What is the best treatment approach for osteoporosis in a 70-year-old female?

Treatment of Osteoporosis in a 70-Year-Old Female

First-line pharmacologic treatment should be a bisphosphonate (alendronate, risedronate, or zoledronic acid) or denosumab, combined with calcium 1,200 mg daily and vitamin D 800 IU daily, for an initial 5-year treatment period. 1

Diagnostic Confirmation and Risk Assessment

Before initiating treatment, confirm the diagnosis with:

• DEXA scan showing T-score ≤ -2.5 establishes osteoporosis diagnosis 2, 1
• If T-score is between -1.0 and -2.5 (osteopenia), use FRAX to calculate 10-year fracture risk 2, 3
• Treat if FRAX shows ≥20% risk of major osteoporotic fracture OR ≥3% risk of hip fracture 2, 3
• Consider treatment even without osteoporosis on DEXA if patient has history of low-trauma fracture 2

First-Line Pharmacologic Options

Bisphosphonates are the preferred initial therapy based on high-quality evidence showing they reduce hip fractures by 50% and vertebral fractures by 47-56% over 3 years 2, 1, 4:

Oral Bisphosphonates:

• Alendronate 70 mg once weekly (most common choice) 2, 1
• Risedronate 35 mg once weekly 2
• Must be taken on empty stomach with full glass of water, remain upright for 30 minutes after dosing 2, 5
• Contraindicated if esophageal abnormalities or inability to stand/sit upright for 30 minutes 2

Alternative First-Line Options:

• Denosumab 60 mg subcutaneous every 6 months if bisphosphonates are contraindicated or not tolerated 1, 6
• Zoledronic acid 5 mg IV annually for patients with adherence concerns or GI intolerance 1

Essential Supplementation (All Patients)

• Calcium 1,200 mg daily 2, 1
• Vitamin D 800 IU daily (at age 71+) 2, 1
• Target serum vitamin D level ≥20 ng/mL 2

Lifestyle Modifications (All Patients)

• Weight-bearing exercise (walking, dancing) 2, 1
• Resistance training exercises (squats, push-ups) 4
• Balance exercises (heel raises, standing on one foot) to prevent falls 4
• Smoking cessation 2, 1
• Limit alcohol intake 2, 1

Treatment Duration and Monitoring

• Initial treatment duration: 5 years 1
• Do NOT monitor bone density during the initial 5-year period 1
• After 5 years, reassess fracture risk to determine if continuation is warranted 1, 3
• Consider discontinuation after 3-5 years in patients who become low fracture risk 3

Special Considerations for Denosumab

• Generally well-tolerated with favorable safety profile 1
• Critical warning: Discontinuation causes rebound bone loss and increased risk of multiple vertebral fractures 1, 6
• If stopping denosumab, MUST transition to a bisphosphonate to prevent rebound fractures 1
• Monitor for hypocalcemia, especially in patients with renal impairment 6

Adverse Effects to Monitor

Bisphosphonates:

• Short-term: Upper GI symptoms (abdominal pain, nausea, dyspepsia), influenza-like symptoms 3, 7
• Long-term (rare): Atypical femoral fractures, osteonecrosis of the jaw (risk increases with duration >5 years) 3, 4
• Hypocalcemia (nadir occurs ~10 days after dosing) 6

Denosumab:

• Mild GI symptoms, increased infection risk, rash/eczema 1
• Hypocalcemia (more common in renal impairment) 6

When to Consider Alternative Agents

Reserve anabolic agents (teriparatide, abaloparatide, romosozumab) for very high-risk patients 4, 8:

• Recent vertebral fractures
• Hip fracture with T-score ≤ -2.5
• Multiple fractures despite bisphosphonate therapy
• Severe osteoporosis (T-score < -3.0) 2

Raloxifene may be considered in younger postmenopausal women (not optimal for 70-year-old) 2

Calcitonin should only be used if all other options are contraindicated or not tolerated, as it has weaker efficacy data 2

Common Pitfalls to Avoid

• Do not skip calcium and vitamin D supplementation - pharmacologic therapy is less effective without adequate supplementation 2
• Ensure proper bisphosphonate administration technique to minimize GI adverse effects and maximize absorption 2, 5
• Never abruptly discontinue denosumab without transitioning to bisphosphonate 1
• Do not use proton pump inhibitors unnecessarily as they decrease calcium absorption and increase fracture risk 2
• Avoid SSRIs when possible as they increase bone loss and fracture risk 2

Treatment Algorithm Summary

1. Confirm diagnosis with DEXA (T-score ≤ -2.5) or calculate FRAX if T-score -1.0 to -2.5 2, 1
2. Start calcium 1,200 mg + vitamin D 800 IU daily 2, 1
3. Initiate bisphosphonate (alendronate 70 mg weekly preferred) or denosumab if contraindicated 1
4. Implement lifestyle modifications (exercise, smoking cessation, fall prevention) 2, 1, 4
5. Continue treatment for 5 years without bone density monitoring 1
6. Reassess fracture risk at 5 years to determine continuation 1