SUMMARY:

Osteoporosis is a common disease that can result in bone fractures. Through screening, risk assessment, and pharmacologic treatment, fractures can be prevented. DEXA scans should be used for screening starting at age 65 for most women. Biphosphonates are the first line therapy for patients found to be high risk patients and should be used for most postmenopausal patients

Diagnosis

• Dual Energy X-Ray (DEXA) is preferred method
  • Hip and lumbar bone mineral density measurements most accurate
  • Osteoporosis diagnosed with T Score ≤–2.5
  • T-score between −1.0 and −2.5 and increased risk of fracture using a formal clinical risk-assessment tool such as the US Fracture Risk Assessment (FRAX) tool
• Clinically diagnosed if patient has a fragility fracture
  • Fracture occurs after a fall at less than standing height
  • Usual site: Hip | Humerus | Rib | Pelvis | Wrist | Spine
  • Includes asymptomatic vertebral fracture

Treatment

Lifestyle Modifications

• Weight bearing exercises
• Adequate intake of vitamin D and calcium
  • Calcium RDA:
    • Age 19 to 50 years: 1000 mg per day
    • >50 years: 1200 mg per day 
  • Vitamin D RDA
    • ≤70 years: 600 IU
    • >70 years: 800 IU per day
• Fall prevention strategies

Pharmacotherapy: Work-up and Candidates for Treatment

• Patient with high risk of fracture should be treated pharmacologically
• Before starting pharmacotherapy, patients should be evaluated for secondary causes of bone loss
  • HIV/AIDs | Anorexia | Diabetes | Hyperparathyroidism | Renal impairment | Rheumatoid arthritis | Turner’s syndrome | Vitamin D Deficiency | Medication induced
• Secondary Osteoporosis Evaluation
  • Complete blood count | Metabolic profile | 24-hour collection for Ca, Na, Cr excretion | Liver function tests | TSH with or without free T4 | 25-hydroxyvitamin D

Pharmacotherapy Options

• Bisphosphonates
  • First line therapy
  • Discontinue in patients who are at low-to-moderate risk if stable after
    • 5 years of treatment with oral bisphosphonates or
    • 3 years of treatment with IV zoledronic acid
• Denosumab
  • Use if a patient prefers less frequent medication administration
  • 6-month subcutaneous administration
  • Patients who discontinue denosumab therapy should be transitioned to treatment with another antiresorptive agent
• Raloxifene
  • Can be used for postmenopausal women who
    • Are at increased risk of vertebral fracture and breast cancer
    • Have low risk of venous thromboembolism
    • Have no significant vasomotor symptoms
• Teriparatide and abaloparatide
  • Parathyroid hormone analogs
  • Can be used in postmenopausal women for up to 2 years  
    • Who are at very high risk of fracture
    • Continue to sustain fractures
    • Have significant bone loss while taking antiresorptive therapy
• Romosozumab
  • Sclerostin-binding inhibitor
  • Can be used in postmenopausal women for up to 1 year
  • Should meet the following criteria
    • Not at increased risk of cardiovascular disease/stroke and have high risk of fracture or
    • Other treatments have not been effective

Note: If unable to tolerate pharmacologic therapy, patient should consume the recommended daily allowance of calcium and vitamin D, ideally through diet although supplementation acceptable

Treatment Monitoring

• DXA testing every 1 to 3 years if patient is on pharmacotherapy until findings are stable

KEY POINTS:  

• DEXA scan T score of ≤–2.5 gives diagnosis of osteoporosis
• Evaluate all patients for secondary causes of bone loss before starting pharmacotherapy
• Breast cancer patients/survivors are at high risk of osteoporosis development if they were treated with chemotherapy or aromatase inhibitors
• Pharmacologic treatment is recommended for all patients at high risk of fracture
• Bisphosphonates should be initial therapy for most postmenopausal patients
• DXA testing every 1 to 3 years if patient is on pharmacotherapy until findings are stable

Learn More – Primary Sources:

ACOG Clinical Practice Guideline 2: Management of Postmenopausal Osteoporosis

FRAX® Fracture Risk Assessment Tool

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