Osteoporosis in postmenopausal women: Monitoring initial therapy with oral bisphosphonates

Oral bisphosphonates (eg, alendronate, risedronate) are selected as initial therapy for most postmenopausal women with osteoporosis. This algorithm presents our general approach to monitoring bisphosphonate therapy. Monitoring treatment with other osteoporosis agents may differ. The algorithm is intended for use with additional UpToDate content on postmenopausal osteoporosis.

BMD: bone mineral density; CTX: C-telopeptide; DXA: dual-energy x-ray absorptiometry; IV: intravenous; LSC: least significant change.

* Inadequate absorption is often related to insufficient time interval between drug intake and food or calcium ingestion.

¶ A change in BMD is considered significant if it exceeds the LSC for the specific densitometer used. If LSC is not reported, a simplified approximation for exceeding LSC is ≥5%.

Δ Fragility fractures are those occurring spontaneously or from minor trauma (eg, a fall from a standing height or less). The most common sites of fragility fracture are the spine (vertebral compression fractures), hip, and wrist. Fragility fractures also occur at the humerus, rib, and pelvis.

◊ There are many disorders/drugs with adverse skeletal effects. Clinical findings guide the evaluation for a specific concurrent disorder (eg, incident hypercalcemia may indicate primary hyperparathyroidism).

§ If lack of response is related to poor absorption, switching to an IV bisphosphonate should result in an improvement in BMD. Denosumab is a reasonable alternative. There is an increased risk of vertebral fracture after discontinuation of denosumab; the need for indefinite administration of denosumab should be discussed with patients prior to its initiation.

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Osteoporosis in postmenopausal women: Monitoring initial therapy with oral bisphosphonates