What are the recommended treatments for osteoporosis?

Recommended Treatments for Osteoporosis

For patients with osteoporosis, first-line treatment should be oral bisphosphonates, with anabolic agents (teriparatide, abaloparatide) reserved for those at very high fracture risk, and denosumab as an alternative for patients with renal impairment or intolerance to bisphosphonates. 1

Risk Assessment and Treatment Selection

Risk Stratification

1. Very High Risk Patients:

   • Prior osteoporotic fracture(s)
   • BMD T-score ≤−3.5
   • FRAX 10-year risk of major osteoporotic fracture ≥30% or hip ≥4.5%
   • High glucocorticoid use (≥30 mg/day for >30 days or cumulative doses ≥5 g/year)
   • Recommended Treatment: Anabolic agents (teriparatide, abaloparatide) 1, 2

2. High Risk Patients:

   • BMD T-score ≤−2.5 but >−3.5
   • FRAX 10-year risk of major osteoporotic fracture ≥20% but <30% or hip ≥3% but <4.5%
   • Recommended Treatment: Oral bisphosphonates (first-line), with denosumab or anabolic agents as alternatives 3, 1

3. Moderate Risk Patients:

   • FRAX 10-year risk of major osteoporotic fracture ≥10% and <20%
   • Hip fracture risk >1% and <3%
   • BMD T-score between −1 and −2.4
   • Recommended Treatment: Oral bisphosphonates, denosumab, or anabolic agents 3, 1

4. Low Risk Patients:

   • Recommended Treatment: Calcium and vitamin D supplementation with lifestyle modifications 3, 1

Pharmacological Treatments

First-Line Therapy

• Oral Bisphosphonates: Strongly recommended for high and very high fracture risk patients due to efficacy, safety, and cost-effectiveness 3, 1
  • Benefits: Reduces vertebral fractures (risk difference -52 per 1000 person-years) and hip fractures (risk difference -6 per 1000 person-years) 2

Alternative Therapies (when oral bisphosphonates are not appropriate)

1. IV Bisphosphonates: Consider when oral administration is not feasible or tolerated 3

2. Anabolic Agents:

   • Teriparatide: Indicated for postmenopausal women, men with primary or hypogonadal osteoporosis, and glucocorticoid-induced osteoporosis at high fracture risk 4
   • Abaloparatide: Indicated for postmenopausal women and men with osteoporosis at high fracture risk 5
   • Particularly beneficial for patients with very high fracture risk, especially those with vertebral fractures 1, 2

3. Denosumab:

   • Consider for patients with renal impairment 1
   • Conditionally recommended over bisphosphonates for adults ≥40 years at high risk of fracture 3
   • Important: Sequential therapy is required after discontinuation to prevent rebound bone loss 1

4. Raloxifene: Consider only for postmenopausal women when other options are not appropriate 3

Non-Pharmacological Management

Lifestyle Modifications

• Regular weight-bearing and resistance exercises (30 minutes daily) 1, 6, 7
• Balance exercises (tai chi, physical therapy) to prevent falls 1
• Smoking cessation 1, 6, 7
• Limit alcohol to 1-2 drinks per day 1, 6
• Maintain healthy body weight 1

Nutrition

• Calcium intake: 1,000-1,200 mg daily (total from diet and supplements) 1, 2, 6
• Vitamin D: 600-800 IU daily, targeting serum levels ≥30 ng/mL (75 nmol/L) 1, 2, 6
• Calcium citrate may be better absorbed than calcium carbonate, especially in patients on proton pump inhibitors 1

Monitoring and Follow-Up

Assessment Schedule

• BMD testing every 24 months for high-risk patients 1
• Consider more frequent BMD testing (every 12 months) when significant changes in risk factors occur 1
• Fall risk assessment and home safety evaluation 1

Duration of Therapy

• Typical pharmacologic treatment duration is 5 years 1
• After completing anabolic therapy (teriparatide, abaloparatide), transition to an antiresorptive agent is essential to maintain BMD gains 1
• Consider discontinuing bisphosphonates after 5 years unless strong indication for continuation 1

Special Considerations

Glucocorticoid-Induced Osteoporosis

• For adults ≥40 years at very high fracture risk due to glucocorticoid therapy, anabolic agents are conditionally recommended over antiresorptive agents 3, 1
• For adults <40 years receiving high-dose glucocorticoid therapy, anabolic agents may be used (only in those with closed growth plates) 1

Potential Adverse Effects

• Osteonecrosis of the jaw (rare)
• Atypical femur fractures (rare)
• Hypocalcemia (with denosumab)
• Orthostatic hypotension (with abaloparatide) 5

Treatment Adherence

• Critical for effectiveness - 30-50% of patients do not take medication correctly 6
• Consider fracture liaison services to improve medication initiation and adherence (increases adherence by 20%) 2