What is the treatment for osteoporosis?

Treatment of Osteoporosis

Start with oral bisphosphonates (alendronate or risedronate) as first-line pharmacologic treatment for all adults with osteoporosis, regardless of sex. 1, 2

Initial Pharmacologic Treatment

First-Line: Bisphosphonates

• Oral bisphosphonates (alendronate, risedronate) are the preferred initial treatment due to their proven efficacy in reducing vertebral and hip fractures, favorable safety profile, and significantly lower cost compared to other agents 1, 2
• Intravenous zoledronate is an alternative for patients who cannot tolerate oral formulations 2
• These medications work by inhibiting osteoclast activity and reducing bone resorption without directly affecting bone formation 3
• Prescribe generic formulations whenever possible to improve affordability and adherence 1, 2

Second-Line: Denosumab

• Use denosumab (RANK ligand inhibitor) only when patients have contraindications to or experience adverse effects from bisphosphonates 1, 2
• This is a subcutaneous injection given every 6 months 2
• Critical warning: After stopping denosumab, immediately transition patients to an antiresorptive agent to prevent rapid bone loss and rebound vertebral fractures 2

Essential Non-Pharmacologic Interventions (All Patients)

Calcium and Vitamin D

• Daily calcium intake: 1,000 mg for ages 19-50; 1,200 mg for ages 51 and older 2
• Daily vitamin D intake: 600 IU for ages 19-70; 800 IU for ages 71 and older 2
• Target serum vitamin D level of at least 20 ng/mL (50 nmol/L) 2

Lifestyle Modifications

• Regular weight-bearing and muscle-strengthening exercises to reduce fracture risk 1, 2
• Balance training exercises to prevent falls 2
• Smoking cessation and limiting alcohol to less than 3 drinks daily 1

Fall Prevention

• Conduct vision and hearing assessments 2
• Review all medications for those that increase fall risk 1, 2
• Perform home safety evaluation 2

Treatment Duration and Drug Holidays

Bisphosphonate Duration

• Consider stopping bisphosphonate treatment after 5 years unless the patient has strong indications for continuation (such as very high fracture risk, previous fracture on therapy, or very low bone density) 1, 2
• Continuing beyond 5 years reduces vertebral fractures but not other fractures, while increasing risk of osteonecrosis of the jaw and atypical femoral fractures 1
• Individualize drug holiday decisions based on baseline fracture risk, medication type and bone half-life, and potential harms from discontinuation 1

Anabolic Agents (High-Risk Patients)

When to Use Anabolic Therapy

• Reserve teriparatide, abaloparatide, or romosozumab for patients with severe osteoporosis, very high fracture risk, or previous vertebral fractures 2, 4, 5
• Consider as initial therapy in patients at very high risk rather than waiting for bisphosphonate failure 6, 5
• Teriparatide is FDA-approved for postmenopausal women at high risk, men with primary or hypogonadal osteoporosis at high risk, and patients with glucocorticoid-induced osteoporosis 4

Critical Transition After Anabolic Therapy

• Always transition patients to an antiresorptive agent (bisphosphonate or denosumab) after discontinuing anabolic therapy to preserve bone gains and prevent serious rebound vertebral fractures 1, 2
• This transition is mandatory, not optional 1

Special Populations

Men with Osteoporosis

• Use the same treatment algorithm as for postmenopausal women: bisphosphonates first-line, denosumab second-line 1, 2
• Evidence shows no differences in treatment benefits and harms by sex 1

Glucocorticoid-Induced Osteoporosis

• Oral bisphosphonates are recommended for initial treatment in patients receiving sustained glucocorticoid therapy (≥5 mg prednisone equivalent daily) 2, 4
• Teriparatide is indicated for those at high risk who fail or are intolerant to other therapies 4

Older Adults (>65 years)

• Carefully assess for polypharmacy and drug interactions that increase fall and fracture risk 1
• Individualize treatment selection based on comorbidities and concomitant medications 1

Important Safety Considerations

Bisphosphonate Adverse Effects

• Long-term use (>5 years) increases risk of osteonecrosis of the jaw and atypical femoral fractures, though absolute risk remains low 1, 2
• Contraindications include esophageal abnormalities, inability to remain upright for 30 minutes after dosing, hypocalcemia, and hypersensitivity 2

Teriparatide Warnings

• Do not use in children or young adults with open growth plates 4
• Avoid in patients with Paget's disease, bone cancer history, prior skeletal radiation, or conditions increasing bone cancer risk 4
• Instruct patients to sit or lie down if they experience lightheadedness or palpitations after injection 4
• Maximum treatment duration is 2 years due to theoretical osteosarcoma risk (seen in rat studies, not confirmed in humans) 4

Monitoring Adherence

• Encourage adherence to prescribed treatments as poor compliance is a major barrier to fracture prevention 1
• Provide patient education on proper administration technique, especially for oral bisphosphonates (take on empty stomach, remain upright 30 minutes) 2
• Reassess fracture risk periodically based on bone density, fracture history, and response to treatment 1