What is the management of Bone Mineral Density (BMD) suggestive of osteoporosis?

From the Guidelines

Management of bone mineral density (BMD) suggestive of osteoporosis in men requires a comprehensive approach, with first-line pharmacological treatment typically including bisphosphonates, such as alendronate or risedronate, as recommended by the latest evidence-based guideline for the management of osteoporosis in men 1. The treatment approach should be individualized, taking into account the patient's risk factors, such as history of fragility fracture, BMD T-score, and comorbidities.

• Key considerations in the management of osteoporosis in men include:
  • Pharmacological treatment: bisphosphonates, such as alendronate (70mg weekly) or risedronate (35mg weekly), are widely advocated for the treatment of osteoporosis in men 1.
  • Non-pharmacological management: weight-bearing and resistance exercises, smoking cessation, limiting alcohol intake, and fall prevention strategies are essential for maintaining bone health and preventing fractures.
  • Calcium and vitamin D supplementation: all patients should receive calcium supplementation (1000-1200mg daily) and vitamin D (800-1000 IU daily) to support bone mineralization.
  • Regular monitoring: follow-up BMD testing every 1-2 years is recommended to assess treatment efficacy and make necessary adjustments to the management plan. The Endocrine Society guideline recommends treatment for men 'at high risk of fracture', including those with a history of fragility fracture of the hip or vertebra, men with a BMD 2.5 (or more) standard deviations below the mean value for normal young white men, or those with a 20% 10-year risk of major osteoporotic fracture or 10% risk of hip fracture 1.
• Treatment duration and reassessment:
  • Bisphosphonates typically require reassessment after 3-5 years to evaluate the need for continuation or a drug holiday.
  • Anabolic agents like teriparatide may be considered for severe osteoporosis or when other treatments have failed. The management of osteoporosis in men is a complex issue, and the latest evidence-based guideline provides a comprehensive approach to diagnosis, monitoring, and treatment 1.
• Key takeaways:
  • Osteoporosis in men is a significant public health concern, with a substantial risk of morbidity and mortality.
  • Early diagnosis and treatment are crucial to preventing fractures and improving outcomes.
  • A comprehensive approach to management, including pharmacological and non-pharmacological interventions, is essential for optimal care.

From the FDA Drug Label

The efficacy of alendronate sodium 10 mg once daily in men with either a BMD T-score less than or equal to -2 at the femoral neck and less than or equal to -1 at the lumbar spine, or a baseline osteoporotic fracture and a BMD T-score less than or equal to -1 at the femoral neck was demonstrated in a two-year, double-blind, placebo-controlled, multicenter study. At two years, the mean increases relative to placebo in BMD in men receiving alendronate sodium 10 mg/day were significant at the following sites: lumbar spine, 5.3%; femoral neck, 2.6%; trochanter, 3.1%; and total body, 1.6%. The efficacy of teriparatide for treating men with primary or hypogonadal osteoporosis was assessed in a double-blind, multicenter, placebo-controlled clinical study of 437 men. Teriparatide increased lumbar spine BMD in men with primary or hypogonadal osteoporosis. Statistically significant increases were seen at 3 months and continued throughout the treatment period.

Management of BMD suggestive for osteoporosis:

• Alendronate sodium (PO): can be used to increase BMD in men with osteoporosis, with significant increases seen at the lumbar spine, femoral neck, trochanter, and total body.
• Teriparatide (SQ): can be used to increase BMD in men with primary or hypogonadal osteoporosis, with statistically significant increases seen at the lumbar spine.
• Key considerations:
  • Alendronate sodium and teriparatide have been shown to be effective in increasing BMD in men with osteoporosis.
  • The choice of treatment should be based on individual patient needs and medical history.
  • Patients should be monitored regularly to assess the effectiveness of treatment and potential side effects.
  • Treatment should be accompanied by supplemental calcium and vitamin D to support bone health 2, 3.

From the Research

Management of BMD Suggestive for Osteoporosis

• The management of osteoporosis requires lifelong treatment, both non-pharmacological and pharmacological, and drug treatment must be sequential and adapted to the risk of fracture and comorbidities 4.
• Bisphosphonates are commonly used for the treatment of osteoporosis, but stopping bisphosphonates after a period of time, known as a drug holiday, can lead to a decrease in bone mineral density (BMD) 5.
• A study comparing the BMD of postmenopausal women during bisphosphonates treatment and 1 year after a drug holiday found that the average of femoral neck and lumbar spine BMD decreased in both osteopenia and osteoporosis groups after the drug holiday period 5.

Treatment Options

• Denosumab and bisphosphonates are two treatment options for osteoporosis, and a meta-analysis of randomized controlled trials found that denosumab increased BMD more than bisphosphonates at 12 and 24 months 6.
• Another study found that calcium and vitamin D supplementation with 3-year denosumab treatment was beneficial to enhance bone mineral density in postmenopausal patients with osteoporosis and rheumatoid arthritis 7.
• A comparison of once-weekly alendronate 70 mg and once-weekly risedronate 35 mg in women with postmenopausal osteoporosis found that alendronate produced greater gains in BMD and greater reductions in markers of bone turnover than risedronate 8.

Monitoring and Treatment Approach

• Regular monitoring is necessary to assess whether drug treatment should be interrupted, continued, or extended, and the aim is to preserve bone health into old age and prevent fractures 4.
• The effect of a drug holiday on BMD can vary depending on the individual and the treatment approach, and the results of one study suggested that the effect of a drug holiday in osteoporosis patients was more significant compared to osteopenia individuals 5.