DAmeriean celloge of PhysicansLeading Internal Medicine,Improving LivesCLINICAL GUIDELINEPharmacologic Treatment of Primary Osteoporosis or Low BoneMass to Prevent Fractures in Adults:A Living Clinical GuidelineFrom the American College of PhysiciansAmir Qaseem,MD,PhD,MHA;Lauri A.Hicks,DO;Itziar Etxeandia-lkobaltzeta,PharmD;Tatyana Shamliyan,MD,MS;andThomas G.Cooney,MD;for the Clinical Guidelines Committee of the American College of Physicians*Description:This guideline updates the 2017 Americanfemales diagnosed with primary osteoporosis who have contraCollege of Physicians(ACP)recommendations on pharmaco.indications to or experience adverse effects of bisphosphonateslogic treatment of primary osteoporosis or low bone mass to(conditional recommendation;moderate-certainty evidence)prevent fractures in adults.Recommendation 2b:ACP suggests that clinicans use theMethods:The ACP Clinical Guidelines Committee basedRANK ligand inhibitor(denosumab)as a second-line pharmaco-these recommendations on an updated systematic review oflogic treatment to reduce the risk of fractures in males diag-evidence and graded them using the GRADE (Grading ofnosed with primary osteoporosis who have contraindications toRecommendations Assessment,Development and Evaluation)or experience adverse effects of bisphosphonates (conditionalsystem.recommendation;low-certainty evidence).Audience and Patient Population:The audience for thisRecommendation 3:ACP suggests that clinicians use theguideline indudes all clinicians.The patient population includessclerostin inhibitor (romosozumab,moderate-certainty evi-adults with primary osteoporosis or low bone mass.dence)or recombinant PTH (teriparatide,low-certainty evi-dence),followed by a bisphosphonate,to reduce the risk ofRecommendation 1a:ACP recommends that clinicians usefractures only in females with primary osteoporosis with verybisphosphonates for initial pharmacologic treatment to reducehigh risk of fracture (conditional recommendationthe risk of fractures in postmenopausal females diagnosedwith primary osteoporosis(strong recommendation;high-certaintyRecommendation 4:ACP suggests that clinicians take anevidence)individualized approach regarding whether to start pharmaco.logic treatment with a bisphosphonate in females over the ageRecommendation 1b:ACP suggests that clinicians useof 65 with low bone mass (osteopenia)to reduce the risk of frac-bisphosphonates for initial pharmacologic treatment to reducetures (conditional recommendation;low-certainty evidence).the risk of fractures in males diagnosed with primary osteoporo.sis (conditional recommendation;low-certainty evidence)Recommendation 2a:ACP suggests that clinicians use theAnn Intern Med.doi:10.7326/M22-1034Annals.orgRANK ligand inhibitor (denosumab)as a second-line pharmaco-For author,article,and disclosure information,see end of text.logic treatment to reduce the risk of fractures in postmenopausalThis article was published at Annals.org on 3 January 2023.rimary osteopor
