At what age should osteoporosis treatment be stopped or not initiated?

Osteoporosis Treatment Considerations for Older Adults

There is no specific age cutoff at which osteoporosis treatment should be stopped or not initiated, as treatment decisions should be based on fracture risk assessment rather than age alone. 1

Risk Assessment and Treatment Decision Framework

Initial Assessment

• For all adults on glucocorticoid therapy ≥2.5 mg/day for >3 months, perform clinical fracture risk assessment including:
  • Fracture history (symptomatic and asymptomatic)
  • FRAX analysis (for patients ≥40 years)
  • BMD with vertebral fracture assessment (VFA) or spine x-rays 1

Risk Stratification

Risk should be categorized as:

• Low risk
• Moderate risk
• High risk
• Very high risk

Treatment Decisions Based on Risk

1. Very High Risk Patients:

   • Anabolic agents (PTH/PTHrP analogs) are conditionally recommended over antiresorptive agents 1
   • Sequential therapy is required after anabolic treatment to prevent bone loss 1

2. High Risk Patients:

   • Oral bisphosphonates are strongly recommended over no treatment 1
   • For adults ≥40 years, denosumab or PTH/PTHrP are conditionally recommended over bisphosphonates 1

3. Moderate Risk Patients:

   • Oral/IV bisphosphonates, denosumab, and PTH/PTHrP are all conditionally recommended 1

4. Low Risk Patients:

   • Calcium and vitamin D supplementation with lifestyle modifications may be sufficient 1

Treatment Duration Considerations

Bisphosphonate Treatment

• After 5 years of oral bisphosphonate treatment:
  • For patients at moderate-to-high risk who continue glucocorticoid treatment: Continue active treatment (oral bisphosphonate beyond 5 years, switch to IV bisphosphonate, or switch to another class) 1
  • For patients at low risk who discontinue glucocorticoid treatment: Discontinue the osteoporosis medication but continue calcium and vitamin D 1
  • For patients at moderate-to-high risk who discontinue glucocorticoid treatment: Complete the treatment course 1

After Fracture or Treatment Failure

• For patients who fracture after ≥18 months of oral bisphosphonate treatment or have significant bone loss (≥10%/year):
  • Switch to another class of medication (teriparatide, denosumab, or consider IV bisphosphonate if poor absorption/adherence is suspected) 1

Special Considerations for Older Adults

Oldest Old (≥85 years)

• These patients stand to gain substantially from effective anti-osteoporosis treatment despite frequent under-prescription 2
• Convincing anti-fracture efficacy can be seen as early as 12 months after treatment initiation 2
• Safety profiles are generally satisfactory with proper precautions 2

Medication Selection in Elderly

• For patients with renal impairment, denosumab may be preferred over bisphosphonates, but requires careful calcium monitoring 3
• IV bisphosphonates or denosumab 60mg subcutaneously every 6 months are recommended for patients who cannot take oral bisphosphonates 3

Monitoring and Follow-up

• BMD testing every 1-2 years is recommended to assess treatment response 3
• Serum 25(OH)D levels should be checked at baseline and after 3 months of supplementation 3
• Regular dental examinations are recommended to minimize the risk of osteonecrosis of the jaw, which increases with long-term use (>5 years) 3

Common Pitfalls to Avoid

1. Stopping denosumab without follow-up therapy - can cause rapid bone loss 3
2. Inadequate calcium and vitamin D supplementation - optimize calcium intake (1,000-1,200 mg/day) and vitamin D intake (600-800 IU/day) 3
3. Failure to transition to antiresorptive therapy after completing anabolic treatment 3
4. Under-treatment of the oldest old due to misconceptions about efficacy or safety 2
5. Poor medication adherence - particularly problematic in older adults and limits treatment effectiveness 2

Remember that osteoporosis treatment decisions should be based on fracture risk assessment rather than chronological age alone, as even the oldest patients can benefit from appropriate therapy when their risk of fracture outweighs potential treatment risks.