What are the treatment options for osteoporosis?

Osteoporosis Treatment Options

Bisphosphonates are the 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

Understanding Osteoporosis

Osteoporosis is a condition characterized by low bone mass and increased risk of fractures, diagnosed by a T-score ≤ -2.5 in adults over 50 years 1. It affects 10.2% of adults older than 50 years and is expected to increase to 13.6% by 2030 2. Osteoporotic fractures significantly impact morbidity, mortality, and quality of life 3.

Treatment Algorithm

First-Line Treatment:

1. Oral Bisphosphonates

   • Recommended for adults with primary osteoporosis 1
   • Most cost-effective option with proven efficacy

2. If oral bisphosphonates are not tolerated or contraindicated:

   • Zoledronic acid (5 mg IV once yearly) for severe osteoporosis 1
   • Denosumab for patients with T-scores ≤ -2.5 who cannot tolerate bisphosphonates 1

3. For very high fracture risk patients (recent vertebral fractures, hip fracture with T-score ≤ -2.5):

   • Consider anabolic agents (teriparatide, abaloparatide, romosozumab) followed by an antiresorptive agent 1, 3

Non-Pharmacologic Management

Essential for all patients:

• Calcium supplementation: 1000-1200 mg daily (divided doses of ≤600 mg for optimal absorption) 1
• Vitamin D supplementation: 800-1000 IU daily (target serum 25(OH)D level ≥30 ng/ml) 1
• Weight-bearing and resistance training exercises as tolerated 1
• Fall prevention strategies 1
• Smoking cessation and limiting alcohol consumption 1, 4

Monitoring Treatment Response

• DEXA scan should be performed 1-2 years after initiating treatment 1
• Regular monitoring of renal function before each dose of zoledronic acid 1
• For patients on bisphosphonates, consider a drug holiday after 3-5 years of treatment based on fracture risk assessment 5

Special Considerations

• Renal impairment: Reduce zoledronic acid dose or avoid in severe impairment 1
• Dental health: Baseline dental evaluation before starting bisphosphonates or denosumab, maintain good oral hygiene, and avoid invasive dental procedures during therapy 1
• Combination therapy: While combining antiresorptive and anabolic agents may increase BMD compared to monotherapy, more evidence is needed regarding effects on fracture risk 4

Important Caveats

• Even if normal BMD is achieved with treatment, the diagnosis of osteoporosis persists, and ongoing monitoring remains necessary 5
• Discontinuation of treatment leads to resumption of skeletal deterioration—sooner with non-bisphosphonates and later with bisphosphonates 5
• Untreated osteoporosis can lead to a cycle of recurrent fractures, resulting in disability and premature death 5
• Despite effective treatments being available, osteoporosis remains underdiagnosed and undertreated 6

Treatment Duration

• For zoledronic acid, the American Society of Clinical Oncology recommends administration for 3-5 years, with a frequency of every 6 months in postmenopausal women with breast cancer 1
• For other medications, treatment duration should be based on ongoing fracture risk assessment, with consideration of drug holidays for bisphosphonates after 3-5 years 5

Remember that osteoporosis treatments do not cure the disease but effectively reduce fracture risk when taken correctly and for an appropriate duration 5.