Osteoporosis Treatment Guidelines

Risk Assessment and Screening

The American College of Rheumatology recommends initial fracture risk assessment as soon as possible for all adults beginning or continuing glucocorticoid therapy ≥2.5 mg/day for >3 months, including clinical fracture history, BMD testing with vertebral fracture assessment (VFA) or spine x-rays 1, 3
For patients ≥40 years, FRAX assessment should be included in risk stratification; if prednisone dose is >7.5 mg/day, FRAX fracture risk should be adjusted upward (multiply by 1.15 for major osteoporotic fracture risk and by 1.2 for hip fracture risk) 4, 5
BMD testing should be repeated every 1-3 years, with more frequent assessment for those on high-dose glucocorticoids or with history of fractures 6, 2

All patients should receive lifestyle modifications including adequate calcium intake (1,000-1,200 mg/day) and vitamin D (600-800 IU/day, aiming for serum level ≥20-30 ng/ml) 1, 5, 3
Regular weight-bearing and resistance training exercises are recommended 4, 7

The American College of Rheumatology strongly recommends oral bisphosphonates as first-line treatment for adults with high or very high fracture risk 1, 2, 7
For very high-risk patients, anabolic agents (PTH/PTHrP like teriparatide) are conditionally recommended over antiresorptive agents 1, 3
Alternative options for adults ≥40 years with moderate fracture risk include oral bisphosphonates, IV bisphosphonates, denosumab, or PTH/PTHrP agents 4, 2, 1, 3

Reassess fracture risk every 1-3 years 6, 2
For patients on denosumab or anabolic agents, sequential therapy with an antiresorptive agent is recommended to prevent rebound bone loss after discontinuation 1, 3
For men with osteoporosis, treatment recommendations are similar to those for women, with oral bisphosphonates as first-line therapy 7

Failing to adjust FRAX calculations for glucocorticoid use, which underestimates fracture risk 4, 1
Overlooking asymptomatic vertebral fractures, which significantly increase future fracture risk 5, 3
Not considering sequential therapy after discontinuing denosumab or anabolic agents, which can lead to rapid bone loss 1, 3
Delaying treatment in high-risk patients, as bone loss occurs rapidly within the first 3-6 months of glucocorticoid therapy 9