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Osteoporosis is often asymptomatic until a fracture occurs; these can occur with minimal or no trauma.1 Risk factors for osteoporosis include female gender, older age, low calcium intake or vitamin D deficiency, BMI <21 kg/m2, steroid use, excessive alcohol intake, smoking, and inadequate exercise.2-4
| Test bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA,DEXA) in the following:2, 4 • women > 65 and men > 70 • peri/post-menopausal women < 65 and men 50 – 69 with risk factors such as low body weight (BMI < 21 kg/m2) or prior low-trauma fracture • anyone with other risk factors for low bone mass such as rheumatoid arthritis or systemic steroid use for ≥ 3 months • those with a fracture after age 50 • postmenopausal women discontinuing estrogen |
BMD measurements are reported as T-scores. Use the lowest (most negative) of the hip, femoral neck, and lumbar spine scores for diagnosis.4A patient who has had a low/no trauma fracture should be considered to have osteoporosis regardless of BMD.5
Table 1. T-scores and diagnosis
| T-score | Diagnosis |
| > -2.5 | Osteopenia ("low bone mass") |
| Between -1.0 and -2.5 | Osteopenia ("low bone mass") |
| > -1.0 | Normal bone mineral density |
A WHO fracture risk algorithm (FRAX) can be used to calculate the 10-year risk of hip and other major osteoporotic fractures.2 The US-adapted algorithm is available at http://RxFacts.org/FRAX.php for Hispanic, Black, Caucasian, and Asian people. Hardcopy charts of fracture risk are available at the above website. Input parameters are age, gender, weight, height, BMD, and clinical risk factors including previous fracture, family history of hip fracture, use of oral glucocorticoids (in a daily dose ≥ 5 mg prednisone or equivalent for ≥ 3 months), smoking, excessive alcohol use (3 or more drinks per day), and rheumatoid arthritis. The risk calculator can help determine whether or not to start drug therapy (see Figure 1 below). Hardcopy charts of fracture risk are available at the above website and examples of these charts are provided as an appendix to the accompanying evidence document.
| Test | Comments |
| Vitamin D | Vitamin D deficiency is common.2,6,7 Consider checking serum 25-OH vitamin D, especially in older patients and those with low bone density.4 |
| Calcium | Measure serum calcium, and work up if abnormal; a 24-hour urine calcium < 50 mg suggests either insufficient calcium intake or poor absorption.4 |
| Other | If a specific cause of osteoporosis is suspected, other relevant studies may include thyroid function tests, testosterone levels in med, antibody testing for celiac disease, and a serum parathyroid hormone level. |
Several simple dietary and lifestyle interventions can help maintain BMD and/or reduce the risk of falls and fractures, even for patients with normal bone mass.
Table 2. Interventions for all patients
| Intervention | Recommendations and comments |
| Calcium | -Daily intake of at least 1,200 mg of elemental calcium per day for people > 50, including supplements if dietary intake is inadequate.2 -An easy-to-use dietary calcium calculator is available at http://www.myoptumhealth.com/portal/ManageMyHealth/Calcium+Calculator -For optimal absorption, a single dose of calcium supplement should contain no more than 500 mg of elemental calcium, so divided doses may be needed.1,4 -Calcium carbonate should be taken with meals. Calcium citrate is more expensive, but does not need to be taken with meals; it is preferred in patients on acid-suppressive therapies.1,4 |
| Vitamin D | -Daily intake of 800 - 1,000 international units (IU) per day for people > 50.2 Some older patients may need at least 2,000 IU per day to maintain adequate 25(OH)D levels.2 -One strategy for correcting vitamin D deficiency is 50,000 IU weekly of oral vitamin D2 for 8 weeks, followed by a maintenance dosage of 50,000 IU every 2-4 weeks or 1,000 IU of oral vitamin D3 once daily.1 -Re-test serum 25(OH)D levels after at least 12 weeks of supplementation, because steady state of 25(OH)D is not achieved until that time.4 |
| Exercise* | -Weight-bearing and muscle-strengthening exercise reduce the risk of falls and increase bone density.8 |
| Falls prevention* | -Review prescriptions that may cause impaired balance/mobility, sedation, or confusion; check and correct vision and hearing problems; improve home safety. |
| Smoking* and alcohol control | -Smoking and excessive alcohol consumption (over 3 drinks per day) increase the risk of osteoporosis.9 Yet another reason to quit smoking. |
*Comprehensive discussions on exercise for elderly people, falls prevention, and smoking cessation can be found in previous iDiS modules: (i) Preventing Falls and Enhancing Mobility, and (ii) Chronic Obstructive Pulmonary Disease.
Figure 1. Algorithm for use of osteoporosis medications2,4
Bisphosphonates include alendronate (generics, Fosamax, Fosamax plus D, ibandronate (Boniva), risedronate (Actonel, Actonel with calcium), and zoledronate (Reclast).
Table 3. The evidence for efficacy
| Medication | Efficacy |
| Bisphosphonates (alendronate, ibandronate, risedronate, zoledronate) | -Reduce the risk of vertebral, non-vertebral, and hip fractures in postmenopausal women. Treatment beyond 5 years may not provide additional benefit in many women. -Also reduce the risk of vertebral fractures in men, as well as steroid-induced osteoporosis. |
| Teriparatide (Forteo) | -Reduces the risk of vertebral and non-vertebral fractures in postmenopausal women with a prior vertebral fracture. -Duration of therapy (up to 2 years only) and high cost may limit its usefulness. -Also reduces the risk of vertebral fractures in men, as well as steroid-induced osteoporosis. |
| Raloxifene (Evista) | -Reduces the risk of vertebral fractures in postmenopausal women with osteoporosis. |
| Calcitonin (generics, Miacalcin, Fortical) | -Reduces the risk of vertebral fractures in postmenopausal women with osteoporosis. |
| Denosumab (Prolia) | -Reduces the risk of risk of vertebral, non-vertebral, and hip fractures in postmenopausal women with osteoporosis. |
| Estrogen-based Hormone therapy (HT) | -Although HT (estrogens with or without progestogens) is FDA-approved for the prevention of osteoporosis in postmenopausal women, if this is the sole aim of treatment, other drugs should be used because of the cancer and cardiovascular side effects of HT.2 -Long term HT use is not indicated for the treatment of osteoporosis,10 and its BMD benefits are lost soon after discontinuation.4 |
No head-to-head clincal trials have studied bisphosphonates in relation to each other or to other drug classes for anti-fracture efficacy,4 making comparisons difficult.11,12 A large observational study, controlling for patient characteristics, found that patients taking bisphosphonates had lower fracture risks than those taking raloxifene or calcitonin.13 The most affordable and tolerable bisphosphonate should be the first-line treatment for fracture prevention.
Adherence to regimens of medications for osteoporosis (including calcium and vitamin D) is often low.5,11,14 One study found that women with high prescription drug compliance had a 16% lower fracture rate than those with low compliance.15
| • Assess adverse effects and compliance (which is often poor). • Encourage adequate calcium and vitamin D intake, exercise, falls prevention, smoking cessation, and avoidance of excessive alcohol use. • Re-check bone mineral density 2 years after starting a drug, and every 2 years thereafter. More frequent testing may be warranted for some patients, such as those taking high-dose steroids. • Reassess the need for continuing use of a bisphosphonate after 5 years unless the T-score remains lower than -2.5. |
|
Strategies to improve adherence include:5, 11 |
ONJ is a condition of localized "bone death" that has been reported rarely in patients taking oral bisphosphonates, and can be difficult to treat. After widely publicized reports of ONJ, many patients stopped taking their bisphosphonates, and many physicians became concerned about whether to continue prescribing them. However, the risk of bisphosphonate-related ONJ is very low with oral bisphosphonates used to treat osteoporosis; dental surgery increases the risk. The condition is more commonly seen in cancer patients given intravenous bisphosphonates.16
Consider discontinuing an oral bisphosphonate for at least 3 months prior to oral surgery in patients who have taken the drug for >3 years, or in those who have taken it for <3 years and are on corticosteroids. The drug should not be restarted until bone has fully healed.16
Cost may be a barrier to adherence. Generic aledronate is now available, making bisphosphonate therapy more affordable. Injectable drugs may incur an additional up-front expense.5 The costs of a 30-day supply of typical doses of these medications are listed below. The price of calcium and vitamin D varies, but these medications are widely available and inexpensive (under $10 per month).5
Figure 2. Cost of medications used for osteoporosis
SC/IM: subcutaneous/intramuscular injection; SC: subcutaneous injection; IV: intravenous. Prices obtained from www.epocrates.com, May 2010. Price for denosumab obtained June 2010.
1. Sweet MG, Sweet JM, Jeremiah MP, Galazka SS. Diagnosis and treatment of osteoporosis. Am Fam Physician. Feb 1 2009;79(3):193-200. 2. National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis 2010. Available at: http://www.nof.org/professionals/pdfs/NOF_ClinicianGuide2009_v7.pdf. 3. Poole KE, Compston JE. Osteoporosis and its management. BMJ. Dec 16 2006;333(7581):1251-1256. 4. Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. Jan-Feb;17(1):25-54; quiz 55-26. 5. US Department of Health and Human Services. Agency for Healthcare Research and Quality. Clinician's Guide: Fracture Prevention Treatments for Postmenopausal Women with Osteoporosis 2008. Available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=95. 6. Holick MF. Vitamin D deficiency. N Engl J Med. Jul 19 2007;357(3):266-281. 7. Reichrath J. Skin cancer prevention and UV-protection: how to avoid vitamin D-deficiency? Br J Dermatol. Nov 2009;161 Suppl 3:54-60. 8. Bonaiuti D, Shea B, Iovine R, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2002(3):CD000333. 9. Tannirandorn P, Epstein S. Drug-induced bone loss. Osteoporos Int. 2000;11(8):637-659. 10. Farquhar C, Marjoribanks J, Lethaby A, Suckling JA, Lamberts Q. Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2009(2):CD004143. 11. US Department of Health and Human Services. Agency for Healthcare Research and Quality. Comparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis 2007. Available at: http://effectivehealthcare.ahrq.gov/ehc/products/8/73/LowBoneDensityExecSummary.pdf. 12. MacLean C, Newberry S, Maglione M, et al. Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med. Feb 5 2008;148(3):197-213. 13. Cadarette SM, Katz JN, Brookhart MA, Sturmer T, Stedman MR, Solomon DH. Relative effectiveness of osteoporosis drugs for preventing nonvertebral fracture. Ann Intern Med. May 6 2008;148(9):637-646. 14. Papaioannou A, Kennedy CC, Dolovich L, Lau E, Adachi JD. Patient adherence to osteoporosis medications: problems, consequences and management strategies. Drugs Aging. 2007;24(1):37-55. 15. Caro JJ, Ishak KJ, Huybrechts KF, Raggio G, Naujoks C. The impact of compliance with osteoporosis therapy on fracture rates in actual practice. Osteoporos Int. Dec 2004;15(12):1003-1008. 16. Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaw - 2009 update. Available at http://www.aaoms.org/docs/position_papers/bronj_update.pdf.
These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient's clinical condition.