Who to assess
- Everyone over 50: ask about fragility fractures (a fall from standing height or less), height loss over 2 cm, and risk factors: parental hip fracture, glucocorticoids for 3 months or more, rheumatoid arthritis, smoking, more than two drinks a day, low body weight, early menopause (before 45), aromatase inhibitors, and the conditions that cause secondary osteoporosis.
- A fracture risk calculator (FRAX, or CAROC in Canada) turns age, sex, bone density and risk factors into a 10-year probability of a major osteoporotic fracture; it, not the T-score alone, decides treatment.
- Bone density (DXA of hip and spine) at 65 for all women, earlier with risk factors, and after any fragility fracture. A T-score of minus 2.5 or lower is osteoporosis; minus 1 to minus 2.5 is low bone mass, where the risk calculation matters most.
Prevention and treatment
- Repeat DXA no sooner than 1 to 3 years unless something changes; the fracture, not the number, is the outcome.
- Rare harms are real but small against the fracture prevented: atypical femoral fracture and osteonecrosis of the jaw with long antiresorptive use.
| Measure | For whom | Notes |
|---|---|---|
| Calcium about 1200 mg a day (diet first) and vitamin D 800 to 2000 IU | Everyone over 50 | Supplements only make up the shortfall; more is not better |
| Weight-bearing and resistance exercise, balance training, fall prevention | Everyone | Falls, not only bone density, cause fractures |
| Bisphosphonate (alendronate, risedronate, or yearly zoledronic acid) | Osteoporosis, a fragility fracture of hip or spine, or high calculated risk | Upright for 30 minutes after an oral dose; review at 3 to 5 years and consider a drug holiday if risk has fallen; dental review before starting |
| Denosumab | When bisphosphonates fail, are not tolerated or renal function forbids them | Never stop without a plan: rebound vertebral fractures follow missed doses |
| Menopausal hormone therapy | Symptomatic women under 60 or within 10 years of menopause, and premature ovarian insufficiency | Prevents bone loss while used; not started for bone alone in older women |
| Anabolic agents (teriparatide, romosozumab) | Very high risk, multiple vertebral fractures | Specialist; followed by an antiresorptive |
Check
A 67-year-old with a wrist fracture after a fall from standing has a T-score of minus 2.1 at the hip. Does she need treatment?