What is the initial treatment for a 66-year-old female with osteoporosis?

From the Guidelines

The initial treatment for a 66-year-old female with osteoporosis should include bisphosphonate therapy, such as alendronate (Fosamax) 70 mg orally once weekly, risedronate (Actonel) 35 mg weekly, or zoledronic acid (Reclast) 5 mg IV annually, as recommended by the American College of Physicians 1. This treatment approach is based on high-certainty evidence and has been shown to reduce the risk of fractures in postmenopausal women with osteoporosis. The treatment should be accompanied by:

• Calcium supplementation of 1000-1200 mg daily
• Vitamin D supplementation of 800-1000 IU daily
• Weight-bearing and resistance exercises
• Advice to avoid smoking and limit alcohol consumption. Bisphosphonates work by inhibiting osteoclast activity, thereby reducing bone resorption and increasing bone mineral density. They have been shown to significantly reduce fracture risk in postmenopausal women with osteoporosis 1. After 3-5 years of bisphosphonate therapy, the need for continued treatment should be reassessed based on fracture risk, as recommended by the American College of Physicians 1. Fall prevention strategies, including home safety assessment, vision checks, and review of medications that might increase fall risk, are also important aspects of comprehensive osteoporosis management 1. It is essential to note that bisphosphonates are associated with a higher risk for osteonecrosis of the jaw and atypical femoral fractures, but the benefits of bisphosphonates outweigh the harms compared with placebo 1. Denosumab can be used as a second-line treatment in postmenopausal females with primary osteoporosis who have contraindications to bisphosphonates, as recommended by the American College of Physicians 1. The decision to treat should be individualized and based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications, as recommended by the American College of Physicians 1.

From the FDA Drug Label

Alendronate reduces bone resorption with no direct effect on bone formation, although the latter process is ultimately reduced because bone resorption and formation are coupled during bone turnover Osteoporosis in Postmenopausal Women Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. Long-term treatment of osteoporosis with alendronate sodium 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption, deoxypyridinoline and cross-linked N-telopeptides of type I collagen, by approximately 50% and 70%, respectively, to reach levels similar to those seen in healthy premenopausal women

The initial treatment for a 66-year-old female with osteoporosis is alendronate sodium 10 mg/day or once weekly alendronate sodium 70 mg to reduce bone resorption and increase bone mass, as indicated by the reduction in urinary excretion of markers of bone resorption 2.

• Key benefits:
  • Reduces bone resorption
  • Increases bone mass
  • Decreases the risk of fracture
• Important considerations:
  • Treatment should be continuous to suppress osteoclasts on newly formed resorption surfaces
  • Alendronate must be taken as directed to ensure proper absorption and effectiveness

From the Research

Initial Treatment for Osteoporosis

The initial treatment for a 66-year-old female with osteoporosis typically involves the use of bisphosphonates, which are considered the cornerstone of treatment for postmenopausal osteoporosis 3.

Bisphosphonate Therapy

• Alendronate and risedronate are commonly used oral bisphosphonates, given once weekly, which have been shown to reduce significantly the risk of vertebral and nonvertebral fractures 3.
• Alendronate is available in a 70 mg formulation to be taken once a week, providing continuous inhibition of bone resorption 4.
• The effects of bisphosphonates appear early, within 6-12 months, and are sustained 3.

Alternative Treatment Options

• Denosumab, a humanized monoclonal antibody, is an alternative treatment option that has been shown to increase bone mineral density and decrease vertebral, nonvertebral, and hip fractures 5.
• Denosumab is administered by subcutaneous injection every six months, which may improve adherence to treatment 5.

Treatment Considerations for Older Adults

• There is limited data on the pharmacological management of osteoporosis in older adults (>75 years), despite the high risk of fractures in this population 6.
• Risedronate, Alendronate, and Strontium Ranelate have been shown to reduce vertebral fracture risk in older adults, while Strontium Ranelate has also been shown to reduce non-vertebral and hip fracture risk 6.