What is the recommended treatment plan for osteoporosis in postmenopausal women and older men, including calcium, vitamin D, lifestyle measures, first‑line pharmacotherapy and alternative options?

Osteoporosis Treatment in Postmenopausal Women and Older Men

Foundation: Universal Recommendations for All Patients

All patients with osteoporosis should receive calcium 1,000-1,200 mg daily and vitamin D 600-800 IU daily (targeting serum level ≥20 ng/mL), combined with lifestyle modifications including weight-bearing exercise, smoking cessation, maintaining healthy body weight, and limiting alcohol to 1-2 drinks per day. 1

Calcium and Vitamin D Specifics

• Age-specific dosing: 1
  • Ages 19-50: 1,000 mg calcium, 600 IU vitamin D
  • Ages 51-70: 1,200 mg calcium, 600 IU vitamin D
  • Ages 71+: 1,200 mg calcium, 800 IU vitamin D
• Dietary sources are preferred over supplements when possible 2
• Avoid excessive intake (>2,000 mg/day) as this may increase cardiovascular events, kidney stones, and paradoxically even fractures 2

Essential Lifestyle Modifications

• Weight-bearing and resistance training exercise should be prescribed regularly 1, 3
• Smoking cessation is mandatory as tobacco interferes with bone metabolism 1, 3
• Alcohol limitation to 1-2 drinks daily maximum 1, 3
• Maintain healthy body weight as low body weight (<127 lbs) significantly increases fracture risk 1, 3

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First-Line Pharmacotherapy: Oral Bisphosphonates

Oral bisphosphonates are the first-line pharmacologic treatment for postmenopausal women and older men with osteoporosis, chosen for their superior safety profile, proven fracture reduction, and cost-effectiveness. 1

Treatment Indications for Pharmacotherapy

Treat when any of the following are present: 1

• T-score ≤ -2.5 at hip or spine on DEXA
• History of low-trauma/fragility fracture (even if DEXA doesn't show osteoporosis)
• T-score between -1.0 and -2.5 PLUS:
  • FRAX 10-year risk of major osteoporotic fracture ≥20%, OR
  • FRAX 10-year risk of hip fracture ≥3%

Oral Bisphosphonate Options

Available formulations based on patient preference: 1

• Alendronate: 10 mg daily or 70 mg weekly
• Risedronate: 5 mg daily, 35 mg weekly, 75 mg on 2 consecutive days monthly, or 150 mg monthly
• Ibandronate: 2.5 mg daily or 150 mg monthly

Critical Administration Requirements

Oral bisphosphonates are contraindicated in patients with: 1

• Esophageal abnormalities
• Inability to stand or sit upright for at least 30 minutes after dosing
• Hypocalcemia (must be corrected before starting)

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Alternative Pharmacotherapy Options (When Oral Bisphosphonates Inappropriate)

Hierarchy of Second-Line Agents

For high-risk patients who cannot tolerate oral bisphosphonates, the preferred alternatives in order are: IV bisphosphonates, then denosumab, then teriparatide. 1

IV Bisphosphonates

• Zoledronic acid: 5 mg IV annually for treatment 1
• Ibandronate: 3 mg IV every 3 months 1
• Contraindicated if creatinine clearance <35 mL/min/1.73m² 1
• Higher risk profile than oral formulations due to IV administration 1

Denosumab

• Indicated for women at high fracture risk 1
• 60 mg subcutaneous injection (frequency per FDA labeling) 1
• Concerns exist regarding lack of safety data in immunosuppressed patients 1

Teriparatide (Anabolic Agent)

• Reserved for severe osteoporosis or patients with prior fractures 1
• Daily subcutaneous injection creates burden and higher cost 1
• Generally used when antiresorptive therapy has failed or is contraindicated

Special Population: Younger Postmenopausal Women

Raloxifene (60 mg daily) can be considered as initial treatment in younger postmenopausal women who have less severe disease and for whom bisphosphonates are not appropriate. 1

• Contraindicated in women with: venous thromboembolism history or risk 1
• Weaker fracture data compared to bisphosphonates 1
• Should only be used when no other first-line or second-line option is suitable 1

Last Resort: Calcitonin

Calcitonin should only be used in women with less serious osteoporosis who cannot tolerate any other treatment options due to significantly weaker efficacy data. 1

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Monitoring and Reassessment

• Yearly clinical fracture risk assessment 1
• DEXA scanning every 2-3 years depending on individual risk factors 1
• Earlier reassessment needed for: patients with history of fracture, very low BMD, or higher doses of medications affecting bone 1

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Common Pitfalls to Avoid

Calcium Supplementation Errors

• Do not exceed 2,000 mg daily total intake (diet + supplements) due to cardiovascular and kidney stone risks 2
• In elderly patients with achlorhydria: calcium carbonate must be taken with food, or use alternative calcium forms that don't require acid for absorption 4
• Divide calcium doses into 2-3 administrations daily for optimal absorption 4

Bisphosphonate Administration Mistakes

• Failure to ensure 30-minute upright positioning post-dose leads to esophageal complications 1
• Not correcting hypocalcemia before starting bisphosphonates 1
• Prescribing IV bisphosphonates without checking renal function (contraindicated if CrCl <35) 1

Treatment Selection Errors

• Using raloxifene or calcitonin as first-line when bisphosphonates are appropriate and tolerated 1
• Prescribing teriparatide for mild-moderate osteoporosis when less expensive, equally effective options exist 1
• Treating low-risk patients pharmacologically when calcium, vitamin D, and lifestyle modifications alone are sufficient 1