What medication should be ordered for preventative treatment of osteoporosis?

Preventative Treatment for Osteoporosis

For preventative treatment of osteoporosis, oral bisphosphonates (particularly alendronate) are strongly recommended as first-line therapy due to their proven efficacy in fracture reduction, safety profile, and cost-effectiveness. 1

Risk Assessment and Treatment Decision Algorithm

Step 1: Assess Fracture Risk

• For adults ≥40 years: Evaluate using FRAX with GC adjustment (if on glucocorticoids), BMD with vertebral fracture assessment or spinal x-ray 1
• For adults <40 years: Assess history of fractures, glucocorticoid use, BMD with Z-scores 1

Step 2: Determine Risk Category

• Very high risk: Prior osteoporotic fracture(s), BMD T-score ≤−3.5, FRAX 10-year risk of major osteoporotic fracture ≥30% or hip ≥4.5%, high-dose glucocorticoids ≥30 mg/day for >30 days 1
• High risk: BMD T-score ≤−2.5 but >−3.5, FRAX 10-year risk of major osteoporotic fracture ≥20% but <30% or hip ≥3% but <4.5% 1
• Moderate risk: FRAX 10-year risk of major osteoporotic fracture ≥10% and <20%, hip >1% and <3%, or BMD T-score between −1 and −2.4 1
• Low risk: FRAX 10-year risk of major osteoporotic fracture <10%, hip <1%, BMD >−1.0 1

First-Line Treatment Recommendations

For Adults ≥40 Years at Moderate, High, or Very High Risk:

• First choice: Oral bisphosphonates (alendronate 70mg once weekly or risedronate) 1
  • Strong evidence for fracture reduction in high and very high-risk patients 1, 2
  • Alendronate reduces bone resorption markers by 50-70% and formation markers by 25-50% 2
  • Once-weekly dosing improves compliance compared to daily dosing 3, 4

For Adults <40 Years at Moderate or Very High Risk:

• First choice: Oral bisphosphonates with caution in women who may become pregnant 1
• Consider BMD Z-scores and presence of risk factors when making treatment decisions 1

Alternative Treatments (if oral bisphosphonates not appropriate)

For Adults ≥40 Years:

1. IV bisphosphonates (zoledronic acid) 1
2. PTH/PTHrP agonists (teriparatide, abaloparatide) - especially for very high risk 1
3. Denosumab - 60mg subcutaneously every 6 months 1, 5
4. Raloxifene - only for postmenopausal women with no other options 1

For Adults <40 Years:

1. PTH/PTHrP agonists (avoid in those with open growth plates) 1
2. Denosumab (use with caution in women of childbearing potential) 1

Important Considerations and Monitoring

• Calcium and vitamin D supplementation: Optimize intake based on age-appropriate recommended dietary allowances (1,000-1,200 mg calcium, 600-800 IU vitamin D daily) 1
• Follow-up monitoring: BMD with vertebral fracture assessment or spinal x-ray every 1-2 years during treatment 1
• Treatment duration: Consider drug holiday after 5-10 years of bisphosphonate treatment based on fracture risk 6
• Special populations:
  • For glucocorticoid-induced osteoporosis: Adjust FRAX (multiply 10-year risk by 1.15 for major osteoporotic fracture and by 1.2 for hip fracture if dose >7.5 mg/day) 1
  • For women of childbearing potential: Use oral bisphosphonates with effective birth control 1

Common Pitfalls to Avoid

• Undertreatment: Failing to treat moderate-risk patients can lead to preventable fractures 1, 7
• Inadequate calcium/vitamin D: These are essential adjuncts to pharmacologic therapy 1, 7
• Poor adherence: Once-weekly dosing of alendronate (70mg) improves compliance compared to daily dosing 3, 4
• Inappropriate monitoring: Regular BMD testing is needed to assess treatment efficacy 1
• Ignoring secondary causes: Evaluate for underlying conditions contributing to osteoporosis 7