All women over 65 and men over 70 should have bone mineral density (BMD) testing. If fractures or risks, test sooner.
Initiate therapy if:
- Hip or spine fracture and BMD T-score -2.5 or below at hip, spine or femoral neck
- T-score is between -1.0 and -2.5 at femoral neck or spine and the 10-year probability of hip fracture (FRAX score) is 3% or greater
- The 10-year probability of major fracture (FRAX score) is 20% or greater according to
- Bisphosphonates: Standard.
- Alendronate and risedronate are first line
- Zoledronic acid, ibandronate and pamidronate are available in IV forms.
- Calcium is recommended for all patients with osteoporosis. Give 1000-1200 mg/day
- Vitamin D is recommended for all patients. Give 800-1000 IU daily
- Raloxifene (SERM) reduces bone resorption
- Conjugated estrogen and bazedoxifene is like a SERM.
- Calcitonin is not first-line, but can be useful in bone pain. Nasal route.
- Teriparatide is reserved for high-risk patients. Increases calcium concentration, but also increases digoxin toxicity
- Denosumab inhibits bone resorption, alternate to first-line, can lead to cellulitis (subQ) and hypocalcemia