By Department of Family and Community Medicine: Dr. Zhao Yuanping

Treatment of osteoporosis can be divided into pharmacological and non-pharmacological approaches. According to recommendations from the Osteoporosis Society, postmenopausal women with osteoporosis and men aged 50 and above with osteoporosis are advised to consume 1200 milligrams and 1000 milligrams of calcium per day, respectively. All patients should intake at least 800 International Units of vitamin D daily. 

Additionally, it is recommended to supplement both calcium and vitamin D simultaneously. It's important to note that excessive calcium intake (over 1500 milligrams) does not confer additional benefits and may increase the risk of kidney stones or cardiovascular diseases.

In terms of pharmacological treatment, patients with osteoporosis or those who have experienced fragility fractures should undergo both anti-osteoporosis drug therapy and adequate calcium and vitamin D supplementation. Supplementation with calcium and vitamin D alone cannot replace drug therapy.

Antiresorptive medications for osteoporosis can be categorized based on their mechanisms of action into three types: antiresorptive agents, anabolic agents, and combination therapies. During treatment, it is essential to continuously monitor blood calcium, phosphorus levels, and kidney function. Generally, combining antiresorptive and anabolic agents is not recommended.

Antiresorptive medications include bisphosphonates, selective estrogen receptor modulators (SERMs), selective tissue estrogenic activity regulators (STEARs), estrogen, RANKL monoclonal antibody (denosumab), and calcitonin. Anabolic agents primarily consist of parathyroid hormone and its active fragments. Additionally, there are dual-action medications such as sclerostin monoclonal antibody (romosozumab).

Among these medications, bisphosphonates are available in both oral and intravenous forms, offering a variety of options and frequencies of use. Denosumab requires subcutaneous injection every six months. Parathyroid hormone and its active fragments cannot be used in high-risk populations for bone tumors and should be completed within two years of overall treatment. Romosozumab is recommended for treatment periods not exceeding one year, and it should not be used in patients who have had a heart attack or stroke within the past year.

Long-term use of antiresorptive medications may rarely lead to side effects such as osteonecrosis of the jaw (ONJ) and atypical femur fractures (AFF). Therefore, invasive dental procedures should be avoided during treatment. If surgery is necessary, it is advisable to discontinue medications three months before surgery and resume them only after the surgical wound has healed and bone union has occurred.

According to the 2022 Taiwan Osteoporosis Prevention and Treatment Guidelines, it is advisable to maintain treatment for osteoporosis for more than three years to reduce the risk of fractures, and treatment should not be discontinued prematurely. If the accumulated medication dose is less than half of the recommended amount, there is almost no preventive effect against fractures. Besides bisphosphonate therapy, other medications may lead to rapid bone loss after complete cessation of treatment, causing the initial treatment benefits to diminish and potentially increasing the risk of rebound fractures. Therefore, similar to the treatment of other chronic diseases, managing osteoporosis in postmenopausal and elderly patients requires a comprehensive and long-term treatment plan. The goal of treatment is to prevent fractures from occurring; as long as no new fractures occur and bone density does not significantly decrease, the treatment plan is considered successful.

For individuals not undergoing medication therapy, it is generally not recommended to repeat bone density measurements within one year (except for cases of steroid-induced osteoporosis). Typically, a follow-up after two years is advised, though the frequency of bone density monitoring should be determined based on clinical circumstances. Significant changes in bone density during treatment are considered when the change exceeds the minimal significant difference. Using the commonly employed DXA method, this is approximately a 3-6% change in hip bone density or a 2-4% change in lumbar spine density when measured with the same instrument.

1. Chiu, W.-Y., et al., The risk of osteonecrosis of the jaws in Taiwanese osteoporotic patients treated with oral alendronate or raloxifene. The Journal of Clinical Endocrinology & Metabolism, 2014. 99(8): p. 2729-2735.

2. Harris, K., C.A. Zagar, and K.V. Lawrence, Osteoporosis: Common Questions and Answers. American Family Physician, 2023. 107(3): p. 238-246.

3. Tai, T.-W., et al., Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: 2022 update. Journal of the Formosan Medical Association, 2023.