Therapy

Intervention	Guideline
Calcium	NIH Guidelines: If less than 65 years and receiving estrogen, 1000 mg/day; If more than 65 years or not receiving estrogen, 1500 mg/day; Divide doses into 500 mg or 600 mg/dose to improve absorption.
Vitamin D	400-800 IU/day.
Fall Prevention Strategies	Review and implement interventions when applicable and possible
Evaluate for Secondary	Possible causes are evident from medical history and physical examination, and medications that affect bone, hepatic or renal disease, or malabsorption. Selected laboratory tests include: serum creatinine, alkaline phosphatase, calcium, phosphorous hematologic profile, thyroid-stimulating hormone (for everyone), 24-hr urine for calcium (deficiency in calcium absorption suspected), 24-hr urine free cortisol (signs of Cushing's syndrome), one, 25-dihydroxy serum concentration (if deficiency is suspected) and serum electrophoresis (if multiple myeloma suspected).
Estrogen	FDA-approved; doses are the same as those for prevention. 80-85 percent response rate to these doses. Average risk reduction for vertebral fracture is 90 percent. Average risk reduction for hip fracture is 50 percent with long-term use. Give with calcium 1000-1500 mg/day and vitamin D 400 IU.
Evista	FDA approved; 60mg/day. 80-85 percent response rate. Vertebral fractures decreaded by 50 percent. No statistically significant decrease in hip fractures.
Alendronate	FDA-approved; l0mg/day. 95 percent response rate. Vertebral fractures decreased by 63 percent. Hip fractures decreased by 51 percent.
Risedronate	FDA approved; 5mg/day. 95 percent response rate. Vertebral fractures decreased by 65 percent. Hip fractures decreased by 39 percent.
Calcitonin	FDA-approved; Nasal: 200 IU daily (alternate nostrils daily); does not treat bone pain. Spinal bone mineral density increased and spinal fracture rate reduced relative to placebo. 76 percent response rate; no data to demonstrate improvement in hip BMD or fracture rates. Injection: 100 IU SQ or IM daily. Give calcium 1500 mg/day and Vitamin D 400 IU/day. May be helpful if woman is unable to take estrogen or alendronate.
Anabolic Steroids	Not FDA-approved; (testosterone) No data on fracture prevention. Can cause hirsutism. Avoid in women with elevated LDL-cholesterol or low HDL-cholesterol.
Fluoride	Slow-release formulation awaits FDA approval. New vertebral fracture rate reduced by 69 percent.
Combination Therapy	Combination therapy with alendronate and estrogen or Alendronate/Estrogen calcitonin and estrogen is not currently FDA approved. Alendronate/Calcitonin Estrogen and testosterone combination showed an Estrogen/Testosterone increase in biochemical markers of bone formation but no data on BMD increase above that of estrogen alone or fracture prevention.
Pain Due to Osteoporosis	The only osteoporosis therapeutic agent shown to decrease bone pain is calcitonin injection. Pain is usually due to one of two causes--acute pain after a fracture or chronic back pain due to vertebral fractures. The acute pain is usually treated with immobilization and analgesic agents. Chronic pain may be treated with acetaminophen or NSAIDs.

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