Osteoporosis Treatment Guidelines

Diagnosis and Assessment

The American College of Physicians recommends bisphosphonates as first-line pharmacologic treatment for osteoporosis due to their favorable balance of benefits, harms, patient values and preferences, and cost compared to other medications 1
Dual energy x-ray absorptiometry (DEXA) should be performed in all women 65 years and older and in postmenopausal women younger than 65 years with risk factors, and treatment is recommended for patients with a T-score of -2.5 or less 2
For those with T-scores between -1.0 and -2.5, the FRAX calculator can assist in treatment decisions, with pharmacologic therapy recommended for those with a 10-year risk of major osteoporotic fracture of at least 20% or hip fracture risk of at least 3% 2
Patients with a history of low-trauma fracture should be considered for treatment even if DEXA does not indicate osteoporosis 2

The American Academy of Family Physicians recommends a daily calcium intake of 1,000 mg for ages 19-50 and 1,200 mg for ages 51 and older, and a daily vitamin D intake of 600 IU for ages 19-70 and 800 IU for ages 71 and older 2, 3
A serum vitamin D level of at least 20 ng/mL (50 nmol/L) is recommended for good bone health 2
Regular weight-bearing, muscle-strengthening, and balance exercises are recommended to reduce fracture risk, and smoking cessation and limiting alcohol consumption are strongly advised 3, 4
Fall prevention strategies should be implemented, including vision/hearing assessment, medication review, and home safety evaluation 4

The American College of Physicians recommends oral bisphosphonates (alendronate, risedronate) as initial treatment due to their efficacy, safety profile, and lower cost 1, 2
Bisphosphonates are available in daily, weekly, or monthly oral options, as well as intravenous formulations, and contraindications include esophageal abnormalities, inability to remain upright for 30 minutes, hypocalcemia, and hypersensitivity 2
Long-term use (>5 years) of bisphosphonates may increase risk of osteonecrosis of the jaw and atypical femoral fractures, so clinicians should consider stopping treatment after 5 years unless there's a strong indication to continue 1, 5
Denosumab is recommended as second-line treatment for patients with contraindications to or adverse effects from bisphosphonates, and after discontinuation, patients should be transitioned to an antiresorptive agent to prevent rapid bone loss 1, 5
Raloxifene is a selective estrogen receptor modulator that can be a good initial treatment for younger postmenopausal women, but is generally avoided in patients with hormone-responsive cancers 2, 3
Teriparatide is an anabolic agent typically reserved for patients with severe osteoporosis or those who have had fractures, and after discontinuation, patients should be transitioned to an antiresorptive agent to maintain bone gains 1, 2

The American College of Physicians recommends bisphosphonates as first-line treatment for men with osteoporosis, and denosumab as second-line therapy for those with contraindications to or adverse effects from bisphosphonates 1
For adults with glucocorticoid-induced osteoporosis, oral bisphosphonates are recommended for initial treatment, and for those receiving very high-dose glucocorticoids, oral bisphosphonates are preferred over IV bisphosphonates, teriparatide, or denosumab 6
For cancer patients with osteoporosis or at high risk of fracture, bone-modifying agents (oral bisphosphonates, IV bisphosphonates, or subcutaneous denosumab) are recommended, and hormonal therapies for osteoporosis are generally avoided in patients with hormone-responsive cancers 7

Bisphosphonate treatment should be reassessed after 5 years, with consideration for drug holidays based on individual risk factors, and patients initially treated with anabolic agents should be transitioned to antiresorptive therapy to maintain bone gains 1, 5
Bone density should be monitored every 24 months in cancer patients with elevated fracture risk, with more frequent monitoring (12 months) if risk factors change significantly 8
Generic medications should be prescribed when possible to improve affordability and adherence 1