What are the recommended management strategies for osteoporosis?

Comprehensive Management of Osteoporosis

Pharmacologic therapy should be offered to patients with T-scores of -2.5 or less in the femoral neck, total hip, or lumbar spine, or with a 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures based on FRAX assessment. 1, 2

Risk Assessment and Diagnosis

• 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
• FRAX tool should be used to quantify fracture risk beyond BMD alone, with treatment thresholds being a 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20% 3, 1
• A female reference database should be used for densitometric diagnosis of osteoporosis in men 1, 2
• Repeat DXA every 2 years or as clinically indicated to monitor treatment response, but not more frequently than annually 3, 1

High-Risk Factors for Osteoporotic Fractures

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

Non-Pharmacological Management

• Ensure adequate calcium intake of 1,000-1,200 mg/day through diet or supplements 3, 1, 2
• 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 3, 1
  • 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% 1
• Implement fall prevention strategies including:
  • Home safety assessment 3
  • Minimizing medications that increase fall risk 3
  • Vision assessment and correction 4
• Ensure adequate protein intake, as higher levels than the recommended daily allowance may benefit skeletal health 2
• Tobacco cessation and limiting alcohol consumption 3, 1

Pharmacological Management

First-Line Therapy

• Oral bisphosphonates (alendronate, risedronate) are recommended as first-line therapy for most patients due to their safety, efficacy, and cost-effectiveness 1, 2, 5
• Alendronate reduces bone resorption by inhibiting osteoclast activity, leading to progressive gains in bone mass 5
• Oral bisphosphonates have been shown to reduce vertebral fractures (risk difference, -52 per 1000 person-years) and hip fractures (risk difference, -6 per 1000 person-years) 6

Alternative Options

• 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
• Anabolic agents (teriparatide, abaloparatide, romosozumab) should be considered for very high-risk individuals (e.g., recent vertebral fractures, hip fracture with a T score of ≤-2.5 for BMD) 2, 6
• Teriparatide increases lumbar spine BMD by 7.2%, total hip BMD by 3.6%, and femoral neck BMD by 3.7% in patients with glucocorticoid-induced osteoporosis 7
• Hormonal therapies (e.g., estrogens) are generally avoided in patients with hormone-responsive cancers but may be offered along with other bone-modifying agents when clinically appropriate for patients without hormone-responsive cancers 1

Special Populations

Men with Osteoporosis

• Serum total testosterone should be assessed as part of pre-treatment evaluation in men with osteoporosis 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 1, 2

Cancer Survivors

• Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss 1, 2
• Bisphosphonates or denosumab at osteoporosis-indicated dosages are preferred interventions for cancer survivors 3
• 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 3, 1, 2
• 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 1, 2

Common Pitfalls and Caveats

• Poor adherence to oral bisphosphonates significantly reduces treatment effectiveness 2, 8
• Vegetarian and vegan diets may potentially reduce BMD, requiring closer monitoring and supplementation 2
• Caloric restriction (but not intermittent fasting) has been associated with lower BMD 2
• Patients should be educated about osteoporosis to reduce stigma, particularly in men who may view it as a "female condition" 2
• When using teriparatide, patients should be monitored for potential side effects including hypercalcemia and orthostatic hypotension 7
• Patients prescribed medications that cause bone loss or whose BMD is near treatment threshold should have BMD testing performed every 2 years 2