Osteoporosis Treatment
New Medications and Current Guidelines
February 2013
Volume 4, Issue 1

American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis

Endocr Pract. 2011;16(6):1016-9

The American Association of Clinical Endocrinologists (AACE) published these guidelines on diagnosing and treating postmenopausal osteoporosis in 2010.  This summary will focus on the treatment recommendations given in the guidelines.

Bone Loss Prevention
In order to prevent bone loss, the following measures may be taken:

  • Ensure adequate calcium intake.  For women 50 years and older, the recommended daily intake is 1,200 mg. 
  • Ensure adequate vitamin D intake.  Serum levels of 25-hydroxyvitamin D should be between 30 and 60 ng/mL.
  • Limit alcohol intake.  No more than 2 servings each day is recommended.
  • Limit caffeine intake.  Daily intake should be less than 1 to 2 servings (8 to 12 ounces/serving).
  • Stop smoking.
  • Living an active lifestyle.  On most days of the week, weight-bearing exercise and back and posture exercises should be done.  The exercise should be done for at least 30 minutes.

Nonpharmacologic Measures for Treating Osteoporosis
All of the above recommendations should be taken (for bone loss prevention).  Additionally, the following should be considered for treating postmenopausal osteoporosis:

  • Ensure adequate protein intake.
  • Employ good body mechanics.
  • If the patient is at high risk of falling, hip protectors may be worn.
  • Work on fall prevention
  • Consider referring for physical and/or occupational therapy

Candidates for Pharmacologic Treatment
In these guidelines, the AACE endorses the 2008 National Osteoporosis Foundation Clinician’s Guide to Prevention and Treatment of Osteoporosis.  That publication recommends pharmacologic treatment for postmenopausal women who can be described by the following:

  • Have a history of hip or spine fracture
  • Have a T-score of -2.5 or lower
  • Have a T-score between -1.0 and -2.5 and a FRAX major osteoporotic fracture probability of ≥ 20% or hip fracture probability of ≥ 3%.

Pharmacologic Treatment Options for Osteoporosis
As first-line therapies, the guidelines suggest alendronate, risedronate, zoledronic acid, and denosumab.

As a second-line therapy, ibandronate is recommended.

Raloxifene can be considered as a second- or third-line therapy.

Calcitonin should be considered as a last-line therapy.

All of the above medications have proven anti-fracture efficacy.

The guidelines recommend against combination therapies.


The AACE Guidelines are one of the most comprehensive guidelines published in the past five years on the treatment of postmenopausal osteoporosis. It is the first guideline that has suggested the practice of initiating drug holidays for patients on long term bisphosphonate therapy. Readers may obtain a full copy of the guidelineon the AACE website.

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Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline
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