What are the current treatment guidelines for osteoporosis?

Current Osteoporosis Treatment Guidelines

Oral bisphosphonates are the first-line pharmacologic treatment for osteoporosis in adults at moderate to high risk of fracture, with treatment selection based on fracture risk assessment and patient-specific factors. 1, 2

Risk Assessment and Treatment Stratification

Treatment recommendations vary based on fracture risk:

Very High Risk

• Definition: History of osteoporotic fracture, especially recent vertebral fractures or hip fracture with T-score ≤-2.5
• Recommended Treatment:
  • Anabolic agents (teriparatide, abaloparatide, or romosozumab) followed by antiresorptive therapy 2, 3
  • Teriparatide is FDA-approved for postmenopausal women with osteoporosis at high risk for fracture 4

High Risk

• Definition: T-score ≤-2.5, history of fracture, or high 10-year absolute fracture risk (≥20%)
• Recommended Treatment:
  • Oral bisphosphonates (alendronate or risedronate) as first-line 1, 2
  • Alternative options (if bisphosphonates contraindicated):
    1. IV bisphosphonates
    2. Denosumab
    3. Teriparatide
    4. Raloxifene (for postmenopausal women only) 1, 2

Moderate Risk

• Recommended Treatment:
  • Oral bisphosphonates as first-line 1, 2
  • Alternative options include IV bisphosphonates, denosumab, or anabolic agents 2

Low Risk

• Recommended Treatment:
  • Calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) supplementation
  • Lifestyle modifications 1, 2

Specific Medication Considerations

Bisphosphonates

• Benefits: Reduce vertebral fractures (risk difference -52 per 1000 person-years) and hip fractures (risk difference -6 per 1000 person-years) 3
• Duration: Consider stopping after 5 years unless strong indication for continuation 1
• Risks: Higher risk for osteonecrosis of the jaw and atypical femoral fractures, especially with longer treatment duration 1

Denosumab

• Indication: Second-line treatment for those with contraindications or adverse effects to bisphosphonates 1
• Special consideration: Preferred for patients with moderate to severe renal impairment 2
• Caution: Requires continuous treatment as discontinuation leads to rapid bone loss 2

Teriparatide

• Indication: For high-risk patients, particularly those with vertebral fractures 2, 4
• Administration: Daily injections (potential barrier to adherence) 1
• Important note: Must be followed by antiresorptive therapy after discontinuation to preserve gains 1

Raloxifene

• Indication: For postmenopausal women when other treatments are not appropriate 1, 5
• Limitations: Less data on benefits for vertebral and hip fractures in glucocorticoid users 1
• Risks: Potential clotting risks and increased risk of death due to stroke 5

Non-Pharmacological Interventions

All patients with osteoporosis should receive:

1. Structured exercise programs:

   • Weight-bearing and resistance exercises 2, 6
   • Balance training to reduce fall risk 2

2. Nutrition:

   • Calcium: 1,000-1,200 mg/day (diet plus supplements) 2, 3
   • Vitamin D: 800-1,000 IU/day (target serum level ≥20 ng/ml) 2

3. Lifestyle modifications:

   • Smoking cessation 2, 6
   • Limit alcohol to 1-2 drinks per day 2
   • Fall prevention strategies 2

Monitoring and Follow-up

• DEXA scan: Baseline and after 1 year of therapy 2
• Laboratory monitoring: Calcium, phosphate, vitamin D, PTH levels, and renal function 2
• Consider biochemical markers of bone turnover to assess adherence to therapy 2

Special Populations

Glucocorticoid-Induced Osteoporosis

• For adults on long-term glucocorticoids (≥3 months, ≥5 mg prednisone equivalent):
  • Low risk: Calcium and vitamin D only
  • Moderate to high risk: Oral bisphosphonates as first-line therapy 1
  • Teriparatide is FDA-approved for treatment of osteoporosis associated with sustained systemic glucocorticoid therapy 4

Men with Osteoporosis

• Bisphosphonates are suggested as first-line treatment 1
• Denosumab as second-line if bisphosphonates contraindicated or poorly tolerated 1
• Teriparatide is FDA-approved to increase bone mass in men with primary or hypogonadal osteoporosis 4

Implementation Strategies

• Consider fracture liaison services, which increase medication initiation and adherence by 38% compared to 17% without such services 3
• Encourage medication adherence, as up to 64% of men are non-adherent to bisphosphonate therapy by 12 months 2