What is the best way to prevent osteoporosis in high-risk individuals, such as postmenopausal women and older men with a family history of osteoporosis?

Preventing Osteoporosis in High-Risk Individuals

The best way to prevent osteoporosis in high-risk postmenopausal women and older men with family history is through systematic screening with DEXA scans starting at age 65 for women (or younger if high-risk factors present) and age 70 for men, combined with lifestyle modifications including weight-bearing exercise, adequate calcium (1,200 mg/day) and vitamin D (600-1,000 IU/day) intake, smoking cessation, and limiting alcohol—with pharmacologic intervention using bisphosphonates reserved for those who develop documented osteoporosis (T-score ≤-2.5) or high fracture risk. 1

Screening Strategy

For Postmenopausal Women

• Screen all women age 65 and older with DEXA scan of hip and lumbar spine to measure bone mineral density, as this has moderate net benefit for preventing osteoporotic fractures 1
• Screen postmenopausal women younger than 65 years if they have increased risk factors, including family history of hip fracture, body weight less than 70 kg, prior non-traumatic fracture, smoking, excess alcohol use, or glucocorticoid use 1
• For women on aromatase inhibitors or receiving ovarian suppression therapy, obtain baseline DEXA and repeat every 2 years due to accelerated bone loss 1

For Men

• Screen men age 70 and older with DEXA scan 1
• The evidence for screening men is insufficient to determine net benefit, but those with family history of osteoporosis, prior fractures, or on androgen-deprivation therapy warrant evaluation 1

Lifestyle Modifications (Primary Prevention)

Weight-Bearing Exercise

• Engage in regular weight-bearing exercise and muscle resistance training (such as squats, push-ups) combined with balance exercises (heel raises, standing on one foot) to maintain bone mass and reduce fall risk 2, 3
• Physical activity should be consistent and ongoing, as it helps achieve and maintain optimal bone mass 2, 4

Calcium and Vitamin D Supplementation

• Ensure total daily calcium intake of 1,200 mg (from diet plus supplements if needed) for all adults over age 50 1, 5
• Supplement with vitamin D3 at 600-1,000 IU daily to support calcium absorption and bone health 1, 5, 2
• These nutritional interventions should be part of fracture prevention in all individuals with low bone mass or osteoporosis 1

Lifestyle Risk Factor Modification

• Avoid tobacco smoking completely, as it accelerates bone loss and increases fracture risk 1, 2
• Limit alcohol consumption to no more than 2 drinks daily, as excess alcohol intake impairs bone formation 1, 2
• Maintain healthy body weight, avoiding excessively low body weight (less than 70 kg increases risk) 1

Pharmacologic Prevention

When to Initiate Medication

Do not routinely prescribe bisphosphonates or other osteoporosis medications for prevention in individuals without documented osteoporosis. The evidence supports pharmacologic treatment only after osteoporosis is confirmed (T-score ≤-2.5) or in those with high fracture risk based on FRAX assessment 1

For Documented Osteoporosis (T-score ≤-2.5)

• Prescribe generic oral bisphosphonates (alendronate or risedronate) as first-line therapy to reduce vertebral and hip fracture risk, as they have the most favorable balance of benefits, harms, and cost 1, 5
• Bisphosphonates reduce vertebral fractures by approximately 52 per 1,000 person-years and hip fractures by 6 per 1,000 person-years 3
• Plan for 5 years of initial bisphosphonate therapy, then reassess fracture risk to determine if continued treatment is warranted 1, 5

Alternative Agents

• Use denosumab as second-line therapy if bisphosphonates are contraindicated or cause adverse effects (such as esophageal irritation or atypical femoral fractures) 1, 5
• If discontinuing denosumab, transition to a bisphosphonate to prevent rebound bone loss and multiple vertebral fractures 5

Monitoring and Follow-Up

Bone Density Monitoring

• Do not perform routine DEXA scans during the initial 5-year treatment period once pharmacologic therapy is started, as monitoring does not improve outcomes 1, 5
• For high-risk individuals not yet on medication (such as those on aromatase inhibitors), repeat DEXA every 2 years to detect accelerated bone loss 1

Fall Prevention

• Assess home environment for fall hazards and implement modifications (remove loose rugs, improve lighting, install grab bars) 1
• Evaluate medications that increase fall risk, including sedatives, antihypertensives, and drugs causing orthostatic hypotension 1

Common Pitfalls to Avoid

• Do not use menopausal estrogen therapy, estrogen plus progestogen, or raloxifene for osteoporosis treatment, as harms outweigh benefits 1
• Do not combine selective estrogen receptor modulators with aromatase inhibitors in breast cancer patients, as this blunts the reduction in breast cancer recurrence 1
• Do not continue bisphosphonates indefinitely without reassessment, as prolonged use (beyond 5 years) increases risk of osteonecrosis of the jaw and atypical femoral fractures without clear additional fracture reduction benefit 1
• Do not rely solely on calcium and vitamin D supplementation to prevent fractures in those with established osteoporosis—pharmacologic therapy is required 1, 3