What treatment options are available for osteoporosis?

Patisiran is Not a Treatment for Osteoporosis

Patisiran is a medication used to treat hereditary transthyretin-mediated amyloidosis, not osteoporosis. If you are asking about osteoporosis treatment options, the question appears to contain an error, as patisiran has no role in osteoporosis management.

Evidence-Based Treatment Options for Osteoporosis

First-Line Pharmacologic Treatment

Oral bisphosphonates (alendronate or risedronate) are the recommended first-line treatment for osteoporosis in most patients due to their proven efficacy in reducing fractures, favorable safety profile, and lower cost compared to other medications. 1, 2

• For adults ≥40 years at high risk of fracture: Oral bisphosphonates should be used over calcium and vitamin D alone (strong recommendation) 1
• For adults ≥40 years at moderate risk: Oral bisphosphonates are preferred over IV bisphosphonates, teriparatide, denosumab, or raloxifene (conditional recommendation) 1
• Bisphosphonates reduce vertebral fractures by approximately 52 per 1000 person-years and hip fractures by 6 per 1000 person-years 3

Alternative Antiresorptive Agents (Second-Line)

If oral bisphosphonates are not appropriate, the following alternatives should be considered in order of preference: 1, 2

1. IV bisphosphonates (zoledronic acid) - Higher risk profile for IV infusion compared to oral therapy 1
2. Denosumab (60 mg subcutaneously every 6 months) - Effective but requires transition to antiresorptive therapy after discontinuation to prevent rapid bone loss and rebound fractures 2, 1
3. Raloxifene (for postmenopausal women only when other options are inappropriate) - Limited data on hip fracture reduction and potential clotting risks 1

Anabolic Agents (For Very High-Risk Patients)

Anabolic medications should be considered for patients at very high risk, including those with recent vertebral fractures, hip fracture with T-score ≤-2.5, or multiple fractures: 3, 4

• Teriparatide, abaloparatide, or romosozumab are options for severe osteoporosis 2, 5
• Critical caveat: Patients initially treated with anabolic agents must be transitioned to an antiresorptive agent after discontinuation to preserve bone gains and prevent serious rebound vertebral fractures 1, 2

Essential Non-Pharmacologic Interventions

All patients with osteoporosis should receive: 2, 3

• Calcium: 1,000-1,200 mg daily 1, 2
• Vitamin D: 600-800 IU daily (target serum level ≥20 ng/mL) 2, 3
• Weight-bearing and resistance exercises to reduce fracture risk 2, 3
• Smoking cessation and alcohol limitation (≤1-2 drinks/day) 1, 2
• Fall prevention strategies including vision/hearing assessment, medication review, and home safety evaluation 2

Treatment Duration and Monitoring

Bisphosphonate therapy should be reassessed after 5 years: 1, 2

• Consider stopping treatment after 5 years unless strong indication for continuation exists 1
• The decision for a bisphosphonate "drug holiday" should be individualized based on baseline fracture risk, medication type and half-life, and benefit-harm balance 1
• Important pitfall: Long-term bisphosphonate use (>5 years) increases risk of osteonecrosis of the jaw and atypical femoral fractures 2

Special Population: Glucocorticoid-Induced Osteoporosis

For adults ≥40 years receiving glucocorticoids at moderate-to-high fracture risk: 1

• Oral bisphosphonates are strongly recommended as first-line treatment 1
• Denosumab is not recommended in transplant patients on multiple immunosuppressive agents due to infection risk 1

Cost Considerations

Generic oral bisphosphonates should be prescribed when possible rather than expensive brand-name medications to improve affordability and adherence. 1, 2