What is the recommended treatment for an older adult or postmenopausal woman with osteoporosis?

Treatment for Osteoporosis

Start oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) as first-line therapy for all postmenopausal women and older adults with osteoporosis, combined with calcium 1,200 mg daily and vitamin D 800 IU daily. 1, 2, 3

First-Line Pharmacologic Treatment

• Oral bisphosphonates are the mandatory initial treatment based on high-certainty evidence showing 50% reduction in hip fractures and 47-56% reduction in vertebral fractures over 3 years, with the most favorable balance of efficacy, safety, and cost 1, 2, 4

• Specific bisphosphonate options include:

  • Alendronate 70 mg once weekly (preferred) 1, 2, 3
  • Risedronate 35 mg once weekly 1, 2
  • Zoledronic acid 5 mg IV annually for patients unable to tolerate oral formulations 1, 2

• Bisphosphonates are FDA-approved for treatment of postmenopausal osteoporosis, male osteoporosis, and glucocorticoid-induced osteoporosis 3

Essential Supplementation (Non-Negotiable)

• All patients must receive calcium 1,200 mg daily and vitamin D 800 IU daily, as pharmacologic therapy is significantly less effective without adequate supplementation 1, 2

• Target serum vitamin D level ≥20 ng/mL 1

• These supplements alone are insufficient for fracture prevention in established osteoporosis and must be combined with pharmacologic therapy 1, 2

Second-Line Treatment Options

• Denosumab 60 mg subcutaneously every 6 months is the recommended second-line therapy for patients with contraindications to or intolerance of bisphosphonates 1, 2

• Critical warning: Never discontinue denosumab abruptly without transitioning to bisphosphonate therapy—abrupt discontinuation causes rebound multiple vertebral fractures in some patients 1, 2

• IV bisphosphonates (zoledronic acid) are preferred over denosumab if oral bisphosphonates are not tolerated, due to higher risk profile with denosumab in immunosuppressed patients 1

Anabolic Agents for Very High-Risk Patients

• Teriparatide, abaloparatide, or romosozumab should be considered only for very high-risk patients, such as those with recent vertebral fractures, hip fracture with T-score ≤-2.5, or multiple fractures 1, 4, 5

• Mandatory follow-up: Patients initially treated with anabolic agents must transition to an antiresorptive agent after discontinuation to preserve gains and prevent serious rebound multiple vertebral fractures 1, 2

• Teriparatide is third-line after bisphosphonates and IV bisphosphonates due to cost and burden of daily injections 1

Treatment Duration and Monitoring

• Initial treatment duration is 5 years with bisphosphonates, after which fracture risk should be reassessed to determine if continued therapy is warranted 1, 2, 3

• Do not monitor bone density during the initial 5-year treatment period—there is no clinical benefit to routine BMD monitoring during active treatment, and bisphosphonates reduce fractures even without BMD increases 1, 2

• Consider stopping bisphosphonate treatment after 5 years unless the patient has strong indication for treatment continuation, as risk of severe adverse effects increases with prolonged use 1, 2

• Patients at low-risk for fracture should be considered for drug discontinuation after 3 to 5 years of use 3

Mandatory Lifestyle Modifications

• Weight-bearing exercise and resistance training (such as squats, push-ups) are essential for all patients 1, 6, 4

• Balance exercises (such as heel raises, standing on one foot) to prevent falls 4

• Smoking cessation is mandatory 1, 2, 6

• Limit alcohol intake to 1-2 alcoholic beverages per day 1, 6

• Maintain healthy body weight—excessively low body weight increases fracture risk 1, 6

• Fall prevention strategies including home safety evaluation 1, 7

Safety Profile and Adverse Effects

• High-certainty evidence shows bisphosphonates cause no difference in serious adverse events compared to placebo at 2-3 years 1, 2

• Common adverse effects include mild upper GI symptoms, influenza-like symptoms, myalgias, arthralgias, and headaches 2

• Rare but serious adverse effects include osteonecrosis of the jaw and atypical femoral fractures, which increase with prolonged use beyond 5 years 1, 2

Agents to Avoid

• Strongly avoid menopausal estrogen therapy, estrogen plus progestogen therapy, or raloxifene for osteoporosis treatment due to unfavorable benefit-harm balance 1, 2

• Raloxifene may only be considered for postmenopausal women in whom none of the preferred medications (bisphosphonates, IV bisphosphonates, teriparatide, denosumab) is appropriate 1

Special Considerations for Men

• Use the same treatment algorithm for men with primary osteoporosis: bisphosphonates first-line, denosumab second-line 1

• Limited evidence was available for males, so recommendations are extrapolated from postmenopausal women trials with low-certainty evidence 1

Common Pitfalls to Avoid

• Do not prescribe calcium and vitamin D alone for established osteoporosis—this is insufficient and requires pharmacologic therapy 1, 2

• Do not use brand-name medications when generic bisphosphonates are available and equally effective 1

• Do not continue bisphosphonates indefinitely without reassessing fracture risk at 5 years due to increasing harm-to-benefit ratio 1, 2, 3

• Do not stop denosumab without transitioning to bisphosphonates to prevent rebound fractures 1, 2