What is the best management approach for an older postmenopausal woman with a history of osteoporosis and a recent fracture?

Management of Osteoporosis-Related Fractures in Postmenopausal Women

Initiate immediate pharmacologic treatment with oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) as first-line therapy, combined with calcium 1000-1200 mg/day and vitamin D 800 IU/day supplementation, while implementing a multidisciplinary fracture care system that ensures surgery within 48 hours for operative fractures and orthogeriatric comanagement. 1, 2

Immediate Fracture Management

Acute Fracture Care

• All fragility fractures require management within a multidisciplinary clinical system that guarantees adequate preoperative assessment, appropriate pain relief, fluid management, and surgery within 48 hours of injury for operative fractures. 1
• Orthogeriatric comanagement should be provided to improve functional outcomes, reduce hospital length of stay, and decrease mortality, particularly in elderly patients with hip fractures. 1
• For operative fractures, treatment requires balanced decision-making regarding operative versus non-operative approaches and careful selection of fixation devices appropriate for osteoporotic bone. 1
• Most symptomatic vertebral fractures can be managed with analgesics, activity modification, and bracing; only 10% require hospitalization. 1

Post-Fracture Care Essentials

• Implement appropriate pain management immediately, including consideration of calcitonin for fracture-related pain. 1, 3
• Provide early mobilization with physical training and muscle strengthening, followed by long-term balance training and multidimensional fall prevention programs. 1
• Monitor for postoperative complications including cognitive function changes, pressure sores, nutritional status, renal function, and wound healing. 1

Pharmacologic Treatment Initiation

First-Line Therapy: Bisphosphonates

Bisphosphonates are the preferred initial pharmacologic treatment because they have the most favorable balance of benefits, harms, cost, and extensive clinical experience, with proven reduction in vertebral (40-70%), non-vertebral (20-35%), and hip fractures. 1, 2, 4

• Prescribe oral alendronate 70 mg weekly or 10 mg daily, OR risedronate 35 mg weekly, 150 mg monthly, or 5 mg daily. 2
• Generic formulations should be prescribed rather than brand-name medications to reduce costs. 1
• Bisphosphonates reduce vertebral fractures by approximately 50% over 3 years in high-risk patients. 5

Pre-Treatment Evaluation (Mandatory)

• Obtain dental screening examination before starting bisphosphonates to identify and address dental issues, as bisphosphonates increase risk of osteonecrosis of the jaw, particularly with invasive dental procedures. 2
• Check serum calcium level to exclude hypocalcemia (absolute contraindication to bisphosphonates). 2
• Assess renal function, as creatinine clearance <35 mL/min contraindicates zoledronic acid. 2

Essential Supportive Measures

• Ensure total calcium intake of 1000-1200 mg/day (dietary plus supplementation) and vitamin D 800 IU/day, targeting serum 25-OH vitamin D level ≥20 ng/mL. 1, 2, 6
• Counsel on smoking cessation and limiting alcohol consumption. 1, 2, 3
• Implement weight-bearing exercise programs for 30 minutes three times weekly. 3

Risk Stratification and Treatment Selection

Very High-Risk Patients Requiring Anabolic Therapy First

If the patient has very high-risk features—defined as recent vertebral fracture, multiple fractures, or T-score ≤-3.5—initiate anabolic agents (teriparatide or abaloparatide) as first-line therapy instead of bisphosphonates, followed by mandatory transition to an antiresorptive agent. 1, 2, 7

• Teriparatide reduces vertebral fractures by 65% and non-vertebral fractures by 53%. 4
• Patients initially treated with anabolic agents MUST receive an antiresorptive agent after discontinuation to preserve gains and prevent serious risk of rebound and multiple vertebral fractures. 1
• Teriparatide may increase risk for serious adverse events and probably increases withdrawal due to adverse events. 1

Second-Line Therapy: Denosumab

• Use denosumab 60 mg subcutaneously every 6 months as second-line treatment for patients with contraindications to or adverse effects from bisphosphonates. 1, 8
• Denosumab reduces vertebral fractures by 68% and non-vertebral fractures by 19%. 4
• Denosumab does not increase serious adverse events or withdrawals compared to placebo in randomized trials. 1

Monitoring and Duration of Therapy

Treatment Monitoring

• Repeat DXA scan in 1-2 years to assess treatment response, with significant BMD change defined as ≥1.1% based on facility protocol. 2
• Continue DXA monitoring every 1-2 years during treatment. 2
• Assess adherence and tolerance at regular intervals, as most patients discontinue treatment within 1 year despite effectiveness. 9

Duration and Drug Holidays

• Consider stopping bisphosphonate treatment after 5 years unless the patient has strong indication for continuation, as prolonged therapy beyond 5 years probably reduces vertebral fractures but not other fractures, while increasing risk for long-term harms (osteonecrosis of jaw, atypical femoral fractures). 1
• The decision for drug discontinuation should be individualized based on baseline fracture risk, medication type and bone half-life, duration of discontinuation, and higher fracture risk during treatment holidays. 1
• If BMD decreases or shows osteoporosis after a drug holiday, restart treatment immediately. 5

Special Considerations for Elderly Patients

Individualized Assessment Required

• Systematically evaluate each patient aged 50 years and over with a recent fracture for risk of subsequent fractures using clinical risk factors, DXA of spine and hip, spine imaging for vertebral fractures, falls risk assessment, and identification of secondary osteoporosis. 1
• Older postmenopausal women at increased risk for falls and adverse events due to polypharmacy or drug interactions need individualized treatment selection based on comorbidities and concomitant medications. 1
• Evaluate renal function before treatment, as decreased renal function may affect dosing or agent selection. 5

Patient Education and Adherence

• Educate patients about disease burden, fracture risk factors, follow-up requirements, and duration of therapy to improve adherence. 1
• Emphasize that adequate calcium and vitamin D intake must be part of fracture prevention in all postmenopausal women with low bone mass or osteoporosis. 1
• Encourage adherence to recommended drug treatments and healthy lifestyle modifications, including exercise and fall prevention counseling. 1

Common Pitfalls to Avoid

• Do not delay pharmacologic treatment after fracture—this represents treatment failure requiring immediate intervention. 5
• Do not prescribe anabolic agents without planning for subsequent antiresorptive therapy, as this risks rebound vertebral fractures. 1
• Do not start bisphosphonates without dental screening and calcium level assessment. 2
• Do not continue bisphosphonates indefinitely without reassessing at 5 years for potential drug holiday. 1
• Do not rely solely on BMD for treatment efficacy—fracture risk reduction is the primary indicator of treatment success. 10