What are the treatment options for osteoporosis?

Treatment Options for Osteoporosis

Bisphosphonates should be used as first-line pharmacologic treatment for osteoporosis in both men and women due to their proven efficacy in reducing fracture risk, favorable safety profile, and cost-effectiveness. 1

First-Line Treatment Options

Oral Bisphosphonates

• Alendronate and risedronate are recommended as initial treatment due to high-quality evidence showing they reduce vertebral, nonvertebral, and hip fractures by approximately 50% in postmenopausal women 1, 2
• Available in daily, weekly, or monthly oral formulations, with once-weekly dosing (e.g., alendronate 70mg) improving patient convenience and adherence 3, 4
• Mechanism of action: inhibit osteoclast activity without directly affecting bone formation, leading to progressive gains in bone mass 3, 5
• Treatment duration should typically be limited to 5 years, after which clinicians should consider a drug holiday based on individual fracture risk assessment 1

Intravenous Bisphosphonates

• Zoledronic acid is an effective alternative for patients who cannot tolerate oral bisphosphonates or have adherence concerns 1, 6
• Reduces vertebral, nonvertebral, and hip fractures with less frequent dosing (typically annual infusion) 1, 6

Second-Line Treatment Options

Denosumab (RANK Ligand Inhibitor)

• Recommended for patients with contraindications to or adverse effects from bisphosphonates 1, 2
• Administered as a subcutaneous injection every 6 months 7
• Effectively reduces vertebral, nonvertebral, and hip fractures 1, 2
• Important caution: After discontinuation, patients must be transitioned to another antiresorptive agent to prevent rapid bone loss and rebound fractures 1, 8, 7

Anabolic Agents for Severe Osteoporosis

Teriparatide (Parathyroid Hormone Analog)

• Indicated for patients at high risk for fracture, especially those with severe osteoporosis or previous fractures 1, 2, 9
• Administered as daily subcutaneous injection for up to 2 years 9
• Increases bone formation and reduces vertebral and nonvertebral fractures 1, 9
• Must be followed by antiresorptive therapy after completion to maintain bone gains 1, 8

Romosozumab

• Newer anabolic agent that can be considered for very high-risk patients 1, 2
• Limited to 12 months of therapy, after which patients should transition to antiresorptive therapy 1, 10

Treatment Considerations for Special Populations

Men with Osteoporosis

• Bisphosphonates are recommended as first-line treatment, with denosumab as second-line therapy 1
• Evidence for treating men is more limited but supports similar approaches as for women 1

Glucocorticoid-Induced Osteoporosis

• Oral bisphosphonates are recommended as initial treatment 2, 8, 9
• Teriparatide is FDA-approved for this indication in patients at high fracture risk 9

Adjunctive Therapies

Calcium and Vitamin D

• Adequate calcium (1000-1200 mg daily) and vitamin D (600-800 IU daily) intake should be part of all osteoporosis treatment regimens 1, 2, 8
• Serum vitamin D levels should be maintained at least 20 ng/mL (50 nmol/L) 2

Non-Pharmacologic Interventions

• Regular weight-bearing, muscle-strengthening, and balance exercises are recommended 2, 8
• Fall prevention strategies should be implemented, including vision assessment, medication review, and home safety evaluation 2
• Smoking cessation and limiting alcohol consumption are strongly advised 2

Treatment Duration and Monitoring

• Bisphosphonate treatment should be reassessed after 5 years, with consideration for drug holidays based on individual risk factors 1
• Patients initially treated with anabolic agents should be transitioned to antiresorptive therapy to maintain bone gains 1, 2, 8
• Generic medications should be prescribed when possible to improve affordability and adherence 1, 2

Treatments to Avoid

• Menopausal estrogen therapy or menopausal estrogen plus progestogen therapy is not recommended for osteoporosis treatment due to increased risk of cerebrovascular accidents and venous thromboembolic events 1
• Raloxifene is generally not recommended as first-line therapy due to increased risk of serious cardiovascular events, thromboembolic events, and cerebrovascular death 1