice of pharmacologic therapy should be individualized and based on the patient's specific needs and risk factors, as well as their medical history and preferences 5.
Long-Term Management
- Osteoporosis is a chronic condition that requires lifelong management, and treatment decisions should be made continuously over the lifespan of a postmenopausal woman 5.
- Patients should be monitored regularly to assess their response to treatment and to adjust their treatment plan as needed, and should be encouraged to make lifestyle changes to reduce their risk of fractures 2, 3, 4, 5.
- Further research is needed to determine the best approaches for transitioning therapy from one medication to another, and to develop new treatments for osteoporosis that can improve patient outcomes 6.