The document discusses trends in the prevention and treatment of postmenopausal osteoporosis. It focuses on identifying risk factors and selecting lifestyle changes and pharmacologic therapies to reduce risk. Approved drug options for prevention and treatment include bisphosphonates, selective estrogen receptor modulators, and calcitonin. Clinical trials show these drugs significantly reduce risks of vertebral and non-vertebral fractures compared to placebo when combined with calcium and vitamin D supplementation. The magnitude of treatment effects on fractures is presented for various approved drugs. An algorithm is provided for the therapeutic management of postmenopausal osteoporosis based on bone mineral density, fracture risk, and age.

1. Osteoporosis New Trends in Prevention and Treatment Prof. Bari Kaplan MD. . 2-4-2003

2. The management of postmenopausal osteoporosis first focuses on identifying the woman’s risk factors, then selecting measures that will reduce modifiable risk factors through lifestyle changes and, if indicated, pharmacologic therapy .

3. If pharmacologic therapy is indicated FDA-approved options are: Estrogens (prevention only) according FDA new statement. Bisphosphonates and Selective estrogen-receptor modulators (prevention and treatment), Calcitonin (treatment only). PTH

4. Anti fracture efficacy of the most frequently used treatment of postmenopausal osteoporosis in addition to the effects of calcium or vitamin D supplementation, or both, as derived from placebo controlled randomized trials. Delmas, The Lancet 359:2018-2026, 2002 0 ± Vitamin D derivatives ++ +++ Risedronate 0 +++ Raloxifene ++ +++ PTH 0 + HRT - ± Fluoride 0 + Etidronate 0 + Calcitonin ++ +++ Alendronate Non Vertebral # Vertebral # DRUG

5. Magnitude of the Treatment Effect on Vertebral and Non Vertebral Fractures in Postmenopausal Woman with Osteoporosis CRANNEY A et al . ENDOCRINE REV 2002, 23(4);570 - 578 CA=Calcitonon,VIT D=Vitamin D,ALN=Alendronate ,RIS=Risedronate ,RLX=Raloxifen,SCT=Calcitonin,FLU=Fluoride,ETD =Etidronate 0.2 0 0.4 0.6 0.8 1 1.2 1.4 1.6 Relative Risk for Fractures CA n=576 VIT D n=1,130 ALN n=9,360 RIS n=2,604 RLX n=6,828 HRT n=3,117 SCT n=1,108 FLU n=646 SPINE # NONSPINE # P < 0.05 P=0.05 ETD n=1,076

6. Therapeutic Management of Postmenopausal Osteoporosis Osteoporosis prevention T-score –1 to –2.5 Osteoporosis treatment with or without previous fracture T-score < -2.5 Osteoporosis treatment with multiple fractures and at risk for hip fracture 50 55 60 65 70 75 80 85 90 Raloxifene Age (years) HRT=hormone replacement therapy HRT PTH Short-term vasomotor symptom management Bisphosphonates

7. Lower Higher -2.5 BMD (T-score) Bisphosphonates Osteoporosis Therapy Algorithm Postmenopausal Women Raloxifene PTH Calcitonin HRT HRT During Hot Flashes Post Vasomotor Symptoms Pre fracture Post Fracture Risk of Fracture AGE At Risk/Osteopenia Osteoporosis Severe Osteoporosis STAGE