From the Guidelines
Management of osteoporosis with a current fracture should prioritize pharmacological treatment with bisphosphonates, such as alendronate or risedronate, as first-line agents due to their efficacy in reducing the risk of vertebral, non-vertebral, and hip fractures, as well as their tolerability and low cost. When considering the management of osteoporosis in patients with a current fracture, several key points must be addressed to optimize outcomes in terms of morbidity, mortality, and quality of life.
Key Considerations
- Pharmacological Treatment: The choice of pharmacological agent is crucial. Bisphosphonates, including alendronate and risedronate, are recommended as first-line treatments because they have been shown to reduce the risk of vertebral, non-vertebral, and hip fractures, and are generally well-tolerated and cost-effective 1.
- Alternative Agents: For patients who cannot tolerate oral bisphosphonates, alternatives such as zoledronic acid (intravenous) or denosumab (subcutaneous) may be considered. Anabolic agents like teriparatide are options for patients with very severe osteoporosis 1.
- Duration of Treatment: Typically, these drugs are prescribed for 3–5 years, with the possibility of extension in patients who remain at high risk of fractures. However, recent evidence suggests that prolonging bisphosphonate therapy beyond 5 years may not provide additional benefits for non-vertebral fractures and could increase the risk of long-term harms 1.
- Lifestyle Modifications: Adequate calcium and vitamin D intake, exercise, and counseling for fall prevention are essential components of osteoporosis management 1.
- Monitoring and Follow-Up: Regular monitoring of bone mineral density and adherence to treatment, as well as systematic follow-up, are critical for optimizing outcomes and preventing subsequent fractures 1.
Implementation
- First-Line Pharmacological Agents: Alendronate (70 mg weekly) or risedronate (35 mg weekly) should be considered as initial pharmacological treatments.
- Calcium and Vitamin D Supplementation: Ensure adequate intake of calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) to support bone health.
- Fall Prevention: Implement strategies to prevent falls, including home safety assessments, balance training, and review of medications that may increase fall risk.
- Regular Monitoring: Schedule regular follow-ups to assess treatment adherence, bone mineral density, and to adjust the treatment plan as necessary.
From the FDA Drug Label
1 Treatment of Postmenopausal Women with Osteoporosis at High Risk for Fracture TYMLOS is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture (defined as a history of osteoporotic fracture or multiple risk factors for fracture), or patients who have failed or are intolerant to other available osteoporosis therapy In postmenopausal women with osteoporosis, TYMLOS reduces the risk of vertebral fractures and nonvertebral fractures.
1 Treatment of Postmenopausal Women with Osteoporosis at High Risk for Fracture EVENITY is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy.
The management of osteoporosis with a current fracture may include treatment with abaloparatide (TYMLOS) or romosozumab (EVENITY), as both are indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, including those with a history of osteoporotic fracture.
- Abaloparatide (TYMLOS) is administered subcutaneously once daily at a dose of 80 mcg.
- Romosozumab (EVENITY) is administered subcutaneously once every month at a dose of 210 mg. Both treatments should be used in conjunction with supplemental calcium and vitamin D if dietary intake is inadequate 2, 3.
From the Research
Management of Osteoporosis with a Current Fracture
The management of osteoporosis with a current fracture involves several treatment options, including:
- Antiresorptive drugs, such as bisphosphonates and the RANKL inhibitor denosumab, which increase bone mineral density (BMD) and reduce the risk of vertebral, nonvertebral, and hip fractures 4
- Anabolic therapy with teriparatide, which has been shown to be superior to bisphosphonates in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 4
- Treatment with the sclerostin antibody romosozumab, which increases BMD more profoundly and rapidly than alendronate and reduces the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis 4
- Calcium and vitamin D supplementation, which is essential for maintaining bone health and may be beneficial in treating compromised fracture healing in osteoporotic patients 5
Treatment Strategies
Treatment strategies for osteoporosis with a current fracture may include:
- Sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, which may provide better long-term fracture prevention 4
- A "drug holiday" after 5-10 years of bisphosphonate treatment, which may be considered based on fracture risk and pharmacokinetics of the bisphosphonate used 6, 7
- Reappraisal of ongoing use of bisphosphonates after about 5 years, with consideration of the benefit-risk balance and potential for atypical femoral fractures 7
Safety Considerations
Safety considerations for osteoporosis treatment include:
- Rare side effects, such as osteonecrosis of the jaw, musculoskeletal complaints, and atypical fractures, which have been associated with bisphosphonate use 6, 7, 8
- The potential for calcium supplements to cause adverse effects, such as kidney stones and hardening of arteries, which may outweigh their benefits in some patients 7, 8
- The importance of weighing the benefits and risks of treatment, particularly in patients at low risk of fracture, and considering the cost-effectiveness of treatment 8