What is the recommended treatment for a 71-year-old female with osteoporosis in the AP spine, osteopenia in the femoral neck, and mild osteopenia in the total hip?

From the Guidelines

For a 71-year-old female with osteoporosis in the AP spine, osteopenia in the femoral neck, and mild osteopenia in the total hip, I strongly recommend starting bisphosphonate therapy, specifically alendronate 70mg orally once weekly, to reduce the risk of hip and vertebral fractures. This recommendation is based on the strongest and most recent evidence from the American College of Physicians guideline update 1, which suggests that pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab is beneficial for preventing further bone loss and reducing the risk of initial or subsequent fractures in postmenopausal women with osteoporosis. The patient's T-score of -2.5 at the AP spine indicates osteoporosis, and her age puts her at significant risk for fracture. Bisphosphonates, such as alendronate, work by inhibiting osteoclast activity, reducing bone resorption, and increasing bone mineral density. Key points to consider when prescribing bisphosphonates include:

• Ensuring proper administration, such as taking the medication first thing in the morning with a full glass of water and remaining upright for at least 30 minutes before eating or taking other medications
• Monitoring for potential side effects, such as mild gastrointestinal symptoms, and considering alternative options like risedronate, zoledronic acid, or denosumab if necessary
• Recommending calcium supplementation of 1000-1200mg daily and vitamin D 800-1000 IU daily to support bone health
• Encouraging weight-bearing exercises and balance training to reduce fall risk
• Periodically reassessing fracture risk after 3-5 years to determine if a drug holiday or continued therapy is appropriate. It's also important to note that while the evidence is strong for the use of bisphosphonates in women with osteoporosis, the guidelines also recommend considering patient preferences, fracture risk profile, and benefits, harms, and costs of medications when making treatment decisions 1. Additionally, recent guidelines suggest that vitamin D and calcium repletion should be ensured in all individuals above the age of 65 years, and that physical exercise and a balanced diet should be recommended to all individuals with osteoporosis 1.

From the FDA Drug Label

The safety and efficacy of once-daily teriparatide, median exposure of 19 months, were examined in a double-blind, multicenter, placebo-controlled clinical study of 1637 postmenopausal women with osteoporosis. Teriparatide increased lumbar spine BMD in postmenopausal women with osteoporosis. Statistically significant increases were seen at 3 months and continued throughout the treatment period Postmenopausal women with osteoporosis who were treated with teriparatide had statistically significant increases in BMD from baseline to endpoint at the lumbar spine, femoral neck, total hip, and total body

The recommended treatment for a 71-year-old female with osteoporosis in the AP spine, osteopenia in the femoral neck, and mild osteopenia in the total hip is teriparatide (20 mcg subcutaneously once daily), given the significant increases in BMD at these sites and reduction in fracture risk observed in postmenopausal women with osteoporosis in the clinical study 2.

• Key benefits of teriparatide include:
  • Increased lumbar spine BMD
  • Increased femoral neck BMD
  • Increased total hip BMD
  • Reduced risk of new vertebral fractures
  • Reduced risk of new nonvertebral fractures It is essential to note that all women in the study received 1000 mg of calcium and at least 400 IU of vitamin D per day, in addition to teriparatide.

From the Research

Treatment Options for Osteoporosis

The recommended treatment for a 71-year-old female with osteoporosis in the AP spine, osteopenia in the femoral neck, and mild osteopenia in the total hip may involve the use of bisphosphonates or denosumab, as these are commonly used medications for the treatment of osteoporosis 3.

Bisphosphonates

Bisphosphonates are considered first-line therapy for the treatment of most patients with osteoporosis, with proven efficacy to reduce fracture risk at the spine, hip, and other nonvertebral skeletal sites 4. However, bisphosphonates have been associated with rare adverse effects, such as osteonecrosis of the jaw and atypical femur fractures.

Denosumab

Denosumab is another option, which achieves greater suppression of bone turnover and greater increases of bone mineral density (BMD) at all skeletal sites, both in naïve and pretreated patients 3. Denosumab should be preferred in patients with impaired renal function.

Combination Therapy

Combination of teriparatide with denosumab or zoledronic acid may provide increased BMD gains at all sites 3. However, the optimal sequential treatment strategy is yet to be defined.

Considerations for Treatment

When considering treatment, factors such as age and vitamin D status may be important, as teriparatide-induced changes in BMD at the total hip may be dependent on age, and vitamin D status may influence the early anabolic effect to teriparatide 5.

Treatment Duration and Discontinuation

Bisphosphonates are embedded in the bone and continue to act for years after discontinuation, whereas denosumab discontinuation fully and rapidly reverses its effects on bone markers and BMD, and increases the risk for fractures 3. Therefore, denosumab discontinuation should be discouraged, especially in previously treatment-naïve patients, regardless of the conventional fracture risk. In case of discontinuation, other treatment, mainly bisphosphonates, should immediately follow.

• Bisphosphonates and denosumab are effective treatment options for osteoporosis
• Combination therapy with teriparatide may provide increased BMD gains
• Age and vitamin D status may influence treatment response
• Treatment duration and discontinuation should be carefully considered to minimize the risk of fractures 3, 4, 5