Osteoporosis medications for over age 40 years
When should osteoporosis medications be instituted in patients over age 40 years who are on Glucocorticoids therapy? Which medications are effective?
The decision to initiate a bone-active agent is based on risk stratification using the GC-adjusted WHO FRAX tool, lowest T-score value, and history of fragility fracture. Note , in patients on prednisone ≥7.5 mg/day, the calculated WHO FRAX risk is multiplied by 1.15 to get the GC-adjusted value for MOP 10-year fracture risk and by 1.2 for hip 10-year fracture risk.
- • Low risk:
- FRAX risk < 10% MOP and < 1% hip
- • Medium risk:
- FRAX risk of 10% to 19% MOP or 1% to 3% hip, or
- High-dose prednisone exposure (≥30 mg/day and total dose >5 g in last year)
- • High risk:
- FRAX risk ≥ 20% MOP or ≥ 3% hip, or
- T-score <–2.5 at any site in postmenopausal women or men aged >50 years, or
- A history of a previous fragility fracture.
Bisphosphonates (alendronate, risedronate, intravenous [IV] zoledronic acid), denosumab, and teriparatide have been shown in controlled trials to significantly improve BMD and reduce fractures in GC-treated patients. Pharmacologic recommendations for patients aged >40 to 50 years either starting or currently on GCs with an anticipated duration of therapy of ≥3 months are as follows:
• Low-risk patients: treat with oral bisphosphonate (alendronate, risedronate) if > 4% loss of BMD in past year, T-score ≤–1.5, and expected to be on prednisone ≥5 to 7.5 mg/day for >3 months. Patients intolerant to oral bisphosphonates can be treated with IV zoledronic acid or denosumab
• Medium-risk patients: on prednisone ≥2.5 mg/day should be treated with oral bisphosphonates (alendronate, risedronate), denosumab, or IV zoledronic acid
• High-risk patients: same as medium-risk patients or teriparatide. Denosumab may be more effective than oral bisphosphonates. Teriparatide is a good option for high-risk patients who have the lowest T-scores (≤–2.5) and a history of fragility fracture.