Osteoporosis Treatment Guidelines

Initial Assessment and Treatment

The American College of Rheumatology recommends bone health medications should be initiated immediately for adults ≥40 years with high or very high fracture risk, with oral bisphosphonates as first-line therapy 1, 2
Initial assessment should include FRAX calculation for 10-year fracture probability, BMD measurement via DXA with vertebral fracture assessment, and clinical fracture history 1, 3
Treatment thresholds by risk category: very high risk (treat immediately with pharmacotherapy), high risk (strongly recommend treatment), and moderate risk (consider treatment with shared decision-making) 1, 2

The American College of Rheumatology recommends using FRAX with glucocorticoid adjustment, performing BMD with VFA or spine x-rays, and considering additional risk factors not captured by FRAX for risk stratification in GIOP patients ≥40 years 1, 3
RA itself is a clinical risk factor for fracture in FRAX calculations, and many RA patients require long-term glucocorticoids, triggering GIOP treatment thresholds 1, 3

Oral bisphosphonates (alendronate or risedronate) are strongly recommended as first-line therapy for most patients, including women with known osteoporosis and men with osteoporosis 1, 2
Alternative agents when bisphosphonates are inappropriate include anabolic agents (teriparatide, abaloparatide, romosozumab) and denosumab 1

Initial treatment course of 5 years for bisphosphonates, with reassessment of fracture risk after 5 years and continuation if moderate-to-high risk persists 2, 6
Do not perform routine BMD monitoring during the initial 5-year treatment period 2

All patients should receive calcium 1000-1200 mg/day, vitamin D 600-800 IU/day, and be advised on weight-bearing and muscle resistance exercises, smoking cessation, and alcohol limitation 1