How to manage severe osteoporosis in a 58-year-old woman?

Question

Hi doctor,

I am 58 years old, and my osteoporosis has gotten really bad since my hysterectomy and ovary removal two years ago for endometriosis. My bone density scan shows T-scores of -3.6 in the spine and -3.2 in the hip, which my doctor says is severe. I already had two compression fractures in my lower back from just bending over to pick up groceries, and the pain is unbearable most days. I have been on Alendronate 70 mg weekly for eighteen months, but my bones are still getting worse. My recent DEXA scan showed another 4 % bone loss.

My endocrinologist wants to switch me to Prolia (Denosumab) injections every six months, but I am scared of side effects. I have osteoporosis in my wrists, and I fractured my left wrist three months ago from a minor fall. My calcium level is normal at 9.4 mg/dL, and my vitamin D level is 42 ng/mL, so that is not the problem. I tried hormone replacement therapy but had to stop after six months because of high blood pressure and migraine headaches. The chronic back pain from compression fractures makes it hard to exercise, which I know would help. Taking Tramadol 50 mg twice daily for pain management. My height has decreased by 2 inches in the past 2 years due to spine fractures. Family history is bad - my mom had severe osteoporosis and multiple hip fractures. Are there stronger treatments available? Will I end up in a wheelchair from this condition?

Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern.

Yes, stronger treatments exist. Given your severe osteoporosis with fractures and ongoing bone loss on Alendronate, moving to anabolic (bone-building) therapy is the standard clinical next step. The following are my suggestions:

1. Switch from Denosumab: While effective, Denosumab is antiresorptive (slows breakdown). Given your rapid bone loss and fractures, an anabolic agent (which builds new bone) is generally preferred first.

2. Discuss Teriparatide or Abaloparatide: Daily self-injections for approximately two years. These are the strongest bone-building drugs. Romosozumab monthly injection for a year has a heart risk warning, and therefore requires screening.

Denosumab is often used after an anabolic agent to maintain new bone. You are a prime candidate for Teriparatide or Abaloparatide. It is the strongest option to rapidly increase density and reduce fracture risk. The action plan is to ensure calcium (9.4 mg/dL is adequate) and vitamin D (42 ng/mL is optimal) stay at these levels. Physical therapy for safe core-strengthening exercises is crucial to managing pain and preventing falls.

Please ask your doctor this: Given my fractures and bone loss on Alendronate, am I a candidate for an anabolic medication like teriparatide first?

I hope it helped with the query.

Feel free to ask any questions.

I will be happy to guide you.