What is the optimal management of osteoporosis across different age groups?

Optimal Management of Osteoporosis Across Age Groups

For optimal management of osteoporosis across different age groups, oral bisphosphonates should be the first-line treatment for adults ≥40 years with high or very high fracture risk, while anabolic agents like teriparatide should be prioritized for very high-risk patients.1

Foundation for All Age Groups

• All patients should receive lifestyle modifications including adequate calcium intake (1,000-1,200 mg/day), vitamin D supplementation (600-800 IU/day, aiming for serum levels ≥30-50 ng/mL), regular weight-bearing exercise, smoking cessation, and limiting alcohol to ≤2 servings per day 1, 2
• Fracture risk assessment should include clinical fracture history, BMD testing, and for patients ≥40 years, FRAX calculation 1, 2
• BMD testing with vertebral fracture assessment (VFA) or spinal X-rays should be performed every 1-2 years to monitor treatment response 1, 2

Adults ≥40 Years with High/Very High Fracture Risk

• First-line treatment: Oral bisphosphonates (strong recommendation) due to their established efficacy in reducing vertebral and hip fractures, safety profile, and cost-effectiveness 1
• For very high-risk patients (recent vertebral fractures, multiple fractures, or T-score ≤-2.5): Consider anabolic agents (teriparatide, abaloparatide) over antiresorptive agents 1, 3
• Alternative options when oral bisphosphonates are not appropriate (in order of preference):
  • IV bisphosphonates 1
  • Teriparatide (particularly for very high risk) 1, 4
  • Denosumab 1
  • Raloxifene (only for postmenopausal women when other options aren't suitable) 1

Adults ≥40 Years with Moderate Fracture Risk

• Oral bisphosphonates are conditionally recommended over calcium and vitamin D alone 1
• Avoid romosozumab due to potential cardiovascular risks (myocardial infarction, stroke) 1
• Consider IV bisphosphonates, denosumab, or teriparatide if oral bisphosphonates aren't appropriate 1

Adults ≥40 Years with Low Fracture Risk

• Strongly recommended against osteoporosis medications due to limited benefit and potential harms 1
• Focus on calcium, vitamin D, and lifestyle modifications 1

Adults <40 Years with Moderate-to-High Fracture Risk

• Oral bisphosphonates are conditionally recommended over calcium and vitamin D alone 1
• Alternative options when oral bisphosphonates aren't appropriate:
  • IV bisphosphonates 1
  • Teriparatide 1, 4
  • Denosumab 1

Adults <40 Years with Low Fracture Risk

• Optimize calcium and vitamin D intake and implement lifestyle modifications rather than pharmacologic therapy 1, 5

Treatment Duration and Monitoring

• Consider stopping bisphosphonate treatment after 5 years unless there's a strong indication for continuation, as longer treatment reduces vertebral fractures but increases risk of long-term adverse effects 1
• For patients initially treated with anabolic agents, transition to an antiresorptive agent after discontinuation to preserve bone gains and prevent rebound bone loss 1, 6
• Reassess fracture risk every 1-3 years with BMD testing 1, 2

Special Considerations

• For glucocorticoid-induced osteoporosis: Adjust FRAX calculations upward (multiply by 1.15 for major osteoporotic fracture risk and by 1.2 for hip fracture risk) 2
• For older adults (>65 years): Consider polypharmacy, fall risk, and drug interactions when selecting treatment 1, 3
• For transgender persons: Consider history of gonadectomy, sex hormone therapy, and other risk factors when making treatment decisions 1

Common Pitfalls to Avoid

• Failing to recognize asymptomatic vertebral fractures, which significantly increase future fracture risk 2, 3
• Not considering sequential therapy after discontinuing denosumab or anabolic agents, leading to rapid bone loss 1, 2
• Delaying treatment in high-risk patients, as bone loss occurs rapidly within the first 3-6 months of glucocorticoid therapy 2, 5
• Poor medication adherence, which affects 30-50% of patients and compromises treatment efficacy 5