What is the first-line treatment for a 62-year-old female with osteoporosis diagnosed by Dual-Energy X-ray Absorptiometry (DEXA) scan?

From the Guidelines

For a 62-year-old female with osteoporosis confirmed by DEXA scan, the first-line treatment is bisphosphonates, which have the most favorable balance among benefits, harms, patient values and preferences, and cost compared to other drug classes 1. The recommended treatment should be initiated as soon as possible to reduce the risk of fractures.

• The choice of bisphosphonate can be alendronate, risedronate, or zoledronate, as these have been evaluated in eligible primary RCTs and have shown to be effective in reducing fracture risk 1.
• It is essential to note that bisphosphonates are associated with a higher risk for osteonecrosis of the jaw and atypical femoral or subtrochanteric fractures, although the certainty of evidence is low 1.
• In addition to medication, the patient should take calcium and vitamin D supplements, engage in weight-bearing and resistance exercises, avoid smoking, limit alcohol consumption, and take fall prevention measures to support bone health and reduce fracture risk.
• Regular follow-up with DEXA scans every 1-2 years is recommended to monitor treatment effectiveness and adjust the treatment plan as needed.
• The RANK ligand inhibitor, denosumab, can be considered as a second-line treatment for patients at high risk for fracture who have a history of osteoporotic fractures or have been treated with bisphosphonates 1.

From the FDA Drug Label

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

The first line treatment for a 62-year-old female with a DEXA scan showing osteoporosis is alendronate sodium 10 mg/day or once weekly alendronate sodium 70 mg. This is based on the information provided in the drug label, which shows that alendronate reduces bone resorption and increases bone mass in postmenopausal women with osteoporosis 2. Key benefits of alendronate include:

• Reduction in bone resorption
• Increase in bone mass
• Decrease in risk of fracture It is essential to note that the treatment should be tailored to the individual patient's needs and medical history.

From the Research

First Line Treatment for Osteoporosis

• The first line treatment for osteoporosis is oral bisphosphonates 3
• Bisphosphonates are safe and effective agents for the treatment and prevention of osteoporosis, and they increase bone mass and reduce the risk of vertebral fractures 4
• Alendronate and risedronate are the best studied bisphosphonates in terms of efficacy and safety, and they are approved by the US FDA for the prevention of bone loss in recently menopausal women, for the treatment of postmenopausal osteoporosis, and for the management of glucocorticoid-induced bone loss 4

Benefits of Bisphosphonates

• Bisphosphonates have been shown to reduce fractures in women with osteoporosis, and there is increasing evidence that they are also effective in women with osteopenia 5
• They are the only agents shown in prospective trials to reduce the risk of hip fractures and other nonvertebral fractures 4
• Combining a bisphosphonate with estrogen produces greater gains in bone mass compared with either agent used alone 4

Treatment Considerations

• The diagnosis of osteoporosis can be confirmed by DEXA scan, and treatment should be considered in patients with a BMD T-score of -2.5 or below 3
• If oral bisphosphonates are contraindicated or not tolerated, parenteral therapy should be considered 3
• Patients at high risk of fracture should consider treatment with antiresorptive therapy, including bisphosphonates and denosumab 6