What are the guidelines for osteoporosis management?

From the Guidelines

Osteoporosis management should prioritize fracture risk assessment and treatment with bisphosphonates, such as alendronate or risedronate, as first-line therapy for men and women at high risk of fracture, as recommended by the most recent guidelines 1.

Key Recommendations

• Screening with bone mineral density testing is recommended for women aged 65 and older and men aged 70 and older, with earlier screening for those with risk factors like previous fractures, family history, or long-term steroid use.
• First-line treatment includes lifestyle modifications such as regular weight-bearing exercise, adequate calcium intake (1000-1200 mg daily), and vitamin D supplementation (800-1000 IU daily).
• Pharmacological treatment with bisphosphonates, such as alendronate (70 mg weekly) or risedronate (35 mg weekly), is recommended for men and women at high risk of fracture.
• For high-risk patients or those who cannot tolerate bisphosphonates, alternatives include denosumab (60 mg subcutaneously every 6 months), teriparatide or abaloparatide (daily subcutaneous injections for up to 2 years), or romosozumab (monthly injections for 1 year).

Treatment Considerations

• Treatment decisions should be based on fracture risk assessment using tools like FRAX, with therapy generally recommended for those with T-scores ≤ -2.5 or with osteoporotic fractures.
• Regular monitoring with follow-up bone density scans every 1-2 years during early treatment and then every 2-3 years is important to assess treatment effectiveness and guide ongoing management.
• The use of generic medications and consideration of patient preferences, fracture risk profile, and benefits, harms, and costs of medications are also important factors in treatment decisions, as highlighted in recent guidelines 1.

Additional Guidance

• Vitamin D and calcium repletion should be ensured in all men above the age of 65 years, and physical exercise and a balanced diet should be recommended to all men with osteoporosis, as recommended by recent evidence-based guidelines 1.
• Serum total testosterone should be assessed, as part of the pre-treatment assessment of men with osteoporosis, and appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone.

From the FDA Drug Label

Instruct patients to take supplemental calcium and vitamin D, if daily dietary intake is inadequate. Weight-bearing exercise should be considered along with the modification of certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors exist. Teriparatide injection is a prescription medicine used to: treat postmenopausal women who have osteoporosis who are at high risk for having broken bones (fractures) or who cannot use other osteoporosis treatments. increase the bone mass in men with primary or hypogonadal osteoporosis who are at high risk for having broken bones (fractures) or who cannot use other osteoporosis treatments treat both men and women with osteoporosis due to use of glucocorticoid medicines, such as prednisone, for several months, who are at high risk for having broken bones (fractures) or who cannot use other osteoporosis treatments.

The osteoporosis guidelines recommend that patients take supplemental calcium and vitamin D if their daily dietary intake is inadequate. Weight-bearing exercise and modification of certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, should also be considered.

• Teriparatide injection is used to treat postmenopausal women with osteoporosis who are at high risk for fractures.
• Alendronate sodium is used to treat osteoporosis, and patients should be instructed to take it with plain water and to swallow each tablet with a full glass of water. 2 and 3

From the Research

Osteoporosis Treatment Guidelines

• The most widely used medications for the treatment of osteoporosis are bisphosphonates and denosumab, both of which are antiresorptives that target the osteoclast and inhibit bone resorption 4.
• Denosumab achieves greater suppression of bone turnover and greater increases of bone mineral density (BMD) at all skeletal sites, but no superiority on fracture risk reduction has been documented so far 4.
• Bisphosphonates are generally considered safe, but have been correlated to rare adverse events, such as osteonecrosis of the jaw and atypical femoral fractures 4, 5.
• Denosumab should be preferred in patients with impaired renal function, and its discontinuation should be discouraged, especially in previously treatment-naïve patients, as it can lead to rapid reversal of its effects on bone markers and BMD, and increase the risk for fractures 4, 6.

Treatment Strategies

• Antiresorptive drugs, such as bisphosphonates and denosumab, are currently the most widely used osteoporosis medications, and can increase bone mineral density (BMD) and reduce the risk of vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis 5.
• Combination of teriparatide with denosumab or zoledronic acid can provide increased BMD gains at all sites 4.
• Sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, may provide better long-term fracture prevention, especially for patients with severe osteoporosis and high fracture risk 5, 6.

Lifestyle Modifications

• Calcium and vitamin D supplementation may benefit people with a high risk of deficiency, but may not be required in people without risk factors 6, 7.
• Impact and resistance exercises and physical activity can increase bone density and prevent falls 6, 7.
• Adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium 7.

Monitoring and Follow-up

• All patients will need ongoing monitoring and most will require some long-term therapy once started 6.
• The ongoing need for bisphosphonates should be assessed after five years, and treatment may then be interrupted in some patients, but denosumab therapy should not be interrupted without switching to another therapy 6.
• Specialist referral should be considered for patients who sustain fractures while undergoing osteoporosis therapy 6.