Management of Postmenopausal Osteoporosis

<h3 id="Defining">Defining osteoporosis</h3><p dir="ltr">Osteoporosis is characterized by increased bone fragility and susceptibility to fractures. Although a BMD T-score &lt; −2.5 is the traditional diagnostic criterion, BMD alone may not identify all individuals at high fracture risk. Therefore, fracture risk assessment should be considered alongside BMD and clinical risk factors to guide diagnosis and treatment.</p><h3 id="Overview">Overview of Osteoporosis Management</h3><p dir="ltr">Management focuses on preventing bone loss and reducing fracture risk through lifestyle measures and medications when appropriate. Fall prevention is important at all ages. Osteoporosis screening is recommended for postmenopausal women ≥65 years and younger women with clinical risk factors, using fracture-risk assessment with BMD when appropriate. Patients with unexpectedly low BMD should be evaluated for secondary causes of bone loss, including endocrine, inflammatory, malignant, genetic, and medication-related conditions (Table 1).</p><h3 id="Table 1">Table 1: Clinical guideline summary for Osteoporosis management</h3><p style="text-align:center;"><img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791865532883-f7a392233a89-Screenshot_2026-10-13_094710.webp" alt="Clinical guideline summary for Osteoporosis management" width="1409" height="1104"></p><h3 id="Interventions">Interventions to Prevent Fractures</h3><p dir="ltr">The primary goal of osteoporosis management is to prevent fractures through a combination of lifestyle measures, fall prevention, fracture-risk assessment, and appropriate pharmacological treatment.</p><p dir="ltr"><strong>Key interventions include:</strong></p><ul dir="ltr"><li><strong>Optimize bone health:</strong> Maintain a healthy body weight, balanced nutrition, adequate protein intake, weight-bearing/resistance exercise, and safe sunlight exposure.</li><li><strong>Avoid modifiable risk factors:</strong> Do not smoke and limit alcohol intake.</li><li><strong>Prevent falls:</strong> Address home hazards, optimize vision, review sedative and antihypertensive medications, and incorporate balance and strength training.</li><li><strong>Assess fracture risk:</strong> Use validated tools such as FRAX or Garvan, with BMD measurement when appropriate.</li><li><strong>Reduce fracture risk pharmacologically:</strong> Treatment may include bisphosphonates, zoledronate, denosumab, estrogen/SERMs, or anabolic agents, depending on the individual’s fracture risk and clinical circumstances.</li><li><strong>Monitor treatment:</strong> Assess adherence, dosing technique, bone turnover markers where appropriate, and repeat BMD when it is likely to influence management.</li><li><strong>Use appropriate treatment sequences:</strong> In general, anabolic therapy is followed by antiresorptive therapy, while denosumab discontinuation usually requires transition to a bisphosphonate.</li></ul><h3 id="Vitamin D">Vitamin D in Osteoporosis</h3><p dir="ltr">Vitamin D is important for calcium and phosphate absorption and normal bone mineralization, but supplementation does not provide additional fracture prevention benefits in most vitamin D-replete individuals.</p><ul dir="ltr"><li>The need for supplementation should be individualized based on expected 25(OH)D levels, considering factors such as season, lifestyle, body weight, skin pigmentation, and environment.</li><li>Vitamin D supplementation should be individualized, with typical doses of 400–1000 IU/day being sufficient for most individuals. Higher doses may be required in patients with malabsorption or obesity. Very high doses, particularly &gt;2000 IU/day, should generally be avoided unless clinically indicated, as excessive vitamin D may adversely affect BMD and fracture risk.</li></ul><h3 id="Antiresorptive">Antiresorptive Agents</h3><ul dir="ltr"><li>Antiresorptive agents are important for reducing bone loss and fracture risk.</li><li>Bisphosphonates and denosumab are the main antiresorptive drug classes, while estrogen and selective estrogen receptor modulators (SERMs) also have antiresorptive effects.</li></ul><h4 id="Oral">Oral bisphosphonates</h4><p dir="ltr">Bisphosphonates bind to the bone surface and inhibit osteoclast activity, thereby reducing bone resorption and helping to maintain or increase bone mineral density (BMD).</p><p style="text-align:center;"><img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791865605886-fa575989ef5f-Screenshot_2026-10-13_094919.webp" alt="Oral bisphosphonates" width="1413" height="478"></p><h4 id="Zoledronate">Zoledronate</h4><p dir="ltr">Zoledronate is the most potent and long-acting bisphosphonate and is administered as an intravenous infusion. The recommended osteoporosis dose is 5 mg IV, generally administered over 15 minutes, generally once yearly when using the conventional osteoporosis regimen. Adequate hydration and assessment of renal function are important before treatment.</p><p style="text-align:center;"><img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791865651991-322604afef10-Screenshot_2026-10-13_095004.webp" alt="Zoledronate" width="1400" height="601"></p><h4 id="Denosumab">Denosumab</h4><p dir="ltr">Denosumab is a monoclonal antibody that targets RANKL, thereby inhibiting osteoclast formation and activity and strongly reducing bone resorption.</p><p style="text-align:center;"><img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791865720594-c796a1d50561-Screenshot_2026-10-13_095048.webp" alt="Denosumab" width="1404" height="551"></p><h3 id="Estrogen">Estrogen and Selective Estrogen Receptor Modulators (SERMs)</h3><ul dir="ltr"><li><strong>Mechanism:</strong> Reduce bone resorption by acting through estrogen receptors and help maintain bone strength.</li><li><strong>Estrogen:</strong> Reduces vertebral, hip, and overall fracture risk, with efficacy comparable to other antiresorptive therapies.</li><li><strong>Use in osteoporosis:</strong> Estrogen is generally not used as the primary treatment for fracture prevention because of concerns regarding thromboembolism, cardiovascular events, and cancer.</li><li><strong>Early postmenopause:</strong> The benefit–risk profile of estrogen may be more favorable in women during the first decade after menopause, particularly those with increased fracture risk.</li><li><strong>Raloxifene:</strong> Has a smaller effect on BMD than most bisphosphonates and reduces vertebral but not nonvertebral fractures. It is associated with an increased risk of venous thromboembolism but a reduced risk of breast cancer.</li></ul><h3 dir="ltr" id="Anabolic Agents">Anabolic Agents</h3><h4 id="Teriparatide">Teriparatide</h4><p dir="ltr">Teriparatide is a recombinant PTH (1–34) receptor agonist that stimulates osteoblast activity and increases bone formation. The commonly used dose is 20 µg SC once daily.</p><p><img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791865813349-633d3da5c0fa-Screenshot_2026-10-13_095124.webp" alt="Teriparatide" width="1404" height="618"></p><h4 id="Abaloparatide">Abaloparatide</h4><p dir="ltr">Abaloparatide is a synthetic peptide that activates the PTH1 receptor pathway, stimulating bone formation. It is administered at 80 µg subcutaneously once daily. In postmenopausal women with osteoporosis, abaloparatide produced greater increases in BMD than teriparatide.</p><h4 id="Romosozumab">Romosozumab</h4><p dir="ltr">Romosozumab is a monoclonal antibody against sclerostin that simultaneously increases bone formation and decreases bone resorption. It is administered as 210 mg subcutaneously once monthly for 12 months.</p><h3 id="Commonly">Commonly used sequences of interventions for management of osteoporosis (Figure 1)</h3><p style="text-align:center;"><img src="https://cdn.megawecare.com/GHBY/Internal-Images/1791865868422-da120d84804c-Screenshot_2026-10-13_095240.webp" alt="Commonly used sequences of interventions for management of osteoporosis (Figure 1)" width="647" height="284"></p><p dir="ltr">Periods of continuous drug administration are shown as solid bars, for oral bisphosphonates or anabolic drugs. The timing of periodic infusions of zoledronate or injections of denosumab are shown with vertical arrows.</p><p dir="ltr"><strong>Abbreviations:</strong> BMD: Bone Mineral Density; BP: Bisphosphonate; CI: Confidence Interval; FRAX: Fracture Risk Assessment Tool; IV: Intravenous; MOF: Major Osteoporotic Fracture; PTH: Parathyroid Hormone; PTH1: Parathyroid Hormone 1 Receptor; RANKL: Receptor Activator of Nuclear Factor Kappa-B Ligand; RR: Relative Risk; SC: Subcutaneous; SERM: Selective Estrogen Receptor Modulator; SERMs: Selective Estrogen Receptor Modulators</p><h2 data-section="conclusion" id="Disclaimer">Disclaimer</h2><p><i>This scientific information content is facilitated by Mega Lifesciences and is intended for healthcare professionals for their reading and update. Although care has been taken in compiling and checking the information, the facilitator is not responsible, or in any way liable for any errors, omissions or inaccuracies in this content whether arising from negligence or otherwise, however, or for any consequences arising therefrom.</i></p>

1a73a4834668 ORTHO UPDATES 2026   ISSUE   5 1 3 1

<ul><li><a href="#Defining">Defining Osteoporosis</a></li><li><a href="#Overview">Overview of Osteoporosis Management</a></li><li><a href="#Table 1">Table 1: Clinical Guideline Summary</a></li><li><a href="#Interventions">Interventions to Prevent Fractures</a></li><li><a href="#Vitamin D">Vitamin D in Osteoporosis</a></li><li><a href="#Antiresorptive">Antiresorptive Agents</a></li><li><a href="#Anabolic Agents">Anabolic Agents</a></li><li><a href="#Disclaimer">Disclaimer</a></li></ul>

Management of Postmenopausal Osteoporosis

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