ENDO 2019—New osteoporosis guidelines focus on risk-stratified pharmacologic therapy

  • Tara Haelle
  • Conference Reports
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  • New guidelines from the Endocrine Society for management of osteoporosis in postmenopausal women urge pharmacologic treatment of women with high fracture risk, especially women with a recent fracture. 
  • Pharmacologic treatment plans should also include nutritional, lifestyle, and fall prevention interventions and, except with anabolic therapy, calcium and vitamin D supplementation.  


  • Risk assessment of fracture in postmenopausal women should rely on country-specific tools.
  • Bisphosphonates are recommended as first-line treatment, including alendronate, risedronate, zoledronic acid, and, except for nonvertebral or hip fracture risk, ibandronate.
    • Reassess fracture risk after 3-5 years.
    • Continue therapy if still high risk.
    • Consider bisphosphonates “holiday” of 2-5 years without bisphosphonates if low-to-moderate risk.
    • Restart bisphosphonates if fracture occurs, bone mineral density drops significantly, or other risk factors appear.
  • Denosumab is alternative for bisphosphonates. 
    • Reassess fracture risk after 5-10 years; continue denosumab or change therapy if still high risk.
    • Do not interrupt denosumab treatment and replace with antiresorptive if discontinuing.
  • Teriparatide and abaloparatide recommended (up to 2 years) in women with very high fracture risk, including severe or multiple vertebral fractures.
  • Raloxifene or bazedoxifene recommended in women with high fracture risk alongside a low risk of deep vein thrombosis, high risk of breast cancer, or inability to take bisphosphonates/denosumab.
  • Menopausal hormone therapy—tibolone (except in U.S. or Canada) or estrogen—or calcitonin indicated for women with specific described characteristics and/or inability to tolerate other recommended drugs.
  • Use dual-energy X-ray absorptiometry (DEXA) every 1-3 years to monitor bone mineral density in high-risk women receiving osteoporosis treatment.
    • DEXA alternatives to assess therapy response or adherence include bone turnover markers.