Osteoporosis Management Guidelines

Risk Assessment and Diagnosis

The American College of Rheumatology recommends using FRAX as the appropriate tool for assessing fracture risk and setting intervention thresholds in osteoporosis, with thresholds being age-dependent 2, 3
A female reference database should be used for the densitometric diagnosis of osteoporosis in men 3
Trabecular bone score, used with BMD and FRAX probability, provides useful information for fracture risk assessment 2, 4
All individuals with a prior fragility fracture should be considered for treatment with anti-osteoporosis medications 2, 3
Treatment regimens should be adapted to an individual's baseline fracture risk 2, 4

Ensuring vitamin D and calcium repletion is crucial, with recommended daily intake of 1,000-1,200 mg calcium and 800-1,000 IU vitamin D for men above 65 years 2, 5
Physical exercise, including balance training, flexibility exercises, endurance exercise, and resistance training, and a balanced diet should be recommended to all patients with osteoporosis 2, 5
Smoking cessation and limiting alcohol consumption should be actively encouraged 5

Oral bisphosphonates, such as alendronate or risedronate, are recommended as first-line treatments for individuals at high risk of fracture 1, 2
Alendronate significantly improves BMD at the lumbar spine, total hip, and femoral neck 6
Risedronate improves BMD at the lumbar spine, total hip, and femoral neck 6
Denosumab or zoledronate are recommended as second-line treatments for individuals at high risk of fracture 1, 2
Zoledronate significantly improves lumbar spine BMD, femoral neck BMD, and total hip BMD 6, 7
Denosumab administered via 6-monthly subcutaneous injections improves BMD at the lumbar spine, femoral neck, and total hip 6
Sequential therapy starting with a bone-forming agent followed by an anti-resorptive agent should be considered for individuals at very high risk of fracture 1, 2
Abaloparatide is considered an appropriate first-line treatment for patients with osteoporosis at very high risk of osteoporotic fracture 1, 2
Teriparatide significantly improves BMD at the lumbar spine and femoral neck 7

Serum total testosterone should be assessed as part of the pre-treatment assessment of men with osteoporosis 1, 8
Appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone 1, 8
Testosterone replacement has shown significant increases in lumbar spine trabecular volumetric BMD and cortical volumetric BMD 7
Patients with nonmetastatic cancer who are prescribed drugs that cause bone loss should be offered BMD testing every 2 years, or more frequently if medically necessary 5, 9
For cancer patients with osteoporosis or at increased risk of fractures, bone-modifying agents may be offered 5
Hormonal therapies for osteoporosis management are generally avoided in patients with hormonal-responsive cancers 5

Biochemical markers of bone turnover are appropriate tools to assess adherence to anti-resorptive therapy 1, 2
Adherence can be monitored by measuring bone turnover markers at baseline and at 3 months 6
Poor adherence is a significant issue with oral bisphosphonates, with up to 64% of men being non-adherent by 12 months 3