What are the guidelines for treating osteoporosis?

Osteoporosis Treatment Guidelines

Oral bisphosphonates are strongly recommended as first-line treatment for adults at high or very high risk of osteoporotic fractures, while anabolic agents should be used first for those at very high fracture risk. 1

Fracture Risk Assessment

Risk assessment should be performed before initiating treatment:

• For adults ≥40 years:

  • FRAX calculation
  • BMD measurement using DXA
  • Vertebral fracture assessment (VFA) or spine x-rays 1
  • Clinical fracture risk assessment (history of prior fractures, GC use, smoking, alcohol use, etc.)

• For adults <40 years:

  • BMD with VFA or spine x-rays (FRAX not validated in this population) 1
  • Z-score assessment (Z-score <-3 indicates high risk)

Risk Stratification

Fracture risk categories that guide treatment decisions:

1. Very High Risk:

   • History of osteoporotic fracture(s)
   • T-score ≤-2.5 with recent fracture
   • Multiple fractures
   • Very high-dose glucocorticoids (≥30 mg/day) 1

2. High Risk:

   • T-score ≤-2.5 at hip or spine
   • FRAX 10-year risk for major osteoporotic fracture ≥20%
   • FRAX 10-year risk for hip fracture ≥3% 1, 2

3. Moderate Risk:

   • T-score between -1.0 and -2.5 with additional risk factors

4. Low Risk:

   • T-score >-1.0 without risk factors

Treatment Recommendations

First-Line Treatments

• For very high-risk patients:

  • Anabolic agents (teriparatide, abaloparatide, or romosozumab) followed by antiresorptive therapy 1
  • These bone-forming medications provide superior fracture reduction compared to antiresorptives in this population 3

• For high-risk patients:

  • Oral bisphosphonates (alendronate or risedronate) are strongly recommended 1
  • Denosumab or teriparatide are conditionally recommended over bisphosphonates in adults ≥40 years 1

• For moderate-risk patients:

  • Oral bisphosphonates, IV bisphosphonates, denosumab, or anabolic agents are all conditionally recommended 1

• For low-risk patients:

  • Calcium and vitamin D supplementation with lifestyle modifications 1

Special Populations

• Men with osteoporosis:

  • Oral bisphosphonates are first-line treatment for men at high risk 1
  • Consider testosterone assessment and appropriate hormone replacement if levels are low 1

• Glucocorticoid-induced osteoporosis:

  • Oral bisphosphonates are strongly recommended for patients on prednisone ≥2.5 mg/day for >3 months 1
  • For very high-dose glucocorticoids (≥30 mg/day), treatment is strongly recommended regardless of other risk factors 1

• Renal osteoporosis:

  • Denosumab is preferred for patients with moderate to severe renal impairment 4
  • Bisphosphonates should be used with caution in patients with GFR <30-35 mL/min 4

Medication Details

Bisphosphonates

• Oral options: Alendronate 70mg weekly or risedronate 35mg weekly
• IV options: Zoledronic acid 5mg annually
• Benefits: Cost-effective, extensive safety data, proven fracture reduction
• Limitations: GI side effects (oral), acute phase reaction (IV), contraindicated in severe renal impairment

Denosumab

• Dosing: 60mg subcutaneously every 6 months
• Benefits: No renal clearance, suitable for renal impairment, effective fracture reduction
• Limitations: Risk of rebound bone loss upon discontinuation (requires transition to another antiresorptive) 1, 5

Anabolic Agents

• Teriparatide/Abaloparatide: Daily subcutaneous injection for up to 2 years
• Indications: Very high fracture risk, treatment failure with antiresorptives 6
• Limitations: Cost, daily injections, limited duration of use, contraindicated in patients at increased risk of osteosarcoma 6

Supportive Measures

For all patients with osteoporosis:

• Calcium intake: 1,000-1,200 mg/day (diet plus supplements)
• Vitamin D: 600-800 IU/day (target serum level ≥20 ng/ml)
• Weight-bearing and resistance training exercises
• Smoking cessation
• Limit alcohol to 1-2 drinks per day
• Fall prevention strategies 1, 3

Monitoring

• BMD testing every 1-3 years to assess treatment response
• More frequent monitoring for high-risk patients or those on high-dose glucocorticoids
• Consider biochemical markers of bone turnover to assess adherence to antiresorptive therapy 1

Common Pitfalls to Avoid

1. Failure to recognize very high-risk patients who would benefit from anabolic therapy first
2. Discontinuing denosumab without follow-up therapy, which can lead to rapid bone loss and increased vertebral fractures
3. Inadequate calcium and vitamin D supplementation, which can reduce effectiveness of osteoporosis medications
4. Not addressing secondary causes of osteoporosis (thyroid disease, hyperparathyroidism, malabsorption)
5. Undertreatment of glucocorticoid-induced osteoporosis, which can develop rapidly after starting glucocorticoid therapy

By following these evidence-based guidelines, clinicians can effectively reduce fracture risk and improve outcomes for patients with osteoporosis.