From the Guidelines
Treatment of osteoporosis to prevent fragility fractures and reduce arthroplasty risks should prioritize pharmacological interventions, with first-line medications including bisphosphonates such as alendronate, risedronate, or zoledronic acid, as recommended by the most recent guidelines 1. The goal of treatment is to improve bone strength and reduce fracture risk during daily activities and following joint replacement surgery. Key aspects of osteoporosis treatment include:
- Pharmacological interventions:
- Bisphosphonates (alendronate, risedronate, zoledronic acid) as first-line treatment
- Denosumab, teriparatide, or abaloparatide for high-risk patients or those who cannot tolerate bisphosphonates
- Non-pharmacological interventions:
- Weight-bearing and resistance exercises
- Fall prevention strategies
- Smoking cessation
- Limiting alcohol consumption
- Adjunctive therapy:
- Calcium supplementation (1000-1200mg daily)
- Vitamin D (800-1000 IU daily) For patients undergoing arthroplasty, optimizing bone health preoperatively with appropriate osteoporosis treatment for at least 3-6 months can improve implant fixation and reduce periprosthetic fracture risk, as supported by recent guidelines 1. Treatment duration varies by medication but typically continues for 3-5 years before reassessing fracture risk, with some patients requiring longer therapy, as noted in the American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1. These interventions work by either decreasing osteoclast activity (bone breakdown) or increasing osteoblast function (bone formation), ultimately improving bone strength and reducing fracture risk, in line with the recommendations from the American College of Physicians guideline on the treatment of low bone density or osteoporosis to prevent fractures in men and women 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Teriparatide injection is indicated: 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.
14 CLINICAL STUDIES 14. 1 Treatment of Osteoporosis in Postmenopausal Women The fracture efficacy of risedronate sodium 5 mg daily in the treatment of postmenopausal osteoporosis was demonstrated in 2 large, randomized, placebo-controlled, double-blind studies that enrolled a total of almost 4,000 postmenopausal women under similar protocols
The treatment protocols for osteoporosis to prevent fragility fractures and decrease risks associated with arthroplasty include:
- Teriparatide injection for postmenopausal women with osteoporosis at high risk for fracture, which reduces the risk of vertebral and nonvertebral fractures 2.
- Risedronate sodium 5 mg daily for the treatment of postmenopausal osteoporosis, which significantly reduced the incidence of new and worsening vertebral fractures and of new vertebral fractures, as well as nonvertebral osteoporosis-related fractures 3. Key points:
- These treatments are indicated for patients with high risk of fracture or who have failed or are intolerant to other available osteoporosis therapy.
- The goal of these treatments is to reduce the risk of vertebral and nonvertebral fractures, which can decrease the risks associated with arthroplasty.
From the Research
Treatment Protocols for Osteoporosis
To prevent fragility fractures and decrease risks associated with arthroplasty, several treatment protocols for osteoporosis have been established. The primary goal of these treatments is to increase bone mineral density (BMD) and reduce the risk of fractures.
Medications for Osteoporosis
- Antiresorptive drugs, such as bisphosphonates and the RANKL inhibitor denosumab, are currently the most widely used osteoporosis medications 4.
- These drugs increase BMD and reduce the risk of vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis.
- Anabolic therapy with teriparatide has been demonstrated to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 4.
- Treatment with the sclerostin antibody romosozumab increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis 4.
Combination Therapies
- Combination therapies, such as hormone replacement therapy (HRT) with bisphosphonates, calcitonin, or androgens, may provide additional beneficial effects over single-drug therapy in patients with high bone turnover and/or severe osteoporosis 5.
- The combination of HRT and bisphosphonate has been shown to increase lumbar spine BMD by 10.9% and femoral BMD by 7.3% over 4 years, compared with 6.8 and 4.0% with HRT alone, and 6.8 and 1.2% with bisphosphonate alone 5.
Treatment Decisions
- Treatment decisions should be made based on the relative benefit-risk profile in different patient populations 6.
- Bisphosphonates are often considered first-line therapy for osteoporosis and have the largest base of clinical trial data showing efficacy for global fracture risk reduction 6.
- Emerging options, such as denosumab, may hold promise for providing protection from bone loss and for fracture risk reduction 6.
Efficacy of Therapies
- Teriparatide, denosumab, alendronate, and risedronate are effective in reducing the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis 7.
- Denosumab, alendronate, and risedronate can reduce the risk of hip fracture, and risedronate can also reduce the risk of upper-arm fracture 7.