From the Guidelines
The most effective treatment for osteoporosis is bisphosphonates, which should be used as the first-line medication to reduce the risk of fractures. This recommendation is based on the latest evidence from the American College of Physicians, which suggests that bisphosphonates have the most favorable balance of benefits, harms, patient values, and preferences, and cost among the examined drugs 1. The use of bisphosphonates, such as alendronate (70mg weekly), risedronate (35mg weekly), ibandronate (150mg monthly), and zoledronic acid (5mg IV yearly), is recommended to reduce the risk of fractures in adults with primary osteoporosis.
Key Considerations
- Bisphosphonates should be prescribed for 3-5 years before reassessing, unless the patient has a strong indication for treatment continuation 1.
- Generic medications should be prescribed instead of brand-name medications whenever possible 1.
- Adequate calcium and vitamin D intake is essential for all patients, with recommended daily intake of 1000-1200mg of calcium and 800-1000 IU of vitamin D.
- Lifestyle modifications, including regular weight-bearing and resistance exercises, smoking cessation, limiting alcohol consumption, and fall prevention strategies, are crucial for maximizing bone health benefits.
Alternative Treatments
- Denosumab, a RANK ligand inhibitor, may be used as a second-line treatment for postmenopausal women with primary osteoporosis who have contraindications to bisphosphonates 1.
- Romosozumab or teriparatide may be used for women with primary osteoporosis at very high risk of fracture, although the evidence for these treatments is less certain 1.
Patient Assessment
- 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.
From the FDA Drug Label
For the treatment of postmenopausal women with osteoporosis at high risk for fracture (defined herein as having a history of osteoporotic fracture or multiple risk factors for fracture) or who have failed or are intolerant to other available osteoporosis therapy In postmenopausal women with osteoporosis, teriparatide injection reduces the risk of vertebral and nonvertebral fractures. To increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy For the treatment of men and women with osteoporosis associated with sustained systemic glucocorticoid therapy (daily dosage equivalent to 5 mg or greater of prednisone) at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy.
The recommended treatment for osteoporosis includes teriparatide injection for:
- Postmenopausal women with osteoporosis at high risk for fracture
- Men with primary or hypogonadal osteoporosis at high risk for fracture
- Men and women with osteoporosis associated with sustained systemic glucocorticoid therapy at high risk for fracture Key points:
- High risk for fracture is defined as having a history of osteoporotic fracture or multiple risk factors for fracture
- Teriparatide injection is used for patients who have failed or are intolerant to other available osteoporosis therapy 2
From the Research
Osteoporosis Treatment Options
The recommended treatment for osteoporosis includes a combination of calcium and vitamin D, as well as various medications such as bisphosphonates, estrogens, and raloxifene 3, 4.
- Bisphosphonates: Alendronate, risedronate, and zoledronate are examples of bisphosphonates that prevent bone loss and reduce fractures in postmenopausal women and men with osteoporosis 3, 5, 6.
- Estrogens and Raloxifene: Estrogens and raloxifene can prevent bone loss in postmenopausal women and reduce the risk of fractures 3, 4.
- Calcitonin: Calcitonin can increase bone mineral density and reduce the risk of new fractures in osteoporotic women 3.
- Teriparatide: Teriparatide increases bone formation and is effective in the treatment of osteoporotic women and men 3.
Treatment Guidelines
Treatment guidelines recommend measuring bone mineral density (BMD) in all postmenopausal women age 65 years and older, and in all postmenopausal women under 65 years with one or more risk factors 4.
- BMD Measurements: The diagnosis of at-risk postmenopausal women can best be accomplished by measuring BMD 4.
- Treatment Thresholds: Treatment guidelines direct physicians to treat postmenopausal women with T-scores lower than -2.0 SD regardless of their risk profile, and postmenopausal women with T-scores lower than -1.5 SD with one or more risk factors 4.
Intermittent Bisphosphonate Therapy
Intermittent bisphosphonate therapy has been developed to improve patient adherence and reduce adverse reactions 6, 7.