What are the recommended management options for osteoporosis?

Management of Osteoporosis

Diagnostic Assessment and Risk Stratification

All women ≥65 years and postmenopausal women <65 years with risk factors should undergo bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA) of the spine, hip, and femoral neck. 1

• Men ≥70 years and younger men with clinical risk factors should also be screened 1, 2
• Calculate 10-year fracture risk using the FRAX tool, which incorporates BMD and clinical risk factors (age, sex, prior fractures, falls, low body weight, parental hip fracture history, glucocorticoid use, smoking, alcohol consumption) 1, 3
• Obtain lateral spine X-rays to identify existing vertebral fractures, which increase future vertebral fracture risk 5-fold and hip fracture risk 2-fold 4
• Repeat DXA every 2 years to monitor treatment response, or annually if medically indicated 1

Non-Pharmacological Management (Foundation for All Patients)

Every patient with osteoporosis must receive calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) supplementation, targeting serum 25(OH)D levels ≥30-50 ng/mL. 5, 1

• Engage in regular weight-bearing exercises combined with resistance training and balance exercises for at least 30 minutes daily 1, 4
• Implement fall prevention strategies including balance training, home safety assessment, and vision checks 1
• Smoking cessation is mandatory 5, 1
• Limit alcohol to ≤2 servings per day 5
• Maintain weight in the recommended range 1

Pharmacological Treatment Thresholds

Initiate pharmacological therapy for patients with:

• T-score ≤-2.5 at femoral neck, total hip, or lumbar spine 1, 3
• History of hip or vertebral fracture 3, 2
• FRAX-calculated 10-year probability ≥20% for major osteoporotic fractures OR ≥3% for hip fractures 1, 3

First-Line Pharmacological Treatment

Oral bisphosphonates (alendronate) are the first-line therapy for most patients due to proven efficacy, safety profile, and cost-effectiveness. 5, 1, 3

Bisphosphonate Administration (Critical for Efficacy)

• Take on an empty stomach first thing in the morning with a full glass (6-8 ounces) of plain water 6
• Take at least 30 minutes before any food, beverage, or other medication 6
• Remain upright (do not lie down) for at least 30 minutes after taking 6
• Do not chew or suck the tablet due to risk of oropharyngeal ulceration 6
• If a weekly dose is missed, take it the morning after remembering, then return to the original schedule 6

Expected Outcomes with Bisphosphonates

• Reduce vertebral fractures by 52 per 1,000 person-years 3
• Reduce hip fractures by 6 per 1,000 person-years 3
• Continue treatment for at least 3-5 years if fracture risk remains elevated 4

Alternative Antiresorptive Therapy

Denosumab (subcutaneous injection every 6 months) is indicated for patients who cannot tolerate oral bisphosphonates or have contraindications. 1, 7

Critical Denosumab Warnings

• Perform dental screening before initiation to reduce osteonecrosis of the jaw risk 4, 7
• Never stop, skip, or delay denosumab without transitioning to another therapy—this dramatically increases vertebral fracture risk, including multiple simultaneous spine fractures 7
• Monitor for serious infections (skin, abdomen, bladder, ear, endocarditis) as denosumab affects immune function 7
• Watch for unusual thigh bone fractures 7

Anabolic Therapy for Very High-Risk Patients

For patients at very high fracture risk (recent vertebral fractures, hip fracture with T-score ≤-2.5, multiple fractures), initiate anabolic agents (teriparatide, abaloparatide, or romosozumab) followed by antiresorptive therapy. 3, 2

• Anabolic agents are conditionally recommended over antiresorptives for very high-risk patients 5
• Teriparatide increases lumbar and hip BMD and decreases vertebral fractures compared to alendronate in glucocorticoid-induced osteoporosis 5
• Always follow anabolic therapy with an antiresorptive agent to maintain gains 3, 8

Special Population: Glucocorticoid-Induced Osteoporosis

For adults ≥40 years taking prednisone ≥2.5 mg/day for >3 months with high or very high fracture risk, strongly recommend osteoporosis therapy in addition to calcium and vitamin D. 5

• Adjust FRAX scores by multiplying by 1.15 for major osteoporotic fractures and 1.2 for hip fractures if prednisone dose >7.5 mg/day 4
• Oral bisphosphonates are strongly recommended as first-line for high/very high risk patients 5
• For very high risk, conditionally recommend PTH/PTHrP (teriparatide) over bisphosphonates 5

Monitoring and Adherence

Repeat DXA every 2 years to assess treatment response, but not more frequently than annually. 1

• Assess medication adherence at every visit—up to 64% of patients are non-adherent to bisphosphonates by 12 months 1, 4
• Monitor for symptoms of esophageal problems with oral bisphosphonates (difficulty swallowing, retrosternal pain, new/worsening heartburn)—if present, stop medication and contact physician immediately 6
• Utilize fracture liaison services when available, which increase medication initiation and adherence from 17% to 38% and reduce subsequent fracture rates 3

Common Pitfalls to Avoid

• Never allow patients to take bisphosphonates with coffee, orange juice, or other beverages—this markedly reduces absorption 6
• Do not discontinue denosumab without transitioning to another agent 7
• Do not use anabolic agents after prolonged antiresorptive therapy—the bone anabolic effect is blunted 5
• Ensure adequate calcium and vitamin D before starting any osteoporosis medication 5, 1