Osteoporosis Assessment and Treatment

First Risk Stratify:

The People You Need To Asses Are These “High Risk” Groups:



  • All women over 65
  • All men over 75


  • Women age 50-64 (and men age 50-70) who have:
    • Previous fragility fracture
    • Current/frequent use of corticosteroids
    • H/O falls
    • Low BMI
    • Smoker


  • Any secondary cause of osteoporosis (see HERE) = remember GRIME (gastrointestinal, Really our fault (iatrogenic), Inflammatory, Metabolic, Endocrine)

Even Younger

  • People under 50 with following risks:
    • Current/frequent steroid use
    • Untreated premature menopause
    • Previous Fragility fracture

Super Young

  • People under 40 with:
    • Current/recent steroids more than 7.5mg pred daily for 3 months or more
    • Previous fragility fracture of spine/hip/forearm/prox humerus
    • History of multiple fragilty fractures


  • SSRIs
  • Antiepileptics – especially carbamazepine
  • Exemastane
  • GRHA gonadotrophin relasing hormone antagonists
  • PPIs
  • Thiazolidinediones such as pioglitazone

MAKE SURE YOU RULE OUT NON-OSTOPOROTIC CAUSES OF FRAGILITY FRACTURE  – eg bony mets/primary malignancy/myeloma/osteomalacia/paget’s

Now Decide On What To Do:

You’re going to:

1. Offer DXA scan


2. Start drug treatment without DXA scan


3. Calculate 10yr risk of fracture prior to arranging DXA

Offer DXA scan without calculating 10yr risk to:

  • Over 50s with h/o fragilty fracture
  • Younger than 40s with major risk fracture – depending on the BMD T-score – (from the DXA) refer to specialist in treatment of osteoporosis

Start Drug Treatment without DXA if it’s inappropriate or impractical 

For Everyone Else:

  • Calculate 10-yr fragility fracture risk prior to DXA
  • Use Qfracture or FRAX 

If 10yr risk is 10% or highter / or they – get DXA. (theres’ some chinnaginns with this so check out THIS from CKS in practice

Assess Vitamin D Deficiency and inadequate calcium intake

  • Risk of vit D deficiency if:
    • Over 65
    • not exposed to much sunlight (confined indoors or they wear clothes over entire body)
  • Calcium intake should be 1000mg/day for people at risk of fragility fracture

Identify Risk Factors for Falls


Finally – TREATMENT!

People at high risk of fragility fracture:

  • Offer DXA
    • if T-score is -2.5 or less –> bone sparing drug treatment
    • if T-score is -2.5 or more –> modify risk factors, treat underlying conditions and repeat DXA in about 2 years

People with intermediate risk of fragility fracture:

  • Offer DXA
    • If T-scoere is -2.5 offer drug treatment

People with low risk for fragility fracture

fuckem for 5 years – just talk about lifestyle


Give a bisphosphonate to :

  • Postmenopausal women and men over 50 who have T-score -2.5
  • People taking high doses of corticosteroid (more than pred 7.5mg daily for 3months or more)
  • If they cant tolerate – refer to spcialist may need zoledronic acid / stontium / raloxifene / denosumab / teriparatide

If they are having enough calcium but not enough sunlight:

  • prescribe 10micrograms of vitamin D (=colecalciferol) without calcium

If they are not getting enough calcium

  • 10micrograms of vid D with 1000mg calcium daily
  • 20micrograms of vit D with 1000mg calcium daily = if they’re housebound or in a nursing home

Consider prescribing HRT for women who have premature menopause (before 40yrs)