Osteoporosis Treatment Guidelines
Oral bisphosphonates are strongly recommended as first-line treatment for adults with high or very high fracture risk, while anabolic agents like teriparatide are conditionally recommended for very high-risk patients. 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 and BMD testing 1
- For patients ≥40 years, FRAX assessment should be included in risk stratification; for prednisone doses >7.5 mg/day, FRAX fracture risk should be adjusted upward (multiply by 1.15 for major osteoporotic fracture risk and 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
- Osteoporosis is diagnosed by a T-score of -2.5 or less or the presence of a fragility fracture 2
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
- Weight reduction if overweight/obese 3
- Smoking cessation and moderation of alcohol intake 3, 4
- Fall prevention strategies for older adults 5
Pharmacological Treatment Based on Risk Stratification
First-Line Therapy
- Oral bisphosphonates are strongly recommended as first-line treatment for adults with high or very high fracture risk 1
- For very high-risk patients (defined as having a history of osteoporotic fracture or multiple risk factors for fracture), anabolic agents like teriparatide are conditionally recommended over antiresorptive agents 1, 6
Alternative Options
- For adults ≥40 years with moderate fracture risk, options include:
- Oral bisphosphonates
- IV bisphosphonates
- Denosumab
- PTH/PTHrP agents (teriparatide) 1
Special Populations
- For men with osteoporosis, treatment recommendations are similar to those for women, with oral bisphosphonates as first-line therapy 1
- For glucocorticoid-induced osteoporosis, teriparatide is FDA-approved for men and women with osteoporosis associated with sustained systemic glucocorticoid therapy (daily dosage equivalent to 5 mg or greater of prednisone) at high risk for fracture 6
- Teriparatide has been shown to increase lumbar spine BMD by 7.2% from baseline to endpoint in patients with glucocorticoid-induced osteoporosis 6
Treatment Duration and Monitoring
- Fracture risk should be reassessed every 1-3 years 1
- For patients on denosumab or anabolic agents, sequential therapy with an antiresorptive agent is recommended to prevent rebound bone loss after discontinuation 1, 7
- Teriparatide treatment should be administered immediately following removal from refrigeration and stored at 2°C to 8°C (36°F to 46°F) at all times 6
- Each teriparatide injection delivery device can be used for up to 28 days 6
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
- Not considering sequential therapy after discontinuing denosumab, which can lead to rapid bone loss 1, 7
- Delaying treatment in high-risk patients, as bone loss occurs rapidly within the first 3-6 months of glucocorticoid therapy 1
- Poor medication adherence - data indicates that 30%-50% of patients do not take their osteoporosis medication correctly 4
- Stopping denosumab without starting an alternative therapy, which increases risk of vertebral fractures 7
- Failing to monitor for potential side effects of treatments, such as: