Treatment for Confirmed Osteoporosis
For patients with confirmed osteoporosis (T-score ≤ -2.5), oral bisphosphonates are the strongly recommended first-line pharmacologic treatment, combined with calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation plus lifestyle modifications. 1
Risk Stratification and Treatment Intensity
The treatment approach depends on fracture risk severity:
High or Very High Risk Patients
Patients fall into this category if they have: 1
- History of vertebral or hip fracture (most important predictor)
- T-score ≤ -2.5 at hip or spine
- 10-year FRAX risk ≥20% for major osteoporotic fracture OR ≥3% for hip fracture
- Multiple fractures
- Recent vertebral fractures
For very high-risk patients (recent vertebral fractures, hip fracture with T-score ≤-2.5), anabolic agents (teriparatide, abaloparatide, or romosozumab) should be considered as initial therapy, followed by an antiresorptive agent. 1, 2
Standard High-Risk Patients
Oral bisphosphonates are strongly recommended over no treatment. 1 Specific options include: 1
- Alendronate: 10 mg daily or 70 mg weekly
- Risedronate: 5 mg daily, 35 mg weekly, or 150 mg monthly
- Ibandronate: 150 mg monthly or 3 mg IV every 3 months
Treatment Algorithm
First-Line Therapy
- Oral bisphosphonates are preferred based on safety, cost, and proven fracture reduction efficacy 1
Second-Line Options (if oral bisphosphonates inappropriate)
In order of preference: 1
- IV bisphosphonates (zoledronic acid 5 mg IV yearly)
- Denosumab 60 mg subcutaneously every 6 months (particularly for high fracture risk) 1
- Raloxifene 60 mg daily (for younger postmenopausal women with lower fracture risk) 1
Anabolic Therapy Indications
Consider anabolic agents first in very high-risk patients: 1, 3
- Teriparatide 20 mcg subcutaneously daily (maximum 2 years lifetime use)
- Abaloparatide or Romosozumab
Critical caveat: After discontinuing denosumab, romosozumab, or teriparatide, sequential antiresorptive therapy is mandatory to prevent rebound bone loss and vertebral fractures. 1
Essential Foundational Measures
All patients require: 1
Calcium and Vitamin D
- Calcium: 1,000-1,200 mg/day (dietary plus supplemental)
- Vitamin D: 600-800 IU/day, targeting serum 25(OH)D ≥30-50 ng/mL (some guidelines suggest ≥20 ng/mL minimum) 1
Lifestyle Modifications
- Weight-bearing and resistance training exercises (at least 30 minutes daily) 1
- Smoking cessation 1
- Limit alcohol to ≤1-2 servings daily 1
- Fall prevention strategies: vision/hearing checks, home safety assessment, balance exercises (tai chi, physical therapy) 1
- Maintain healthy body weight 1
Monitoring and Duration
- Bone density reassessment every 1-2 years while on treatment 1
- Bisphosphonate treatment duration: Typically 3-5 years, then reassess fracture risk for potential drug holiday 4
- Teriparatide: Maximum 2 years lifetime use due to osteosarcoma risk in animal studies 3
Important Contraindications and Precautions
Bisphosphonates
- Esophageal abnormalities or inability to stand/sit upright for 30 minutes
- Hypocalcemia (must correct before initiating)
- Severe renal impairment (CrCl <35 mL/min for zoledronic acid)
Teriparatide
Avoid in patients with: 3
- Open epiphyses (pediatric/young adults)
- Paget's disease or other metabolic bone diseases
- Prior skeletal radiation therapy
- Bone metastases or skeletal malignancies
- Hereditary disorders predisposing to osteosarcoma
Special Populations
Glucocorticoid-Induced Osteoporosis
For patients on ≥7.5 mg prednisone daily for ≥3 months with high fracture risk, oral bisphosphonates are strongly recommended over calcium/vitamin D alone. 1 FRAX scores should be adjusted upward (multiply major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2) for prednisone >7.5 mg/day. 1
Men with Osteoporosis
Treatment recommendations mirror those for postmenopausal women, with bisphosphonates as first-line therapy for T-score ≤-2.5 or history of fragility fracture. 4, 2