How can osteoporosis and fragility fractures be prevented?

Prevention of Osteoporosis and Fragility Fractures

Prevention of osteoporosis and fragility fractures requires a combination of pharmacological and non-pharmacological interventions, with bisphosphonates (particularly alendronate and risedronate) as first-line drug therapy, along with adequate calcium and vitamin D supplementation, exercise programs, and lifestyle modifications. 1

Risk Assessment and Screening

• Screen women aged 65 years or older with bone mineral density (BMD) testing 1
• Screen postmenopausal women younger than 65 years who are at increased risk 1
• Risk factors include:
  • Increasing age
  • Low body weight
  • Parental history of hip fracture
  • Current smoking
  • Excessive alcohol intake (≥3 drinks daily)
  • Previous fragility fracture
  • Rheumatoid arthritis
  • Prolonged glucocorticoid use 1

Non-Pharmacological Interventions

Calcium and Vitamin D

• Ensure adequate calcium intake of 1000-1200 mg/day (preferably from dietary sources) 1
• Supplement with vitamin D 800 IU/day 1
• Combined calcium and vitamin D supplementation is associated with a 12% reduction in fracture risk 2
• Higher calcium doses (≥1200 mg) and vitamin D doses (≥800 IU) show better treatment effects 2

Exercise and Fall Prevention

• Implement early post-fracture physical training and muscle strengthening 1
• Continue long-term balance training and multidimensional fall prevention 1
• Exercise programs show positive effects on BMD and muscle strength, and reduce fall frequency 1

Lifestyle Modifications

• Stop smoking 1, 3
• Limit alcohol intake 1, 3
• Maintain adequate body weight 1

Pharmacological Treatment

First-Line Therapy

• Alendronate and risedronate (oral bisphosphonates) are first-choice agents due to:
  • Well-established efficacy in reducing vertebral, non-vertebral, and hip fractures
  • Generally good tolerability
  • Low cost (generic forms available)
  • Extensive clinical experience 1

Alternative Medications

• For patients with oral intolerance, dementia, malabsorption, or poor compliance:
  • Zoledronic acid (intravenous bisphosphonate)
  • Denosumab (subcutaneous RANKL inhibitor) 1
• For very severe osteoporosis:
  • Teriparatide (anabolic agent) 1

Duration of Treatment

• Typically prescribed for 3-5 years, longer in patients who remain at high risk 1
• Systematic follow-up is essential due to poor long-term adherence 1

Special Considerations

Proper Administration of Bisphosphonates

• Take on an empty stomach with plain water
• Remain upright for at least 30 minutes after taking
• Wait at least 30 minutes before consuming food, beverages, or other medications 3

Monitoring

• Regular follow-up to assess treatment tolerance and adherence 1
• Patient education about disease burden, risk factors, and treatment duration 1

Common Pitfalls and Caveats

1. Calcium supplementation alone has no demonstrated effect on fracture reduction and may cause gastrointestinal side effects 1
2. High pulse dosages of vitamin D may increase fall risk 1
3. Poor medication adherence significantly reduces effectiveness - systematic follow-up is crucial 1
4. Excessive calcium intake (>2000 mg/day) may potentially increase risk for cardiovascular events, urolithiasis, and possibly fractures 4
5. Delayed initiation of treatment after fragility fracture increases risk of subsequent fractures - early intervention is essential 1

By implementing this comprehensive approach to osteoporosis prevention and management, the risk of fragility fractures can be significantly reduced, improving morbidity, mortality, and quality of life outcomes for patients.