What are the management options for osteoporosis?

Management of Osteoporosis

The management of osteoporosis should follow a structured approach that includes risk assessment, non-pharmacological interventions, and pharmacological therapy, with bisphosphonates or denosumab as first-line agents for patients at high fracture risk. 1, 2

Risk Assessment and Diagnosis

• Bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA) is recommended for women aged 65 and older, postmenopausal women younger than 65 with risk factors, and patients with cancer treatments that may cause bone loss 1
• Osteoporosis is defined as a BMD T-score ≤ -2.5 at the femoral neck, lumbar spine, or total hip 3
• Fracture risk assessment should include the FRAX tool to quantify risk beyond BMD alone, with treatment thresholds of 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20% 3, 1
• Patients with a history of fragility fracture should be considered for treatment without the need for BMD measurement 2

Non-Pharmacological Interventions

• All patients should be counseled on adequate calcium intake (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) through diet or supplements 3, 1
• A multi-component exercise approach is recommended, including:
  • Weight-bearing exercises 1, 4
  • Balance training to reduce fall risk 1, 2
  • Resistance/progressive strengthening exercises 1, 5
• Lifestyle modifications should include:
  • Smoking cessation 3, 2
  • Limiting alcohol consumption (1-2 drinks per day maximum) 3, 2
  • Fall prevention strategies (home safety assessment, vision checks) 2, 6
  • Maintaining healthy body weight 2, 4

Pharmacological Treatment

Indications for Treatment

• Pharmacologic therapy should be offered to patients with:
  • T-scores ≤ -2.5 in the femoral neck, total hip, or lumbar spine 1, 7
  • 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures based on FRAX 1, 2
  • History of fragility fracture 2, 6
  • Significant osteopenia (T-score between -1.0 and -2.5) with additional risk factors 3, 2

First-Line Therapy

• Bisphosphonates (oral or IV) are recommended as first-line therapy for most patients due to their safety, efficacy, and cost-effectiveness 1, 8
  • Alendronate inhibits osteoclast activity without directly affecting bone formation 8, 9
  • Bisphosphonates reduce urinary markers of bone resorption by 50-70% 8, 7
  • Treatment leads to progressive gains in bone mass 8, 6

Alternative Therapies

• Denosumab (subcutaneous injection every 6 months) is an alternative for patients who:
  • Cannot tolerate bisphosphonates 1, 10
  • Are at high risk for fracture 1, 10
  • Have severe renal impairment 10, 9
• Teriparatide (anabolic agent) may be considered for:
  • High-risk patients 2, 7
  • Those with therapeutic failure on antiresorptive agents 7, 9
• Selective estrogen receptor modulators (SERMs) are an option for patients with lower fracture risk, particularly those concerned about spine fractures 2, 9

Special Populations

Cancer Survivors

• Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss 3, 1
• Specific populations appropriate for bone-modifying agents include:
  • Premenopausal women receiving GnRH therapies 3, 1
  • Postmenopausal women receiving aromatase inhibitors 3, 1
  • Men receiving androgen deprivation therapy 3, 1
  • Patients with history of bone marrow transplantation 3, 1

Glucocorticoid-Induced Osteoporosis

• For patients on glucocorticoids, fracture risk should be adjusted by 1.15 for major osteoporotic fracture risk and 1.2 for hip fracture risk if prednisone dose is >7.5 mg/day 2, 8
• Clinical fracture risk reassessment should be performed every 12 months for patients on glucocorticoids 2, 8

Monitoring

• Repeat DXA every 2 years to monitor treatment response 3, 1
• BMD assessment should not be conducted more frequently than annually 3, 1
• Monitor for medication adherence, as up to 64% of patients are non-adherent to bisphosphonate therapy by 12 months 1, 6

Common Pitfalls to Avoid

• Failing to identify and treat secondary causes of osteoporosis (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 2, 4
• Poor adherence to preventive therapies is common; only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 2, 6
• Discontinuing denosumab without follow-up therapy can lead to increased risk of vertebral fractures due to rebound bone turnover 10, 7
• Not recognizing serious but rare side effects of bone-modifying agents:
  • Osteonecrosis of the jaw with bisphosphonates and denosumab 10, 9
  • Atypical femur fractures with long-term bisphosphonate use 10, 9