Some principles

There are a number of principles which should guide the treatment of osteoporosis:

• in the elderly, a holistic approach to fall prevention should be taken
• all patients should be advised not to smoke cigarettes or drink excessive alcohol.
• all patients should have adequate calcium and vitamin D in their diets and should exercise regularly within the limits of their illness
• Secondary prevention of fractures in postmenopausal women:
  • HRT was frequently used to prevent osteoporosis in postmenopausal women - however HRT, including tibolone, is not recommended for postmenopausal women over the age of 50 years unless other treatments for osteoporosis are contraindicated or not tolerated (1)
    
    
  • Bisphosphonates - first-line therapy
    • NICE suggest that alendronate is recommended as the initial bisphosphonate treatment option for the secondary prevention of osteoporotic fragility fractures (3)
      
      
  • Strontium ranealate is an alternative to bisphosphonate therapy (3)
    
    
  • Raloxifene -women who meet treatment criteria but:
    • bisphosphonate contraindicated or unable to comply with dosing instructions
    • unsatisfactory response (another low trauma fracture despite adhering fully to therapy for 1 year, and BMD decrease below pre-treatment baseline)
    • unable to tolerate oral bisphosphonate (oesophageal ulceration, erosion or stricture, severe lower gastrointestinal symptoms resulting in discontinuation of treatment)
      
      
  • Teriparatide - women >=65 years, secondary prevention, secondary care treatment
    • unsatisfactory response or bisphosphonates not tolerated
    • AND T-score >= -4 OR T-score >= -3 AND >2 fractures
    • AND >=1 additional age-independent risk factors:
      • BMI <19 kg/m2
      • maternal hip fracture <75 years
      • untreated premature menopause
      • conditions associated with prolonged immobility

Fractures are treated by normal orthopaedic means. Fractures of the spine require short periods of bed rest and analgesia.

Notes:

• NICE suggest that strontium ranelate and raloxifene are recommended as alternative treatment options for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (3):
  • recommended as an alternative treatment option for the secondary prevention of osteoporotic fragility fractures in postmenopausal women: who are unable to comply with the special instructions for the administration of alendronate and either risedronate or etidronate,
  • or have a contraindication to or are intolerant of alendronate and either risedronate or etidronate and
  • who also have a specified combination of T-score, age and number of independent clinical risk factors for fracture

Reference:

1. MHRA (2005) Latest data on HRT from the UK Million Women Study. Medicines and Healthcare products Regulatory Agency.
2. ARC. Hands On 2007;11:1-6.
3. NICE (January 2011). Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women