Do I Need Treatment for Osteoporosis?

Osteoporosis is one of the questions older patients most often ask in clinic. The osteoporosis society recently produced a very thorough patient education booklet that is well worth downloading and reading for those who need it.

The content below is excerpted in part from the osteoporosis society’s download-area education booklet.

Epidemiology

According to a survey by the Health Promotion Administration, among men over the age of 50 in Taiwan, one in five has osteoporosis, and the proportion in women is even higher, about twice that of men. Osteoporosis has no obvious symptoms in its early stages and is easily overlooked, but later, besides pain, fractures can cause problems such as reduced mobility and long-term bed rest. One year after a hip fracture, about 40% of people are unable to walk independently, around 30% have physical disability, and there is roughly a 20% chance of death.

Risk factors

These include older age, menopause in women, being underweight, a family history of osteoporosis, long-term corticosteroid use, little sun exposure, lack of weight-bearing exercise, long-term insufficient calcium intake, rheumatoid arthritis, hormone therapy for breast or prostate cancer, smoking and heavy drinking, hyperthyroidism, and kidney disease.

Quick screening

Have your parents ever broken a hip from a minor bump or fall?
Have you yourself ever broken a bone from a minor bump or fall?
Have you taken corticosteroids for more than three months?
Is your current age minus your weight greater than or equal to 20? (For example, age 60 with a body weight of 40 kg?)
Have you lost more than 3 cm in height compared with your younger years?
Do you drink three or more glasses of alcohol a day, or smoke more than 20 cigarettes a day?
Do you have diabetes, an enlarged thyroid, or malnutrition?
(Women only) Did you reach menopause at 45 or earlier?
(Women only) Aside from during pregnancy, have you ever stopped menstruating for more than 12 months?
(Men only) Have you experienced impotence, reduced libido, or other related symptoms due to low testosterone?

If you answer yes to even one question, you have some risk of osteoporosis, and it is advisable to discuss with a physician whether further testing is needed.

Medication treatment options

If osteoporosis is confirmed, it is generally advised to supplement 800-1000 units of vitamin D and 1200 mg of calcium at the same time. Medications can mainly be divided into the following groups.

Bisphosphonates

There are more than four products; they work by reducing bone loss. National Health Insurance covers oral and intravenous formulations (from weekly to yearly). If you do not meet the insurance criteria, the out-of-pocket cost is roughly NT$27-35 per day.
They can increase bone density in the spine and hip. Apart from ibandronate, the other drugs have research support for reducing the chance of spine and hip fractures.
People with hypocalcaemia should have it corrected before starting them, and renal function should be checked before use. According to the package inserts approved by Taiwan’s Ministry of Health and Welfare, alendronate is not recommended when creatinine clearance is below 35 mL/min, and risedronate and ibandronate are not recommended below 30 mL/min; zoledronic acid (Aclasta) is contraindicated below 35 mL/min or in acute renal impairment. People with severe renal impairment, such as those on dialysis, generally do not use them, and this needs to be assessed by a physician. In addition, there have been rare cases of osteonecrosis of the jaw and atypical femoral fracture.

Selective oestrogen receptor modulators (SERMs)

They work by reducing bone loss and require daily oral dosing. If you do not meet the insurance criteria, the out-of-pocket cost is about NT$40 per day.
They can increase bone density in the spine and hip, and there are research data for reducing spine fractures (but not for the hip).

RANKL monoclonal antibody (denosumab)

It works by reducing bone loss and is given as a subcutaneous injection every six months. If you do not meet the insurance criteria, the out-of-pocket cost is about NT$45 per day.
It can increase bone density in the spine and hip, and there is research support for reducing the chance of spine and hip fractures.
A small number of cases have involved hypocalcaemia, as well as rare osteonecrosis of the jaw and atypical femoral fracture.

Parathyroid hormone analogue (teriparatide)

Unlike the previous drugs, it works by increasing bone formation. Its drawback is the daily subcutaneous injection, and if you do not meet the insurance criteria it must be paid out of pocket. The package insert previously limited its use to a maximum of two years, and the US Food and Drug Administration removed this limit in 2020. In Taiwan, National Health Insurance covers at most 18 pens (about 18 months), which must be used within two years, and the Taiwanese Osteoporosis Association’s 2025 guideline still takes a maximum of 2 years as the general rule. How long to use it is assessed by a physician, after which patients usually switch to another type of medication.
It can increase bone density in the spine and hip, and there are data for reducing the chance of spine and hip fractures, with no notable rare cases reported so far.

Sclerostin-inhibiting monoclonal antibody (romosozumab)

This is the newest drug, working by increasing bone formation together with reducing bone loss, given as a subcutaneous injection once a month, two injections each time, over a 12-month course, after which another type of medication is usually started.
It can increase bone density in the spine and hip, and there are data for reducing the chance of spine and hip fractures. There have been rare cases of osteonecrosis of the jaw, so for patients with poor dental health, assessment is advised before use. Studies have raised concerns about an increase in cardiovascular events such as myocardial infarction and stroke; it is not recommended for people who have had a myocardial infarction or stroke within the past year, and people at risk of cardiovascular disease should discuss it with a physician first.

Summary

Guarding against osteoporosis early can help avoid future regrets. Based on the quick screening, your assessed risk, and the values shared between doctor and patient, it is advisable to choose a treatment approach that offers the most benefit for the patient.

Frequently asked questions

How common is osteoporosis in Taiwan?

According to a survey by the Health Promotion Administration, about one in five men over the age of 50 has osteoporosis, and the rate in women is roughly twice that of men. There are often no obvious symptoms early on, and fractures later may lead to limited mobility or long-term bed rest.

Who is at higher risk of osteoporosis?

Common risk factors include older age, menopause in women, being underweight, a family history of osteoporosis, long-term corticosteroid use, little sun exposure, lack of weight-bearing exercise, and long-term insufficient calcium intake, as well as smoking and heavy drinking, rheumatoid arthritis, hyperthyroidism, and kidney disease.

How can I quickly self-assess my osteoporosis risk?

You can use the osteoporosis society's quick screening questions to check yourself, for example whether you or a parent has broken a bone from a minor bump or fall, whether you have taken corticosteroids for more than three months, or whether you have lost more than 3 cm in height compared with your younger years. If you answer yes to even one, you have some risk, and it is advisable to discuss with a physician whether further testing is needed.

What medication options are there for osteoporosis?

If osteoporosis is confirmed, treatment usually includes supplementing both vitamin D and calcium. Medications fall broadly into two groups, those that reduce bone loss (such as bisphosphonates, SERMs, and denosumab) and those that increase bone formation (such as parathyroid hormone analogues and romosozumab). Each drug differs in formulation, cost, and rare side effects, and studies show supporting data for bone density or fracture risk; the actual choice needs to be assessed by a physician based on individual circumstances.

References

Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, Shamliyan T, Cooney TG, Cross JT Jr, et al. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med. 2023;176(2):224-238. PMID: 36592456. DOI: 10.7326/M22-1034
LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022;33(10):2049-2102. PMID: 35478046. DOI: 10.1007/s00198-021-05900-y
Morin SN, Feldman S, Funnell L, Giangregorio L, Kim S, McDonald-Blumer H, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023;195(39):E1333-E1348. PMID: 37816527. DOI: 10.1503/cmaj.221647
Händel MN, Cardoso I, von Bülow C, Rohde JF, Ussing A, Nielsen SM, et al. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ. 2023;381:e068033. PMID: 37130601. DOI: 10.1136/bmj-2021-068033
Taiwan Food and Drug Administration, Ministry of Health and Welfare. Drug license package inserts: Fosamax Plus (衛部藥輸字第026136號), Walkin (衛部藥輸字第026272號), Bonviva injection (衛署藥輸字第024630號), Aclasta (衛署藥輸字第024692號). https://mcp.fda.gov.tw/
Taiwanese Osteoporosis Association. 2025台灣成人骨質疏鬆症防治之共識及指引 (2025 Taiwan consensus and guidelines for the prevention and treatment of osteoporosis in adults, including NHI drug reimbursement regulations 5.6.2 and 5.6.3). 2025. https://www.toa1997.org.tw/news/content.php?id=224&t=6