Recommended Treatment for Osteoporosis
Oral bisphosphonates, particularly alendronate, are the recommended first-line treatment for osteoporosis, followed by denosumab as an alternative first-line option when oral bisphosphonates are contraindicated, with anabolic agents reserved for patients at very high fracture risk or those who have failed other treatments. 1
Treatment Algorithm Based on Fracture Risk
First-Line Treatment
Oral bisphosphonates (alendronate preferred):
- Indicated for patients with T-score ≤ -2.5 or high fracture risk (FRAX ≥20% for major osteoporotic fracture or ≥3% for hip fracture) 1
- Mechanism: Inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 2
- Dosing: Available as 70mg once-weekly formulation, improving convenience while maintaining efficacy 3
Alternative first-line: Denosumab
Second-Line/High-Risk Treatment
- Anabolic agents (teriparatide, abaloparatide, romosozumab):
- Reserved for very high fracture risk patients: 1, 4
- Prior fracture
- T-score ≤ -3.5
- FRAX ≥30% for major osteoporotic fracture or ≥4.5% for hip fracture
- Recent vertebral fractures
- Hip fracture with T-score ≤ -2.5
- Teriparatide specifically indicated for: 5
- Postmenopausal women with osteoporosis at high fracture risk
- Men with primary/hypogonadal osteoporosis at high fracture risk
- Patients with glucocorticoid-induced osteoporosis (prednisone ≥5mg daily)
- Those who have failed or are intolerant to other osteoporosis therapies
- Teriparatide dosage: 20 mcg subcutaneously once daily for up to 2 years 5
- Reserved for very high fracture risk patients: 1, 4
Essential Adjunctive Measures
Calcium and Vitamin D Supplementation
- Calcium: 1,000-1,200 mg daily (diet plus supplements) 1
- Vitamin D: 800-1,000 IU daily 1
- Target serum vitamin D level: ≥20 ng/ml 1
- These supplements should be prescribed alongside all osteoporosis medications 1, 5
Lifestyle Modifications
- Regular weight-bearing and resistance exercises
- Smoking cessation
- Limiting alcohol consumption
- Maintaining healthy weight
- Fall prevention strategies 1
Monitoring and Follow-up
- Reassess bone mineral density after 2 years of treatment 1
- Monitor vitamin D levels and fracture risk 1
- Follow-up FRAX assessment every 1-2 years to evaluate treatment efficacy and adherence 1
- Consider drug holiday after 5 years of bisphosphonate therapy unless strong indication for continued treatment exists 1, 6
Special Considerations
Sequential Therapy
For severe osteoporosis, sequential treatment starting with an anabolic agent followed by an antiresorptive may provide better long-term fracture prevention 7
Contraindications for Teriparatide
- Hypersensitivity to teriparatide
- Open epiphyses
- Metabolic bone diseases other than osteoporosis
- Bone metastases or history of skeletal malignancies
- Prior radiation therapy involving the skeleton
- Hereditary disorders predisposing to osteosarcoma 5
Duration of Treatment
- Bisphosphonates: Consider drug holiday after 5-10 years based on fracture risk 6
- Teriparatide: Limited to 2 years lifetime use; only consider longer use if patient remains at high fracture risk 5
Common Pitfalls to Avoid
- Undertreatment: Despite proven efficacy, many high-risk patients are not started on appropriate therapy 7
- Inadequate follow-up: Failure to monitor BMD and reassess fracture risk can lead to suboptimal outcomes 1
- Overlooking underlying causes: Always consider secondary causes of osteoporosis, especially in men or premenopausal women
- Discontinuing bisphosphonates abruptly: Due to their reservoir effect in bone, a structured approach to drug holidays is needed 6
The evidence strongly supports a stratified approach to osteoporosis treatment based on fracture risk, with oral bisphosphonates as the cornerstone of therapy for most patients, while reserving more potent anabolic agents for those at highest risk of fracture.