Treatment of postmenopausal osteoporosis: a literature-based algorithm for use in the public health care system

Abstract

Bisphosphonates are considered first-line agents in the treatment of postmenopausal osteo-porosis based on extensive experience of use, safety, and proven efficacy in reducingvertebral, non-vertebral and femur fractures. However, post-marketing reports based onthe treatment of millions of patients/year over lengthy periods of time have revealed theoccurrence of initially unexpected adverse effects, such as osteonecrosis of the jaw andatypical femoral fracture, leading to the restriction of treatment duration with bisphospho-nates by global regulatory agencies. However, despite the association between these effectsand bisphosphonates, this risk should be analyzed in the context of osteoporosis treatment,alongside the benefit of preventing osteoporotic fractures and their clinical consequences.Therefore, we consider it plausible to discuss the restriction to the use of bisphosphonates,possible indications for prolonged treatment and alternative therapies following the suspen-sion of this drug class for patients with persistent high risk of fracture after initial treatment,especially considering the problems of public health funding in Brazil and the shortage ofdrugs provided by the government. Thus, to standardize the treatment of osteoporosis in thepublic health care system, we aim to develop a proposal for a scientifically-based pharmaco-logical treatment for postmenopausal osteoporosis, establishing criteria for indication andallowing the rational use of each pharmacological agent. We discuss the duration of the ini-tial bisphosphonate treatment, the therapeutic options for refractory patients and potentialindications of other classes of drugs as first-choice treatment in the sphere of public health,in which assessing risk and cost effectiveness is a priority.