As with all diseases, it is actually management of the osteoporosis rather than treatment of the disease. This includes following aspects:
Counselling about risk of fractures with osteoporosis and reduction of fracture risk with treatment, is an important part of management. This also includes information about side effects of medications.
Besides main medical treatment, importance of calcium supplements and vitamin D must be informed to the patient.
Physical exercise is a part of any management program for osteoporosis. Physical activity plays a major role in strengthening bones and helps delaying onset of osteoporosis.
Evaluation of patients for the type of osteoporosis is important for management plan. Primary osteoporosis is post-menopausal in women and senile in both genders. Secondary osteoporosis is a part of many other diseases which result in bone loss. Few drugs may also result in low bone density.
Diagnostic modalities include DEXA (Dual Energy X-Ray Absorptiometry) scan, radiology and biochemical markers.
DEXA is considered to be the gold-standard test for osteoporosis. Interpretation of DEXA result is on the basis of T-score.
Osteopenia: T-score between -1.0 and -2.5 at the femoral neck or lumbar spine
Osteoporosis: T-score ≤ -2.5 at the femoral neck, total hip or lumbar spine.
Radiology helps to get an idea about low bone mass but it does not show precise measurements for current status and to evaluate progress. Radiological interpretation is different by various observers depending on experience. Radiology is important to diagnose fractures including vertebral compression fractures and incomplete fractures of femoral neck
Who Should Be Considered for Treatment?
Patients with primary osteoporosis, postmenopausal women and elderly people of both genders are definite candidates for active treatment. Cases of secondary osteoporosis must also be included. Apart from these, patient having any of the following should be treated.
• Fracture at hip or vertebral body found on clinical examination or by radiology. Many studies have suggested that patients having these fractures with minor injuries need treatment for osteoporosis. In these T-score is not important, the fracture itself is more important indicator. With medical treatment, future fracture risk can be reduced.
• DEXA scan with T-score ≤ -2.5 either at femoral neck, or at lumbar spine. These patients are at higher risk for fragility fractures and need proper treatment.
• DEXA scan with T-score between -1.0 and -2.5 at the femoral neck or lumbar spine, are also candidates for pharmacological treatment.
• Patients with a 10-year probability of a hip fracture of ≥3 % or a 10-year probability of a major osteoporosis-related fracture of ≥20 % also need treatment.
FDA approved drugs for the treatment of osteoporosis (1)
Antiresorptive drugs decrease osteoclastic activity and decrease fracture risk. Approved drugs in this category are of two types:
Bisphonates include alendronate, risedronate, ibandronate and zoledronic acid.
Other antiresorptive drugs include oestrogen therapy / hormone replacement therapy (HRT), raloxifene, denosumab and romosozumab
Anabolic medications increase new bone formation by osteoblastic activity and as a result reduce fracture risk. At present only triparatide is the FDA approved drug in this category
Besides, there are other drugs which are not yet approved by FDA for the treatment of osteoporosis. These are sodium ranelate, calcitriol, sodium fluoride and tibolone.