What is the treatment for osteoporosis of the femur?

Treatment of Osteoporosis of the Femur

Bisphosphonates are the first-line pharmacologic treatment for osteoporosis of the femur due to their proven efficacy in reducing fracture risk with a favorable benefit-risk profile. 1

Diagnostic Criteria

• Osteoporosis is diagnosed when bone mineral density (BMD) at the femoral neck, total hip, or lumbar spine is ≥2.5 standard deviations below the mean BMD value for a young adult (T-score ≤ -2.5) 1
• Low bone mass (osteopenia) is defined as a BMD value between 1 and 2.5 standard deviations below the mean BMD value for a young adult (T-score between -1 and -2.5) 1

Treatment Algorithm

First-Line Therapy

• Bisphosphonates (strong recommendation; high-certainty evidence) 1
  • Mechanism: Inhibit osteoclast activity without directly inhibiting bone formation 2
  • Benefits: Reduce risk of vertebral, hip, and non-vertebral fractures 1
  • Cost-effective: Available in generic formulations 1
  • Duration: Consider stopping after 5 years unless strong indication for continuation exists 1

Second-Line Therapy

• Denosumab (RANK ligand inhibitor) for patients with contraindications to bisphosphonates (conditional recommendation; moderate-certainty evidence) 1
  • Administered subcutaneously every 6 months 3
  • Important: Must transition to another antiresorptive agent after discontinuation to prevent rebound fractures 1

For Very High-Risk Patients

• Romosozumab (sclerostin inhibitor) or Teriparatide (recombinant PTH) (conditional recommendation; low-certainty evidence) 1
  • Consider for patients with:
    • Recent vertebral fractures
    • Hip fracture with T-score ≤ -2.5 4
  • Must follow with antiresorptive therapy after discontinuation 1

Non-Pharmacologic Interventions

• Calcium and vitamin D supplementation 1

  • Calcium: 1,000-1,200 mg daily 1
  • Vitamin D: 800-1,000 IU daily 1
  • If dietary intake is insufficient, supplements are recommended 1

• Exercise 1, 5

  • Combination of:
    • Balance training
    • Flexibility/stretching exercises
    • Endurance exercise
    • Resistance/progressive strengthening exercises 1
  • Weight-bearing exercise at least 3 days per week for 30 minutes 1

• Lifestyle modifications 1, 5

  • Smoking cessation 1
  • Limit alcohol consumption 1
  • Fall prevention counseling 1

Monitoring and Follow-up

• BMD testing every 2 years for patients at high risk 1
• More frequent monitoring may be necessary based on individual risk factors 1
• Generally, testing should not be conducted more than annually 1

Potential Adverse Effects

• Bisphosphonates:

  • Osteonecrosis of the jaw (higher risk with longer treatment duration) 1
  • Atypical femoral fractures 1
  • Consider drug holiday after 5 years of treatment 1

• Denosumab:

  • Risk of hypocalcemia (especially in patients with renal impairment) 3
  • Increased risk of serious infections 3
  • Dermatologic adverse reactions 3

Special Considerations

• For patients with cancer-induced bone loss, the same treatment principles apply, but with closer monitoring 1
• Patients initially treated with anabolic agents should transition to antiresorptive therapy to maintain bone density gains 1
• Generic medications should be prescribed when possible to improve adherence and reduce costs 1

Treatment Pitfalls to Avoid

• Failing to diagnose and treat secondary causes of osteoporosis 1
• Discontinuing denosumab without transitioning to another antiresorptive agent (risk of multiple vertebral fractures) 3
• Inadequate calcium and vitamin D supplementation during osteoporosis treatment 1
• Not considering drug holidays for long-term bisphosphonate users to reduce risk of rare but serious adverse effects 1