What are the recommendations for managing osteoporosis?

Management of Osteoporosis

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

Risk Assessment and Diagnosis

• Osteoporosis risk factors include:

  • Previous fragility fracture
  • Oral corticosteroid use (≥5 mg prednisolone for >3 months)
  • Hypogonadism
  • Height loss >4 cm
  • Early maternal hip fracture (<60 years)
  • Low body mass index (<19 kg/m²) 1

• Diagnostic criteria:

  • T-score ≤ -2.5 on DXA scan
  • Presence of fragility fracture
  • FRAX 10-year major osteoporotic fracture risk ≥10%
  • FRAX 10-year hip fracture risk ≥3% 1

• DXA scan is the primary diagnostic tool, with consideration of quantitative CT in patients with advanced degenerative changes in the spine 1

Treatment Algorithm

First-line Treatment

1. Oral bisphosphonates (alendronate or risedronate)
   • Take with plain water first thing upon arising
   • Wait at least 30 minutes before first food or beverage
   • Remain upright for at least 30 minutes 2
   • Monitor for esophageal irritation

Second-line Treatment (if oral bisphosphonates not tolerated or contraindicated)

1. Intravenous bisphosphonates (zoledronate)
   • Reduces vertebral fracture risk by 70% 1

Third-line Treatment

1. Denosumab
   • Subcutaneous injection every 6 months
   • Effective for BMD improvement at lumbar spine (5.80%), femoral neck (2.07%), and total hip (2.28%) 1
   • Monitor for hypocalcemia, serious infections, and skin problems 3
   • Risk of rebound bone loss if discontinued without follow-up treatment

For Very High Fracture Risk

1. Anabolic agents (teriparatide, abaloparatide)
   • Teriparatide significantly improves BMD at lumbar spine (8.19%) 1
   • Must be stored under refrigeration (2°C to 8°C) 4
   • Should be followed by antiresorptive therapy when completed

Nutritional and Lifestyle Recommendations

• Calcium supplementation: 1,200 mg daily for women aged 51-70 years 1
• Vitamin D supplementation: 800-1,000 IU daily (target serum level ≥20 ng/mL) 1
• Regular weight-bearing and resistance training exercises 1
• Fall prevention strategies, especially for elderly patients 1
• Smoking cessation and limiting alcohol intake 1

Special Populations

Men with Osteoporosis

• Assess serum testosterone levels as part of pre-treatment evaluation
• Consider testosterone replacement if levels are low 1
• One in five men over age 50 will experience an osteoporotic fracture in their lifetime 5

Glucocorticoid-Induced Osteoporosis

• For adults ≥40 years taking glucocorticoids who are at high fracture risk:
  • Oral bisphosphonates are first-line therapy
  • If discontinuing glucocorticoids, consider continuing osteoporosis treatment until fracture risk is low 5
  • Teriparatide increased lumbar spine BMD by 7.2% in patients with glucocorticoid-induced osteoporosis 4

Cancer Survivors

• At higher risk of accelerated bone loss from cancer treatments
• Bone-modifying agents recommended for those with T-scores ≤ -2.5 or high fracture risk
• Avoid hormonal therapies (estrogens) in patients with hormone-responsive cancers 1, 5

Monitoring and Follow-up

• DXA testing recommended every 2 years during treatment, or more frequently if medically necessary 1
• Reassessment of treatment after 5 years of bisphosphonate therapy 1
• Regular clinical fracture risk assessment yearly 1

Common Pitfalls to Avoid

• Misinterpreting DXA results
• Assuming osteoporosis is cured when BMD improves
• Discontinuing treatment without follow-up
• Focusing solely on BMD and neglecting fracture risk
• Neglecting secondary causes of osteoporosis 1
• Failing to recognize that even if normal BMD is achieved, osteoporosis and elevated fracture risk persist 1

Serious Medication Side Effects to Monitor

• Bisphosphonates: Esophageal irritation, atypical femur fractures, osteonecrosis of the jaw
• Denosumab: Hypocalcemia, serious infections, skin problems, rebound bone loss if discontinued 3
• Teriparatide: Orthostatic hypotension, hypercalcemia 4

Remember that osteoporosis treatment does not cure the disease but reduces fracture risk. Ongoing monitoring and strategic interventions are necessary for long-term fracture prevention.