From the Guidelines
Oral medication for osteoporosis is strongly recommended for this 62-year-old female patient with prediabetes and hyperlipidemia, given her bone density scan results showing osteoporosis with T-scores of -2.6 in both the AP spine and femoral neck, meeting the World Health Organization's diagnostic criteria for osteoporosis (T-score at or below -2.5) 1. The patient's lowest T-score meets the World Health Organization's criteria for osteoporosis at one or more sites, indicating an increased risk of fracture. According to the American College of Physicians guideline update, pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab is recommended to reduce the risk for hip and vertebral fractures in women with known osteoporosis 1.
Treatment Options
- First-line treatment would be an oral bisphosphonate such as alendronate 70 mg once weekly or risedronate 35 mg once weekly.
- These medications should be taken first thing in the morning with a full glass of water, remaining upright for 30-60 minutes afterward without consuming food or other medications.
- The patient should also take calcium supplementation (1000-1200 mg daily) and vitamin D (800-1000 IU daily) to support bone health.
Monitoring and Prevention
- Treatment effectiveness should be monitored with a repeat bone density scan in 1-2 years.
- Weight-bearing exercise and fall prevention strategies should also be implemented as part of a comprehensive treatment approach.
- Given her prediabetes, it's essential to monitor her metabolic status as well, as some osteoporosis treatments may have effects on glucose metabolism. The American College of Physicians recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men and women who have clinically recognized osteoporosis 1.
Key Considerations
- Bisphosphonates work by inhibiting osteoclast activity, thereby reducing bone resorption and increasing bone mineral density.
- Potential side effects of bisphosphonates include mild upper GI symptoms, atypical subtrochanteric fracture, and osteonecrosis of the jaw, which should be discussed with the patient and monitored during treatment 1.
From the FDA Drug Label
The American Association of Clinical Endocrinologists (AACE) and National Osteoporosis Foundation (NOF) recommend pharmacologic intervention for all postmenopausal women whose T-score is in this range.
The patient has a T-score of -2.6 in the AP Spine (L1-L4) and Femoral Neck (Right), which meets the World Health Organization's criteria for osteoporosis. Given this diagnosis, oral medication for osteoporosis is recommended. The patient should follow a healthful lifestyle, including good nutrition with adequate calcium and vitamin D, and appropriate weight-bearing exercise. Ibandronate (PO), as described in the drug label 2, is an option for the treatment of osteoporosis in postmenopausal women.
- Key points:
- Patient has osteoporosis based on T-score
- Pharmacologic intervention is recommended
- Ibandronate (PO) is an option for treatment
- Patient should follow a healthful lifestyle
From the Research
Osteoporosis Treatment
The patient's bone density test results indicate osteoporosis, with a T-score of -2.6 in the AP Spine (L1-L4) and Femoral Neck (Right) regions, and osteopenia in the Total Hip (Right) region. According to the World Health Organization criteria, a T-score of -2.5 or below is classified as osteoporosis.
Treatment Options
Studies have shown that various medications can be effective in preventing osteoporotic fractures. These include:
- Bisphosphonates such as alendronate 3, 4, 5, 6, risedronate 3, 4, 5, 6, and zoledronate 3, 4, 5, 6
- Denosumab 4, 5, 6
- Parathyroid hormone 4
- Selective estrogen receptor modulators such as raloxifene and bazedoxifene 4
- Romosozumab 4
- Teriparatide 4, 5
Recommendations
The American Association of Clinical Endocrinologists (AACE) and National Osteoporosis Foundation (NOF) recommend pharmacologic intervention for postmenopausal women with a T-score in this range 3. The patient should also follow a healthful lifestyle, including good nutrition with adequate calcium and vitamin D, and appropriate weight-bearing exercise.
Considerations
When selecting an osteoporosis treatment, it is essential to consider individual factors, such as underlying fracture risk, medical comorbidities, medication burden, and fracture risk reduction profiles 7. Polypharmacy can be a risk factor for hip and fall-related fractures, and worse adherence to pharmacologic therapy 7.
Follow-Up
A repeat BMD and Vertebral Fracture Assessment (VFA) exam is recommended in 2 years or sooner if medically necessary to reassess the patient's status.