Review of the guideline of the American College of Physicians
on the treatment of osteoporosis
J. A. Kanis
Received: 25 October 2017 / Accepted: 11 January 2018 / Published online: 4 June 2018
International Osteoporosis Foundation and National Osteoporosis Foundation 2018
Summary 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 guide-
lines of the American College of Physicians (ACP) on the treatment of low bone density or osteoporosis to prevent fractures.
Introduction The ACP recently issued guidelines for the treatment of low bone density or osteoporosis to prevent fractures.
Methods Literature review and critical review of the ACP guidelines.
Results 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.
Conclusions The ACP guideline appears outdated.
Keywords Bone mineral density
The American College of Physicians (ACP) recently issued
guidelines for the treatment of low bone density or osteopo-
rosis to prevent fractures . ACP recommends that clinicians
offer pharmacological treatment to reduce spine and hip frac-
ture risk in women with osteoporosis, and consider treatment
in women at high risk. More specifically, ACP strongly rec-
ommends Bthat clinicians offer pharmacologic treatment with
alendronate, risedronate, zoledronic acid, or denosumab to
reduce the risk for hip and vertebral fractures in women who
have known osteoporosis.^
The recommendations are largely based on a systematic review
of randomized controlled trials. Whereas a review of such evi-
dence is to be commended, the guideline largely ignores other
important evidence that might modulate the way guidelines are
formulated [2–5]. The areas of concern discussed below include
the scope of guidelines, the position on FRAX, the limited dura-
tion of therapy, and the use of anabolic interventions.
The restricted scope of the ACP guidelines is exemplified in the title
that refers to treatment in men and women with osteoporosis. Two
definitions of osteoporosis are provided; one, the WHO definition
based on the T-score for bone mineral density and the other an
individual with a prior fragility fracture. Except for teriparatide
and raloxifene (not recommended as first-line treatments), the
ACP guideline considers that the evidence is insufficient to recom-
mend treatment of patients with prior fracture with other interven-
tions. Thus, the gateway to treatment is a BMD diagnosis of osteo-
porosis though no recommendations are provided on who should
have a BMD measurement in the first place. The guideline fails in
the sense that there is no indication to whom they apply and no
reference to any relevant literature.
* J. A. Kanis
Centre for Metabolic Bone Diseases, University of Sheffield Medical
School, Beech Hill Road, Sheffield S10 2RX, UK
Mary McKillop Health Institute, Australian Catholic University,
MRC Lifecourse Epidemiology Unit, University of Southampton,
NIHR Musculoskeletal Biomedical Research Unit, University of
Oxford, Oxford, UK
Service of Bone Diseases, Faculty of Medicine, Geneva University
Hospitals, Geneva, Switzerland
Department of Public Health, Epidemiology and Health Economics,
University of Liège, Liège, Belgium
WHO Collaborating Centre for Public Health Aspects of
Musculoskeletal Health and Aging, Liège, Belgium
Osteoporosis International (2018) 29:1505–1510