What are the management options for osteoporosis in women?

From the Guidelines

Osteoporosis management for women should prioritize pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures, as recommended by the American College of Physicians 1. The management of osteoporosis in women involves a combination of lifestyle modifications and medication therapy. Key lifestyle modifications include:

• Maintaining adequate calcium intake of 1000-1200mg daily through diet or supplements
• Vitamin D supplementation of 800-1000 IU daily to support bone health
• Regular weight-bearing exercise for 30 minutes most days of the week to help maintain bone density First-line medications for osteoporosis management in women include:
• Bisphosphonates such as alendronate (70mg weekly), risedronate (35mg weekly or 150mg monthly), or zoledronic acid (5mg IV yearly)
• Denosumab (60mg subcutaneously every 6 months) as an alternative for those who cannot tolerate bisphosphonates
• Anabolic agents like teriparatide (20mcg subcutaneously daily for up to 24 months) or abaloparatide (80mcg subcutaneously daily for up to 24 months) for women at high fracture risk Treatment duration varies based on fracture risk, with medication holidays considered after 3-5 years of bisphosphonate therapy for moderate-risk patients, as suggested by recent guidelines 1. Bone mineral density testing should be performed every 1-2 years to monitor treatment effectiveness. These interventions work by either reducing bone resorption (bisphosphonates, denosumab) or increasing bone formation (teriparatide, abaloparatide), addressing the imbalance in bone remodeling that occurs with age and estrogen deficiency in women. The American College of Physicians recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women, except in specific cases 1. Additionally, the use of menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women is not recommended due to the potential risks and harms associated with these therapies 1. Overall, the goal of osteoporosis management in women is to reduce the risk of fractures and improve quality of life, and treatment decisions should be individualized based on a patient's specific risk factors, medical history, and preferences.

From the FDA Drug Label

Osteoporosis in Postmenopausal Women Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. The diagnosis can be confirmed by the finding of low bone mass, evidence of fracture on x-ray, a history of osteoporotic fracture, or height loss or kyphosis, indicative of vertebral (spinal) fracture Osteoporosis occurs in both males and females but is most common among women following the menopause, when bone turnover increases and the rate of bone resorption exceeds that of bone formation. Daily oral doses of alendronate (5,20, and 40 mg for six weeks) in postmenopausal women produced biochemical changes indicative of dose-dependent inhibition of bone resorption, including decreases in urinary calcium and urinary markers of bone collagen degradation Long-term treatment of osteoporosis with alendronate sodium 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption

The management options for osteoporosis in women include alendronate sodium 10 mg/day for the treatment of osteoporosis, and alendronate sodium 5 mg/day for the prevention of osteoporosis, as well as once weekly alendronate sodium 70 mg for the treatment of osteoporosis and once weekly alendronate sodium 35 mg for the prevention of osteoporosis 2.

• Key benefits of alendronate include:
  • Inhibition of bone resorption
  • Reduction in urinary excretion of markers of bone resorption
  • Decrease in the rate of bone turnover
• Treatment goals include reducing the risk of fracture and increasing bone mass. The use of alendronate has been shown to decrease the markers of bone formation and resorption, and to reduce the risk of fractures in postmenopausal women 2.

From the Research

Management Options for Osteoporosis in Women

The management options for osteoporosis in women include:

• Antiresorptive drugs, such as bisphosphonates and the RANKL inhibitor denosumab, which increase bone mineral density (BMD) and reduce the risk of vertebral, nonvertebral, and hip fractures 3
• Anabolic therapy with teriparatide, which has been shown to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 3
• Treatment with the sclerostin antibody romosozumab, which increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis 3
• Sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, which may provide better long-term fracture prevention for patients with severe osteoporosis and high fracture risk 3

Bisphosphonates

Bisphosphonates, such as alendronate and risedronate, are effective in reducing the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis 4, 5, 6, 7

• Alendronate and risedronate have been shown to reduce the risk of hip fractures 4, 5, 6, 7
• Ibandronate and zoledronic acid also have anti-fracture efficacy, although the evidence for hip fracture reduction is less clear for ibandronate 7
• The choice of bisphosphonate should be based on efficacy, risk profile, cost-effectiveness, and patient preference 7

Other Treatment Options

Other treatment options for osteoporosis in women include:

• Raloxifene, which has been shown to be effective in preventing the initial vertebral fracture in postmenopausal osteoporotic women without prevalent vertebral fractures 4
• Parathyroid hormone (PTH), which may be considered in patients with severe osteoporosis, although its use is limited to 2 years or less 4
• Strontium ranelate, which has been shown to be effective in preventing vertebral and nonvertebral fractures 4