American College of Physicians recommends bisphosphonates for initial treatment for osteoporosis in males and postmenopausal females diagnosed with primary osteoporosis

1. American College of Physicians recommends bisphosphonates for initial treatment for osteoporosis in males and postmenopausal females diagnosed with primary osteoporosis
Guideline: https://www.acpjournals.org/doi/10.7326/M22-1034
Review: https://www.acpjournals.org/doi/10.7326/M22-0684
Editorial: https://www.acpjournals.org/doi/10.7326/M22-3580
Note: High-definition soundbites from ACP President, Ryan Mire, MD, MACP are available for download at https://www.dssimon.com/MM/ACP-osteoporosis-paper.
URL goes live when the embargo lifts
The American College of Physicians (ACP) has issued an update of its guideline with clinical recommendations for treatments of primary osteoporosis and low bone mass in adults. In the new guideline, ACP recommends bisphosphonates as initial pharmacologic treatment to reduce the risk of fractures in males and postmenopausal females diagnosed with primary osteoporosis. The full guideline is published in Annals of Internal Medicine.

Osteoporosis is a systemic skeletal disease characterized by decreasing bone mass and deterioration of bone tissue that leads to an increased risk for bone fragility and fracture, especially in the hip, spine, and wrist. Overall, an estimated 10.2 million people aged 50 and older in the United States have osteoporosis and about 43.3 million people (> 40% of older US adults) have low bone mass associated with a high risk of progression to osteoporosis.

The guideline examines new evidence that has emerged on the efficacy of human parathyroid hormone-related peptides, sclerostin inhibitors, the comparative effectiveness of treatments, and treatments in males. In postmenopausal females and males with primary osteoporosis, bisphosphonates had the most favorable balance between benefits, harms, patient values and preferences, and cost among the drug classes that were evaluated. In addition to net clinical benefits, bisphosphonates are much cheaper than other pharmacologic treatments and are available in generic oral and injectable formulations.

Current evidence suggests that increasing the duration of bisphosphonate therapy longer than 3-5 years reduced the risk of new vertebral fractures but not the risk of other fractures. However, there is an increased risk of long-term harms. Therefore, clinicians should consider stopping bisphosphonates after five years of treatment unless there is a strong indication to continue treatment.

The guideline also suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females and males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates.

ACP suggests that clinicians use the sclerostin inhibitor (romosozumab) or recombinant PTH (teriparatide), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture.

The guideline is based on a systemic review and network meta-analysis conducted by the ACP Center for Evidence Reviews at the Portland Veteran Affairs Research Foundation. ACP’s Clinical Guidelines Committee is planning to maintain this topic as a living guideline with literature surveillance and periodic updating of the systematic review and the clinical recommendations.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone from ACP, please contact Andrew Hachadorian at ahachadorian@acponline.org.
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2. Both medication-based and procedural first-trimester abortions safe and effective, with slightly more complications reported with medicated-based abortion
Complications occur for fewer than 4 in 1000 women for any procedure during the first trimester
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2568
Editorial: https://www.acpjournals.org/doi/10.7326/M22-3634
URL goes live when the embargo lifts
A cohort study of 39,000 women found that both medication-induced abortions and procedural abortions are safe and effective, with adverse events occurring in fewer than 4 in 1000 procedures. Complications were slightly more common among women having medication-based abortions. The findings are published in Annals of Internal Medicine.

In June 2022, the United States Supreme Court issued in a decision in Dobbs v. Jackson Women’s Health Organization that overturned Roe v. Wade, a previous Supreme Court ruling that enshrined the right for Americans to undergo abortions without state interference or restriction. The new precedent established under Dobbs invites state lawmakers to restrict or eliminate their constituents’ right to undergo an abortion. This includes the right to obtain medications remotely to induce abortion.

Researchers from ICES and the University of Toronto conducted a population-based cohort study of all women who underwent an induced abortion in Ontario, Canada. This included 39,856 women who received mifepristone-misoprostol in an outpatient setting; 65,176 who had an abortion procedure in a nonhospital clinic setting; and 8,861 who had an abortion procedure in a hospital-based outpatient setting. The authors found that severe complications, including the need for a gynecologic procedure, intensive care, bleeding requiring a blood transfusion, and infection, occurred in only 3.3 per 1000 women after medication and 1.8 per 1000 women after a procedure in a hospital-based clinic. The authors highlight that their findings underscore the overall short-term safety of either method to achieve an accessible first-trimester abortion.

An accompanying editorial by Carol Hogue of Emory University highlights the safety of first-trimester abortion procedures and mifepristone-misoprostol managed abortions. She calls attention to misdirected concerns about the mortality rates related to abortion procedures, while maternal mortality rates are currently much higher, and might increase with new abortion restrictions. She also calls for legislators to provide bipartisan support to the Right to Contraception Act, which will affirm a person’s right to access contraceptives and the right of healthcare providers to provide contraceptive services. The author says that while this bill will not end the war on reproductive healthcare, it will prevent unintended and unwanted pregnancies that could severely injure or kill American women.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Joel G. Ray, MD, MSc, please email Joel.Ray@unityhealth.to. To speak with the editorialist, Carol J. Hogue, PhD, MPH, please contact Brian Katzowitz at brian.katzowitz@emory.edu.
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