Osteoporosis Management

Patient Risk Assessment

• Patients are considered high risk if their FRAX 10-year risk of major osteoporotic fracture is ≥20% or hip fracture ≥3%, very high risk if they have prior osteoporotic fracture(s), BMD T-score ≤-3.5, FRAX 10-year risk of major osteoporotic fracture ≥30% or hip fracture ≥4.5%, or high glucocorticoid use (≥30 mg/day for >30 days or cumulative doses ≥5 g/year) 1, 2
• Moderate risk is defined as a FRAX 10-year risk of major osteoporotic fracture 10-19% or hip fracture 1-3%, and low risk is defined as a FRAX 10-year risk of major osteoporotic fracture <10% or hip fracture ≤1% 3
• For patients on glucocorticoids >7.5 mg/day, FRAX scores should be adjusted by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 3

Treatment Recommendations

• Anabolic agents, such as teriparatide, may be preferred as initial therapy for very high-risk patients 2
• After completing anabolic agents, antiresorptive therapy should be initiated to maintain gains 2
• The following treatment options are recommended:

Supplement Recommendations

• The American Academy of Family Physicians recommends calcium and vitamin D supplementation, with 1,200 mg calcium and 600 IU vitamin D daily for ages 51-70, and 1,200 mg calcium and 800 IU vitamin D daily for ages 71+ 1
• Lifestyle modifications, including adequate calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) intake, regular weight-bearing exercise, and fall prevention strategies, are recommended as first-line management for patients with osteopenia 2, 5, 6

Treatment Monitoring and Adjustment

• DXA testing is recommended every 2 years during treatment, or more frequently if medically necessary, with reassessment of treatment after 5 years of bisphosphonate therapy 5, 7, 3
• Regular monitoring, including BMD testing with DXA every 2 years during treatment, and bone turnover markers (P1NP and CTX) before treatment and at 3 months, is essential to evaluate treatment effectiveness 6
• Sequential therapy is necessary after discontinuation of certain medications, such as starting bisphosphonate 6-7 months after denosumab discontinuation, and starting antiresorptive therapy after teriparatide discontinuation 2

Special Populations

• Patients with cancer are at higher risk of accelerated bone loss from cancer treatments, and bone-modifying agents are recommended for those with T-scores ≤ -2.5 or high fracture risk, as suggested by the American College of Radiology 5
• Men with osteoporosis should be assessed for serum testosterone levels as part of pre-treatment evaluation, and consideration should be given to testosterone replacement if levels are low, as recommended by the American Academy of Family Physicians 6
• Patients who have undergone gastrectomy are at high risk for bone disease, with an osteoporosis incidence of 32-42%, and DXA testing is recommended for patients who are at least 10 years post-gastrectomy, especially postmenopausal women and men over 50, as suggested by the American College of Radiology 8

Diagnostic Tools

• The American College of Radiology recommends using DXA scan as the primary diagnostic tool for evaluating bone mineral density in patients with degenerative bone changes, with consideration of quantitative CT in patients with advanced degenerative changes in the spine 9, 10
• Trabecular bone score (TBS) can provide qualitative assessment of bone microarchitecture, especially useful in osteopenic patients, as recommended by the American Academy of Family Physicians 9

Common Mistakes and Adherence

• Underestimating fracture risk in osteopenic patients can lead to inadequate treatment, highlighting the importance of using FRAX assessment to guide intervention decisions 6
• Poor medication adherence can reduce the effectiveness of pharmacological therapy in patients with osteopenia, with up to 64% of men being non-adherent to bisphosphonate therapy by 12 months 6
• Common mistakes that can lead to undertreatment and increased fracture risk include misinterpreting DXA results, assuming osteoporosis is cured, discontinuing treatment without follow-up, focusing solely on BMD, and neglecting secondary causes, as highlighted by the American College of Radiology 9, 10, 6