What is the recommended treatment for osteoporosis?

Osteoporosis Treatment Recommendations

Bisphosphonates should be used as first-line pharmacologic treatment for osteoporosis to reduce fracture risk in both men and women with primary osteoporosis. 1, 2

First-Line Treatment

• Oral bisphosphonates (alendronate, risedronate):
  • Mechanism: Inhibit osteoclast activity, reducing bone resorption without directly inhibiting bone formation 3
  • Benefits: Reduce radiographic vertebral fractures by approximately 140 per 1000 treated patients 1
  • Duration: Consider stopping after 5 years unless strong indication for continuation exists 1
  • Safety: No significant difference in serious adverse events compared to placebo 1

Second-Line Treatment

• Denosumab (RANK ligand inhibitor):
  • Recommended when patients have contraindications to or experience adverse effects from bisphosphonates 1, 2
  • Important: Requires transition to another antiresorptive agent when discontinued to prevent rebound bone loss 2

Special Populations - Very High Fracture Risk

For patients at very high fracture risk (recent vertebral fractures, multiple fractures, or T-score ≤ -2.5):

• Anabolic agents (teriparatide, abaloparatide, romosozumab):
  • Teriparatide is indicated for postmenopausal women, men with primary/hypogonadal osteoporosis, and glucocorticoid-induced osteoporosis 4
  • Maximum treatment duration: 2 years lifetime due to potential osteosarcoma risk 4
  • Critical: Must transition to an antiresorptive agent after discontinuation to preserve bone gains and prevent rebound fractures 1, 2

Essential Supplementation

• Calcium and vitamin D:
  • All patients should receive adequate calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) 1, 2
  • Target vitamin D serum levels ≥30 ng/mL (75 nmol/L) 2
  • Check baseline serum 25(OH)D levels before initiating therapy 2

Lifestyle Modifications

• Exercise:
  • Regular weight-bearing and resistance exercises (30 minutes daily) 2, 5
  • Balance exercises (tai chi, physical therapy) to prevent falls 2
• Other modifications:
  • Smoking cessation 2, 6
  • Limit alcohol to 1-2 drinks per day 2
  • Maintain healthy body weight 2

Treatment Duration and Monitoring

• Bisphosphonates:

  • Consider stopping after 5 years 1
  • Decision to discontinue should be individualized based on fracture risk, medication type, and half-life 1

• Monitoring:

  • Bone mineral density (BMD) testing every 24 months for high-risk patients 2
  • Use FRAX calculator to assess 10-year fracture risk 2, 7
  • Monitor renal function, serum calcium, and urinary albumin before and during treatment 2

Important Precautions

• Osteonecrosis of jaw: Dental examination before starting treatment, especially with denosumab 2
• Atypical femur fractures: Rare but serious complication of long-term bisphosphonate use 2
• Hypocalcemia: Particularly with denosumab 2
• Orthostatic hypotension: Particularly with abaloparatide and teriparatide (administer first dose where patient can sit or lie down) 2, 4

Treatment Algorithm

1. Assess fracture risk using FRAX calculator and BMD testing
2. Start with bisphosphonates for most patients with osteoporosis
3. Consider denosumab if bisphosphonates are contraindicated or poorly tolerated
4. Consider anabolic agents for very high-risk patients, followed by antiresorptive therapy
5. Ensure adequate calcium and vitamin D for all patients
6. Implement lifestyle modifications including exercise, smoking cessation, and limiting alcohol
7. Monitor treatment response with periodic BMD testing and assessment for adverse effects

Remember that osteoporosis is a chronic condition requiring long-term management to effectively reduce fracture risk and improve outcomes 7, 8.