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, while anabolic agents like teriparatide are conditionally recommended over antiresorptives 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, adjust FRAX fracture risk 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 patients 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, 2
  • Smoking cessation and moderation of alcohol intake 2, 3
  • Weight management for those who are overweight or obese 2

Pharmacological Treatment Algorithm

First-Line Treatment Options:

1. For high or very high fracture risk patients:

   • Oral bisphosphonates are strongly recommended as first-line therapy 1

2. For very high-risk patients (history of osteoporotic fracture or multiple risk factors):

   • Anabolic agents (teriparatide) are conditionally recommended over antiresorptive agents 1, 4
   • Teriparatide is FDA-approved for postmenopausal women with osteoporosis at high risk for fracture, men with primary or hypogonadal osteoporosis at high risk for fracture, and patients with glucocorticoid-induced osteoporosis 4

3. For moderate fracture risk patients ≥40 years:

   • Treatment options include oral bisphosphonates, IV bisphosphonates, denosumab, or PTH/PTHrP agents 1
   • Denosumab is FDA-approved for treatment of osteoporosis in postmenopausal women at high risk for fracture 5

Special Populations:

• Glucocorticoid-induced osteoporosis:

  • Teriparatide has demonstrated significant increases in BMD (7.2% at lumbar spine, 3.6% at total hip, and 3.7% at femoral neck) 4
  • Treatment should begin promptly as bone loss occurs rapidly within the first 3-6 months of glucocorticoid therapy 1

• Men with osteoporosis:

  • Treatment recommendations are similar to those for women, with oral bisphosphonates as first-line therapy 1
  • Teriparatide is approved to increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture 4

Treatment Duration and Monitoring

• Reassess fracture risk 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, 2
• Each teriparatide delivery device can be used for up to 28 days, then should be discarded even if it still contains unused solution 4

Important Considerations and Pitfalls

• Medication adherence: 30-50% of patients do not take their osteoporosis medication correctly, which significantly reduces effectiveness 3
• Denosumab discontinuation: Failure to provide sequential therapy after stopping denosumab can lead to rapid bone loss 1, 5
• FRAX calculation adjustment: Not adjusting FRAX calculations for glucocorticoid use will underestimate fracture risk 1
• Overlooking vertebral fractures: Asymptomatic vertebral fractures significantly increase future fracture risk and should be identified through imaging 1
• Potential side effects to monitor:
  • Denosumab: serious infections, skin problems, severe jaw bone problems (osteonecrosis), and unusual thigh bone fractures 5
  • Teriparatide: hypercalcemia and orthostatic hypotension 4