What are the guidelines for managing osteoporosis?

Guidelines for Managing Osteoporosis

Oral bisphosphonates (alendronate or risedronate) are recommended as first-line treatments for individuals at high risk of fracture, while sequential therapy starting with bone-forming agents followed by anti-resorptive agents should be considered for those at very high risk of fracture. 1

Risk Assessment and Diagnosis

• FRAX is the appropriate tool for assessing fracture risk and setting intervention thresholds in osteoporosis, with thresholds being age-dependent 1
• A female reference database should be used for the densitometric diagnosis of osteoporosis in men 1
• Trabecular bone score, used with BMD and FRAX probability, provides useful information for fracture risk assessment 1
• All individuals with a prior fragility fracture should be considered for treatment with anti-osteoporosis medications 1
• Treatment regimens should be adapted to an individual's baseline fracture risk 1

Non-Pharmacological Interventions

• Vitamin D and calcium repletion should be ensured in all men above the age of 65 years (1,000-1,200 mg calcium and 800-1,000 IU vitamin D daily) 1
• Physical exercise (including balance training, flexibility exercises, endurance exercise, and resistance training) and a balanced diet should be recommended to all patients with osteoporosis 1
• Smoking cessation and limiting alcohol consumption should be actively encouraged 1

Pharmacological Management

First-Line Treatment for High-Risk Patients

• Oral bisphosphonates (alendronate or risedronate) are recommended as first-line treatments for individuals at high risk of fracture 1
• Alendronate significantly improves BMD at the lumbar spine (5.2%), total hip (2.34%), and femoral neck (2.53%) 1
• Risedronate improves BMD at the lumbar spine (4.39%), total hip (2.46%), and femoral neck (1.95%) 1
• Weekly dosing regimens (e.g., alendronate 70mg once weekly) provide equivalent efficacy to daily dosing with improved convenience and potentially better adherence 2
• Oral bisphosphonates must be taken with plain water first thing in the morning, at least 30 minutes before food, with patients remaining upright for at least 30 minutes afterward 3

Second-Line Treatment

• Denosumab or zoledronate are recommended as second-line treatments for individuals at high risk of fracture 1
• Zoledronate significantly improves lumbar spine BMD (6.10%), femoral neck BMD (3.1%), and total hip BMD (3.8%) 1
• Denosumab administered via 6-monthly subcutaneous injections improves BMD at the lumbar spine (5.80%), femoral neck (2.07%), and total hip (2.28%) 1

Treatment for Very High-Risk Patients

• Sequential therapy starting with a bone-forming agent followed by an anti-resorptive agent should be considered for individuals at very high risk of fracture 1
• Based on available BMD data, abaloparatide is considered an appropriate first-line treatment for patients with osteoporosis at very high risk of osteoporotic fracture 1
• Teriparatide significantly improves BMD at the lumbar spine (8.19%) and femoral neck (1.33%) 1
• Bone-forming agents should be used in accordance with regulatory authorities' recommendations 1

Special Considerations

Men with Osteoporosis

• Serum total testosterone should be assessed as part of the pre-treatment assessment of men with osteoporosis 1
• Appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone 1
• Testosterone replacement has shown significant increases in lumbar spine trabecular volumetric BMD (7%) and cortical volumetric BMD (3%) 1

Cancer Patients

• Patients with nonmetastatic cancer who are prescribed drugs that cause bone loss should be offered BMD testing every 2 years, or more frequently if medically necessary 1
• For cancer patients with osteoporosis or at increased risk of fractures, bone-modifying agents (oral bisphosphonates, IV bisphosphonates, or subcutaneous denosumab) may be offered 1
• Hormonal therapies for osteoporosis management are generally avoided in patients with hormonal-responsive cancers 1

Monitoring and Adherence

• Biochemical markers of bone turnover are appropriate tools to assess adherence to anti-resorptive therapy 1
• Adherence can be monitored by measuring bone turnover markers at baseline and at 3 months to identify decreases above the least significant change (reductions of more than 38% for P1NP and 56% for CTX) 1
• Poor adherence is a significant issue with oral bisphosphonates, with up to 64% of men being non-adherent by 12 months 1

Safety Considerations

• Bisphosphonates may cause esophageal irritation; patients should be instructed on proper administration techniques 3
• Denosumab may cause hypocalcemia, serious infections, skin problems, and osteonecrosis of the jaw 4
• Teriparatide has been associated with osteosarcoma in rats, though no increased risk has been observed in adult humans 5

The management of osteoporosis requires a systematic approach to risk assessment, appropriate selection of pharmacological interventions based on fracture risk, and attention to non-pharmacological measures to reduce fracture risk and improve bone health.