Osteoporosis Treatment Options for NPs

Osteoporosis management goes beyond just prescribing calcium and vitamin D. As new nurse practitioners in primary care, you’ll see patients who already have a diagnosis — or who screen positive with a DEXA. The key is knowing when to treat, which therapy to choose, and how to monitor safely.

Who Needs Treatment?

Start therapy if any of the following:

• T-score ≤ -2.5 at femoral neck, total hip, or lumbar spine.

• History of fragility fracture (hip, vertebra, wrist).

• Osteopenia (T-score -1.0 to -2.5) with high FRAX risk:

  • ≥20% risk of major osteoporotic fracture OR

  • ≥3% risk of hip fracture in 10 years.

📌 Clinical Pearl: Don’t forget secondary osteoporosis workup if Z-score < -2.0.

Lifestyle Foundation

Even with meds, these are non-negotiable:

• Calcium: 1,000–1,200 mg/day (diet + supplements if needed).

• Vitamin D: 800–1,000 IU/day (adjust for deficiency).

• Exercise: Weight-bearing + strength training.

• Fall prevention: Home safety, balance exercises, vision/hearing checks.

• Smoking cessation, alcohol moderation.

Medications: First-Line & Beyond

1. Bisphosphonates (first-line)

• Examples: Alendronate, risedronate, ibandronate, zoledronic acid.

• Pros: Reduce vertebral + hip fractures; affordable.

• Cons: GI irritation (oral), rare ONJ/atypical fractures with long use.

• Pearl: Reassess after 3–5 years → consider a “drug holiday” if low risk.

2. Denosumab (Prolia)

• Subcutaneous injection q6 months.

• Strong antiresorptive, good for patients with renal impairment.

• Must continue or transition → stopping can cause rebound fractures.

3. SERMs (Raloxifene)

• Vertebral fracture benefit; helpful in postmenopausal women.

• May reduce breast cancer risk.

• Risk: VTE, hot flashes.

4. Anabolic Agents (Teriparatide, Abaloparatide, Romosozumab)

• Reserved for severe osteoporosis (multiple fractures, very low T-score).

• Expensive; usually specialist-initiated.

• Limited duration (1–2 years), then transition to antiresorptive.

Monitoring Therapy

• DEXA every 2 years (sooner if new fracture or major clinical change).

• Labs: Calcium, vitamin D, renal function before bisphosphonates; dental evaluation if high risk for ONJ.

• Track fracture history and falls at each visit.

When to Refer

• Multiple fragility fractures.

• Severe or rapidly progressive osteoporosis.

• Suspected secondary cause that’s complex (endocrine, hematologic).

• Considering anabolic therapy or PCSK9 inhibitors (specialist management).

Clinical Pearls for New NPs

• Educate patients that osteoporosis meds prevent fractures — they don’t “cure” bone loss.

• Bisphosphonates are first choice for most; denosumab if renal impairment or poor oral tolerance.

• Reassess therapy regularly — avoid lifelong bisphosphonate use without breaks.

• Lifestyle matters just as much as medication.

Takeaway for Primary Care Nurse Practitioners

Osteoporosis treatment is about fracture prevention. Combine lifestyle counseling with evidence-based meds, individualize based on risk, and monitor carefully. With a structured plan, you’ll help patients stay independent and avoid life-changing fractures.

✉️ Want more plug-and-play workflows like this? Join my NP mentorship program — designed to give new nurse practitioners in primary care the confidence and tools they need.