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Continuing our article on Osteoporosis. Please see Part 1 Diagnosis from 30 September and Part 2 prevention from 1-3 October

TREATMENT

OSTEOPOROSIS TREATMENT—Who needs treatment with a medication? — People with the highest risk of fracture are the ones most likely to benefit from drug therapy. In the United States, the National Osteoporosis Foundation (NOF) recommends use of a medication to treat postmenopausal women (and men ≥50 years) with a history of hip or vertebral fracture or with osteoporosis (T-score ≤-2.5).

In addition, the NOF recommends drug therapy for people who have osteopenia (T-score between -1.0 and -2.5) as well as one of the following risk factors:

High risk of bone loss from long-term use of prednisone or another glucocorticoid

High risk of future fracture based upon previous history of fracture with minimal force (eg, fall from standing height)

Estimated 10-year risk of hip or osteoporosis-related fracture ≥3 or ≥20 percent, respectively

The 10-year risk of hip and osteoporotic fractures can be calculated using the World Health Organization FRAX calculator.

However, some people who do not meet these criteria will benefit from a medication to treat osteoporosis or osteopenia. The final decision about use of a medication should be shared between the patient and healthcare provider.

Bisphosphonates — Bisphosphonate are medications that slow the breakdown and removal of bone (ie, resorption). They are widely used for the prevention and treatment of osteoporosis.

These drugs need to be taken first thing in the morning on an empty stomach with a full 8 oz glass of plain (not sparkling) water. Patients should remain upright (sitting or standing) for at least 30 minutes after taking any oral bisphosphonate to minimize the risk of reflux.

“Estrogen-like” medications — Certain medications, known as selective estrogen receptor modulators (SERMs) produce some estrogen-like effects in the bone. These medications provide protection against postmenopausal bone loss. In addition, SERMs decrease the risk of breast cancer in women who are at high risk. Currently available SERMs include raloxifene (Evista®) and tamoxifen. These medications may be less effective in preventing bone loss than bisphosphonates or estrogen.

SERMs are not recommended for premenopausal women.

Estrogen/progestin therapy — In the past, estrogen or estrogen-progestin therapy was considered the best way to prevent postmenopausal osteoporosis and was often used for treatment. Data from the Women’s Health Initiative (WHI), a large clinical trial, found that combined estrogen-progestin treatment reduced hip and vertebral fracture risk by 34 percent. A similar reduction in fracture risk was seen in women who took estrogen alone.

Estrogen had the additional advantage of controlling menopausal symptoms. However, the WHI found that estrogen plus progestin does not reduce the risk of coronary artery disease, and slightly increases the risk of breast cancer, stroke, and blood clots. However, some postmenopausal women continue to use estrogen, including women with persistent menopausal symptoms and those who cannot tolerate other types of osteoporosis treatment.

Calcitonin — Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps to regulate calcium concentrations in the body. Synthetic calcitonin is sometimes recommended as a treatment for osteoporosis. Calcitonin may be administered via nasal spray or injection (subcutaneous salmon calcitonin).

Parathyroid hormone (PTH) — PTH is produced by the parathyroid glands and stimulates both bone resorption and new bone formation. Intermittent administration stimulates formation more than resorption. Clinical trials suggest that PTH therapy is effective in both the prevention and treatment of osteoporosis in postmenopausal women and in men.

A PTH preparation called Forteo®, given by daily injection, is approved for the treatment of severe osteoporosis for two years.

Denosumab — Denosumab (Prolia®) is an antibody directed against a factor (RANKL) involved in the formation of cells that break down bone. Denosumab improves bone mineral density and reduces fracture in postmenopausal women with osteoporosis. It is administered as an injection under the skin once every six months.

Because it is a new drug, denosumab is usually reserved for patients who are intolerant of or unresponsive to other therapies.

MONITORING RESPONSE TO TREATMENT — Testing may be recommended to monitor a person’s response to osteoporosis therapy. This may include measurement of bone mineral density (DXA scan) or laboratory tests that indicate bone turnover (ie, rate of new bone formation and breakdown).