At what age is osteoporosis medication typically started?

When to Start Osteoporosis Medication

Osteoporosis medication should be started in women aged 65 years or older with diagnosed osteoporosis (T-score ≤-2.5) or in postmenopausal women younger than 65 years who are at high risk of fracture. 1

Criteria for Starting Medication

Women

1. Age 65 and older:

   • All women with T-score ≤-2.5 (osteoporosis) 1
   • Consider treatment in women with T-score between -1.0 and -2.5 (osteopenia) if:
     • 10-year risk of major osteoporotic fracture ≥20% or
     • 10-year risk of hip fracture ≥3% 1

2. Postmenopausal women under 65:

   • With T-score ≤-2.5 1
   • With history of fragility fracture 1
   • With high fracture risk factors:
     • Weight less than 127 lb (58 kg)
     • Medications or diseases causing bone loss
     • Parental history of hip fracture 1

Men

• Men of any age with clinically recognized osteoporosis (T-score ≤-2.5) 1
• Men with history of fragility fractures 1

Risk Assessment Approach

1. Screening recommendations:

   • DEXA scan for all women 65 years and older 1
   • DEXA scan for postmenopausal women <65 years with risk factors 1
   • Risk assessment tools (FRAX) to guide treatment decisions in those with osteopenia 1

2. High-risk indicators requiring earlier treatment:

   • Previous fragility fracture (especially vertebral or hip)
   • Multiple risk factors (low body weight, smoking, excessive alcohol, glucocorticoid use)
   • T-score significantly below -2.5
   • Rapid bone loss 1, 2

Medication Selection Algorithm

1. First-line therapy:

   • Bisphosphonates (alendronate, risedronate, zoledronic acid) for both men and women 1

2. Second-line therapy (if contraindications or adverse effects to bisphosphonates):

   • Denosumab 1

3. For very high-risk patients (recent vertebral fractures, hip fracture with T-score ≤-2.5):

   • Consider anabolic agents (romosozumab or teriparatide) followed by bisphosphonates 1, 2

Important Clinical Considerations

• Treatment duration is typically 5 years for bisphosphonates, with reassessment after this period 1
• Calcium (1000-1200 mg) and vitamin D (600-800 IU) supplementation should accompany pharmacologic treatment 1, 2
• Lifestyle modifications (weight-bearing exercise, smoking cessation, limiting alcohol) should be implemented alongside medication 1

Common Pitfalls to Avoid

1. Delayed treatment: Many high-risk patients, especially men, do not receive timely treatment despite meeting criteria 1
2. Inadequate monitoring: Avoid unnecessary BMD monitoring during the initial 5-year treatment period 1
3. Medication non-adherence: Poor adherence significantly reduces fracture prevention benefits; address side effects and emphasize importance of compliance 1
4. Overlooking secondary causes: Ensure evaluation for secondary causes of osteoporosis before initiating treatment 2
5. Discontinuing treatment without transition plan: Especially with denosumab, which can lead to rebound vertebral fractures if stopped abruptly 3

By following these evidence-based guidelines, clinicians can appropriately time the initiation of osteoporosis medication to effectively reduce fracture risk and associated morbidity and mortality.