What are the recommendations for patients with osteoporosis?

From the Guidelines

For patients with osteoporosis, I strongly recommend a comprehensive approach including both medication and lifestyle modifications, prioritizing bisphosphonates such as alendronate (70mg once weekly), risedronate (35mg once weekly), or zoledronic acid (5mg IV annually) as first-line treatments, as supported by the most recent and highest quality study 1.

Medication Therapy

The medication regimen should be tailored to the individual patient's needs, with consideration of their fracture risk profile, benefits, harms, and costs of medications.

• Bisphosphonates, such as alendronate, risedronate, or zoledronic acid, are recommended as first-line treatments for patients with osteoporosis, due to their efficacy in reducing the risk of hip and vertebral fractures 1.
• Denosumab or teriparatide may be considered as second-line treatments for patients at high risk of fracture or those who have failed other treatments 1.
• Selective estrogen receptor modulators, such as raloxifene, may be appropriate for postmenopausal women, but their use should be carefully considered due to potential cardiovascular risks 1.

Lifestyle Modifications

Lifestyle modifications are essential adjuncts to medication therapy, and should include:

• Weight-bearing exercises for 30 minutes most days of the week and resistance training 2-3 times weekly to strengthen bones and improve balance 1.
• Fall prevention strategies, including home safety assessments, proper footwear, and vision correction 1.
• Smoking cessation and limiting alcohol consumption to no more than 2 drinks daily 1.
• Adequate calcium and vitamin D intake, with supplementation of 1000-1200mg daily and 800-1000 IU daily, respectively, as necessary 1.

Monitoring and Treatment Duration

• Bone density monitoring during the 5-year pharmacologic treatment period is not recommended, unless there are significant changes in the patient's clinical status or treatment regimen 1.
• The decision to continue or stop bisphosphonate treatment after 5 years should be based on individual patient factors, including fracture risk profile and potential long-term harms 1.

From the FDA Drug Label

Instruct patients to take supplemental calcium and vitamin D, if daily dietary intake is inadequate. Weight-bearing exercise should be considered along with the modification of certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors exist. Patients should be informed regarding the roles of supplemental calcium and/or vitamin D.

The recommendations for patients with osteoporosis include:

• Taking supplemental calcium and vitamin D if daily dietary intake is inadequate 2
• Engaging in weight-bearing exercise 2
• Modifying certain behavioral factors, such as:
  • Cigarette smoking 2
  • Excessive alcohol consumption 2

From the Research

Recommendations for Patients with Osteoporosis

• The primary treatment for osteoporosis is bisphosphonates, which have been shown to increase bone density, reduce bone turnover rate, and reduce the risk of fractures 3, 4, 5.
• Alendronate, a type of bisphosphonate, is available in a 70 mg formulation to be taken once a week, which has been shown to be therapeutically equivalent to the daily regimen 3.
• Risedronate, another type of bisphosphonate, has been shown to reduce vertebral fracture risk by 62% and clinical fracture risk by 69% in the first year of treatment, and is considered a first-line treatment for postmenopausal women with osteoporosis 6.
• The treatment duration for bisphosphonates is typically 3-5 years, after which a treatment holiday may be considered, depending on the individual's risk factors and response to treatment 4, 7.
• For patients at high risk of fracture, continuation of treatment for up to 10 years (oral) or 6 years (intravenous) may be considered, with periodic evaluation 7.
• A drug holiday of 2-3 years may be considered for patients not at high fracture risk after 3-5 years of treatment 7.

Specific Treatment Options

• Alendronate: 70 mg once a week, or 10 mg daily 3.
• Risedronate: 35 mg once a week, or 5 mg daily 6.
• Other bisphosphonates, such as ibandronate and zoledronate, may also be considered, depending on the individual's needs and response to treatment 4, 5, 7.

Monitoring and Follow-up

• Regular monitoring of bone density and fracture risk is recommended to assess the effectiveness of treatment and adjust the treatment plan as needed 4, 7.
• Patients should be evaluated for their individual risk factors, such as age, sex, and medical history, to determine the best course of treatment 7.