The aim of treatment is to prevent the development of osteoporosis and to prevent further bone loss in order to decrease the risk of osteoporotic fracture. Today there is a wide range of therapeutic options and several safe and effective pharmacological treatments that have been shown to act quickly (within one year) and to reduce the risk of fracture by up to 50%. It is important that the choice of treatment be tailored to a patient's specific medical needs and lifestyle.

Osteoporosis can be managed and treated by physicians from various areas of specialization; including general practitioners, endocrinologists, gynaecologists, rheumatologists, and orthopaedic surgeons. Osteoporosis patient and medical societies may be able to provide further information about physicians with special expertise in treating osteoporosis.

Types of therapy

• Antiresorptive drugs , already available, slow the progressive thinning of bone.
• Bone-building agents help to rebuild the skeleton and are now becoming available or are in the developmental pipeline.
• Non-pharmacological interventions are also very important in reducing the risk of fracture.

Antiresorptive drugs

Bisphosphonates
Bisphosphonates inhibit bone resorption. They are currently the first choice of treatment in a variety of bone metabolism disorders characterised by high bone resorption. They bring about an increase in bone mass and a decrease in fracture incidence in osteoporosis. There are different types of bisphosphonates which differ widely in their efficacy, side effects and possible routes of administration, thus offering a flexible range of therapeutic options.

Alendronate has been extensively studied for the treatment of osteoporosis under randomized controlled clinical trial conditions. Alendronate increases BMD at all skeletal sites and reduces the incidence of fracture by around 50% in both hip and spine. A newer bisphosphonate, risedronate, has also been shown to increase bone mass in postmenopausal women, reduce the rate of vertebral and nonvertebral fractures and reduce the risk of hip fractures in elderly women with a low BMD. More bisphosphonates, such as ibandronate and zoledronate, are in the late clinical development stage, offering additional options with respect to therapeutic formulations and dosage regimens.

Estrogen Analogs
Selective estrogen receptor modulators (SERMS) mimic estrogens in some tissues and anti-estrogens in others, and ideally provide the bone-retaining effects of estrogen without its unwanted side effects. Currently, the only marketed SERM is raloxifene. Raloxifene prevents bone loss and is indicated for the prevention and treatment of vertebral fractures in postmenopausal women. The incidence of new spinal fractures is reduced by 30-50% according to dose and existence or not of vertebral fractures at baseline – so far, no significant reduction in nonvertebral fractures has been reported. Raloxifene lowers serum cholesterol, does not induce endometrium bleeding or proliferation, and markedly decreases the incidence of breast cancer in osteoporotic women. Other SERMs, such as bazedoxifene and lasofoxifene, are in the late stages of clinical development.

Tibolone
Tibolone is a synthetic analog of the gonadal steroids with combined estrogenic, progestogenic and androgenic properties. Its effects on bone density are comparable to those of hormone replacement therapy. Its efficacy on fracture risk has not yet been assessed.

Calcitonin
Intranasal or injectable calcitonin is an alternative to HRT or bisphosphonates. The results of a study show that salmon calcitonin nasal spray reduces the incidence of vertebral fractures by 25-35% at a daily dose of 200 IU. This is a smaller reduction than that achieved by bisphosphonates or raloxifene, but some patients may benefit from the analgesic effect intranasal calcitonin has on bone pain. Salmon calcitonin nasal spray is available in some countries for the treatment of patients with vertebral fractures.

Hormone Replacement Therapy (HRT)
As a result of new studies on large numbers of women, the role of HRT has recently been re-evaluated. Although HRT has been shown to have a beneficial effect on bone and is still an option for the treatment of menopausal symptoms, there are other more effective and non-hormonal therapies available for the treatment of osteoporosis.

Bone-forming drugs

Parathyroid Hormone (Teriparatide)
The bone-forming effects of parathyroid hormone (PTH) have been known to exist for more than 70 years. However, it is only in the last 5-10 years that data have emerged that provide consistent and encouraging results in animals and humans. A recent multinational study on postmenopausal women with prior vertebral fractures demonstrates that a synthetic fragment of PTH will be useful in the management of osteoporosis. The results showed that the risk of vertebral fracture was reduced by 70% within 18 months of treatment. Nonvertebral fracture risk was reduced by 50%. It is expected that a form of injectable PTH will be available in some countries in the near future.

Strontium Ranelate
Strontium ranelate is a compound that has been shown in animal models to decrease bone resorption and increase bone formation. Following positive effects in a phase II clinical study, phase III clinical studies of strontium ranelate are under way to determine its effect on fracture in women with osteoporosis.

Nonpharmacological Interventions
Nutrition and lifestyle play an important role in osteoporosis prevention and treatment. Other factors, like fall prevention techniques, or hip protectors to reduce the impact in case of a fall, are also very important.

Calcium, vitamin D, and protein
Calcium supplements (0.5-1 g/day) and low doses of vitamin D (800 IU/day) have been shown to reduce the risk of hip fracture in elderly women living in nursing homes (who are often vitamin D deficient). In addition, calcium and vitamin D supplementation is often part of the treatment regimen for osteoporosis in younger patients. Sufficient protein intake is mandatory to help maintain muscle function and bone mass.

Exercise
Regular weight-bearing exercise has been shown to help maintain and build up bone mass. The stronger muscles, better balance and agility to which exercise contributes can also help in fall prevention. The type of exercise should be tailored to the individual's needs and abilities. People with osteoporosis must take special care when exercising to reduce the risk of fracture due to impact or falls.

Psychological and practical support
Rehabilitation following fractures, strategies for the prevention of falls, and psychological and practical support are important components of treatment. In addition to the practical help offered by many osteoporosis patient support groups, such groups can also be of great help in alleviating the feelings of isolation and depression experienced by many patients with severe osteoporosis.