What are the symptoms and treatment options for osteoporosis?

Osteoporosis: Clinical Presentation and Management

Clinical Symptoms

Osteoporosis is typically a silent disease that produces no symptoms until a fracture occurs 1, 2, 3. The condition remains asymptomatic in most patients during its progression, making early detection through screening essential rather than waiting for clinical manifestations 2, 3.

When Fractures Occur

Once vertebral or other osteoporotic fractures develop, patients may experience:

• Back pain - the most common presenting symptom after vertebral compression fractures 1, 2, 4
• Loss of height - progressive height loss from vertebral compression 1, 4
• Postural changes and kyphosis (forward curvature of the spine) 1, 4
• Functional impairment and disability affecting daily activities 4
• Diminished quality of life 4, 5

Critical Clinical Context

Only one in three vertebral fractures is diagnosed clinically, as many occur without severe trauma and may be dismissed as routine back pain 4. This represents a major diagnostic pitfall - clinicians must maintain high suspicion for vertebral fractures in at-risk patients presenting with back pain, even without significant trauma history 4.

Diagnostic Approach

Who Should Be Screened

Bone mineral density (BMD) testing via dual-energy x-ray absorptiometry (DEXA) should be performed in high-risk individuals before fractures occur 1, 2, 3:

• Postmenopausal women 1, 2
• Men aged ≥50 years 1
• Anyone with prior fragility fracture (fracture from standing height or less) 1, 2
• Patients on long-term glucocorticoid therapy (≥3 months) 1, 3
• Individuals with multiple risk factors: low body weight, parental hip fracture history, current smoking, excessive alcohol use (≥3 drinks daily), rheumatoid arthritis, inflammatory bowel disease, chronic kidney or liver disease 1, 2, 5

Diagnostic Criteria

Osteoporosis is diagnosed when BMD T-score is ≤-2.5 at the femoral neck, lumbar spine, or total hip 1, 2. The T-score represents the number of standard deviations below the mean BMD of young healthy adults 1.

Low bone mass (osteopenia) is defined as T-score between -1.0 and -2.5 1.

Fracture Risk Assessment

Use the FRAX tool (Fracture Risk Assessment Tool) to calculate 10-year absolute fracture risk, combining clinical risk factors with BMD measurements 6, 2. This provides more accurate risk stratification than BMD alone, as BMD testing identifies less than half of patients who will eventually sustain osteoporotic fractures 1.

Treatment Recommendations

Non-Pharmacologic Management (All Patients)

Every patient should receive counseling on calcium and vitamin D supplementation, weight-bearing exercise, and fall prevention 1, 2, 5:

• Calcium intake: 1,000-1,200 mg daily 6, 2
• Vitamin D: 600-800 IU daily (higher doses if deficient) 6, 2
• Weight-bearing and muscle-strengthening exercises (30 minutes daily) - includes resistance exercises like squats and push-ups 6, 2
• Balance training (tai chi, standing on one foot, heel raises) to reduce fall risk 6, 2, 3
• Smoking cessation and alcohol limitation (≤1-2 drinks daily) 6, 5
• Home safety assessment to remove fall hazards 6, 3

Pharmacologic Treatment

Postmenopausal Women with Osteoporosis

For women with known osteoporosis (T-score ≤-2.5 or prior fragility fracture), offer alendronate, risedronate, zoledronic acid, or denosumab as first-line therapy 1. This is a strong recommendation based on high-quality evidence showing these agents reduce vertebral fractures by approximately 52 per 1,000 person-years and hip fractures by 6 per 1,000 person-years 2.

Oral bisphosphonates (alendronate or risedronate) should be considered the routine first-line option due to established efficacy, safety profile, and cost-effectiveness 6, 7.

Treatment duration should be 5 years for initial bisphosphonate therapy 1. After 5 years, reassess fracture risk to determine if continued therapy is warranted 1.

Do NOT use menopausal estrogen therapy, estrogen plus progestogen, or raloxifene for osteoporosis treatment - this is a strong recommendation against these agents 1. While raloxifene reduces vertebral fracture risk by 55% 4, the ACP guideline explicitly recommends against its use due to the balance of benefits and harms 1.

Men with Osteoporosis

Offer bisphosphonates to men with clinically recognized osteoporosis to reduce vertebral fracture risk 1. This is a weak recommendation based on low-quality evidence, but bisphosphonates remain the standard approach 1.

For men with hypogonadism, measure serum testosterone and provide replacement if low 1. If testosterone is normal or BMD does not improve with testosterone replacement, add bisphosphonate or calcitonin 1.

Very High-Risk Patients

For patients at very high fracture risk (recent vertebral fracture, hip fracture with T-score ≤-2.5, multiple fractures), consider anabolic agents as initial therapy 2, 7:

• Teriparatide (parathyroid hormone analog) 8, 2, 7
• Abaloparatide (parathyroid hormone analog) 2, 7
• Romosozumab (sclerostin inhibitor) 1, 2, 7

Anabolic therapy must be followed by antiresorptive therapy (bisphosphonate or denosumab) to maintain gains in bone density 1, 2, 7. Discontinuing anabolic agents without sequential antiresorptive therapy leads to rapid bone loss 1.

Glucocorticoid-Induced Osteoporosis

For patients on glucocorticoid therapy ≥6 months at high fracture risk, initiate bisphosphonates, denosumab, or anabolic agents 1, 2. Treatment thresholds are lower for glucocorticoid users, as they sustain fractures at higher BMD levels than those not taking glucocorticoids 1, 3.

Osteopenia (Low Bone Mass)

For osteopenic women ≥65 years at high fracture risk (FRAX 10-year risk ≥20% for major osteoporotic fracture or ≥3% for hip fracture), discuss treatment options including benefits, harms, and costs 1, 6. Treatment decisions should be individualized based on absolute fracture risk, not T-score alone 1, 6.

Acute Fracture Management

For patients with acute osteoporotic vertebral compression fractures (0-5 days post-injury), prescribe calcitonin (nasal 200 IU or suppository 200 IU) for the first 4 weeks to provide clinically significant pain reduction 9, 10.

Strongly recommend AGAINST vertebroplasty for osteoporotic compression fractures 9, 10. Kyphoplasty may be considered for persistent symptomatic fractures after 3 months of conservative management 9, 10.

Monitoring During Treatment

Do NOT perform routine BMD monitoring during the 5-year treatment period in women receiving osteoporosis therapy 1. This is a weak recommendation, but routine monitoring has not been shown to improve outcomes and may lead to unnecessary treatment changes 1.

For bisphosphonates and calcitonin, measure BMD yearly only if there is concern about treatment failure 1. If BMD falls >4% per year for two successive years, consider switching to another agent 1.

Critical Pitfalls to Avoid

• Missing the diagnosis: Most vertebral fractures are asymptomatic or minimally symptomatic - maintain high clinical suspicion in at-risk patients with back pain 4, 3
• Failing to treat after fracture: Even patients with documented fractures often go untreated, despite being at extremely high risk for subsequent fractures 3
• Stopping treatment abruptly: Discontinuing denosumab without sequential bisphosphonate therapy can cause rebound vertebral fractures within 6-7 months 1. Always transition to antiresorptive therapy when stopping denosumab, teriparatide, or romosozumab 1
• Relying solely on T-score: Use comprehensive fracture risk assessment (FRAX) rather than BMD alone, as many patients who fracture have osteopenia, not osteoporosis 1, 6
• Inadequate calcium/vitamin D: Ensure adequate supplementation in all patients, as deficiency undermines pharmacologic therapy effectiveness 1, 2, 5

Prognosis and Consequences

Women with severe vertebral fractures have 12.6 times the risk of new vertebral fractures and 3.4 times the risk of hip fracture 4. Nearly 20% will experience another fracture within 1 year 4.

Vertebral fractures increase mortality risk nearly 9-fold 4. Hip fractures are associated with substantial morbidity, disability, and mortality 1, 2.

Fracture liaison services (comprehensive inpatient/outpatient programs after fracture) increase medication initiation and adherence from 17% to 38% (absolute increase 20%), which may reduce subsequent fracture rates 2.