A Modern Approach to Osteoporosis Management Save

Osteoporosis is a prevalent disorder affecting nearly 20% of the global population, with women disproportionately impacted compared to men. Characterized by reduced bone strength and increased fracture risk, osteoporosis carries serious consequences. Fragility fractures—particularly of the hip and spine—are associated with significant morbidity, long-term disability, reduced quality of life, and increased mortality.

Gina Woods, MD, presented her lecture, "Treating Osteoporosis: current treatment approaches," at the recent Rheumatology Winter Clinical Symposium in Maui, Hawaii.

Several well-established risk factors contribute to the development of osteoporosis, including postmenopausal status, nutritional deficiencies (notably calcium and vitamin D), and prolonged exposure to glucocorticoids. Despite the availability of multiple FDA-approved therapies that effectively reduce fracture risk, treatment rates have declined over recent years. 

Currently, fewer than half of patients diagnosed with osteoporosis receive appropriate pharmacologic therapy.

This treatment gap reflects several challenges in osteoporosis management, including limited disease awareness, barriers to medication access, clinician discomfort with therapy selection, and uncertainty regarding the optimal timing of treatment initiation.

To address these challenges, a 2024 position statement from the American Society for Bone and Mineral Research and the Bone Health and Osteoporosis Foundation advocates for a goal-directed, individualized approach to osteoporosis care. This paradigm shifts away from a universal first-line bisphosphonate strategy toward a “treat-to-target” model that prioritizes rapid fracture risk reduction in patients at very high risk. Bone mineral density (BMD) plays a central role in guiding therapy decisions and monitoring treatment success.

The first step in management is identifying patients who qualify for pharmacologic treatment. This includes individuals with a history of hip, vertebral, or multiple fragility fractures; those with a high 10-year fracture risk as estimated by FRAX; or patients with a BMD T-score of ≤ −2.5. A thorough evaluation for secondary causes of osteoporosis and potential contraindications to therapy is essential before initiating treatment.

Once treatment eligibility is established, patients should be stratified by fracture risk. For individuals at low fracture risk, pharmacologic therapy is not routinely indicated; instead, periodic reassessment of clinical risk factors is recommended. Patients at high fracture risk should begin antiresorptive therapy, typically with bisphosphonates for several years, followed by consideration of a drug holiday if clinical stability is achieved. Denosumab may be used as an alternative in patients for whom bisphosphonates are inappropriate.

For patients at very high fracture risk, an anabolic-first strategy is recommended. Initial treatment with anabolic agents such as teriparatide, abaloparatide, or romosozumab for a defined duration should be followed by antiresorptive therapy to maintain bone density gains. Evidence demonstrates that this sequence results in faster and greater increases in BMD at both the hip and spine compared with the reverse approach.

Ongoing management requires regular monitoring of treatment adherence, potential side effects, and incident fractures. Repeat BMD testing is generally recommended every two to three years to assess treatment response and guide future therapeutic decisions. By adopting a personalized, risk-based treatment strategy, clinicians can improve outcomes for patients with osteoporosis and reduce the substantial burden of fracture-related morbidity and mortality.