Bone
Osteoporosis Management
search
Osteoporosis Management
, Osteoporosis Prevention
See also
Osteoporosis
Osteoporosis Evaluation
Osteoporosis Secondary Causes
Medication Causes of Osteoporosis
Indications
Treatment with
Osteoporosis
agents
Hip Fracture
or
Vertebra
l
Fracture
history or
Other
Fracture
site AND
Osteopenia
at femoral neck, hip or spine (
T-Score
-1.0 to -2.5) or
Osteoporosis
based on femoral neck, hip or spine BMD (
T-Score
<-2.5)
Evaluate for
Osteoporosis Secondary Causes
prior to treatment
Osteopenia
AND high
Fracture
risk secondary cause (e.g. prolonged
Glucocorticoid
use)
Osteopenia
(T score -1.0 to -2.5) AND abnormal FRAX Score
See Frax Calculator
http://www.shef.ac.uk/FRAX/
Requires hip
Bone Mineral Density
FRAX score (10 year
Fracture
probability) of
Hip Fracture
>3% or
FRAX score for any
Osteoporosis
related
Fracture
>20%
Efficacy
Number Needed to Treat
(NNT) per agent
Prevention of
Hip Fracture
over 3 years (NNT)
Vitamin D
800 IU daily: NNT 45
Bisphosphonates
(
Risedronate
,
Alendronate
, Zoledronic acid): NNT 77-91
Hormone Replacement Therapy
: NNT 385
Prevention of
Vertebra
l
Fracture
over 3 years (NNT)
Bisphosphonates
(Zoledronic acid,
Risedronate
,
Ibandronate
): NNT 13-20
Note that
Alendronate
(
Fosamax
) was less effective with a NNT 37
Calcitonin
(Miacalcin): NNT 10 (5 years)
Possible increased risk of cancer
Teriparatide
(
Forteo
): NNT 11 (1.5 years)
Significantly more expensive than
Bisphosphonates
or
Calcitonin
($600/month)
Management
Gene
ral measures and prevention for all patients
Gene
ral
Calcium and
Vitamin D
supplementation are most cost effective medications
Even
Alendronate
(
Fosamax
), which is generic, costs >$50 per month
Dietary Supplementation
Calcium Supplementation
1200 to 1500 mg per day
Does not increase bone density (but slows loss)
Overdosage above 1500 mg daily weakens bone
Vitamin D
Supplementation 800 to 2000 IU (20-50 mcg) orally per day
Increases bone density 1% per year
Goal Serum 25-Hydroxy
Vitamin D
level: 30-100 ng/ml
If
Vitamin D Deficiency
, then use
Vitamin D Replacement
protocol
Postmenopausal women in community, age <75 do not appear to benefit from
Vitamin D
supplement
Does not effect
Bone Mineral Density
,
Muscle Strength
, fall risk or function
Hansen (2015) JAMA Intern Med 175(10): 1612-21 [PubMed]
Weight bearing
Exercise
See
Exercise in Osteoporosis
Include balance training for
Fall Prevention
Lifestyle changes
Tobacco Cessation
Limit
Alcohol
to moderate use (2 or less drinks per day)
Limit
Caffeine
to <250 mg per day
Sunlight exposure for 30 minutes daily on at least 5 days per week
Limit
Proton Pump Inhibitor
use (associated with higher risk of
Hip Fracture
s)
Yang (2006) JAMA 296:2947-53 [PubMed]
Fall Prevention
and
Hip Fracture
prevention
See
Fall Prevention in the Elderly
See Hip Protectors (underwear with trochanter pads)
Management
Osteoporosis
Treatments considered effective
Gene
ral
See Indications as above
See general measures for all patients (as above)
Bisphosphonates
Increases bone density 5-6% per year
Consider stopping oral
Bisphosphonates
after 5 years (and reclast after 3 years)
See
Bisphosphonates
for protocol
Preparations
Alendronate
(
Fosamax
)
Indicated for the prevention and treatment of
Osteoporosis
(hip,
Vertebra
l, non-
Vertebra
l)
Oral: 10 mg daily or 70 mg weekly (half dose for prevention)
Available with
Cholecalciferol
2800-5600 IU (
Fosamax
plus D weekly)
Most cost effective agent ($60/year in 2020)
Risedronate
(
Actonel
)
Indicated for the prevention and treatment of
Osteoporosis
(hip,
Vertebra
l, non-
Vertebra
l)
Oral: 5 mg daily or 35 mg weekly or 150 mg monthly
Available as delayed release (Atelvia) 35 mg weekly
Costs $1700 per year in 2020
Ibandronate
(
Boniva
)
Indicated for the prevention and treatment of
Osteoporosis
(
Vertebra
l only)
Oral: 2.5 mg daily or 150 mg monthly
IV: 3 mg every 3 months (treatment only)
Zoledronic Acid (Reclast)
Indicated for the prevention and treatment of
Osteoporosis
(hip,
Vertebra
l, non-
Vertebra
l)
IV: 5 mg yearly (every 2 years for prevention)
Costs $270 per year (in addition to infusion cost)
Contraindicated in
Hypocalcemia
or GFR <35 ml/min
Estrogen Replacement Therapy
(ERT or HRT) in women
Benefits may not outweigh risks of CVA, VTE, CAD,
Breast Cancer
Cauley (2003) JAMA 290(13): 1729-38 [PubMed]
Standard Dosing
Minimum preventive plasma estradiol level: 60 pg/ml
Maximal effect requires Premarin 0.625
Increases bone density 3-4% per year
Alternative
Estrogen
dosing
Some effect seen at 0.3 mg or
Transdermal Estrogen
17-beta-estradiol 0.25 mg increases BMD
Prestwood (2003) JAMA 290:1042-8 [PubMed]
Fracture
protection lost 5 years after stopping ERT
Yates (2004) Obstet Gynecol 103:440-6 [PubMed]
Selective Estrogen Receptor Modulator
(e.g.
Raloxifene
) in women
Similar benefit to
Estrogen Replacement
with the risks of VTE, but not
Breast Cancer
, CVA, CAD
Indicated if unable to take
Estrogen Replacement
, and only for
Vertebra
l
Fracture
prevention and treatment
Raloxifene
(
Evista
) 60 mg orally daily
Testosterone Replacement
in men
Increases bone density
Unclear if prevents osteoporotic
Fracture
s
Consider in men with symptomatic
Hypogonadism
Example: Low testosterone and low libido
Management
Osteoporosis
Treatments for high risk patients
Indications: High risk
Osteoporosis
patients
History of osteoporotic
Fracture
Multiple
Fracture
risk factors
Intollerance to or contraindication of other medications
Recombinant
Parathyroid Hormone Analog
:
Teriparatide
(
Forteo
),
Abaloparatide
(
Tymlos
)
Indicated for
Osteoporosis
treatment (
Vertebra
l, non-
Vertebra
l, hip) and
Vertebra
l spine
Fracture
s
Daily
Subcutaneous Injection
(20 mcg SQ daily for
Forteo
, 80 mcg SQ daily for
Tymlos
)
Precautions: Do not use with bisphosphonate and do not use longer than 2 years (
Osteosarcoma
risk)
Very expensive ($20,000 to 46,000 per year in 2020)
Efficacy: Reduced risk for osteoporotic
Vertebra
l
Fracture
s
Neer (2001) N Engl J Med 344:1434-41 [PubMed]
Romosozumab (Evenity) Injection
SQ Injectable
Monoclonal Antibody
, sclerositin inhibitor
Increases bone growth and decreases bone breakdown
Indicated for high risk women with
Fracture
s despite bisphosphonate or multiple
Vertebra
l
Fracture
s
Contraindicated if MI or CVA in last year (associated with increased cardiovascular risk)
Limit to one year of use (effects wane after this) and then switch to bisphosphonate
Costs $22,000 per year in 2019 (covered under Medicare Part B)
(2019) Presc Lett 26(6)
Denosumab (Prolia) Injection
Indicated for
Osteoporosis
treatment (
Vertebra
l, non-
Vertebra
l) and
Vertebra
l spine
Fracture
s
Monoclonal Antibody
blocks
Osteoclast
s (nuclear factor kappa B
Ligand
activator receptor)
Dose: 60 mg SQ every 6 months
Increased risk of infection
Risk of rebound
Vertebra
l
Fracture
s when stopped or dose delayed
Switch to bisphosphonate when course completed
Consider in men with high
Fracture
risk secondary to androgen deprivation therapy (for
Prostate Cancer
)
Cost $2600 per year in 2020
Management
Vertebra
l spine
Fracture
medical management
See
Vertebral Compression Fracture
Management
Agents under investigation for possible benefit in
Osteoporosis
HMG-CoA Reductase Inhibitor
(
Statin
drugs)
Thiazide Diuretic
s (e.g.
Hydrochlorothiazide
)
Decreases urinary calcium loss
Reduction in
Hip Fracture
if used >10 years
Consider in hypertensive patients
LaCroix (2000) Ann Intern Med 133:516-26 [PubMed]
Dietary
Magnesium
600 mg/day or more
Dietary
Soy Protein
40 grams/day or more
Scheiber (1999) Menopause 6:233-41 [PubMed]
Management
Agents no longer recommended for
Osteoporosis
treatment
Fluoride Supplementation
Initial studies showed increased bone density 10% per year
However, unclear whether bone strength was increased
References
(2020) presc lett 27(10): 58-9
Andrews (1998) Postgrad Med 104(4): 89-97 [PubMed]
Campion (2003) Am Fam Physician 67(7):1521-6 [PubMed]
Jeremiah (2015) Am Fam Physician 92(4): 261-8 [PubMed]
Lindsay (1984) Obstet Gynecol 63:759-63 [PubMed]
South-Paul (2001) Am Fam Physician 63(6):1121-8 [PubMed]
Taxel (1998) Geriatrics 53(8): 22-3 [PubMed]
Type your search phrase here