What are the recommended treatments for osteoporosis?

Recommended Treatments for Osteoporosis

Bisphosphonates should be used as first-line pharmacologic treatment for osteoporosis in most patients, with alternative agents selected based on fracture risk severity and patient-specific factors. 1, 2

Risk Assessment and Diagnosis

• Fracture risk should be assessed using:

  • FRAX score (for patients ≥40 years)
  • Bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA)
  • Vertebral fracture assessment (VFA) or spinal x-rays
  • History of fragility fractures
  • Clinical risk factors (glucocorticoid use, smoking, alcohol consumption, low body weight)

• Osteoporosis is diagnosed by:

  • T-score ≤-2.5 at hip or spine
  • History of fragility fracture
  • High fracture risk (FRAX 10-year risk ≥20% for major osteoporotic fracture or ≥3% for hip fracture) 1, 3

Treatment Algorithm Based on Fracture Risk

1. All Patients with Osteoporosis

• Optimize calcium intake (1,000-1,200 mg/day) 2, 1
• Optimize vitamin D intake (600-800 IU/day; serum level ≥20 ng/ml) 2, 1
• Implement lifestyle modifications:
  • Regular weight-bearing and resistance training exercises
  • Smoking cessation
  • Limit alcohol to 1-2 drinks/day
  • Maintain healthy body weight 2, 1

2. Pharmacologic Treatment by Risk Category

High or Very High Fracture Risk

(T-score ≤-2.5, history of fragility fracture, or high FRAX score)

1. First-line: Oral bisphosphonates (strong recommendation)

   • Alendronate 70mg weekly or risedronate 35mg weekly 2, 1
   • Take with full glass of water, remain upright for 30 minutes

2. If oral bisphosphonates are not appropriate:

   • IV bisphosphonates (zoledronic acid 5mg annually) 2, 1
   • Denosumab 60mg subcutaneously every 6 months 2
   • Teriparatide (for very high fracture risk, especially with vertebral fractures) 2, 4

3. For very high fracture risk patients:

   • Consider anabolic agents (teriparatide, abaloparatide) over antiresorptive agents 2, 3
   • Follow with antiresorptive therapy to maintain gains 2

Moderate Fracture Risk

• Oral or IV bisphosphonates, denosumab, or anabolic agents are conditionally recommended 2
• Selection based on patient factors, comorbidities, and preferences

Low Fracture Risk (Adults <40 years)

• Calcium and vitamin D optimization with lifestyle modifications
• No pharmacologic therapy unless specific risk factors present 2

Special Populations

Glucocorticoid-Induced Osteoporosis

• For adults ≥40 years on prednisone ≥2.5mg/day for >3 months:
  • Oral bisphosphonates as first-line therapy 2
  • For very high risk: consider anabolic agents first 2
  • Alternative options: IV bisphosphonates, denosumab 2

Men with Osteoporosis

• Bisphosphonates as first-line therapy 2
• Denosumab as second-line if bisphosphonates contraindicated 2
• Teriparatide for men with primary or hypogonadal osteoporosis at high fracture risk 4

Women of Childbearing Potential

• Oral bisphosphonates if not planning pregnancy and using effective contraception 2
• Avoid denosumab and IV bisphosphonates due to potential fetal risks 2

Monitoring and Duration of Therapy

• BMD testing every 1-2 years to assess treatment response 1
• Consider discontinuing bisphosphonates after 5 years unless strong indication for continuation 2
• When stopping denosumab, transition to another antiresorptive agent to prevent rebound bone loss 1

Common Pitfalls to Avoid

1. Inadequate calcium/vitamin D supplementation before initiating pharmacologic therapy
2. Failing to transition to antiresorptive therapy after completing anabolic treatment
3. Abrupt discontinuation of denosumab without follow-up therapy (causes rapid bone loss)
4. Overlooking dental health - dental examination recommended before starting bisphosphonates or denosumab to reduce risk of osteonecrosis of the jaw
5. Insufficient treatment duration - osteoporosis requires long-term management as it is treated but not cured by medications 5

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