6 Updates on Osteoporosis Treatment

#1: Give Bisphosphonates to Women.

To reduce the risk of hip and vertebral fractures in women who have known osteoporosis, offer pharmacologic treatment with a bisphosphonate (alendronate, risedronate, or zoledronic acid) or the biologic denosumab. When prescribing bisphosphonates, discuss with patients the importance of adherence and factors that contribute to poor adherence, such as adverse effects, the inconvenience of taking medications, and the absence of symptoms of underlying disease.

2: Treat Women for 5 Years.

Treat osteoporotic women with pharmacologic therapy for 5 years. For some patients, continuing treatment after 5 years may be beneficial and may be appropriate after the risks and benefits are reassessed. The incidence of new clinical vertebral fractures was decreased in patients treated with alendronate who had preexisting fractures and those with a BMD of –2.5 or less after 5 years of initial therapy.

#3: Avoid Bone Density Monitoring.

Do not use bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. Current evidence does not show any benefit for monitoring during treatment. There was no evidence for BMD monitoring for men.

#4: Provide Bisphosphonates to Men.

Offer pharmacologic treatment with bisphosphonates to reduce the risk of vertebral fracture in men who have clinically recognized osteoporosis. No evidence suggests that men and women with similar BMDs would have different outcomes associated with pharmacologic treatment. In 1 study, zoledronic acid reduced vertebral fractures in osteoporotic men.

#5: Forgo Menopausal Estrogen Therapy.

Do not use menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women. Estrogen treatment is associated with serious harms, such as increased risk of cerebrovascular accidents and venous thromboembolism that significantly outweigh the potential benefits.

#6: Make Educated Osteopenia Decisions.

Base decisions on whether to treat osteopenic women age ≥ 65 years at high risk for fracture on a discussion of patient preferences; fracture risk profile; and benefits, harms, and costs of medications. Treatment with risedronate in women with osteopenia near the osteoporosis threshold may reduce their fracture risk. Clinicians can use their own judgment based on risk factors for fracture or on a risk assessment tool, such as FRAX (World Health Organization Fracture Risk Assessment Tool).