What are the treatment options for osteoporosis?

From the Guidelines

Treatment for osteoporosis should prioritize bisphosphonates, such as alendronate or risedronate, as first-line medications, along with ensuring adequate calcium and vitamin D intake, and promoting lifestyle changes like weight-bearing exercises and fall prevention measures. According to the most recent and highest quality study 1, bisphosphonates are effective in reducing the risk of fractures, and their use should be considered for 3-5 years before reassessing. The American College of Physicians guideline update from 2023 1 also recommends encouraging adherence to recommended treatments and healthy lifestyle modifications.

Key considerations for treatment include:

• Ensuring adequate calcium intake (1000-1200mg daily) and vitamin D (800-1000 IU daily) to support bone health
• Promoting weight-bearing exercises, such as walking or resistance training, for at least 30 minutes most days
• Counseling patients on fall prevention measures to reduce the risk of fractures
• Assessing baseline risk for fracture based on individualized assessment of bone density, history of fractures, and multiple risk factors for fractures
• Considering the use of generic medications instead of brand-name medications to reduce costs

It's also important to note that the choice of treatment should be based on individual patient needs and risk factors, and that clinicians should consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication for treatment continuation, as suggested by the study 1. Additionally, the study 1 recommends that vitamin D and calcium repletion should be ensured in all men above the age of 65 years, and that oral bisphosphonates are first-line treatments for men at a high risk of fracture.

Overall, the goal of treatment for osteoporosis is to reduce the risk of fractures and improve quality of life, and clinicians should work with patients to develop a personalized treatment plan that takes into account their individual needs and risk factors.

From the FDA Drug Label

Alendronate does not interfere with osteoclast recruitment or attachment, but it does inhibit osteoclast activity. In osteoporosis treatment studies alendronate sodium 10 mg/day decreased the markers of bone formation, osteocalcin and bone specific alkaline phosphatase by approximately 50%, and total serum alkaline phosphatase by approximately 25 to 30% to reach a plateau after 6 to 12 months Osteoporosis in Postmenopausal Women Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. Daily oral doses of alendronate (5,20, and 40 mg for six weeks) in postmenopausal women produced biochemical changes indicative of dose-dependent inhibition of bone resorption, including decreases in urinary calcium and urinary markers of bone collagen degradation Long-term treatment of osteoporosis with alendronate sodium 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption, deoxypyridinoline and cross-linked N-telopeptides of type I collagen, by approximately 50% and 70%, respectively, to reach levels similar to those seen in healthy premenopausal women 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 Teriparatide injection is indicated: For the treatment of postmenopausal women with osteoporosis at high risk for fracture (defined herein as having a history of osteoporotic fracture or multiple risk factors for fracture) or who have failed or are intolerant to other available osteoporosis therapy In postmenopausal women with osteoporosis, teriparatide injection reduces the risk of vertebral and nonvertebral fractures. To increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy The treatment for osteoporosis includes:

• Alendronate (PO): 5,20, and 40 mg for six weeks, or 10 mg/day for up to five years, to reduce bone resorption and increase bone mass.
• Denosumab (SQ): 1 time every 6 months, to treat osteoporosis in women after menopause, increase bone mass in men with osteoporosis, and treat osteoporosis in men and women who will be taking corticosteroid medicines.
• Teriparatide (SQ): to treat postmenopausal women with osteoporosis at high risk for fracture, increase bone mass in men with primary or hypogonadal osteoporosis, and treat men and women with osteoporosis associated with sustained systemic glucocorticoid therapy 2, 3, 4.

From the Research

Treatment Options for Osteoporosis

• Bisphosphonates are a class of drugs that are safe and effective for the treatment and prevention of osteoporosis, as shown in studies 5, 6, 7, 8.
• Alendronate and risedronate are the most well-studied bisphosphonates for osteoporosis, and they have been shown to increase bone mass and reduce the risk of vertebral and nonvertebral fractures 5.
• Other bisphosphonates, such as etidronate, pamidronate, zoledronate, and ibandronate, are also available and can be used for the treatment of osteoporosis 5, 6, 7.
• Selective estrogen receptor modulators (SERMs), such as raloxifene, can also be used to treat osteoporosis, particularly in postmenopausal women, and have been shown to increase bone mineral density (BMD) and reduce the risk of vertebral fractures 6.
• Teriparatide, a recombinant human formulation of parathyroid hormone (PTH) 1-34, has been shown to have a strong anabolic effect on bone and can be used to treat osteoporosis, particularly in patients who have not responded to other treatments 6.
• Strontium ranelate, a new divalent strontium salt, has been shown to have both anti-catabolic and anabolic effects on bone and can be used to treat osteoporosis 6.

Combination Therapy

• Combining bisphosphonates with estrogen or other medications, such as raloxifene or calcitonin, may be beneficial for some patients, but the evidence is limited 5, 6.
• A fixed-combination pack of bisphosphonate, calcium, and vitamin D can improve patient compliance and adherence to treatment, and can be a useful tool for optimizing osteoporosis therapy 9.

Patient Selection and Monitoring

• Patient selection for bisphosphonate therapy should be based on individual risk factors, such as bone mineral density, fracture history, and other medical conditions 8.
• Pretreatment evaluation should include assessment of renal function, hepatic function, and other medical conditions that may affect treatment 8.
• Monitoring of treatment should include regular assessment of bone mineral density, fracture risk, and potential adverse effects, such as gastrointestinal symptoms or hypocalcemia 8.