What are the treatment options for osteoporosis?

Treatment Options for Osteoporosis

Bisphosphonates are recommended as first-line pharmacologic treatment for osteoporosis due to their favorable balance of benefits, harms, patient values and preferences, and cost compared to other medications. 1

Diagnosis and Assessment

• Dual energy x-ray absorptiometry (DEXA) should be performed in all women 65 years and older and in postmenopausal women younger than 65 years with risk factors (history of fragility fracture, weight less than 127 lb, medications or diseases causing bone loss, parental history of hip fracture) 1
• Treatment is recommended for patients with a T-score of -2.5 or less 1
• For those with T-scores between -1.0 and -2.5, the FRAX calculator can assist in treatment decisions, with pharmacologic therapy recommended for those with a 10-year risk of major osteoporotic fracture of at least 20% or hip fracture risk of at least 3% 1
• Patients with a history of low-trauma fracture should be considered for treatment even if DEXA does not indicate osteoporosis 1

Non-Pharmacologic Interventions

Calcium and Vitamin D

• Recommended daily calcium intake: 1
  • Ages 19-50: 1,000 mg
  • Ages 51 and older: 1,200 mg
• Recommended daily vitamin D intake: 1
  • Ages 19-70: 600 IU
  • Ages 71 and older: 800 IU
• A serum vitamin D level of at least 20 ng/mL (50 nmol/L) is recommended for good bone health 1

Lifestyle Modifications

• Regular weight-bearing, muscle-strengthening, and balance exercises are recommended to reduce fracture risk 1
• Smoking cessation and limiting alcohol consumption are strongly advised 1
• Fall prevention strategies should be implemented, including vision/hearing assessment, medication review, and home safety evaluation 1

Pharmacologic Treatment Options

First-Line Therapy: Bisphosphonates

• Oral bisphosphonates (alendronate, risedronate) are recommended as initial treatment due to their efficacy, safety profile, and lower cost 1
• Bisphosphonates work by inhibiting osteoclast activity, reducing bone resorption without directly affecting bone formation 2
• Available formulations include daily, weekly, or monthly oral options, as well as intravenous formulations 1
• Contraindications include esophageal abnormalities, inability to remain upright for 30 minutes, hypocalcemia, and hypersensitivity 1
• Long-term use (>5 years) may increase risk of osteonecrosis of the jaw and atypical femoral fractures, so clinicians should consider stopping treatment after 5 years unless there's a strong indication to continue 1

Second-Line Options:

Denosumab

• RANK ligand inhibitor recommended as second-line treatment for patients with contraindications to or adverse effects from bisphosphonates 1
• Administered as a subcutaneous injection every 6 months 3
• Effective at reducing fracture risk but may cause serious side effects including osteonecrosis of the jaw, atypical femoral fractures, and serious infections 3
• After discontinuation, patients should be transitioned to an antiresorptive agent to prevent rapid bone loss 1

Raloxifene

• Selective estrogen receptor modulator that can be a good initial treatment for younger postmenopausal women 1
• Associated with increased risk of thromboembolic events 4
• Generally avoided in patients with hormone-responsive cancers 1

Teriparatide

• Anabolic agent (recombinant parathyroid hormone) typically reserved for patients with severe osteoporosis or those who have had fractures 1, 5
• Administered as daily subcutaneous injections 5
• May increase risk of serious adverse events and withdrawal due to side effects 1
• After discontinuation, patients should be transitioned to an antiresorptive agent to maintain bone gains 1

Special Populations

Men with Osteoporosis

• Bisphosphonates are suggested as first-line treatment 1
• Denosumab is recommended as second-line therapy for those with contraindications to or adverse effects from bisphosphonates 1

Glucocorticoid-Induced Osteoporosis

• Oral bisphosphonates are recommended for initial treatment 1
• For adults receiving very high-dose glucocorticoids (prednisone ≥30 mg/day and cumulative dose >5 gm in 1 year), oral bisphosphonates are preferred over IV bisphosphonates, teriparatide, or denosumab 1

Cancer-Related Bone Loss

• Bone-modifying agents (oral bisphosphonates, IV bisphosphonates, or subcutaneous denosumab) are recommended for cancer patients with osteoporosis or at high risk of fracture 1
• Hormonal therapies for osteoporosis are generally avoided in patients with hormone-responsive cancers 1

Treatment Duration and Monitoring

• Bisphosphonate treatment should be reassessed after 5 years, with consideration for drug holidays based on individual risk factors 1
• Patients initially treated with anabolic agents should be transitioned to antiresorptive therapy to maintain bone gains 1
• Bone density should be monitored every 24 months in cancer patients with elevated fracture risk, with more frequent monitoring (12 months) if risk factors change significantly 1

Common Pitfalls and Caveats

• Untreated osteoporosis can lead to a cycle of recurrent fractures, resulting in disability and premature death 6
• Despite available treatments, many high-risk patients are not diagnosed or treated after fractures 6
• Even when normal BMD is achieved with treatment, the diagnosis of osteoporosis persists, and ongoing monitoring and interventions remain necessary 6
• Medication adherence is critical for fracture prevention; healthcare providers should emphasize its importance 4
• Generic medications should be prescribed when possible to improve affordability and adherence 1