What are the management options for osteoporosis?

Management of Osteoporosis

The comprehensive management of osteoporosis should include both non-pharmacological interventions (lifestyle modifications, calcium and vitamin D supplementation) and pharmacological therapies (bisphosphonates as first-line, with alternatives including denosumab and anabolic agents for high-risk patients), tailored according to fracture risk assessment. 1

Diagnosis and Risk Assessment

• Bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA) is recommended for all women ≥65 years and younger postmenopausal women with risk factors 1
• Osteoporosis is diagnosed when BMD T-score is ≤-2.5 at the femoral neck, lumbar spine, or total hip 2
• FRAX calculator should be used to assess overall fracture risk beyond BMD alone 1
• Patients with existing vertebral fractures have a 5-fold increased risk of new vertebral fractures and 2-fold increased risk of hip fractures 2

Non-Pharmacological Management

Calcium and Vitamin D

• Ensure adequate calcium intake of 1,000-1,200 mg/day through diet or supplements 1
• Vitamin D supplementation of 800-1,000 IU/day is recommended to maintain serum levels ≥20 ng/ml 1
• These supplements are foundational but insufficient alone for treating established osteoporosis 3

Exercise and Physical Activity

• Regular weight-bearing, muscle-strengthening, and balance exercises are essential 2
• Adults should aim for at least 30 minutes of moderate physical activity daily 2
• Exercise reduces fall risk by 23% and improves BMD in middle-aged and older adults 1
• Recommended activities include tai chi, physical therapy, and dancing to improve balance 2

Lifestyle Modifications

• Avoid tobacco use and limit alcohol consumption 2
• Implement fall prevention strategies: correct vision/hearing problems, review medications affecting balance, improve home safety 2
• Consider hip protectors for patients at high risk of falling 2

Pharmacological Management

Treatment Thresholds

• Pharmacologic therapy should be offered to patients with: 1
  • T-scores ≤-2.5 in femoral neck, total hip, or lumbar spine
  • 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures based on FRAX
  • History of fragility fractures

First-Line Therapy

• Bisphosphonates (oral or IV) are first-line therapy for most patients with significant fracture risk 1, 3
• Oral bisphosphonates are preferred due to safety, cost, and efficacy 4
• Common options include alendronate, risedronate, and zoledronic acid 3

Alternative Therapies

• Denosumab (subcutaneous) is an alternative for patients at high risk of fracture or who cannot tolerate bisphosphonates 1
• Anabolic agents (teriparatide, abaloparatide, romosozumab) may be considered for high-risk patients or those with therapeutic failure on antiresorptives 3
• Selective estrogen receptor modulators (SERMs) like raloxifene can be considered for specific patients 3

Special Populations

Cancer Patients

• Cancer survivors may have additional risk factors from treatment-related bone loss 1
• Patients beginning cancer therapy that induces early menopause, reduces sex steroids, or includes glucocorticoids should undergo bone loss risk assessment 2
• Therapeutic intervention should be strongly considered in cancer patients with BMD T-score below -2.0 2

Men with Osteoporosis

• A female reference database should be used for densitometric diagnosis of osteoporosis in men 1
• Men receiving androgen deprivation therapy should be considered for bone-modifying agents 1
• Medication adherence should be closely monitored as up to 64% of men are non-adherent to bisphosphonate therapy by 12 months 1

Monitoring and Follow-up

• Repeat DXA every 2 years to monitor treatment response 1
• More frequent assessment (12-month follow-up) is reasonable when bone loss risks have changed significantly or after major therapeutic intervention 2
• BMD assessment should not be conducted more frequently than annually 1
• Regular assessment of medication adherence is crucial as 30-50% of patients do not take their medication correctly 5

Common Pitfalls and Caveats

• Underdiagnosis and undertreatment are common despite effective available therapies 6
• Patients often discontinue treatment prematurely, with most not remaining on treatment for >1 year 7
• Risk of subsequent fractures after initial fracture is grossly under-recognized 2
• Combination of antiresorptive and anabolic agents may increase BMD compared to monotherapy, but more data is needed regarding effects on fracture risk 3