What is the recommended treatment for a 73-year-old male with moderate fracture risk due to osteoporosis based on Bone Mineral Density (BMD)?

From the Guidelines

For a 73-year-old male with moderate fracture risk due to osteoporosis based on BMD, the recommended first-line treatment is typically an oral bisphosphonate such as alendronate (Fosamax) 70 mg once weekly. This recommendation is based on the latest evidence from the 2024 guideline for the management of osteoporosis in men, which suggests that oral bisphosphonates are first-line treatments for men at a high risk of fracture 1. Although the patient has a moderate fracture risk, the guideline recommends ensuring vitamin D and calcium repletion in all men above the age of 65 years, which is essential for treatment effectiveness 1.

The patient should take alendronate with a full glass of water on an empty stomach in the morning, remaining upright for at least 30 minutes afterward to prevent esophageal irritation. In addition to medication, the following are essential components of treatment:

• Calcium supplementation of 1000-1200 mg daily
• Vitamin D supplementation of 800-1000 IU daily
• Regular weight-bearing exercise for 30 minutes at least three times weekly
• Implementation of fall prevention strategies at home

Bisphosphonates work by inhibiting bone resorption by osteoclasts, effectively slowing bone loss and reducing fracture risk. Treatment effectiveness should be monitored with follow-up BMD testing every 1-2 years, and medication reassessment after 3-5 years to evaluate the need for continuation, drug holiday, or alternative therapy based on response and risk reassessment. It is also important to note that the 2023 living clinical guideline from the American College of Physicians suggests using bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis 1. However, the 2024 guideline provides more specific and up-to-date recommendations for the management of osteoporosis in men 1.

From the FDA Drug Label

Treatment of men with osteoporosis with alendronate sodium 10 mg/day for two years reduced urinary excretion of cross-linked N-telopeptides of type I collagen by approximately 60% and bone-specific alkaline phosphatase by approximately 40%. A one-year, double-blind, placebo-controlled, multicenter study of once weekly alendronate sodium 70 mg enrolled a total of 167 men between the ages of 38 and 91 (mean, 66) At one year, the mean increases relative to placebo in BMD in men receiving alendronate sodium 70 mg once weekly were significant at the following sites: lumbar spine, 2.8%; femoral neck, 1.9%; trochanter, 2.0%; and total body, 1. 2%.

The recommended dose of alendronate for a 73-year-old male with moderate fracture risk due to osteoporosis based on Bone Mineral Density (BMD) is 10 mg/day or 70 mg once weekly 2.

From the Research

Alendronate Dosing for Osteoporosis

• The recommended dose of alendronate for the treatment of osteoporosis in men is 70 mg once-weekly or 10 mg daily 3.
• A study comparing the efficacy and safety of once-weekly alendronate 70 mg, twice-weekly alendronate 35 mg, and daily alendronate 10 mg in postmenopausal women with osteoporosis found that all three dosing regimens were effective in increasing bone mineral density (BMD) and reducing biochemical markers of bone resorption and formation 3.
• Another study found that alendronate 70 mg once-weekly, in combination with vitamin D and calcium, increased lumbar spine BMD by 5.2% in HIV-infected patients with osteopenia or osteoporosis 4.

Considerations for Older Patients with Reduced Renal Function

• A retrospective cohort study found that alendronate use in older patients with reduced renal function (creatinine clearance <35 ml/min) was not associated with significant deterioration in renal function or increased incidence of osteoporotic fractures or acute kidney injury 5.
• However, the study noted that oral bisphosphonates are not recommended in patients with creatinine clearance <35 ml/min, although this is not supported by post hoc analyses of pivotal oral bisphosphonate studies 5.

Fracture Risk Assessment

• The FRAX tool estimates a 10-year probability of fracture based on multiple clinical risk factors and an optional BMD measurement obtained from the femoral neck 6.
• A study found that discordance between lumbar spine and femoral neck T-scores is common and can be a source of clinical confusion, and developed a simple procedure for adjusting FRAX probability based on the T-score difference between the two sites 6.
• The study found that the offset between the lumbar spine and femoral neck T-scores significantly affected fracture risk, and formulated a rule for adjusting FRAX estimates based on this offset 6.

Recommended Treatment for a 73-year-old Male with Moderate Fracture Risk

• Based on the available evidence, a 73-year-old male with moderate fracture risk due to osteoporosis may be treated with alendronate 70 mg once-weekly or 10 mg daily, in combination with vitamin D and calcium supplementation 3, 4.
• The patient's renal function should be monitored, and the dose of alendronate adjusted accordingly 5.
• The patient's fracture risk should be assessed using the FRAX tool, and the offset between the lumbar spine and femoral neck T-scores taken into account when interpreting the results 6.