What is the recommended management for osteoporosis?

Recommended Management for Osteoporosis

For patients with osteoporosis, oral bisphosphonates (alendronate or risedronate) are strongly recommended as first-line pharmacologic treatment, with intravenous bisphosphonates or denosumab as second-line options, and anabolic agents reserved for patients at very high fracture risk. 1, 2

Risk Assessment and Diagnosis

• Use FRAX (Fracture Risk Assessment Tool) to evaluate 10-year fracture risk and guide treatment decisions 1, 2
• Diagnosis based on:
  • T-score ≤ -2.5 in femoral neck, total hip, or lumbar spine
  • Prior fragility fracture
  • FRAX 10-year major osteoporotic fracture risk ≥10% or hip fracture risk ≥3% 2
• Consider trabecular bone score (TBS) with BMD and FRAX for additional fracture risk assessment 1

Non-Pharmacologic Management

• Calcium supplementation: 1,000-1,200 mg daily 2
• Vitamin D supplementation: 800-1,000 IU daily (target serum level ≥20 ng/mL) 2
• Regular weight-bearing and resistance training exercises 1, 2
• Smoking cessation and limiting alcohol intake to 1-2 drinks per day 2
• Fall prevention strategies, especially for elderly patients and those with balance issues 1

Pharmacologic Treatment Algorithm

First-Line Therapy

• Oral bisphosphonates (alendronate or risedronate) 1, 2
  • Alendronate 70 mg once weekly or 10 mg daily 3, 4
  • Must be taken with plain water first thing in the morning, 30 minutes before food/beverages 3
  • Patient must remain upright for 30 minutes after taking 3

Second-Line Therapy (if oral bisphosphonates not tolerated or contraindicated)

• Intravenous bisphosphonates (zoledronate) 1
  • Single yearly 15-minute infusion of 5 mg
  • Reduces vertebral fracture risk by 70% 1

Third-Line Therapy

• Denosumab 1, 2
  • 60 mg subcutaneous injection every 6 months
  • Effective for BMD improvement at lumbar spine (5.80%), femoral neck (2.07%), and total hip (2.28%) 1
  • Caution: rapid bone loss upon discontinuation 2

For Very High-Risk Patients

• Sequential therapy starting with a bone-forming agent followed by an antiresorptive agent 1
• Anabolic agents for patients with:
  • Recent vertebral fractures
  • Hip fracture with T-score ≤ -2.5
  • Multiple fragility fractures 5, 6
• Options include:
  • Abaloparatide: 80 mcg subcutaneously once daily 7
  • Teriparatide: Significant BMD improvement at lumbar spine (8.19%) 1
  • Romosozumab: Consider risks of cardiovascular events 2

Monitoring Treatment

• BMD testing with DXA every 2-3 years during treatment 2
• Bone turnover markers (P1NP and CTX) before treatment and at 3 months to assess adherence 1, 2
• Reassessment after 5 years of bisphosphonate therapy 2

Special Populations

Men with Osteoporosis

• Similar treatment approach as for women 1
• Assess serum testosterone as part of pre-treatment evaluation 1
• Consider testosterone replacement if levels are low 1

Cancer Survivors

• Higher risk of accelerated bone loss from cancer treatments 1, 2
• Bone-modifying agents recommended for those with T-scores ≤ -2.5 or high fracture risk 1
• Avoid hormonal therapies (estrogens) in patients with hormone-responsive cancers 1

Safety Considerations

• Bisphosphonates: Risk of osteonecrosis of jaw, atypical femur fractures, esophageal irritation 2
• Denosumab: Risk of rapid bone loss upon discontinuation, hypocalcemia 2
• Anabolic agents: Teriparatide carries theoretical risk of osteosarcoma; abaloparatide may cause orthostatic hypotension 2, 7

Common Pitfalls to Avoid

• Undertreatment due to misinterpreting DXA results 2
• Assuming osteoporosis is cured and discontinuing treatment without follow-up 2
• Focusing solely on BMD without considering overall fracture risk 2
• Neglecting to identify and address secondary causes of osteoporosis 2

By following this evidence-based approach to osteoporosis management, clinicians can significantly reduce fracture risk and associated morbidity and mortality in affected patients.