Societies Issue Joint Guidance for Osteoporosis Management During the COVID-19 Pandemic

In a joint statement,¹ a coalition of experts representing the American Society for Bone and Mineral Research, American Association of Clinical Endocrinologists, Endocrine Society, European Calcified Tissue Society, and National Osteoporosis Foundation issued guidance on the management of osteoporosis during the coronavirus disease 2019 (COVID-19) pandemic.

Understanding the need for social distancing and the potential for interruptions in osteoporosis treatment, the experts recommended that clinicians consider the following guidance:

1. Initiation of oral bisphosphonate therapy should not be delayed for patients at high risk for fracture. Appointments can be furnished via telemedicine.
2. Patients who are already receiving osteoporosis medications should continue their treatment when it is safe to do so. There is no evidence of a relationship between COVID-19 severity and osteoporosis therapy. However, caution should be used with estrogen and raloxifene therapy given the potential risk for hypercoagulable complications associated with COVID-19, as both treatments have been linked to a modest increase in thrombotic risk.
3. Bone mineral density examinations may need to be delayed.
4. Standard pretreatment laboratory measurements for intravenous (IV) bisphosphonates or denosumab can be skipped if results within the preceding year were normal. Laboratory testing is indicated in patients with fluctuating renal function and in those at heightened risk for hypocalcemia. 
5. Consider alternative methods of delivering parenteral osteoporosis medication. These include the use of off-site clinics, home delivery and administration from a healthcare professional, self-injection (which may be available in some locales), or drive-through administration.
6. For patients who are unable to receive their prescribed regimen of denosumab, consider a delay in treatment. It is strongly recommended that these patients are temporarily transitioned to oral bisphosphonates if the time from last injection exceeds 7 months (ie, a 1-month delay). Monthly dosing of ibandronate and weekly/monthly dosing of risedronate are recommended for patients with underlying gastrointestinal disorders. A low-dose regimen of oral bisphosphonates can be considered for patients with chronic renal insufficiency.
7. For patients who are unable to receive their prescribed regimen of teriparatide, abaloparatide, or romosozumab, consider a delay in treatment. If this delay exceeds 2 to 3 months, consider temporarily transitioning patients to oral bisphosphonates.
8. For patients who are unable to receive their prescribed regimen of IV bisphosphonates, treatment can be delayed. Even a delay of multiple months is unlikely to be harmful.

This joint guidance was based on expert opinion given the scarcity of evidence on which to base the recommendations.

“The scale of the COVID-19 pandemic is unprecedented. There is a paucity of data to provide clear guidance for healthcare professionals on how to adjust treatment for these patients to oral bisphosphonates,” said Suzanne Jan De Beur, MD, incoming president for the American Society for Bone and Mineral Research and member of the Endocrine Society, in a press release.² “These recommendations and the supporting evidence provide a roadmap to clinicians and their patients.”

References

1. Joint guidance on osteoporosis management from the American Society for Bone and Mineral Research (ASBMR), American Association of Clinical Endocrinologists (AACE), Endocrine Society, European Calcified Tissue Society (ECTS) and National Osteoporosis Foundation (NOF). Published May 7, 2020. Accessed May 8, 2020. https://www.endocrine.org/-/media/endocrine/files/membership/joint-statement-on-covid19-and-osteoporosis-final.pdf

2. Coalition of bone health experts issue joint guidance on managing osteoporosis in the COVID-19 era. News release. Endocrine Society; May 7, 2020.