What are the recommended management strategies for osteoporosis?

Comprehensive Management of Osteoporosis

The recommended management strategy for osteoporosis should include both non-pharmacologic interventions (adequate calcium and vitamin D intake, exercise, lifestyle modifications) and pharmacologic treatments (oral bisphosphonates as first-line therapy, followed by other agents based on risk stratification). 1

Diagnosis and Risk Assessment

• Osteoporosis is diagnosed when:

  • T-score ≤ -2.5 in postmenopausal women and men over 50 1
  • Presence of fragility fracture regardless of bone mineral density (BMD) 1

• Risk assessment should include:

  • FRAX tool to calculate 10-year risk of major osteoporotic fracture or hip fracture
  • Treatment threshold: ≥20% risk for major osteoporotic fracture or ≥3% risk for hip fracture 2, 1
  • Dual-energy X-ray absorptiometry (DXA) of spine, hip, and femoral neck 2

Non-Pharmacologic Interventions

Calcium and Vitamin D

• Ensure adequate daily intake:
  • Calcium: 1,000-1,200 mg/day 2, 1, 3
  • Vitamin D: 800-1,000 IU/day 2, 1, 3
  • Supplements recommended if dietary intake is insufficient 2

Exercise

• Implement a combination of exercise types:
  • Balance training to prevent falls
  • Flexibility/stretching exercises
  • Weight-bearing endurance exercises
  • Resistance/progressive strengthening exercises 2, 1
• Exercise should be tailored to individual needs and abilities 2

Lifestyle Modifications

• Smoking cessation 2, 1
• Limit alcohol consumption 2, 1
• Fall prevention strategies 1

Pharmacologic Treatment

Treatment Algorithm

1. Risk Assessment:

   • Evaluate BMD with DXA
   • Calculate FRAX score
   • Assess for fragility fractures

2. Treatment Decision:

   • Initiate treatment if:
     • T-score ≤ -2.5 2, 1
     • FRAX score ≥20% for major osteoporotic fracture or ≥3% for hip fracture 2, 1
     • History of fragility fracture 1

3. First-Line Treatment:

   • Oral bisphosphonates (e.g., alendronate) 1, 4
     • Inhibits osteoclast activity without directly inhibiting bone formation 4
     • Must be taken on empty stomach with plain water
     • Patient must remain upright for 30-60 minutes after administration 1

4. Alternative Options (if intolerant or contraindicated to oral bisphosphonates):

   • Intravenous bisphosphonates 1
   • Denosumab 2, 1
   • Anabolic agents for very high fracture risk:
     • Teriparatide 1, 5
     • Abaloparatide 3
     • Romosozumab (with caution due to cardiovascular risk) 1, 6

Special Populations

• Cancer survivors:

  • Bone-modifying agents recommended for those with T-scores ≤ -2.5 or high fracture risk 2
  • Consider bisphosphonates or denosumab at osteoporosis-indicated dosages 2
  • Avoid hormonal therapies in patients with hormone-responsive cancers 2

• Men with osteoporosis:

  • Often underdiagnosed despite affecting 1 in 5 men over age 50 2
  • Similar treatment approach as for women 2
  • Consider using female reference database for densitometric diagnosis 2

• Glucocorticoid-induced osteoporosis:

  • Teriparatide shown to increase lumbar spine BMD by 7.2% from baseline 5
  • Consider bisphosphonates or teriparatide based on fracture risk 1, 5

Monitoring and Follow-up

• BMD testing with DXA:

  • Every 2 years during treatment, or more frequently if medically necessary 2, 1
  • Generally not more than annually 2

• Reassess treatment after 5 years of bisphosphonate therapy:

  • Consider drug holiday or continuation based on risk assessment 1

• For anabolic agents (e.g., teriparatide):

  • Limited to 2 years of therapy 1, 5
  • Follow with antiresorptive agent to maintain bone gains 1

Potential Adverse Effects and Precautions

• Bisphosphonates:

  • Risk of osteonecrosis of jaw - dental screening recommended before initiation 1
  • Atypical femur fractures with long-term use
  • Esophageal irritation with oral formulations 4

• Denosumab:

  • Rapid bone loss upon discontinuation - transition to another agent required 6
  • Risk of hypocalcemia

• Teriparatide:

  • Theoretical risk of osteosarcoma (seen in rat studies) 5
  • Orthostatic hypotension - advise patients to sit/lie down if symptoms occur 5
  • Hypercalcemia 5

• Romosozumab:

  • Increased risk of myocardial infarction, stroke, and cardiovascular death 1
  • Not recommended as first-line for moderate fracture risk patients 1

The management of osteoporosis requires a comprehensive approach that combines lifestyle modifications with appropriate pharmacologic therapy based on individual fracture risk. Regular monitoring and adjustment of treatment strategies are essential to optimize outcomes and reduce fracture risk.