What are the treatment options for a 63-year-old female with osteoporosis and a 10-year major fracture risk of 14%?

From the Guidelines

For a 63-year-old female with a 14% 10-year risk of major fracture, I recommend starting bisphosphonate therapy, specifically alendronate 70mg orally once weekly, as first-line treatment for osteoporosis. This recommendation is based on the most recent and highest quality study, which suggests that bisphosphonates have the most favorable balance among benefits, harms, patient values and preferences, and cost among the examined drugs 1. Before initiating medication, ensure adequate calcium intake of 1000-1200mg daily and vitamin D supplementation of 800-1000 IU daily. The patient should take the alendronate tablet with a full glass of water first thing in the morning, remain upright for at least 30 minutes afterward, and avoid other food or medications during this time to maximize absorption and minimize esophageal irritation.

Treatment duration should initially be 3-5 years, with periodic reassessment of fracture risk. Bisphosphonates work by inhibiting osteoclast activity, thereby reducing bone resorption and increasing bone mineral density. This recommendation is appropriate given the patient's age and moderate fracture risk, which exceeds the typical treatment threshold of 10% for 10-year major osteoporotic fracture risk. Alternative medications to consider if bisphosphonates are contraindicated include denosumab (Prolia) 60mg subcutaneously every 6 months or raloxifene 60mg daily, as suggested by previous studies 1.

Additionally, recommend weight-bearing and resistance exercises 2-3 times weekly to complement pharmacological therapy, as these activities help maintain bone strength and reduce fall risk. It is also important to assess baseline risk for fracture based on individualized assessment of bone density, history of fractures, response to prior treatments for osteoporosis, and multiple risk factors for fractures in postmenopausal females with primary osteoporosis, as recommended by recent clinical guidelines 1.

Some key points to consider when treating this patient include:

• Ensuring adequate calcium and vitamin D intake
• Monitoring for potential side effects of bisphosphonate therapy, such as osteonecrosis of the jaw and atypical femoral fractures
• Regularly reassessing fracture risk and adjusting treatment as needed
• Encouraging a healthy lifestyle, including exercise and fall prevention strategies
• Considering alternative medications if bisphosphonates are contraindicated or not tolerated.

From the FDA Drug Label

1. 1 Treatment of Postmenopausal Women with Osteoporosis at High Risk for Fracture Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy

For a 63-year-old female with a 14% 10-year risk of major fracture, denosumab (Prolia) may be considered as a treatment option for osteoporosis, as it is indicated for postmenopausal women with osteoporosis at high risk for fracture.

• The patient's 10-year risk of major fracture is relatively high, which may classify her as being at high risk for fracture.
• However, the decision to initiate denosumab should be based on a comprehensive evaluation of the patient's overall health, medical history, and other risk factors for fracture.
• It is essential to consult with a healthcare provider to determine the best course of treatment for this patient 2.

From the Research

Osteoporosis Treatment Options

For a 63-year-old female with a 14% 10-year risk of major fracture, several treatment options are available.

• Denosumab has been shown to reduce new vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis 3.
• A network meta-analysis found that denosumab, along with other medications such as romosozumab, alendronate, and zoledronate, significantly reduced the risk of hip, vertebral, and nonvertebral fractures in postmenopausal women 4.
• Another study found that denosumab was superior to risedronate in increasing lumbar spine and total hip bone mineral density (BMD) in patients with glucocorticoid-induced osteoporosis 5.

Considerations for Treatment

When considering treatment options, it's essential to weigh the benefits and risks of each medication.

• A study found that teriparatide, abaloparatide, denosumab, and romosozumab were associated with the highest relative risk reductions for fracture prevention, while ibandronate and selective estrogen receptor modulators had lower efficacy 4.
• The safety and efficacy of long-term bisphosphonate use are concerns, and expert consensus recommends reappraising ongoing use after about 5 years and considering "drug holidays" 6.

Fracture Risk Assessment

The FRAX algorithm can estimate the 10-year probability of hip and major osteoporotic fracture.

• A study using FRAX estimates found that among adults aged 50 and over, 19% had an elevated probability of hip fracture, and 8% had an elevated probability of major osteoporotic fracture 7.
• The study also found that fracture probabilities varied significantly by age, sex, and race and Hispanic origin 7.