From the Guidelines
The treatment of osteoporosis and osteopenia should prioritize fracture prevention through medication, lifestyle modifications, and fall prevention, with first-line pharmacological treatment typically including bisphosphonates such as alendronate (70mg weekly), risedronate (35mg weekly), or zoledronic acid (5mg IV annually) 1.
Key Considerations
- The American College of Physicians recommends offering pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis 2.
- For postmenopausal women at high fracture risk, denosumab (60mg subcutaneously every 6 months) or teriparatide/abaloparatide (daily subcutaneous injections for up to 2 years) may be considered 1.
- Bisphosphonate therapy should generally be reassessed after 3-5 years, with possible drug holidays for lower-risk patients 1.
- All patients should receive calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation 3.
- Weight-bearing and resistance exercises are essential components of treatment, helping to build bone density and improve balance 3.
- Fall prevention strategies include home safety assessments, vision checks, and review of medications that may increase fall risk 1.
Treatment Decisions
- Treatment decisions should be individualized based on fracture risk (using tools like FRAX), bone mineral density, age, gender, and comorbidities 1.
- Monitoring typically involves bone mineral density testing every 1-2 years initially, then less frequently as stability is established 1.
- For men at a high risk of fracture, oral bisphosphonates (alendronate or risedronate) are first-line treatments, with denosumab or zoledronate as second-line treatments 3.
Lifestyle Modifications
- Physical exercise and a balanced diet should be recommended to all men with osteoporosis 3.
- Serum total testosterone should be assessed, as part of the pre-treatment assessment of men with osteoporosis 3.
- Appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone 3.
From the FDA Drug Label
Prolia is a prescription medicine used to: Treat osteoporosis (thinning and weakening of bone) in women after menopause ("change of life") who: are at high risk for fracture (broken bone) cannot use another osteoporosis medicine or other osteoporosis medicines did not work well Increase bone mass in men with osteoporosis who are at high risk for fracture Treat osteoporosis in men and women who will be taking corticosteroid medicines (such as prednisone) for at least 6 months and are at high risk for fracture.
Instruct patients to take supplemental calcium and vitamin D, if daily dietary intake is inadequate. Weight-bearing exercise should be considered along with the modification of certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors exist.
The guidelines for osteoporosis/osteopenia treatment include:
- Treating osteoporosis in women after menopause who are at high risk for fracture, cannot use another osteoporosis medicine, or other osteoporosis medicines did not work well
- Increasing bone mass in men with osteoporosis who are at high risk for fracture
- Treating osteoporosis in men and women who will be taking corticosteroid medicines for at least 6 months and are at high risk for fracture
- Taking supplemental calcium and vitamin D if daily dietary intake is inadequate
- Considering weight-bearing exercise and modifying certain behavioral factors, such as cigarette smoking and/or excessive alcohol consumption, if these factors exist [4] [5]
From the Research
Guidelines for Osteoporosis/Osteopenia Treatment
- The diagnosis of osteoporosis is generally agreed upon by major guidelines, including those from the RACGP, ESCEO-IOF, NOGG, NAMS, ES, and ACOG, with a T-score of -2.5 or less or the presence of a fragility fracture 6.
- Lifestyle modifications, such as calcium and vitamin D intake, normal body weight, reduction of alcohol consumption, and smoking cessation, are suggested by all guidelines 6, 7, 8.
- Pharmacologic agents, including bisphosphonates, denosumab, hormone therapy, and parathyroid hormone analogs, are recognized as effective treatments for osteoporosis 6, 7, 8, 9, 10.
- The use of hip protectors to reduce the risk of fractures is supported by some guidelines, such as RACGP, NOGG, and NAMS, for high-risk elderly patients in residential care settings 6.
- Referral to a bone specialist is reserved for complex cases of osteoporosis or in case of inadequate access to care 6.
Treatment Options
- Bisphosphonates are a common treatment option for osteoporosis, with proposed intervals of repeat bone mineral density testing after initiation of drug therapy varying between guidelines 6.
- Denosumab is another treatment option, with some studies showing it to be more effective than bisphosphonates in increasing bone mineral density 9, 10.
- Teriparatide is also an effective treatment option, with studies showing it to be superior to bisphosphonates in decreasing the risk of fracture 10.
- Anabolic agents, such as teriparatide, abaloparatide, and romosozumab, should be considered for patients at very high risk or with previous vertebral fractures 7.
Monitoring and Prevention
- Bone mineral density testing is an important tool for monitoring osteoporosis treatment, with guidelines suggesting repeat testing at intervals of 1-5 years 6.
- Fall prevention and weight-bearing exercise are also important components of osteoporosis prevention and treatment 7, 8.
- Adequate intake of calcium and vitamin D is essential for maintaining bone health and preventing osteoporosis 7, 8.