What is the treatment for osteoporosis?

Treatment of Osteoporosis

Bisphosphonates (alendronate, risedronate, or zoledronate) are the first-line pharmacologic treatment for osteoporosis in both postmenopausal women and men, as they effectively reduce vertebral and hip fractures with an established safety profile and low cost. 1

Foundation Treatment for All Patients

Before initiating pharmacologic therapy, ensure all patients receive:

• Calcium supplementation: 1,000-1,200 mg daily for adults over 50 years 1
• Vitamin D supplementation: 600-800 IU daily, targeting serum levels ≥20 ng/mL 1, 2
• Weight-bearing exercise and muscle strengthening 1, 2
• Smoking cessation 1, 2
• Alcohol limitation to ≤2 servings per day 2
• Fall prevention counseling and evaluation 1

Pharmacologic Treatment Algorithm

First-Line: Oral Bisphosphonates

For postmenopausal women and men with primary osteoporosis, prescribe oral bisphosphonates as initial therapy 1, 2:

• Alendronate: 10 mg daily or 70 mg weekly 1, 3
• Risedronate: 5 mg daily, 35 mg weekly, or 150 mg monthly 1
• Zoledronic acid: 5 mg IV annually (alternative route if oral intolerance) 1

Bisphosphonates work by binding to bone hydroxyapatite and inhibiting osteoclast activity, reducing bone resorption without directly affecting bone formation 3. They reduce radiographic vertebral fractures by approximately 140 fewer per 1,000 treated patients over 2-3 years 1.

Critical prescribing requirements for oral bisphosphonates 3:

• Take on empty stomach with full glass of water
• Remain upright (sitting or standing) for at least 30 minutes after administration
• Contraindicated in patients with esophageal abnormalities or inability to remain upright
• Contraindicated with creatinine clearance <35 mL/min (for zoledronic acid) 1

Second-Line: Denosumab

If bisphosphonates are contraindicated or cause intolerable adverse effects, use denosumab 1:

• Dosing: 60 mg subcutaneously every 6 months 1
• RANK ligand inhibitor that reduces fracture risk 1
• Does not require renal dose adjustment 1

Very High-Risk Patients: Anabolic Agents First

For patients at very high fracture risk (prior vertebral fracture, multiple fractures, T-score ≤-3.0, or fracture on therapy), consider anabolic agents as initial treatment 2, 4:

Teriparatide 5:

• Dosing: 20 mcg subcutaneously daily for maximum 2 years
• Increases bone formation by stimulating osteoblasts
• Reduces vertebral and nonvertebral fractures 5
• Contraindications: Paget's disease, open epiphyses, prior skeletal radiation, history of osteosarcoma, malignancy prone to bone metastases 4, 5
• Common side effects: Orthostatic hypotension, lightheadedness, palpitations 5

Abaloparatide 4:

• May have better tolerability profile than teriparatide based on BMD data
• Long-term safety beyond clinical trials remains uncertain 4

Romosozumab 2:

• Consider for very high-risk patients
• Limited by cardiovascular contraindications

Alternative Agents

Raloxifene 1:

• 60 mg daily
• Reduces vertebral fractures in younger postmenopausal women
• Contraindicated with history of venous thromboembolism 1

Calcitonin 1:

• Reserved only for patients who cannot tolerate other treatments
• Weakest evidence for fracture reduction 1

Treatment Duration and Monitoring

Bisphosphonate Duration

Reassess bisphosphonate therapy after 5 years and consider discontinuation ("drug holiday") unless strong indication for continuation 1:

• Continuing beyond 5 years reduces vertebral fractures but increases long-term harm risk 1
• Decision to continue should be based on: current fracture risk, medication type and bone half-life, prior fracture history, and BMD trends 1

Monitoring Schedule

• BMD testing with vertebral fracture assessment: Every 1-2 years to assess treatment response 2
• Bone turnover markers: At baseline and 3 months for anabolic therapy to confirm response 4

Critical Transition After Anabolic Therapy

Always transition patients from anabolic agents (teriparatide, abaloparatide, romosozumab) to antiresorptive therapy (bisphosphonate or denosumab) immediately after discontinuation 1, 4:

• This prevents serious rebound bone loss and multiple vertebral fractures 1, 4
• Failure to transition results in rapid loss of bone gains 4

Special Populations

Men with Primary Osteoporosis

• Same treatment algorithm as postmenopausal women 1
• Bisphosphonates first-line, denosumab second-line 1

Glucocorticoid-Induced Osteoporosis

• Treat men and women on ≥5 mg prednisone equivalent daily at high fracture risk 5
• Multiply FRAX scores by 1.15 for major osteoporotic fracture and 1.2 for hip fracture 2

Older Adults (>65 years)

• Assess polypharmacy, fall risk, and drug interactions before selecting treatment 1
• Consider medications that may increase fall risk 1

Common Pitfalls to Avoid

Generic medication preference: Always prescribe generic formulations when available to reduce cost 1

Inadequate calcium/vitamin D: Ensure supplementation is adequate before and during pharmacologic therapy, as this is foundational to all treatment 1, 2

Premature bisphosphonate discontinuation: Do not stop before 5 years unless adverse effects occur 1

Forgetting post-anabolic transition: Never discontinue anabolic therapy without immediately starting antiresorptive therapy 1, 4

Ignoring contraindications: Screen for esophageal disorders before oral bisphosphonates, check renal function before zoledronic acid, and exclude osteosarcoma risk factors before teriparatide 1, 4, 3, 5