What are the guidelines for treating osteoporosis?

Osteoporosis Treatment Guidelines

Oral bisphosphonates are the first-line pharmacological treatment for most patients with osteoporosis at high fracture risk, while anabolic agents like teriparatide should be prioritized for very high-risk patients, particularly those with prior vertebral fractures. 1, 2

Risk Assessment and Screening

• All women ≥65 years and postmenopausal women with clinical risk factors should undergo bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA). 3

• For patients ≥40 years, incorporate FRAX assessment into risk stratification to calculate 10-year fracture probability. 1

• Critical adjustment for glucocorticoid users: If prednisone dose exceeds 7.5 mg/day, multiply FRAX major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2, as standard FRAX underestimates true risk. 1

• Include vertebral fracture assessment (VFA) or spine x-rays during initial evaluation, as asymptomatic vertebral fractures dramatically increase future fracture risk and are frequently missed. 1

• Repeat BMD testing every 1-3 years, with more frequent monitoring for patients on high-dose glucocorticoids or with fracture history. 1

Non-Pharmacological Management (Universal for All Patients)

• Calcium supplementation: 1,000-1,200 mg/day from diet and supplements combined. 1, 4

• Vitamin D supplementation: 600-800 IU/day, targeting serum 25-hydroxyvitamin D levels ≥20-30 ng/mL. 1, 5

• Weight-bearing and resistance training exercises should be performed regularly to maintain bone strength and reduce fall risk. 1, 4

• Smoking cessation and alcohol moderation are essential modifiable risk factors. 5, 3

Pharmacological Treatment Algorithm

High-Risk Patients (Standard Osteoporosis)

• Oral bisphosphonates (alendronate, risedronate, ibandronate) are strongly recommended as first-line therapy for postmenopausal women and men with osteoporosis. 1, 4

• Alternative antiresorptive options include IV bisphosphonates or denosumab for patients who cannot tolerate oral formulations or have contraindications. 1, 6

Very High-Risk Patients

• Anabolic agents (teriparatide, abaloparatide, romosozumab) are conditionally recommended over antiresorptives for patients with: 1, 3

  • Prior vertebral fractures
  • Multiple fragility fractures
  • T-score ≤-3.0
  • Fractures despite ongoing antiresorptive therapy

• Teriparatide is FDA-approved for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and patients with glucocorticoid-induced osteoporosis (≥5 mg/day prednisone equivalent). 2

Glucocorticoid-Induced Osteoporosis

• Initiate fracture risk assessment immediately for all adults on glucocorticoid therapy ≥2.5 mg/day for >3 months. 1

• Bone loss occurs rapidly within the first 3-6 months of glucocorticoid therapy—do not delay treatment in high-risk patients. 1

• Treatment recommendations mirror those for postmenopausal osteoporosis, with oral bisphosphonates as first-line and anabolic agents for very high-risk patients. 1, 2

Treatment Duration and Sequential Therapy

• Reassess fracture risk every 1-3 years during treatment to guide continuation or modification of therapy. 1

• Critical warning for denosumab discontinuation: After stopping denosumab, patients experience rapid rebound bone loss and dramatically increased vertebral fracture risk. 6

  • Sequential therapy with a bisphosphonate is mandatory after discontinuing denosumab or anabolic agents to prevent this rebound effect. 1, 6
  • Do not stop, skip, or delay denosumab doses without transitioning to alternative therapy. 6

• Denosumab is administered subcutaneously every 6 months and requires careful adherence to dosing schedule. 6

Critical Pitfalls to Avoid

• Dental evaluation before initiating bisphosphonates or denosumab is essential, as both carry risk of osteonecrosis of the jaw, particularly with invasive dental procedures. 6

• Patients on denosumab have increased infection risk, including serious skin infections, endocarditis, and other severe infections requiring hospitalization. 6

• Atypical femoral fractures can occur with long-term antiresorptive therapy—counsel patients to report new hip, groin, or thigh pain immediately. 6

• Ensure adequate calcium and vitamin D supplementation before and during treatment to prevent hypocalcemia, especially with denosumab. 6

• Poor medication adherence (30-50% of patients) significantly undermines treatment efficacy—address barriers to compliance at each visit. 5