From the Guidelines
Treatment for osteoporosis should be initiated in individuals with a fragility fracture of the hip or spine, or those with multiple fragility fractures, regardless of bone mineral density (BMD) results, as well as in those with a T-score of -2.5 or lower at the spine, hip, or femoral neck, according to the most recent guidelines. When considering treatment, clinicians should 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 1.
Key Considerations for Treatment
- First-line medications include oral bisphosphonates, such as alendronate 70mg weekly, risedronate 35mg weekly, or 150mg monthly, which have been shown to reduce the risk of vertebral and nonvertebral fractures 1.
- Second-line options include denosumab (60mg subcutaneously every 6 months) and zoledronic acid (5mg IV yearly), which have also demonstrated efficacy in reducing fracture risk 1.
- For high-risk patients, anabolic agents like teriparatide or romosozumab may be considered, although their use should be carefully weighed against potential risks and benefits.
- Treatment duration typically ranges from 3-5 years for bisphosphonates, with reassessment after this period to determine the need for continued treatment, as increasing the duration of bisphosphonate therapy to longer than 3 to 5 years reduces risk for new vertebral fractures but not risk for other fractures and increases the risk for long-term harms 1.
Lifestyle Modifications and Supplement Use
- Adequate calcium and vitamin D intake is crucial for fracture prevention in all adults with low bone mass or osteoporosis, with recommended calcium intake of 1200mg daily and vitamin D supplementation of 800-2000 IU daily 1.
- Clinicians should encourage adherence to recommended treatments and healthy lifestyle modifications, including exercise and counseling for evaluation and prevention of falls, to reduce the risk of fractures and improve overall bone health 1.
From the Research
Treatment Guidelines for Osteoporosis
According to Osteoporosis Canada guidelines, the management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool 2. The guidelines recommend that treatment should be individualized and based on the patient's absolute fracture risk, rather than just their bone mineral density (BMD) category 3.
Factors to Consider for Treatment
The following factors should be considered when deciding whether to treat osteoporosis:
- Fracture history
- 10-year major osteoporotic fracture (MOF) risk
- BMD T-score
- Age
- Glucocorticoid use
- Fragility fracture history
Treatment Recommendations
The Osteoporosis Canada 2023 clinical practice guidelines provide the following treatment recommendations:
- Individuals with a high risk of fracture (>20% 10-year fracture risk) should be recommended for treatment 3
- Individuals with a moderate risk of fracture (10-20% 10-year fracture risk) may be suggested for treatment, depending on their individual circumstances 3
- Individuals with a low risk of fracture (<10% 10-year fracture risk) may not require treatment 3
Comparison to Previous Guidelines
The 2023 guidelines differ from the 2010 guidelines in that they eliminate risk categories and provide more clear treatment guidance for individuals who fell within the moderate-risk category 4. The 2023 guidelines also increase the number of individuals recommended or suggested for anti-osteoporosis pharmacotherapy.
Key Elements of Management
The key elements of osteoporosis management include:
- Exercise
- Nutrition
- Pharmacotherapy
- Monitoring of BMD and fracture risk
These elements should be individualized and based on the patient's specific needs and circumstances 2.