What are the recommended management options for osteoporosis?

Management of Osteoporosis

For patients with osteoporosis, a comprehensive approach including bone mineral density assessment, lifestyle modifications, and appropriate pharmacologic therapy should be implemented to reduce fracture risk and improve outcomes.

Diagnosis and Assessment

• Bone mineral density (BMD) testing with central/axial dual-energy x-ray absorptiometry (DXA) should be offered to patients with risk factors for osteoporotic fracture 1
• DXA testing should be performed in all women 65 years and older, and in postmenopausal women younger than 65 with risk factors 2
• Fracture risk assessment should include tools such as FRAX to quantify fracture risk beyond BMD alone 1, 2
• Patients prescribed medications that cause bone loss or whose BMD is near treatment threshold should have BMD testing every 2 years (not more frequently than annually) 1

Non-Pharmacologic Interventions

Nutrition

• Patients should consume adequate calcium (1,000-1,200 mg/day) and vitamin D (at least 800-1,000 IU/day) through diet or supplements 1, 2
• A balanced diet with adequate protein intake is important for skeletal health, with higher protein intake associated with lower fracture risk when calcium intake is sufficient 3
• Dairy products, particularly fermented dairy products, are valuable sources of calcium and high-quality protein and are associated with lower risk of hip fracture 3
• At least 5 servings per day of fruits and vegetables should be consumed, as they are associated with reduced fracture risk 3

Exercise

• Patients should engage in a combination of exercise types, including:
  • Balance training to reduce fall risk
  • Flexibility/stretching exercises
  • Endurance exercise
  • Resistance/progressive strengthening exercises 1
• A multi-component exercise approach has demonstrated significant benefits for BMD in middle-aged and older men 1
• Exercise reduces the risk of falls by 23%, emphasizing its potential benefits on musculoskeletal health 1

Lifestyle Modifications

• Active encouragement to stop smoking and limit alcohol consumption is essential, as both are risk factors for osteoporosis 1
• Fall prevention strategies should be implemented, especially for patients with impaired gait or balance 1

Pharmacologic Interventions

Indications for Treatment

• Pharmacologic therapy should be offered to patients with:
  • T-scores of -2.5 or less in the femoral neck, total hip, or lumbar spine
  • 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures based on FRAX 1, 2
  • History of prior osteoporotic fracture 1, 4

First-Line Therapy

• Bisphosphonates (oral or IV) are first-line therapy for most patients with significant fracture risk 2, 5
• Alendronate binds to bone hydroxyapatite and specifically inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 5
• Bisphosphonates have been shown to reduce vertebral fractures (risk difference, -52 per 1000 person-years) and hip fractures (risk difference, -6 per 1000 person-years) 4

Alternative Therapies

• Denosumab (subcutaneous) is an alternative for patients at high risk of fracture or who cannot tolerate bisphosphonates 2, 6
• For very high-risk individuals (e.g., recent vertebral fractures, hip fracture with T-score ≤-2.5), anabolic medications (teriparatide, abaloparatide, romosozumab) should be considered, followed by an antiresorptive agent 4
• Hormonal therapies (e.g., estrogens) are generally avoided in patients with hormone-responsive cancers but may be offered along with other bone-modifying agents when clinically appropriate for patients without hormone-responsive cancers 1

Special Populations

Cancer Survivors

• Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss due to:
  • Hypogonadism from endocrine therapy (oophorectomy, GnRH agonists, chemotherapy-induced ovarian failure, aromatase inhibitors, anti-androgens)
  • Chemotherapy or other cancer therapy-associated medications (e.g., glucocorticoids) 1
• Specific populations appropriate for bone-modifying agents include:
  • Premenopausal women receiving GnRH therapies causing ovarian suppression or with chemotherapy-induced ovarian failure
  • Postmenopausal women receiving aromatase inhibitors
  • Men receiving androgen deprivation therapy
  • Patients with history of bone marrow transplantation
  • Patients on chronic (>3-6 months) glucocorticoid use 1

Men with Osteoporosis

• A female reference database should be used for densitometric diagnosis of osteoporosis in men 1
• Treatment with alendronate in men with osteoporosis for two years reduces urinary markers of bone resorption by approximately 60% and bone-specific alkaline phosphatase by approximately 40% 5
• Patient education is important, as some men may have misconceptions about osteoporosis being a "female" condition 1

Monitoring

• Repeat DXA every 2 years or as clinically indicated to monitor treatment response 1
• BMD assessment should not be conducted more frequently than annually 1
• Patients should be monitored for medication adherence, as up to 64% of men are non-adherent to bisphosphonate therapy by 12 months 1

Potential Side Effects and Considerations

• Bisphosphonates may cause gastrointestinal side effects, and rare complications include osteonecrosis of the jaw and atypical femoral fractures 5
• Denosumab may cause serious side effects including serious infections, skin problems, severe allergic reactions, severe jaw bone problems, and unusual thigh bone fractures 6
• Increased risk of broken bones, including spine fractures, may occur after stopping, skipping, or delaying denosumab treatment 6