What are the guidelines for treating osteoporosis?

Osteoporosis Treatment Guidelines

Oral bisphosphonates are strongly recommended as first-line treatment for adults with high or very high fracture risk due to their established efficacy in reducing fractures, favorable safety profile, and cost-effectiveness. 1

Risk Assessment and Screening

• Initial fracture risk assessment should be performed as soon as possible for all adults beginning or continuing glucocorticoid therapy ≥2.5 mg/day for >3 months, including clinical fracture history, BMD testing with vertebral fracture assessment (VFA) or spine x-rays 1
• For patients ≥40 years, FRAX assessment should be included in risk stratification; if prednisone dose is >7.5 mg/day, FRAX fracture risk should be adjusted upward (multiply by 1.15 for major osteoporotic fracture risk and by 1.2 for hip fracture risk) 1
• BMD testing should be repeated every 1-3 years, with more frequent assessment for those on high-dose glucocorticoids or with history of fractures 1

Non-Pharmacological Management

• All patients should receive lifestyle modifications including:
  • Adequate calcium intake (1,000-1,200 mg/day) and vitamin D (600-800 IU/day, aiming for serum level ≥20-30 ng/ml) 1
  • Regular weight-bearing and resistance training exercises 1
  • Maintaining weight in recommended range 1, 2
  • Smoking cessation and limiting alcohol to 1-2 drinks per day 1, 2

Pharmacological Treatment Based on Risk Stratification

Adults ≥40 Years with High or Very High Fracture Risk

• First-line treatment: Oral bisphosphonates (strong recommendation) 1
• For very high-risk patients (prior fragility fracture, very high-dose glucocorticoids), anabolic agents (PTH/PTHrP like teriparatide) are conditionally recommended over antiresorptive agents 1, 3
• If oral bisphosphonates are not appropriate, alternative treatments in order of preference: 1
  • IV bisphosphonates
  • Denosumab
  • Teriparatide (particularly for very high-risk patients) 3, 4

Adults ≥40 Years with Moderate Fracture Risk

• Oral bisphosphonates are conditionally recommended 1
• Alternative options include IV bisphosphonates, denosumab, or PTH/PTHrP agents 1

Adults <40 Years with Moderate-to-High Fracture Risk

• Oral bisphosphonates are conditionally recommended if any of the following: 1
  • History of osteoporotic fracture
  • Z-score <-3 at hip or spine and prednisone ≥7.5 mg/day
  • ≥10% bone loss per year at hip or spine and prednisone >7.5 mg/day
• Alternative options if oral bisphosphonates not appropriate: 1
  • IV bisphosphonates
  • Teriparatide
  • Denosumab (use with caution in immunosuppressed patients)

Adults <40 Years with Low Fracture Risk

• Optimize calcium and vitamin D intake and lifestyle modifications only 1
• Pharmacological therapy not recommended unless risk factors change 1

Special Populations

• Women of childbearing potential at moderate-to-high risk:

  • Oral bisphosphonates are preferred if not planning pregnancy and using effective contraception 1
  • Teriparatide as second-line option 1, 3
  • IV bisphosphonates and denosumab should be used with extreme caution due to potential fetal risks 1

• Patients with organ transplants:

  • Follow age-related guidelines for non-transplant patients 1
  • Consider drug interactions with immunosuppressive agents 1, 4

Treatment Duration and Monitoring

• Reassess fracture risk every 1-3 years 1
• For patients on denosumab or anabolic agents (teriparatide, abaloparatide, romosozumab), sequential therapy with an antiresorptive agent is recommended to prevent rebound bone loss after discontinuation 1
• For men with osteoporosis, treatment recommendations are similar to those for women, with oral bisphosphonates as first-line therapy 1

Common Pitfalls to Avoid

• Failing to adjust FRAX calculations for glucocorticoid use, which underestimates fracture risk 1
• Overlooking asymptomatic vertebral fractures, which significantly increase future fracture risk 1
• Inadequate calcium and vitamin D supplementation, which can reduce effectiveness of osteoporosis medications 1, 2
• Not considering sequential therapy after discontinuing denosumab or anabolic agents, which can lead to rapid bone loss 1
• Delaying treatment in high-risk patients, as bone loss occurs rapidly within the first 3-6 months of glucocorticoid therapy 1