What are the medications for osteoporosis treatment?

Medications for Osteoporosis Treatment

Bisphosphonates are the recommended first-line pharmacologic treatment for osteoporosis in both men and women due to their proven efficacy in reducing fracture risk, favorable safety profile, and low cost. 1, 2

First-Line Treatment Options

Bisphosphonates

• Oral bisphosphonates:

  • Alendronate (70mg once weekly)
  • Risedronate (35mg once weekly)
  • Both reduce the risk of vertebral, nonvertebral, and hip fractures 2
  • Must be taken with at least 4 ounces of plain water 3
  • Patient must remain upright for at least 30 minutes after taking 3

• Intravenous bisphosphonate:

  • Zoledronic acid (5mg annual IV infusion)
  • Recommended for patients who cannot tolerate oral bisphosphonates due to GI issues 2

Second-Line Treatment Options

Denosumab

• RANK ligand inhibitor
• Recommended for patients with contraindications to bisphosphonates 1, 2
• Important safety consideration: Risk of rebound bone loss and multiple vertebral fractures after discontinuation 2
• Requires transition to another antiresorptive agent if discontinued 2

Treatment for Very High Fracture Risk

Anabolic Agents

• Teriparatide (recombinant PTH)

  • Indicated for patients at very high risk for fracture 1, 4
  • Defined as those with history of osteoporotic fracture or multiple risk factors 4
  • Limited to 24 months of treatment 2, 5
  • Should be followed by antiresorptive therapy to maintain gains 2, 5
  • Common side effects: nausea, dizziness, headache, and leg cramps 2

• Romosozumab (sclerostin inhibitor)

  • Suggested for females with primary osteoporosis at very high risk of fracture 1
  • Limited to 12 months of treatment 5
  • Should be followed by antiresorptive therapy 5

Supplemental Therapy

• Calcium and Vitamin D:
  • Essential components of all osteoporosis treatment regimens 1, 2
  • Calcium: 1200 mg daily 2
  • Vitamin D: 800-1000 IU daily 2
  • Low calcium levels must be corrected before starting bisphosphonates 3

Treatment Duration and Monitoring

• For bisphosphonates:

  • Consider a "drug holiday" after 3-5 years of treatment 2
  • Patients with severe osteoporosis (T-score ≤ -3.5 or history of fragility fractures) may require continued therapy beyond 5 years 2
  • Annual reassessment for adverse effects is recommended 2

• For denosumab:

  • Requires continuous treatment or transition to bisphosphonate when discontinued to prevent rebound bone loss 2, 5

• For anabolic agents:

  • Must be followed by antiresorptive therapy to maintain bone gains 2, 5

Important Safety Considerations

• Bisphosphonates:

  • Risk of osteonecrosis of the jaw with long-term use 1, 2, 3
  • Risk of atypical femoral fractures 1, 2, 3
  • GI side effects with oral formulations 3, 6

• Denosumab:

  • Risk of hypocalcemia 2
  • Rebound bone loss after discontinuation 2, 5

• Teriparatide:

  • Higher risk of withdrawal due to adverse events compared to bisphosphonates 1, 2

Treatment Algorithm

1. Start with bisphosphonates for all patients with osteoporosis unless contraindicated
2. If bisphosphonates are contraindicated or not tolerated, use denosumab
3. For patients at very high fracture risk (history of osteoporotic fracture or multiple risk factors):
   • Consider starting with an anabolic agent (teriparatide or romosozumab)
   • Follow with antiresorptive therapy (bisphosphonate or denosumab)
4. For all patients: Ensure adequate calcium and vitamin D intake, recommend weight-bearing exercise, and implement fall prevention strategies

Generic medications should be prescribed when possible to reduce cost while maintaining efficacy 1, 2.