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Osteoporosis

NICE clinical guideline [CG146] Osteoporosis: assessing the risk of fragility fracture. Last updated: Feb 2017. NOGG Clinical guideline for the prevention and treatment of osteoporosis. Last updated: Dec 2024.

Background Information

Osteoporosis can be defined by low bone mass and microarchitectural deterioration of bone tissue.

Objectively, osteoporosis can be defined by measuring bone mineral density (BMD) by dual energy X-ray absorptiometry (DEXA):
  • T score less than -2.5: osteoporosis
  • T score between -1.5 and -2.5: osteopaenia

Lifestyle-related risk factors:
  • Post-menopausal women
  • Advancing age
 
  • Inadequate physical activity
  • Low body weight
  • Smoking and excess alcohol consumption

Secondary causes
  • Medications
    • Systemic steroids
    • SSRIsSelective serotonin reuptake inhibitor
    • PPIsProton pump inhibitor
    • Thiazolidinediones 
    • Heparin
    • Aromatase inhibitors
    • GnRH agonist
    • Anti-epileptic drugs
 
  • Medical conditions
    • Hyperparathyroidism and CKDChronic kidney disease
    • Hyperthyroidism
    • Hypercortisolism
    • Hypogonadism 
    • RARheumatoid arthritis and other inflammatory arthropathies 

Guidelines

The author has deliberately organised this section that is friendly for learning, revision and application in exam questions. At glance, it might not align with NICE and NOGG guidelines due to the way the recommendations are organised and presented.

The nature of the investigation and management of osteoporosis is complicated and overlaps a lot, read through this article a few times and one should understand it well.
 

Always exclude the following first:
  • Secondary causes of osteoporosis (via routine bloods)
  • Non-osteoporotic causes of fracture (e.g. Paget's disease, bone metastases, myeloma)

Once the above is excluded, the next step is deciding who needs what:
  • Calculation of 10-year fragility fracture risk (via FRAX or QFracture without DEXA results) is indicated in any of the following
    • ALL women >65 y/o and men >75 y/o 
    • Women <65 y/o and men <75 y/o with risk factors
    • <50 y/o only with major RF (previous fragility fracture / untreated premature menopause / current or frequent use of oral steroids)
 
  • DEXA scan without calculating fragility fracture risk is indicated in any of the following
    • >50 y/o with history of fragility fracture 
    • <40 y/o with major risk factors (previous fragility fracture / untreated premature menopause / current or frequent use of oral steroids)
    • Before starting treatment that may have a rapid adverse effect on bone density (e.g. sex hormone deprivation therapy for breast / prostate cancer)
 

The calculated 10-year fragility fracture risk in % would fall under 4 risk category which guides subsequent action
 
Risk Subsequent action
Low risk DEXA and bone-sparing drugs not indicated, advise on conservative management
Intermediate risk Perform DEXA to decide on treatment (treat with bone-sparing drugs if BMD confirms osteoporosis, i.e. less than -2.5)
High risk Treat with bone-sparing drugs and perform DEXA (but do not wait until BMD results)
Very high risk Treat and consider specialist referral
 

Note that if indicated for this pathway, perform DEXA straight away without calculating 10-year fragility fracture risk.

Subsequent action is simpler, depends largely on BMDBone mineral density:
  • If BMDBone mineral density <-2.5 (i.e. osteoporosis) → start bone sparing treatment

The following should be given to ALL patients (even those with low fracture risk):
  • Lifestyle advice
    • Healthy, balanced diet rich in calcium and vitamin D
    • Weight bearing and muscle-strengthening exercise
    • Smoking cessation and reducing alcohol intake
    • Assess and address risk of falls
 
  • Calcium intake
    • Dietary source preferred, do not routinely give supplements
    • Only give supplements if <700mg/day intake
  • Vitamin D intake
    • Give supplements if there are insufficiencies or risk factors (e.g. housebound)

The main indication is BMDBone mineral density T score <-2.5 measured by DEXA (i.e. osteoporosis)

However, there are exceptions to start bone sparing treatment WITHOUT performing DEXA (i.e. without BMDBone mineral density T score):
  • High or very high 10-year fragility fracture risk (start bone sparing treatment before performing BMD)
  • Postmenopausal women / ≥50 y/o men following fragility fracture (because risk of re-fracture is highest immediately after a fracture and risk remains elevated)
  • Patients who take glucocorticoid therapy and any of the following
    • Postmenopausal women and men >50 y/o that takes high dose steroid (≥7.5 mg/day prednisolone or equivalent for the next 3 months)
    • Prior fragility fracture
    • Women >70 y/o
    • Postmenopausal women and men >50 y/o with high FRAX score

 

For exam purposes the key indications to start bone sparing treatment straight away (without DEXA):

  • High or very high 10-year fragility fracture risk
  • After fragility fracture
  • Postmenopausal women who take high-dose steroid (≥7.5mg/day of prednisolone)

Of course, DEXA <-2.5 is the most standard indication to start bone sparing treatment.

1st line: bisphosphonates 
  • Oral alendronate or risedronate
 
  • IV zoledronic acid (annual infusion) is reserved for
    • Oral bisphosphonates not appropriate (e.g. GI contraindications, patient unable to tolerate)
    • Following hip fracture (recommended by NOGG)

2nd line (any of the following)
  • Denosumab - generally top 2nd line choice (not explicitly stated in guidelines but common practice and applicable for exams)
  • Raloxifene 
  • Teriparatide
  • Romosozumab
  • Strontium ranelate (rarely used due to concern with its safety profile)
 

Ensuring the patient's calcium and vitamin D deficiency is corrected before starting bone sparing treatments.

For those treated with anabolic treatment (i.e. teriparatide and romosozumab), start anti-resorptive therapy (bisphosphonate or denosumab) immediately to maintain the gained bone.

Category Drug MoA Route of Administration Schedule
Anti-Resorptive Bisphosphonates (Alendronic acid, Risedronate, Zoledronic acid) Inhibit osteoclast-mediated bone resorption Oral (alendronic acid, risedronate)

IV infusion (zoledronic acid)		 Alendronic acid, risedronate: once weekly

Zoledronic acid: 5 mg infusion once yearly
Denosumab Monoclonal antibody against RANKL → inhibit osteoclast Subcutaneous injection 6 monthly
Raloxifene Selective estrogen receptor modulator (agonist in bone → reduces resorption) Oral Once daily
Strontium Ranelate (limited use due to safety concerns) Dual action: stimulates osteoblast bone formation and reduces osteoclast activity Oral Once daily
Anabolic Teriparatide Recombinant parathyroid hormone → activate osteoblast Subcutaneous injection Daily for up to 24 months
Romosozumab Monoclonal antibody against sclerostin → increase bone formation and reduce resorption Subcutaneous injection Once monthly for 12 months
 

Initial follow up:
  • Check treatment tolerance after 3-4 months + ask about adverse effects
  • Check adherence after 12 months of treatment

Follow up specific to oral bisphosphonates:
  • Reassess need for continuing treatment after 5 years
  • Still high risk = continue for at least 10 years (previous hip / vertebral fracture or experienced fragility fractures during treatment)
  • T socre <-2.5 = continue another 5 years
  • T score >-2.5 = pause treatment for 1.5-3 years 

Follow up specific to those who take oral steroids
  • Continue treatment until steroid is stopped, then reassess risk

References

Author: Adams Lau
Reviewer:
Last edited: 22/07/25