Medical therapy to prevent fractures in people with osteoporosis

25(OH)D: 25-hydroxyvitamin D; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; GI: gastrointestinal.

* Refer to additional UpToDate content on evaluation of hypercalcemia and hypocalcemia.

¶ Very high risk of fracture: No consensus exists on the definition of very high fracture risk. Examples may include: T-score of ≤–3.0 even in the absence of fractures, T-score of ≤–2.5 plus a fragility fracture, severe or multiple vertebral fractures.

Δ Patients most likely to benefit from anabolic therapy are those with the highest risk of fracture (eg, T-score ≤–3.5 with fragility fracture[s], T-score ≤–4.0, recent major osteoporotic fracture, or multiple recent fractures).

◊ Increased risk of vertebral fracture is evident after discontinuation of denosumab; the need for indefinite administration of denosumab should be discussed with patients prior to its initiation.

§ Anabolic agents include teriparatide, abaloparatide, romosozumab.

¥ Oral bisphosphonates are poorly absorbed and must be taken on an empty stomach first thing in the morning with at least 240 mL (8 oz) of water. After administration, the patient should not have food, drink, medications, or supplements and should remain upright for at least 1 half-hour.

‡ Denosumab is an alternative to intravenous zoledronic acid for women at high risk for fracture who have difficulty with the dosing requirements of oral bisphosphonates or who prefer to avoid intravenous bisphosphonates due to side effects. However, increased risk of vertebral fracture is evident after discontinuation of denosumab so the need for either indefinite treatment or transition to another osteoporosis medication should be addressed with patients before denosumab initiation.