What are the guidelines for managing osteoporosis?

Osteoporosis Management Guidelines

The management of osteoporosis requires comprehensive risk assessment, appropriate diagnostic testing, and a combination of non-pharmacological and pharmacological interventions tailored to fracture risk, with bisphosphonates or denosumab as first-line therapy for high-risk patients. 1, 2

Risk Assessment and Diagnosis

• FRAX is the recommended tool for assessing fracture risk and establishing intervention thresholds, with thresholds being age-dependent 2
• Bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA) should be performed in all women 65 years and older, postmenopausal women younger than 65 with risk factors, and patients with nonmetastatic cancer 1
• A female reference database should be used for densitometric diagnosis of osteoporosis in men 3, 2
• Trabecular bone score, used with BMD and FRAX probability, provides additional information for fracture risk assessment 2
• All individuals with a prior fragility fracture should be considered for treatment with anti-osteoporosis medications 2

High-Risk Factors for Osteoporotic Fractures

• Advanced age, current cigarette smoking, excessive alcohol consumption 3
• History of prior nontraumatic fractures in adulthood 3, 2
• Hypogonadism, impaired mobility, increased risk for falls 3
• Long-term exposure to glucocorticoids 3, 4
• Low body weight, parental history of hip fracture 3
• Postmenopausal status 3
• Cancer treatment-related bone loss (aromatase inhibitors, antiandrogens, GnRH agonists) 3, 1

Non-Pharmacological Management

• Ensure adequate calcium intake of 1,000-1,200 mg/day through diet or supplements 1, 2, 5
• Optimize vitamin D intake with 800-1,000 IU/day, targeting serum levels ≥20 ng/ml 1, 2
• Implement a multi-component exercise program including:
  • Weight-bearing exercises 1, 5
  • Resistance/strength training 1, 2
  • Balance training to reduce fall risk 1, 2
  • Flexibility/stretching exercises 1
• Exercise has been shown to reduce the risk of falls by 23% 3
• Encourage smoking cessation and limit alcohol consumption 2, 6
• Implement fall prevention strategies 1, 4
• Ensure adequate protein intake, as higher levels than the recommended daily allowance may benefit skeletal health 3

Pharmacological Management

Treatment Thresholds

• Pharmacologic therapy should be offered to patients with:
  • T-scores of -2.5 or less in the femoral neck, total hip, or lumbar spine 1
  • 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures based on FRAX 1, 4
  • History of prior osteoporotic fracture 2
  • Very high risk of fracture 2

First-Line Treatments

• Oral bisphosphonates (alendronate, risedronate) are recommended as first-line therapy for most patients due to their safety, efficacy, and cost-effectiveness 2, 7
• Alendronate must be taken with plain water first thing upon arising, at least 30 minutes before food, beverages, or other medications 5
• Patients should remain upright for at least 30 minutes after taking alendronate to reduce the risk of esophageal irritation 5

Alternative and Second-Line Treatments

• Intravenous bisphosphonates (zoledronate) or denosumab are recommended for patients who cannot tolerate oral bisphosphonates or at very high fracture risk 1, 2
• Denosumab is administered via 6-monthly subcutaneous injections and significantly improves BMD at multiple sites 2
• Sequential therapy starting with a bone-forming agent (teriparatide, abaloparatide) followed by an anti-resorptive agent should be considered for individuals at very high risk of fracture 2
• Raloxifene may be considered for postmenopausal women at risk for invasive breast cancer, but is not indicated for treatment of invasive breast cancer or reduction of recurrence risk 8

Special Populations

Men with Osteoporosis

• Serum total testosterone should be assessed as part of pre-treatment evaluation 2
• Appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone 2
• A multi-component exercise approach has demonstrated significant benefits for BMD in middle-aged and older men 3

Cancer Survivors

• Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss 3, 1
• Bisphosphonates or denosumab at osteoporosis-indicated dosages are preferred interventions 3
• Hormonal therapies are generally avoided in patients with hormone-responsive cancers 1
• Specific populations appropriate for bone-modifying agents include:
  • Premenopausal women receiving GnRH therapies 1
  • Postmenopausal women receiving aromatase inhibitors 1
  • Men receiving androgen deprivation therapy 1
  • Patients with history of bone marrow transplantation 1
  • Patients on chronic glucocorticoid use 1

Monitoring and Follow-up

• Repeat DXA every 2 years to monitor treatment response, but not more frequently than annually 1, 4
• Biochemical markers of bone turnover can be used to assess adherence to anti-resorptive therapy, measured at baseline and at 3 months 2
• Monitor for medication adherence, as up to 64% of men are non-adherent to bisphosphonate therapy by 12 months 3
• For patients prescribed medications that cause bone loss or whose BMD is near treatment threshold, BMD testing should be performed every 2 years 1

Common Pitfalls and Caveats

• Poor adherence to oral bisphosphonates significantly reduces treatment effectiveness 2, 6
• Taking alendronate with orange juice or coffee markedly reduces absorption 5
• Lying down within 30 minutes of taking oral bisphosphonates increases risk of esophageal irritation 5
• Vegetarian and vegan diets may potentially reduce BMD, requiring closer monitoring and supplementation 3
• Caloric restriction (but not intermittent fasting) has been associated with lower BMD 3
• Patients should be educated about osteoporosis to reduce stigma, particularly in men who may view it as a "female condition" 3