From the Guidelines
The recommended management for osteoporosis includes both pharmacological and non-pharmacological approaches, with a focus on reducing morbidity, mortality, and improving quality of life, as outlined in the most recent guidelines from 2025 1.
Initial Workup
Initial workup should include a comprehensive history and physical examination, bone mineral density (BMD) testing via dual-energy X-ray absorptiometry (DXA), and laboratory tests to rule out secondary causes.
- DXA BMD measurement should be performed at the lumbar spine, total hip, femoral neck and, if indicated one-third radius, as recommended by the European Journal of Nuclear Medicine and Molecular Imaging 1.
- Consider DXA in all women at the age ≥ 65 years, men age > 70 years, and women and men age ≥ 50 years with risk factors for osteoporosis, as suggested by the IWG consensus 1.
Pharmacological Treatment
First-line pharmacological treatment typically involves bisphosphonates such as alendronate (70mg weekly), risedronate (35mg weekly or 150mg monthly), or zoledronic acid (5mg IV annually), which work by inhibiting osteoclast activity, thereby reducing bone resorption.
- For patients who cannot tolerate bisphosphonates or have severe disease, alternatives include denosumab (60mg subcutaneously every 6 months), which inhibits RANK ligand to decrease osteoclast formation, or anabolic agents like teriparatide or abaloparatide (both 20mcg subcutaneously daily for up to 2 years), which stimulate bone formation, as recommended by the American College of Physicians 1 and the Nature Reviews Rheumatology 1.
- All patients should receive calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation, as suggested by the Annals of Internal Medicine 1.
Non-Pharmacological Management
Non-pharmacological management includes:
- Weight-bearing and resistance exercises
- Smoking cessation
- Limiting alcohol intake
- Fall prevention strategies
- Physical exercise and a balanced diet should be recommended to all men with osteoporosis, as recommended by the Nature Reviews Rheumatology 1.
Treatment Duration and Monitoring
Treatment duration varies by medication and risk profile, with bisphosphonates typically requiring reassessment after 3-5 years for possible drug holiday, while denosumab requires continuous therapy to prevent rebound bone loss.
- Regular monitoring with BMD testing is recommended every 1-2 years initially, then every 2-3 years once stabilized, as suggested by the European Journal of Nuclear Medicine and Molecular Imaging 1.
- The frequency of BMD testing in clinical practice may be influenced by the patient’s clinical state, national clinical guidelines, cost and reimbursement, with suggested intervals between BMD testing typically 1–5 years after starting or changing therapy, as recommended by the European Journal of Nuclear Medicine and Molecular Imaging 1.
From the FDA Drug Label
Instruct patients to take supplemental calcium and vitamin D, if daily dietary intake is inadequate. Weight-bearing exercise should be considered along with the modification of certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors exist. For osteoporosis treatment or prevention, patients should be instructed to take supplemental calcium and/or vitamin D if intake is inadequate. Patients at increased risk for vitamin D insufficiency (e.g., over the age of 70 years, nursing home bound, chronically ill, or with gastrointestinal malabsorption syndromes) should be instructed to take additional vitamin D if needed. Weight-bearing exercises should be considered along with the modification of certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors exist.
The recommended management and workup for patients with osteoporosis includes:
- Supplementation: taking supplemental calcium and vitamin D if daily dietary intake is inadequate
- Exercise: weight-bearing exercises
- Lifestyle modifications: modification of certain behavioral factors, such as:
From the Research
Osteoporosis Management
- The management of osteoporosis involves a combination of lifestyle modifications and pharmacological interventions 4, 5, 6, 7, 8.
- Lifestyle modifications include adequate daily intake of calcium and vitamin D, regular weight-bearing exercise, and avoidance of smoking and excessive alcohol intake 4, 5, 6, 7.
- Pharmacological interventions include oral bisphosphonates, calcitonin, estrogens, teriparatide, and raloxifene 4, 5, 6, 7, 8.
Workup for Osteoporosis
- The workup for osteoporosis involves risk-factor assessment and measurement of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DEXA) 4, 5, 6.
- The diagnosis of osteoporosis can be confirmed by DEXA if the BMD T-score values at the lumbar spine, femoral neck, or total hip are at or below -2.5 6.
- Vertebral fractures are generally taken as diagnostic of osteoporosis, even if spine BMD values are not in the osteoporotic range 6.
Treatment Options
- Oral bisphosphonates are the first-line treatment for osteoporosis, with alendronate and risedronate being preferred due to their efficacy in reducing spine and nonspine fractures 4, 8.
- Teriparatide therapy should be considered for high-risk patients, such as those with very low bone density or with fractures 4.
- Other treatment options include calcitonin, estrogens, and raloxifene, which can be used in patients who are intolerant or contraindicated to bisphosphonates 4, 5, 7.
- Strontium ranelate and denosumab are also available as treatment options, although their use may be limited by side effects and cost 8.
Monitoring and Follow-up
- Ongoing monitoring and strategic interventions are necessary to prevent fractures in patients with osteoporosis 5.
- Regular follow-up appointments with a healthcare provider are essential to assess response to treatment and adjust the treatment plan as needed 5.
- Patients should be educated about their treatment and the importance of adherence to their medication regimen to ensure optimal outcomes 8.