What is the recommended treatment for osteoporosis?

Treatment of Osteoporosis

For patients with osteoporosis, oral bisphosphonates (alendronate, risedronate, or zoledronic acid) are the first-line pharmacologic treatment to reduce fracture risk, with denosumab as an alternative for those who cannot tolerate bisphosphonates. 1

Diagnosis and Risk Assessment

Before initiating treatment, proper assessment is essential:

• DEXA scan for all women ≥65 years and men ≥70 years
• Earlier screening for postmenopausal women <65 years with risk factors:
  • History of fragility fracture
  • Weight <127 lb (58 kg)
  • Medications causing bone loss
  • Diseases causing bone loss
  • Parental history of hip fracture 1
• Fracture risk assessment using FRAX tool for patients ≥40 years 1
• Vertebral fracture assessment (VFA) or spinal x-rays to identify asymptomatic vertebral fractures 1

Treatment Algorithm

1. Non-pharmacologic Interventions (for all patients)

• Calcium intake: 1,000-1,200 mg daily
• Vitamin D: 600-800 IU daily (800 IU for those >70 years)
• Weight-bearing and resistance exercises
• Smoking cessation
• Limit alcohol to 1-2 drinks per day
• Fall prevention strategies 1

2. Pharmacologic Treatment

For Postmenopausal Women with Osteoporosis (T-score ≤-2.5 or fragility fracture):

First-line therapy:

• Oral bisphosphonates (strong recommendation, high-quality evidence):
  • Alendronate: 70 mg weekly
  • Risedronate: 35 mg weekly or 150 mg monthly
  • Ibandronate: 150 mg monthly 1

If oral bisphosphonates are not appropriate:

1. IV bisphosphonates:

   • Zoledronic acid: 5 mg IV annually
   • Ibandronate: 3 mg IV every 3 months

2. Denosumab: 60 mg subcutaneously every 6 months (particularly for patients with renal impairment) 1

3. Teriparatide: 20 mcg subcutaneously daily (for very high-risk patients with severe osteoporosis or multiple fractures) 2

For Men with Osteoporosis:

• Bisphosphonates are first-line therapy (weak recommendation, low-quality evidence) 1
• Teriparatide for men at high fracture risk who have failed or are intolerant to bisphosphonates 2

For Glucocorticoid-Induced Osteoporosis:

• Oral bisphosphonates for adults at moderate-to-high risk of fracture taking prednisone ≥2.5 mg/day for >3 months 1
• For very high fracture risk: Consider anabolic agents (teriparatide) over antiresorptives 1

Duration of Therapy and Monitoring

• Initial treatment duration: 5 years for most patients (weak recommendation, low-quality evidence) 1
• Against bone density monitoring during the 5-year treatment period (weak recommendation, low-quality evidence) 1
• Reassessment after 5 years to determine whether to continue or switch therapy 1

Special Considerations

Treatment Adherence

Poor adherence is a major issue with oral bisphosphonates. Factors affecting adherence include:

• Side effects (especially GI symptoms)
• Complex administration requirements
• Absence of symptoms for underlying disease 1

Potential Adverse Effects

• Bisphosphonates: Mild GI symptoms, atypical femoral fractures, osteonecrosis of jaw (rare)
• Zoledronic acid: Hypocalcemia, influenza-like symptoms, arthralgia, headache
• Denosumab: Infection risk, rash/eczema, rebound bone loss after discontinuation
• Teriparatide: Hypercalcemia, hypercalciuria 1

Common Pitfalls to Avoid

1. Not checking vitamin D status before initiating therapy
2. Inadequate calcium/vitamin D supplementation during treatment
3. Poor patient education about proper administration of oral bisphosphonates
4. Failing to recognize secondary causes of osteoporosis
5. Not addressing modifiable risk factors like smoking or alcohol consumption
6. Discontinuing denosumab without sequential therapy (causes rapid bone loss)

By following this evidence-based approach to osteoporosis treatment, clinicians can significantly reduce fracture risk and improve patient outcomes.