What are the treatment options for osteoporosis?

Treatment Options for Osteoporosis

Bisphosphonates are the first-line pharmacologic treatment for osteoporosis in both men and women, with oral formulations such as alendronate being the preferred initial choice due to their established efficacy, safety profile, and cost-effectiveness. 1

Comprehensive Treatment Algorithm

Step 1: Risk Assessment and Diagnosis

• Dual energy x-ray absorptiometry (DEXA) should be performed in all women 65 years and older 2
• DEXA can also be performed in younger postmenopausal women with risk factors for fracture 2
• Treatment is recommended for:
  • T-score of -2.5 or less
  • 10-year risk of major osteoporotic fracture ≥20% or hip fracture ≥3% using FRAX
  • History of low-trauma fracture, even if DEXA doesn't indicate osteoporosis 2

Step 2: Non-Pharmacologic Interventions

Calcium and Vitamin D

• Ensure adequate calcium intake: 1,000-1,200 mg daily 2, 1
• Ensure adequate vitamin D intake: 600-800 IU daily (800 IU for those 71+ years) 2, 1
• Target serum vitamin D level of at least 20 ng/mL (50 nmol/L) 2

Exercise and Lifestyle Modifications

• Regular weight-bearing and resistance exercises (30 minutes daily) 2, 1
• Balance training exercises (tai chi, physical therapy) to prevent falls 2
• Smoking cessation 2
• Limit alcohol consumption 2
• Fall prevention strategies (vision checks, medication review, home safety) 2

Step 3: Pharmacologic Treatment

First-Line Therapy

• Oral bisphosphonates (alendronate, risedronate) 2, 1
  • Mechanism: Inhibit osteoclast activity and reduce bone resorption 3
  • Efficacy: Reduce vertebral fractures by approximately 140 per 1000 treated patients 1
  • Dosing: Alendronate 70mg weekly or 10mg daily 3
  • Consider stopping after 5 years with reassessment of fracture risk 2

Second-Line Options (if bisphosphonates contraindicated or not tolerated)

• Denosumab
  • Must transition to another antiresorptive agent when discontinued to prevent rebound bone loss 1
  • Administered as subcutaneous injection every 6 months

For Very High-Risk Patients

• Anabolic agents (teriparatide, abaloparatide, romosozumab) 1, 4
  • Consider for patients with:
    • Very high fracture risk
    • Multiple vertebral fractures
    • Failure of prior bisphosphonate therapy
    • T-score below -3.0
  • Maximum treatment duration of 2 years lifetime due to potential osteosarcoma risk 1, 4
  • Must transition to an antiresorptive agent after discontinuation 2, 1

Special Populations

• Premenopausal women receiving GnRH therapies or with chemotherapy-induced ovarian failure
• Postmenopausal women on aromatase inhibitors
• Men on androgen deprivation therapy
• Patients with history of bone marrow transplantation
• Patients on chronic glucocorticoids
  • These groups may require treatment at higher bone density thresholds 2

Monitoring and Follow-Up

• Bone mineral density testing every 24 months for high-risk patients 2
• For patients on treatment, consider follow-up DEXA after 12 months if bone loss risks have changed significantly 2

Important Considerations and Pitfalls

Medication Adherence

• Poor adherence is common and significantly reduces fracture prevention benefits
• Use generic medications when possible to improve affordability 2

Bisphosphonate Drug Holiday

• Consider temporary discontinuation after 3-5 years of treatment
• Decision should be based on fracture risk assessment 2

Anabolic Agent Transition

• Patients treated with anabolic agents must transition to an antiresorptive agent to preserve bone gains and prevent rebound fractures 2, 1

Osteonecrosis of Jaw and Atypical Femur Fractures

• Rare but serious complications of long-term antiresorptive therapy
• Risk increases with duration of therapy 1

By following this comprehensive approach to osteoporosis management, focusing on both pharmacologic and non-pharmacologic interventions, the risk of osteoporotic fractures can be significantly reduced, improving morbidity, mortality, and quality of life outcomes.