AACE/ACE Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update: Risk Stratification and Intervention Thresholds

The recently published 2020 update of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis provides some valuable insights into the management of osteoporosis. 1 Camacho P.M. Petak S.M. Binkley N. et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 update. Endocr Pract. 2020; 26: 1-46 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar The timely incorporation into the guidelines of recent developments in the field, including fracture risk stratification and recognition of the category of very high risk will indeed have a significant impact on clinical osteoporosis treatment strategies. However, I would like the authors to shed some light on the rationale behind 2 recommendations in the guidelines. I hope that these questions will encourage meaningful discourse on the subject. 1.Among other indications, pharmacologic therapy to reduce fracture risk is indicated if T-scores are between −1.0 and −2.5 and the patient has a Fracture Risk Assessment Tool (FRAX) 10-year probability of major osteoporotic fracture (MOF) ≥20%, or a 10-year probability of hip fracture (HF) ≥3% in the United States. These thresholds (ie, a 3% HF probability that was assumed to be equivalent to a 20% MOF probability) were derived by Tosteson et al 2 Tosteson A.N. Melton 3rd, L.J. Dawson-Hughes B. et al. Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int. 2008; 19: 437-447 Crossref PubMed Scopus (357) Google Scholar based on a cost-effectiveness analysis performed in 2008 in the United States, with costs represented in 2005 United States dollars. Recommendations based on this subsequently found their way into the National Osteoporosis Foundation (NOF) Guide Committee’s revised clinician guide for the prevention and treatment of osteoporosis in the same year. Given that the authors of the AACE/ACE guidelines themselves note that “These criteria were based on a pharmacoeconomic analysis from a decade ago. Were the same quality-adjusted life year criterion applied today, the treatment thresholds would be notably lower,” could the authors kindly explain the rationale for continuing to advocate these obviously outdated thresholds in a guideline published 12 years later? 2.Regarding the stratification of fracture risk, the authors state that patients at very high fracture risk include “those with a very high fracture probability by FRAX (eg, major osteoporosis fracture >30%, HF >4.5%).” I do appreciate that the authors use the words “eg” (exempli gratia”) by which it is understood that these numbers are intended to be examples and not definitive cut-points. However, would the authors kindly explain why they chose these numbers as examples? Since these examples of very high-risk probabilities of 4.5% and 30% are obviously based on the former “baseline” ITs of 3% and 20% HF and MOF intervention thresholds (ITs) respectively, wouldn’t this also only serve to promulgate the continued usage of outdated ITs? A real concern also exists that these examples might be adopted without question in many areas of the world considering that the AACE/ACE guidelines have a far-reaching impact. This may become akin to the issue raised by Kanis et al 3 Kanis J.A. Harvey N.C. Cooper C. et al. A systematic review of intervention thresholds based on FRAX. Arch Osteoporos. 2016; 11: 25 Crossref PubMed Scopus (209) Google Scholar , who in their systematic review of worldwide FRAX-based IT guidelines, discovered that in more than half the 58 publications they identified, MOF/HF thresholds of 20%/3% were recommended with no other rationale provided other than that they were the recommendations of the NOF of the United States. That is despite all major guidelines including the AACE/ACE exhorting the use of country-specific ITs. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 UpdateEndocrine Practice Vol. 27Issue 4PreviewWe thank Dr. Chandran for her thoughts and questions about the recently published American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) Postmenopausal Osteoporosis Diagnosis and Treatment Guidelines.1 Before addressing the issue of “intervention thresholds,” which could probably be debated endlessly, we should point out that the FRAX is not the final answer for predicting risk for individual patients. There are important risk factors that are not captured by FRAX, such as the dose and duration of glucocorticoid use, amount and duration of smoking, effects of alcohol, location and the number of fractures, falls, and more. Full-Text PDF