What are the treatment options for osteoporosis?

Treatment Options for Osteoporosis

Oral bisphosphonates are strongly recommended as first-line pharmacologic treatment for osteoporosis due to their favorable balance of benefits, harms, patient values and preferences, and cost compared to other medications. 1, 2

Diagnosis and Risk Assessment

• Dual energy x-ray absorptiometry (DEXA) should be performed in all women 65 years and older and in postmenopausal women younger than 65 years with risk factors 2
• Treatment is recommended for patients with a T-score of -2.5 or less or those with a history of fragility fracture 2
• For those with T-scores between -1.0 and -2.5, the FRAX calculator can assist in treatment decisions, with pharmacologic therapy recommended for those with a 10-year risk of major osteoporotic fracture of at least 20% or hip fracture risk of at least 3% 2

Non-Pharmacologic Interventions

• Optimize calcium intake: 1,000 mg daily for ages 19-50 and 1,200 mg daily for ages 51 and older 2
• Vitamin D supplementation: 600 IU daily for ages 19-70 and 800 IU daily for ages 71 and older, with a target serum level of at least 20 ng/mL (50 nmol/L) 2
• Regular weight-bearing, muscle-strengthening, and balance exercises are recommended to reduce fracture risk 2, 3
• Smoking cessation and limiting alcohol consumption to 1-2 drinks per day 1, 2
• Fall prevention strategies including vision/hearing assessment, medication review, and home safety evaluation 2

Pharmacologic Treatment Options

First-Line Treatment: Bisphosphonates

• Oral bisphosphonates (alendronate, risedronate) are strongly recommended as initial treatment for osteoporosis 1, 2
• Mechanism: Inhibit osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
• Available in daily, weekly, or monthly oral options, as well as intravenous formulations 2
• Contraindications: Esophageal abnormalities, inability to remain upright for 30 minutes, hypocalcemia, and hypersensitivity 2
• Long-term use (>5 years) may increase risk of osteonecrosis of the jaw and atypical femoral fractures 1, 2
• Clinicians should consider stopping treatment after 5 years unless there's a strong indication to continue 1, 2

Second-Line Treatment Options

• Denosumab (Prolia):

  • Recommended for patients with contraindications to or adverse effects from bisphosphonates 2
  • Mechanism: RANKL inhibitor that decreases osteoclast formation and activity 5
  • Administered as subcutaneous injection every 6 months 5
  • Important: After discontinuation, patients should be transitioned to an antiresorptive agent to prevent rapid bone loss 2, 3
  • Side effects: Potential for serious infections, skin problems, osteonecrosis of the jaw, and atypical femoral fractures 5

• Anabolic Agents (Teriparatide):

  • Indicated for patients at high risk for fracture or who have failed other osteoporosis therapy 6
  • Particularly beneficial for patients with severe osteoporosis or multiple fractures 2, 7
  • Mechanism: Stimulates new bone formation 6
  • After discontinuation, patients should be transitioned to an antiresorptive agent to maintain bone gains 1, 2

• Selective Estrogen Receptor Modulators (Raloxifene):

  • Can be a good option for younger postmenopausal women 2
  • Generally avoided in patients with hormone-responsive cancers 2

Special Populations

Glucocorticoid-Induced Osteoporosis

• For adults receiving glucocorticoid therapy (≥2.5 mg/day for >3 months), calcium and vitamin D supplementation plus lifestyle modifications are conditionally recommended 1
• For adults ≥40 years with high or very high fracture risk, oral bisphosphonates are strongly recommended 1
• For adults with very high fracture risk, PTH/PTHrP (teriparatide) is conditionally recommended over anti-resorptives 1
• For adults <40 years at moderate-to-high risk, oral bisphosphonates are preferred over IV bisphosphonates, teriparatide, or denosumab 1

Men with Osteoporosis

• Bisphosphonates are recommended as first-line treatment 2
• Denosumab is recommended as second-line therapy for those with contraindications to or adverse effects from bisphosphonates 2
• Teriparatide is indicated to increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture 6

Cancer Patients

• Bone-modifying agents (oral bisphosphonates, IV bisphosphonates, or subcutaneous denosumab) are recommended 2
• Hormonal therapies for osteoporosis are generally avoided in patients with hormone-responsive cancers 2

Treatment Duration and Monitoring

• Reassess bisphosphonate treatment after 5 years, with consideration for drug holidays based on individual risk factors 1, 2
• Patients initially treated with anabolic agents should be transitioned to antiresorptive therapy to maintain bone gains 1, 2
• Bone density should be monitored every 1-2 years depending on risk factors 1, 2
• Generic medications should be prescribed when possible to improve affordability and adherence 1, 2

Important Cautions

• Denosumab therapy should not be interrupted without switching to another therapy, as post-treatment bone loss can progress rapidly 3
• Patients who sustain fractures while undergoing osteoporosis therapy should be considered for specialist referral 3
• Women of childbearing potential should use effective birth control when taking bisphosphonates 1