Prevention and treatment of osteoporosis in postmenopausal women - Clinical Update

Journal of Family Practice, Oct, 2002 by Linda French, Mindy Smith, Leslie Shimp

Osteoporosis risk
assessment instrument (17)

    Patient characteristic        Points

Age (years)
  75 or older                       15
  65 to 74                           9
  55 to 64                           5
  54 or younger                      0
Weight
  <132 lb (60 kg)                    9
  132 to 153.9 lb (60 to 70 kg)      3
  >154 lb (>70 kg)                   0
No current estrogen use              2
                             Total:

Patients with a score of 9 or higher are at risk for
diagnosis of osteoporosis by bone mineral density measurement.
Sensitivity 97.5%, specificity 28%, positive
predictive value 28%, negative predictive value 99.6%
given a 10% baseline risk of a bone mineral
density 2.5 SD less than the mean.
TABLE 2
Drug theraphy for prevention and treatment of
postmenopausal osteoporosis

Drug                         Indication and dosage
(trade name)

Calcium and vitamin D        Prevention and treatment:
(generic, Tums, Citracal,    1200-1500 mg/day calcium
and others)                  and 800 IU/day vitamin D

Estrogen ([dagger])          Prevention:
(Premarin, Ogen, Estrace,    0.625 mg/day conjugated
Estraderm, and others)       equine estrogen or the
                             equivalent; 0.3 mg/day may
                             be effective

Alendronate                  Prevention and treatment:
(Fosamax)                    5 mg/day or 35 mg/week

Risedronate                  Prevention and treatment:
(Actonel)                    5 mg/day or 35 mg/week

Raloxifene                   Treatment:
(Evista)                     60 mg/day

Calcitonin nasal spray       Treatment: 200 IU/day
(Miacalcin)                  (1 spray in 1 nostril
                             per day)

Drug                         Possible side effects
(trade name)                 (% of patients)

Calcium and vitamin D        Nausea, dyspepsia
(generic, Tums, Citracal,    (uncommon),
and others)                  constipation (10%)

Estrogen ([dagger])          Nausea, breast tenderness,
(Premarin, Ogen, Estrace,    vaginal bleeding,
Estraderm, and others)       mood alterations,
                             headache, bloating

Alendronate                  Nausea, dyspepsia
(Fosamax)                    esophageal irritation

Risedronate                  Abdominal pain,
(Actonel)                    nausea, diarrhea

Raloxifene                   Hot flashes (6%),
(Evista)                     leg cramps (3%)

Calcitonin nasal spray       Rhinitis (5%),
(Miacalcin)                  epistaxis, sinusitis

Drug                         Cost per month *
(trade name)

Calcium and vitamin D        $5
(generic, Tums, Citracal,    (both)
and others)

Estrogen ([dagger])          $14-$28
(Premarin, Ogen, Estrace,
Estraderm, and others)

Alendronate                  $67
(Fosamax)

Risedronate                  $67
(Actonel)

Raloxifene                   $70
(Evista)

Calcitonin nasal spray       $66
(Miacalcin)

* Average wholesale cost to the pharmacy for 30 days of therapy;
(Drug Topics Red Book. Montvale, NJ; Medical Economics Co., Inc, 2002.)

([dagger]) Women with a uterus need to take a progestin such as
medroxyprogesterone (Provera $30/month, generic $9/month) or a
combination estrogen/progestin product (Prempro $33/month, FEmHRT
$26/month).
TABLE 3
Clinical trials of drug therapy for the prevention of
fracture in postmenopausal women with osteoporosis

    Trial, year              Therapy         Outcome prevented

Elderly, postmenopausal women

 Chapuy, 1992 (67)      Calcium/vitamin D       Hip fracture

Postmenopausal women

   WHI, 2002 (42)            Hormone            Hip fracture
                       replacement therapy

Postmenopausal women with osteoporosis

Ettinger, 1999 (56)        Raloxifene        Vertebral fracture
Liberman, 1995 (54)        Alendronate       Vertebral fracture
 Heaney, 2002 (53)        Risendronate       Vertebral fracture
 McClung, 2001 (70)        Risedronate          Hip fracture

Postmenopausal women with osteoporosis and previous vertebral fracture

 Harris, 1999 (51)         Risedronate       Vertebral fracture
  Black, 1996 (52)         Alendronate       Vertebral fracture
  Black, 1996 (52)         Alendronate          Hip fracture

    Trial, year        Number needed to treat for
                                n years

Elderly, postmenopausal women

 Chapuy, 1992 (67)      48 women for 1.5 years

Postmenopausal women

   WHI, 2002 (42)       2000 women for 5 years

Postmenopausal women with osteoporosis

Ettinger, 1999 (56)      29 women for 3 years
Liberman, 1995 (54)      34 women for 3 years
 Heaney, 2002 (53)       15 women for 3 years
 McClung, 2001 (70)      91 women for 3 years

Postmenopausal women with osteoporosis and previous vertebral fracture

 Harris, 1999 (51)       20 women for 3 years
  Black, 1996 (52)       35 women for 3 years
  Black, 1996 (52)       86 women for 3 years