From the Guidelines
Bisphosphonate therapy for osteoporosis prevention should be considered in patients with a T-score of -1.9 and additional risk factors, such as a 10-year probability of hip fracture of 3.2% or other high-risk conditions, as supported by the most recent guidelines from the American College of Physicians 1 and the American College of Rheumatology 1.
Key Considerations for Initiating Medication Therapy
- A history of fragility fractures, especially hip or vertebral fractures, significantly increases future fracture risk
- Advanced age (over 65 for women, over 70 for men) warrants consideration for treatment
- Family history of osteoporosis, low body weight (BMI less than 20), smoking, excessive alcohol consumption, and long-term use of medications like glucocorticoids (prednisone ≥5mg daily for ≥3 months) are important criteria
- Medical conditions that increase fracture risk, such as rheumatoid arthritis, type 1 diabetes, early menopause, malabsorption disorders, and hyperparathyroidism, should also factor into treatment decisions
- The FRAX tool can guide treatment when the score indicates a 10-year risk of major osteoporotic fracture ≥20% or hip fracture ≥3%, as recommended by the American College of Physicians 1 and other guidelines 1
Recommended Treatment Strategy
- Bisphosphonates, such as alendronate, risedronate, or zoledronic acid, are first-line treatments for osteoporosis prevention
- Denosumab, a monoclonal antibody against RANKL, is also an effective option for reducing fracture risk
- Treatment should be individualized based on patient preferences, potential adverse effects, quality of life considerations, adherence, safety, cost, and availability, as suggested by the American Society of Clinical Oncology 1
Important Considerations for Patient Care
- Regular monitoring of bone mineral density and fracture risk is essential for adjusting treatment plans
- Patient education and shared decision-making can improve adherence to therapy and overall outcomes
- A comprehensive approach to osteoporosis management, including lifestyle modifications and pharmacologic therapy, can help reduce fracture risk and improve quality of life, as emphasized by the European League Against Rheumatism and the European Federation of National Associations of Orthopaedic and Traumatology 1
From the Research
Additional Criteria for Initiating Medication Therapy
Besides a T-score of -1.9, the following criteria may support the initiation of medication therapy for the prevention of osteoporosis:
- Being treated for rheumatoid arthritis 2
- Having a history of smoking, such as smoking 2 packs of cigarettes per day for the past 20 years 2
- Having a family history of hip fracture, such as a parent who experienced a hip fracture at age 60 2
- Having a high 10-year probability of hip fracture, such as 3.2% 3
Risk Factors for Osteoporosis
The following are risk factors for osteoporosis that may support the initiation of medication therapy:
- Family history of osteoporosis or hip fracture 4
- Personal history of fracture 4
- Low bone mineral density (BMD) 4
- High risk of falls 5
- Presence of other medical conditions, such as rheumatoid arthritis 2
Medication Options
The following medications may be considered for the prevention of osteoporosis: