What are the recommended treatments for osteoporosis?

Recommended Treatments for Osteoporosis

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

Risk Assessment and Treatment Selection

Adults ≥40 years at moderate-to-high fracture risk:

1. First-line therapy: Oral bisphosphonates (strong recommendation for high-risk patients; conditional for moderate-risk) 2, 1
2. Alternative therapies (in order of preference when oral bisphosphonates are inappropriate):
   • IV bisphosphonates
   • Teriparatide
   • Denosumab
   • Raloxifene (only for postmenopausal women) 2

Adults <40 years:

• Low fracture risk: Optimize calcium and vitamin D intake and lifestyle modifications over pharmacologic treatment 2
• Moderate-to-high fracture risk: Oral bisphosphonates are recommended over calcium and vitamin D alone 2

Special populations:

• Very high fracture risk patients: Consider anabolic agents (teriparatide, abaloparatide, romosozumab) as initial therapy, especially for those with recent vertebral fractures or hip fracture with T-score ≤-2.5 1, 3
• Glucocorticoid-induced osteoporosis: Teriparatide is conditionally recommended over antiresorptive agents for adults ≥40 years on high-dose glucocorticoids (≥30 mg/day for ≥30 days or cumulative dose ≥5g over 1 year) 1, 4

Essential Non-Pharmacologic Interventions

All patients with osteoporosis should receive:

• Calcium supplementation: 1,000-1,200 mg/day 2, 1
• Vitamin D supplementation: 600-800 IU/day (target serum level ≥30 ng/mL) 1
• Regular weight-bearing and resistance exercises (30 minutes daily) 1
• Balance exercises (tai chi, physical therapy) 1
• Smoking cessation 2, 1
• Limiting alcohol to 1-2 drinks per day 2, 1
• Maintaining healthy body weight 1

Pharmacologic Treatment Details

Bisphosphonates

• Reduce vertebral fractures by approximately 140 per 1000 treated patients 1
• Most cost-effective first-line therapy with established safety profile 1
• Monitor for rare adverse effects: osteonecrosis of jaw, atypical femur fractures 1

Denosumab

• Indicated when bisphosphonates are contraindicated or poorly tolerated 1
• Requires transition to another antiresorptive agent when discontinued to prevent rebound bone loss 1
• Monitor for hypocalcemia 1

Anabolic Agents (Teriparatide, Abaloparatide, Romosozumab)

• Maximum treatment duration of 2 years lifetime due to potential osteosarcoma risk 1
• Must transition to an antiresorptive agent after discontinuation to preserve bone gains 1
• Teriparatide is indicated for postmenopausal women with osteoporosis at high risk for fracture, men with primary or hypogonadal osteoporosis at high risk, and patients with glucocorticoid-induced osteoporosis 4

Monitoring Treatment

• BMD testing every 24 months for high-risk patients 1
• Use FRAX calculator to assess 10-year fracture risk 1
• Check baseline serum 25(OH)D levels before initiating therapy 1
• Monitor renal function, serum calcium, and urinary albumin before and during treatment 1

Treatment Sequence for Very High-Risk Patients

1. Start with anabolic agent (teriparatide, abaloparatide, or romosozumab)
2. Follow with antiresorptive therapy to maintain bone gains 3

Common Pitfalls to Avoid

• Failing to transition from anabolic to antiresorptive therapy, resulting in rapid bone loss
• Discontinuing denosumab without follow-up antiresorptive therapy, causing rebound fractures
• Inadequate calcium and vitamin D supplementation, reducing effectiveness of osteoporosis medications
• Not monitoring for potential adverse effects of medications
• Overlooking secondary causes of osteoporosis before initiating treatment

Fracture liaison services can increase medication initiation and adherence by 38% compared to 17% for patients without such services, potentially reducing subsequent fracture rates 3.