What is the best treatment to prevent fragility fractures in patients with osteoporosis?

From the Guidelines

The best treatment to prevent fragility fractures in patients with osteoporosis typically involves bisphosphonates as first-line therapy, particularly alendronate (70mg once weekly) or risedronate (35mg once weekly), accompanied by calcium supplementation (1000-1200mg daily) and vitamin D (800-1000 IU daily) to support bone mineralization. This approach is supported by high-quality evidence from recent studies, including those published in the Annals of Internal Medicine 1 and the Annals of the Rheumatic Diseases 1. The use of bisphosphonates has been shown to reduce fracture risk by 40-70% by inhibiting bone resorption and allowing bone formation to outpace breakdown, thereby increasing bone mineral density. Weight-bearing exercise and balance training are essential complementary interventions to improve bone strength and reduce fall risk. For patients who cannot tolerate bisphosphonates or have very high fracture risk, alternatives include denosumab (60mg subcutaneously every 6 months) or anabolic agents like teriparatide or abaloparatide (daily subcutaneous injections for up to 2 years). Treatment duration typically involves 3-5 years of bisphosphonate therapy followed by reassessment, with possible drug holidays for those at moderate risk and continued treatment for high-risk patients. Fall prevention strategies, including home safety assessment, vision correction, and review of medications that may cause dizziness, are also crucial components of comprehensive fracture prevention, as highlighted in the 2019 EULAR points to consider for non-physician health professionals 1. Key considerations in the management of patients with osteoporosis include:

• Non-pharmacological interventions such as stopping smoking, limiting alcohol intake, and promoting a healthy lifestyle to support bone health
• Pharmacological treatment with bisphosphonates or other agents to reduce fracture risk
• Regular monitoring for tolerance and adherence to treatment
• Multicomponent interventions, including exercise, fall-prevention strategies, and education about bone health, to reduce fall risk and improve bone strength. Overall, a comprehensive approach to preventing fragility fractures in patients with osteoporosis requires careful consideration of both pharmacological and non-pharmacological interventions, as well as ongoing monitoring and adjustment of treatment as needed.

From the FDA Drug Label

In postmenopausal women with osteoporosis, teriparatide injection reduces the risk of vertebral and nonvertebral fractures. In postmenopausal women with osteoporosis, Prolia reduces the incidence of vertebral, nonvertebral, and hip fractures.

The best treatment to prevent fragility fractures in patients with osteoporosis is teriparatide (SQ) or denosumab (SQ), as both have been shown to reduce the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis 2 3.

• Teriparatide (SQ) is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture.
• Denosumab (SQ) 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.

From the Research

Treatment Options for Preventing Fragility Fractures

The best treatment to prevent fragility fractures in patients with osteoporosis involves a combination of non-pharmacologic and pharmacologic approaches.

• Non-pharmacologic treatment includes calcium and vitamin D supplementation, which has been shown to prevent osteoporosis in postmenopausal women when used together 4.
• Pharmacologic treatment options include:
  • Bisphosphonates, such as alendronate and risedronate, which prevent bone loss and reduce fractures in healthy and osteoporotic postmenopausal women, and in osteoporotic men 4, 5.
  • Selective estrogen receptor modulators (SERMs), such as raloxifene, which prevent bone loss in postmenopausal women and reduce the risk of further fractures 4.
  • Teriparatide, an anabolic agent that increases bone formation and is effective in the treatment of osteoporotic women and men 4, 5.
  • Denosumab, a humanized monoclonal antibody that has been shown to reduce the risk of fractures in patients with osteoporosis 6, 7.

Safety and Efficacy of Treatment Options

The safety profiles of these drugs are well defined, with data from extensive programs of pharmacovigilance to support their use 6.

• The most serious adverse events are either rare or predictable, and osteoporosis treatment is a favorable choice in patients at moderate-high risk of fracture 6.
• However, in patients at low risk, pharmacological prevention should involve consideration of the balance between the beneficial effects of treatment, the probability of adverse effects, and costs 6.

Current Practice and Future Directions

Current practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture vary, with some studies showing that no patients with fragility fractures received investigation or treatment for underlying osteoporosis 8.

• Future directions in the treatment of osteoporosis and fragility fractures include the development of new pharmacological options, such as mesenchymal stem cells, and a greater emphasis on preventing future fractures in patients who have already experienced a fragility fracture 7.