Osteoporosis International

, Volume 29, Issue 7, pp 1505–1510 | Cite as

Review of the guideline of the American College of Physicians on the treatment of osteoporosis

  • J. A. Kanis
  • C. Cooper
  • R. Rizzoli
  • J.-Y. Reginster
Position Paper



This review, endorsed by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, summarizes several failings of the recent guidelines of the American College of Physicians (ACP) on the treatment of low bone density or osteoporosis to prevent fractures.


The ACP recently issued guidelines for the treatment of low bone density or osteoporosis to prevent fractures.


Literature review and critical review of the ACP guidelines.


The guideline is lacking in scope due to the endorsement of treatment based on T-scores rather than fracture risk assessment and in failure to adequately consider anabolic therapies.


The ACP guideline appears outdated.


Bone mineral density Fracture risk FRAX Intervention thresholds Treatment guidelines 



We are grateful to the Committee of Scientific Advisors and the Committee of National Societies of the International Osteoporosis Foundation (IOF) and the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) for their reviews and endorsement of this manuscript.

Compliance with ethical standards

Conflicts of interest

JAK reports grants from Amgen, Eli Lilly, and Radius Health; non-financial support from Medimaps and Asahi; and other support from AgNovos. JAK is the architect of FRAX but has no financial interest. Professor Cooper reports personal fees from Alliance for Better Bone Health, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda, and UCB. RR has received consulting fees or advisory board fees from Radius Health, Labatec, Danone, and Nestlé. J-YR has received advisory board or speaker fees from Asahi-Kasei, Eli Lilly, IBSA-Genévrier, Nycomed-Takeda, PharmEvo, Radius Health, Roche, Servier, UCB, Will Pharma, and Zodiac.


  1. 1.
    Qaseem A, Forciea MA, Mclean RM, Denberg TD, Clinical Guidelines Committee of the American College of Physicians (2017) Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. Ann Intern Med 166:818–839CrossRefPubMedGoogle Scholar
  2. 2.
    Caplan L, Hansen KE, Saag KG (2017) Response to the ACP osteoporosis guideline 2017 revision. Arthritis Rheumatol 69:2097–2101CrossRefPubMedGoogle Scholar
  3. 3.
    Lieweki EM (2017) Treatment of low bone density or osteoporosis to prevent fractures in men and women. Ann Int Med 167:902CrossRefGoogle Scholar
  4. 4.
    Reginster J-Y, Rizzoli R, Kanis JA, Cooper C (2017) Treatment of low bone density or osteoporosis to prevent fractures in men and women. Ann Int Med 167:902–903CrossRefPubMedGoogle Scholar
  5. 5.
    Miller PD (2017) Treatment of low bone density or osteoporosis to prevent fractures in men and women. Ann Int Med 167:903–904CrossRefPubMedGoogle Scholar
  6. 6.
    Cranney A, Jamal SA, Tsang JF, Josse RG, Leslie WD (2007) Low bone mineral density and fracture burden in postmenopausal women. CMAJ 177:575–580CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    World Health Organisation (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report Series 843. WHO, GenevaGoogle Scholar
  8. 8.
    Kanis JA, Johnell O, Oden A, Jonsson B, De Laet C, Dawson A (2000) Risk of hip fracture according to World Health Organization criteria for osteoporosis and osteopenia. Bone 27:585–590CrossRefPubMedGoogle Scholar
  9. 9.
    Odén A, Kanis JA, McCloskey EV, Johansson H (2014) The effect of latitude on the risk and seasonal variation in hip fracture in Sweden. J Bone Miner Res 29:2217–2223CrossRefPubMedGoogle Scholar
  10. 10.
    Johnell O, Borgstrom F, Jonsson B, Kanis J (2007) Latitude, socioeconomic prosperity, mobile phones and hip fracture risk. Osteoporos Int 18:333–337CrossRefPubMedGoogle Scholar
  11. 11.
    Kanis JA, Odén A, McCloskey EV, Johansson H, Wahl D, Cyrus Cooper C on behalf of the IOF Working Group on Epidemiology and Quality of Life (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23:2239–2256CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Nguyen ND, Frost SA, Center JR, Eisman JA, Nguyen TV (2008) Development of prognostic nomograms for individualizing 5-year and 10-year fracture risks. Osteoporos Int 19:1431–1444CrossRefPubMedGoogle Scholar
  13. 13.
    Hippisley-Cox J, Coupland C (2009) Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFracture Scores. BMJ 339:b4229CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Dachverband Osteologie e.V (2011) DVO guideline 2009 for prevention, diagnosis and therapy of osteoporosis in adults. Osteologie 20:55–74CrossRefGoogle Scholar
  15. 15.
    Kanis JA, Johnell O, Oden A, Johansson H, McCloskey EV (2008) FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–397CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kanis JA on behalf of the World Health Organization Scientific Group (2008) Assessment of osteoporosis at the primary health-care level. Technical Report. WHO Collaborating Centre, University of Sheffield, UK. Available at
  17. 17.
    Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D, on behalf of the EFFO (1997) Guidelines for diagnosis and management of osteoporosis. Osteoporos Int 7:390–406CrossRefPubMedGoogle Scholar
  18. 18.
    Royal College of Physicians (1999) Osteoporosis: clinical guidelines for prevention and treatment. Royal College of Physicians, LondonGoogle Scholar
  19. 19.
    Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N et al (2017) The National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 12:43. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Compston J, Cooper A, Cooper C, on behalf of the National Osteoporosis Guideline Group (NOGG) et al (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 62:105–108CrossRefPubMedGoogle Scholar
  21. 21.
    Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster J-Y, on behalf of the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF) (2013) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 24:23–57CrossRefPubMedGoogle Scholar
  22. 22.
    Lekamwasam S, Adachi JD, Agnusdei D, Bilezikian J, Boonen S, Borgström F, for the Joint IOF-ECTS GIO Guidelines Working Group et al (2012) A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. Osteoporos Int 23:2257–2276CrossRefPubMedGoogle Scholar
  23. 23.
    Kanis JA, Harvey NC, Cyrus Cooper C, Johansson H, Odén A, McCloskey EV, the Advisory Board of the National Osteoporosis Guideline Group (2016) A systematic review of intervention thresholds based on FRAX. A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 11:25. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S et al (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25:2359–2381CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL et al (2016) American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2016—executive summary. Endocr Pract 22:1111–1118CrossRefPubMedGoogle Scholar
  26. 26.
    Johansson H, Kanis JA, Oden A, Compston J, McCloskey E (2012) A comparison of case-finding strategies in the UK for the management of hip fractures. Osteoporos Int 23:907–915CrossRefPubMedGoogle Scholar
  27. 27.
    Kanis JA, McCloskey E, Johansson H, Oden A, Leslie WD (2012) FRAXs with and without BMD. Calcif Tissue Int 90:1–13CrossRefPubMedGoogle Scholar
  28. 28.
    Leslie WD, Majumdar SR, Lix L, Johansson H, McCloskey EV, Kanis JA (2012) High fracture probability with FRAX usually indicates densitometric osteoporosis: implications for clinical practice. Osteoporos Int 23:391–397CrossRefPubMedGoogle Scholar
  29. 29.
    McCloskey E (2016) A BMD threshold for treatment efficacy in osteoporosis? A need to consider the whole evidence base. Osteoporos Int 27:417–419CrossRefPubMedGoogle Scholar
  30. 30.
    Kanis JA, Jönsson B, Odén A, McCloskey EV (2011) A meta-analysis of the effect of strontium ranelate on the risk of vertebral and non-vertebral fracture in postmenopausal osteoporosis and the interaction with FRAX®. Osteoporos Int. 22: 2347–2355 with erratum Osteoporos Int 22: 2357–2358Google Scholar
  31. 31.
    Kanis JA, Johansson H, Oden A, McCloskey EV (2009) Bazedoxifene reduces vertebral and clinical fractures in postmenopausal women at high risk assessed with FRAX®. Bone 44:1049–1054CrossRefPubMedGoogle Scholar
  32. 32.
    Kanis JA, Johansson H, Oden A, McCloskey EV (2010) A meta-analysis of the efficacy of raloxifene on all clinical and vertebral fractures and its dependency on FRAX®. Bone 47:729–735CrossRefPubMedGoogle Scholar
  33. 33.
    McCloskey EV, Johansson H, Oden A, Vasireddy S, Kayan K, Pande K et al (2009) Ten-year fracture probability identifies women who will benefit from clodronate therapy—additional results from a double-blind, placebo-controlled randomised study. Osteoporos Int 20:811–817CrossRefPubMedGoogle Scholar
  34. 34.
    Harvey NC, Kanis JA, Odén A, Burge RT, Mitlak BH, Johansson H, McCloskey EV (2015a) FRAX and the effect of teriparatide on vertebral and non-vertebral fracture. Osteoporos Int 26:2347–2353CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Harvey NC, Kanis JA, Odén A, Nakamura T, Shiraki M, Sugimoto T, Kuroda T, Johansson H, McCloskey EV (2015b) Efficacy of weekly teriparatide does not vary by baseline fracture probability calculated using FRAX. Osteoporos Int 26:2347–2354CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    McCloskey EV, Johansson H, Oden A, Harvey NC, Jiang H, Modin S et al (2017) The effect of abaloparatide-SC on fracture risk is independent of baseline FRAX fracture probability: a post hoc analysis of the ACTIVE study. J Bone Miner Res 32:1625–1631CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    McCloskey EV, Johansson H, Oden A, Austin M, Siris E, Wang A et al (2012) Denosumab reduces the risk of all osteoporotic fractures in postmenopausal women, particularly in those with moderate to high fracture risk as assessed with FRAX®. J Bone Miner Res 27:1480–1486CrossRefPubMedGoogle Scholar
  38. 38.
    Donaldson MG, Palermo L, Ensrud KE, Hochberg MC, Schousboe JT, Cummings SR (2012) Effect of alendronate for reducing fracture by FRAX score and femoral neck bone mineral density: the Fracture Intervention Trial. J Bone Miner Res 27:1804–1810CrossRefPubMedGoogle Scholar
  39. 39.
    Shepstone L, Lenaghan E, Cooper C, Clarke S, Fordham R, Gittoes NJ et al (2017) A randomized controlled trial of screening in the community to reduce fractures in older women—the SCOOP Study. Lancet 391(10122):741–747Google Scholar
  40. 40.
    Dawson-Hughes B, Looker AC, Tosteson ANA, Johansson H, Kanis JA, Melton LJ (2012) The potential impact of the National Osteoporosis Foundation guidance on treatment eligibility in the U.S.: an update in NHANES 2005–2008. Osteoporos Int 23:811–820CrossRefPubMedGoogle Scholar
  41. 41.
    Kanis JA, McCloskey EV, Harvey NC, Johansson H, Leslie WD (2015) Intervention thresholds and the diagnosis of osteoporosis. J Bone Miner Res 30:1747–1753CrossRefPubMedGoogle Scholar
  42. 42.
    Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, FLEX Research Group et al (2006) Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA 296:2927–2938CrossRefPubMedGoogle Scholar
  43. 43.
    Black DM, Reid IR, Boonen S, Bucci-Rechtweg C, Cauley JA, Cosman F et al (2012) The effect of 3 versus 6 years of zoledronic acid treatment of osteoporosis: a randomized extension to the HORIZON-Pivotal Fracture Trial (PFT). J Bone Miner Res 27:243–254CrossRefPubMedGoogle Scholar
  44. 44.
    Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC et al (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 348:1535–1541CrossRefPubMedGoogle Scholar
  45. 45.
    Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA et al (1988) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 280:2077–2082CrossRefGoogle Scholar
  46. 46.
    Schwartz AV, Bauer DC, Cummings SR, Cauley JA, Ensrud KE, Palermo L, FLEX Research Group et al (2010) Efficacy of continued alendronate for fractures in women with and without prevalent vertebral fracture: the FLEX trial. J Bone Miner Res 25:976–982CrossRefPubMedGoogle Scholar
  47. 47.
    Bone HG, Bolognese MA, Yuen CK, Kendler DL, Miller PD, Yang YC et al (2011) Effects of denosumab treatment and discontinuation on bone mineral density and bone turnover markers in postmenopausal women with low bone mass. J Clin Endocrinol Metab 96:972–980CrossRefPubMedGoogle Scholar
  48. 48.
    Astasilakis AD, Polyzos SA, Makras P, Aubry-Rozier B, Kaouri S, Lamy O (2017) Clinical features of 24 patients with rebound-associated vertebral fractures after denosumab discontinuation: systematic review and additional cases. J Bone Miner Res 32:1291–1296CrossRefGoogle Scholar
  49. 49.
    Cummings SR, Ferrari S, Eastell R, Gilchrist N, Jensen JB, McClung M et al (2018) Vertebral fractures after discontinuation of denosumab: a post hoc analysis of the randomized placebo-controlled FREEDOM trial and its extension. J Bone Miner Res 33:190–198Google Scholar
  50. 50.
    Bone HG, Wagman RB, Brandi ML, Brown JP, Chapurlat R, Cummings SR et al (2017) 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension. Lancet Diabetes Endocrinol 7:513–523. CrossRefGoogle Scholar
  51. 51.
    Ferrari S, Adachi JD, Lippuner K, Zapalowski C, Miller PD, Reginster JY et al (2015) Further reductions in nonvertebral fracture rate with long-term denosumab treatment in the FREEDOM open-label extension and influence of hip bone mineral density after 3 years. Osteoporos Int 26:2763–2771CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    McClung MR (2016) Cancel the denosumab holiday. Osteoporos Int 27:1677–1682CrossRefPubMedGoogle Scholar
  53. 53.
    Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA et al (2017) Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2017 executive summary. Endocr Pract 23:207–238CrossRefPubMedGoogle Scholar
  54. 54.
    Kendler DL, Marin F, Zerbini CAF, Russo LA, Greenspan SL, Zikan V, Bagur A et al (2017) Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet S0140-6736(17):32137–32132. CrossRefGoogle Scholar
  55. 55.
    Miller PD, Hattersley G, Riis BJ, Williams GC, Lau E, Russo LA et al (2016) Effect of abaloparatide vs placebo on new vertebral fractures in postmenopausal women with osteoporosis: a randomized clinical trial. JAMA 316:722–733CrossRefPubMedGoogle Scholar
  56. 56.
    Saag KG, Petersen J, Brandi ML, Karaplis AC, Lorentzon M, Thomas T et al (2017) Romosozumab or alendronate for fracture prevention in women with osteoporosis. N Engl J Med 377:1417–1427CrossRefPubMedGoogle Scholar
  57. 57.
    Kanis JA, Rizzoli R, Cooper C, Reginster J-Y (2014) Challenges for the development of bone forming agents in Europe. Calcif Tissue Int 94:469–473CrossRefPubMedGoogle Scholar
  58. 58.
    Bone HG, Cosman F, Miller PD, Williams GC, Hattersley G, Hu M et al (2017) Sustained fracture risk reduction with sequential abaloparatide/alendronate: results of ACTIVEextend. J Bone Miner Res 32(Suppl 1):S25–S26 abstract 1074Google Scholar
  59. 59.
    Kanis JA, Cooper C, Abrahamsen B, Al-Daghri N, Brandi ML, Cannata-Andia J et al (2017) Identification and management of patients at increased risk of osteoporotic fracture. Osteoporos Int 28:2023–2034CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  1. 1.Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffieldUK
  2. 2.Mary McKillop Health InstituteAustralian Catholic UniversityMelbourneAustralia
  3. 3.MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
  4. 4.NIHR Musculoskeletal Biomedical Research UnitUniversity of OxfordOxfordUK
  5. 5.Service of Bone Diseases, Faculty of MedicineGeneva University HospitalsGenevaSwitzerland
  6. 6.Department of Public Health, Epidemiology and Health EconomicsUniversity of LiègeLiègeBelgium
  7. 7.WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and AgingLiègeBelgium

Personalised recommendations