The epidemiology and management of postmenopausal osteoporosis: a viewpoint from Brazil

Figures & data

Table 1 World Health Organization’s definition of osteoporosis based on bone mineral density

Classification	T-score
Normal	≥−1.0
Low bone mass (osteopenia)	Between −1.0 and −2.5
Osteoporosis	≤−2.5
Severe or established osteoporosis	≤−2.5 with one or more fractures

Note: Data from Kanis et al.¹⁹

Table 2 Drugs available to treat postmenopausal osteoporosis in Brazil

	Main effects
Bisphosphonates
Alendronate	Reduces the incidence of spinal and femoral fractures by approximately 50% over 3 years in patients with a history of prior vertebral fracture.^Citation38 Reduces the incidence of vertebral fracture by 44% in patients without a history of prior vertebral fracture.^Citation39
Risedronate	Reduces the risk of vertebral fractures by 41%–49% and nonvertebral fractures by 33%–39% in patients with previous fractures.^Citation40
Ibandronate	Reduces the incidence of vertebral fractures by approximately 50% over 3 years.^Citation41 Meta-analyses suggest that it is effective in reducing nonvertebral fractures.^Citation42
Pamidronate	Used intravenously has similar efficacy to alendronate in improvement in bone mineral density at lumbar spine.^Citation43 Effective in reducing bone loss after solid organ transplantation and in chronic users of corticoids.^Citation20 “Off-label” use for osteoporosis treatment.
Zoledronic acid	Reduces the risk of vertebral fractures by 70%, femoral neck fractures by 41%, and nonvertebral fractures by 25%.^Citation44
Hormone therapy with estrogen	Reduces the risk of clinical vertebral fractures and hip fractures by 34% and other osteoporotic fractures by 23%.^Citation45
Raloxifene	Reduces the risk of vertebral fractures in women with osteopenia or osteoporosis by 30%–50%.^Citation46^–^Citation49 Does not diminish the risk of nonvertebral fractures. Reduces the risk of invasive estrogen-dependent breast cancer in postmenopausal women with osteoporosis^Citation50,Citation51 and/or at high risk of breast cancer.^Citation52
Calcitonin	Reduces the risk of vertebral fractures by 33% in patients without previous fractures.^Citation53 Reduces the risk of new vertebral fractures by 36% in patients who already have a history of vertebral fracture.^Citation53 Does not reduce the risk of nonvertebral fractures.^Citation53
Teriparatide	Reduces the incidence of vertebral fractures by approximately 65% and of nonvertebral fractures by approximately 53%.^Citation54 Because there is a theoretical risk of osteosarcoma, the medication should be used for a maximum of 2 years.^Citation54
Denosumab	Patients with osteoporosis who received denosumab for 3 years experienced a 68% reduction in the risk of new vertebral fractures, a 20% reduction in nonvertebral fractures, and a 40% reduction in femoral neck fractures.^Citation55
Strontium ranelate	Reduces the risk of a new vertebral fracture by 49% after 1 year of treatment and by 41% after 3 years of treatment in women with a prior vertebral fracture.^Citation56 Reduces the risk of vertebral fractures in women without a history of previous fractures by 45%, and the risk of nonvertebral fractures by 16%.^Citation57

Table 3 Criteria for the initiation of medical treatment for postmenopausal osteoporosis

Low-impact fracture of the femur, hip, or vertebrae (clinical or morphometric) radiologically confirmed

T-score ≤−2.5 at femoral neck or spine

Low bone mass (T-score between −1.5 and −2.5 at the femoral neck or spine) in patients aged 70 years or more if they have suffered two or more falls in the last 6 months

Glucocorticoid treatment in a dose higher than 5 mg of prednisone per day (or equivalent dose of another corticosteroid) for a period of 3 months or more

Notes: Data from Ministério da Saúde.²⁰

Figure 1 Flow chart with the medications available free of charge through SUS.

Note: *Women with an intact uterus should make use of an estrogen and progesterone association.
Abbreviation: SUS, Sistema Único de Saúde.

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