What are the non-pharmacological and pharmacological treatment plans for osteoporosis?

Non-Pharmacological and Pharmacological Treatment Plans for Osteoporosis

Bisphosphonates are strongly recommended as first-line pharmacologic treatment for patients with osteoporosis to reduce fracture risk, while non-pharmacological interventions including exercise, adequate calcium and vitamin D intake, and fall prevention should be implemented for all patients. 1

Non-Pharmacological Interventions

Exercise

• Regular weight-bearing and resistance exercises are strongly recommended to improve bone mineral density (BMD) and reduce fracture risk 2
• Aerobic, aquatic, and resistance exercises should be incorporated into treatment plans for patients with osteoporosis 1
• Multi-component exercise approaches have demonstrated significant benefits for BMD in both men and women 2
• Exercise reduces the risk of falls by 23%, providing additional protection against fracture 2

Nutrition

• Adequate calcium intake (800-1200 mg daily) is recommended for all patients with osteoporosis 2
• Vitamin D supplementation (800 IU daily) is recommended, especially for those at increased risk of deficiency or fracture 2
• A balanced diet rich in minerals, proteins, and antioxidants supports overall bone health 3

Fall Prevention

• Implementation of fall prevention strategies is essential, particularly in elderly patients 1
• Home safety assessment and modification should be considered for all patients with osteoporosis 4
• Evaluation for appropriate assistive devices (walking aids) should be conducted for patients with mobility issues 1

Other Non-Pharmacological Approaches

• Smoking cessation and limiting alcohol intake are recommended to prevent further bone loss 1
• Joint protection techniques and assistive devices may help manage symptoms in patients with osteoarthritis and osteoporosis 1
• Thermal modalities (heat/cold) can provide symptomatic relief for pain associated with osteoporosis 1

Pharmacological Treatment

First-Line Therapy

• Bisphosphonates (alendronate, risedronate, ibandronate, zoledronate) are strongly recommended as initial pharmacologic treatment for patients with primary osteoporosis 1
• Oral bisphosphonates are suggested as first-line therapy, with intravenous formulations as alternatives 2
• Treatment with bisphosphonates should typically be limited to 3-5 years, as extending beyond this period may increase risk of rare but serious adverse effects 2
• Common side effects include gastrointestinal issues with oral formulations and acute phase reactions with intravenous administration 1
• Long-term risks include osteonecrosis of the jaw and atypical femoral fractures 1

Second-Line Therapy

• Denosumab (RANK ligand inhibitor) is conditionally recommended as second-line treatment for patients with contraindications to bisphosphonates 1
• Denosumab has demonstrated significant improvements in BMD at the lumbar spine, femoral neck, and total hip 2
• Caution is needed regarding hypocalcemia, osteonecrosis of the jaw, atypical femoral fractures, and rebound bone resorption after discontinuation 1

For Very High-Risk Patients

• Anabolic agents such as teriparatide (recombinant PTH) or romosozumab (sclerostin inhibitor) are conditionally recommended for patients with very high fracture risk 1
• Teriparatide has shown significant improvements in BMD at the lumbar spine and femoral neck compared to placebo 2, 5
• Romosozumab followed by antiresorptive therapy has demonstrated increased BMD at the hip and spine 1
• Patients initially treated with anabolic agents should transition to an antiresorptive agent after discontinuation to preserve gains and prevent rebound bone loss 2

Special Considerations

Glucocorticoid-Induced Osteoporosis

• For patients beginning or continuing >3 months of glucocorticoid treatment, fracture risk assessment should be performed as soon as possible 1
• Pharmacologic treatment is strongly recommended for adults at medium, high, or very high fracture risk on glucocorticoids 1
• Choice between bisphosphonates, denosumab, or parathyroid hormone analogs should be made through shared decision-making 1
• Anabolic agents may be conditionally recommended as initial therapy for those with high and very high fracture risk on glucocorticoids 1

Chronic Kidney Disease

• In patients with mild to moderate CKD, anti-resorptive and anabolic agents increase BMD and lower fracture risk 1
• For patients with advanced CKD, careful consideration of potential adverse effects is needed, as many osteoporosis medications are used off-label in CKD G4-G5D 1
• Nonpharmacologic approaches are particularly important in CKD patients and should be implemented as first-step measures 1

Treatment Algorithm

1. Assessment: Evaluate fracture risk using clinical fracture assessment, bone mineral density testing, and Fracture Risk Assessment Tool (FRAX) if ≥40 years old 1

2. Non-pharmacological interventions: Implement for all patients regardless of fracture risk:

   • Exercise program (weight-bearing, resistance)
   • Adequate calcium and vitamin D intake
   • Fall prevention strategies
   • Lifestyle modifications (smoking cessation, limiting alcohol)

3. Pharmacological treatment:

   • For patients with osteoporosis or high fracture risk:
     • First-line: Bisphosphonates (oral preferred initially) 1
     • Second-line (if contraindications to bisphosphonates): Denosumab 1
     • For very high-risk patients: Consider anabolic agents (teriparatide or romosozumab) 1

4. Monitoring:

   • Assess treatment adherence regularly
   • Consider measuring bone turnover markers at baseline and at 3 months 2
   • Evaluate for adverse effects at each visit

5. Duration and Sequential Therapy:

   • Limit bisphosphonate treatment to 3-5 years initially 2
   • After anabolic therapy, transition to an antiresorptive agent 2
   • For patients on denosumab, avoid abrupt discontinuation without follow-up therapy 1