Help Manage Osteoporosis and Fracture Prevention

You’ll see more emphasis on preventing fractures in postmenopausal women and in men over 50 years...due to updated Canadian guidelines.

More than 2 million Canadians live with osteoporosis and about 150 people per 100,000 suffer a hip fracture each year.

Follow these strategies to optimize therapy.

Lifestyle. Recommend balance and functional exercises (heal raises, stair climbing, etc) at least twice prevent falls and possibly fractures.

Also advise getting 1,000 mg to 1,200 mg of elemental calcium...and 600 units to 800 units of vitamin D daily from diet and supplements.

Screening. Identify patients at risk...prior fracture after age 40, chronic glucocorticoid therapy, smoker, etc.

Suggest at-risk patients get a bone mineral density test and calculate their 10-yr fracture risk using an assessment tool, such as FRAX.

Medications. Recommend meds for patients at high risk, such as those with a 10-yr fracture risk of 20% or more...over 70 years with a T-score below -2.5...or a prior hip or spine fracture.

Continue to recommend a bisphosphonate (alendronate, risedronate, zoledronic acid) first in most cases.

Taking a bisphosphonate for 3 years results in 20 to 30 fewer spine fractures and 3 fewer hip fractures per 1,000 people compared to no treatment.

Suggest menopausal hormone therapy in postmenopausal women as an alternative to a bisphosphonate...only if it doubles as a treatment for menopausal symptoms.

If patients can’t take a bisphosphonate, consider long-term denosumab (Prolia) given twice a year by subcutaneous injection.

Point out that delayed dosing or discontinuing denosumab may result in rapid bone loss and lead to spine fractures.

Save teriparatide (Forteo, Osnuvo) or romosozumab (Evenity) for patients with a recent severe spine fracture...or more than 1 spine fracture and a T-score below -2.5...or possibly for when other meds fail.

Teriparatide or romosozumab results in 35 fewer spine fractures and 5 fewer hip fractures per 1,000 people than bisphosphonates.

But keep in mind that their injection schedules and high cost may limit use. Either costs over $7,000/year.

Monitoring. Assess adherence and ask about side effects. For example, GI intolerance with oral meds, or mouth pain or swelling that may suggest osteonecrosis of the jaw.

Find other advice in our resource, Managing Osteoporosis: Screening, Treatment, and More.

Key References

  • Morin SN, Feldman S, Funnell L, et al. Clinical practice guidelines for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10;195(39):E1333-E1348.
Pharmacist's Letter Canada. December 2023, No. 391218

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