Osteoporosis treatment

AACE2020Grade Grade A

Treat pharmacologically when fracture risk is high: a T-score of -2.5 or lower at the spine, femoral neck, total hip, or one-third radius; a prior hip or vertebral fragility fracture with osteopenia; or osteopenia with a US-adapted FRAX 10-year risk of at least 20 percent for major osteoporotic fracture or 3 percent for hip fracture. The Endocrine Society and the Bone Health and Osteoporosis Foundation use similar criteria. ACP 2023 sets no FRAX threshold and individualizes treatment of osteopenia over 65.

ACP2023

Bisphosphonates (alendronate, risedronate, or zoledronate) are initial therapy for postmenopausal women with osteoporosis (ACP strong, high-certainty) and are suggested for men (conditional, low-certainty); denosumab is second-line. The Endocrine Society also puts bisphosphonates first, while AACE lists denosumab as an equal initial option. There is no evidence that ibandronate reduces hip fractures. Reevaluate periodically, and consider stopping after 3 to 5 years in those at low fracture risk.

Endocrine Society2019

Denosumab is an effective antiresorptive: an alternative first-line option for the Endocrine Society and AACE, while ACP places it second-line after bisphosphonate intolerance or contraindication. Load-bearing safety point: do not delay or stop denosumab without transitioning to another antiresorptive such as a bisphosphonate, because stopping causes rebound bone loss and multiple vertebral fractures.

Endocrine Society2020

For very high fracture risk, such as a recent fracture, multiple vertebral fractures, or a very low T-score, start with an anabolic agent: teriparatide or abaloparatide for up to 2 years, or romosozumab for up to 1 year (avoid romosozumab with a recent myocardial infarction or stroke or high cardiovascular risk). Always follow an anabolic with an antiresorptive to preserve the gains. Bisphosphonate drug holiday: reassess oral bisphosphonates at 3 to 5 years and consider a holiday if risk is no longer high, while continuing in those who stay high-risk; end the holiday if fracture risk rises or bone density falls.

ACP2023Grade Conditional recommendation, low-certainty evidence

Women over 65 with low bone mass (osteopenia): take an individualized approach to whether to start a bisphosphonate, weighing baseline fracture risk against harms and cost. The evidence comes largely from a single trial in women 65 and older in which zoledronate may have reduced clinical and vertebral fractures (low certainty). Evidence was insufficient to recommend for or against treatment in men with low bone mass.