Osteoporosis is asymptomatic until fracture occurs.
Diagnosis is based on a history of prior fragility fracture or low bone mineral density, which is defined as a T-score ≤-2.5.
Screening is based on individual risk factors, including female sex, maternal history of fragility fracture/osteoporosis, older age, low body mass index (<20 kg/m²), androgen deprivation treatment (in males), aromatase inhibitor treatment (in females), corticosteroid use, tobacco use, and excessive alcohol intake.
Adequate calcium and vitamin D intake is recommended for all patients. Bisphosphonates are first-line pharmacologic therapy for postmenopausal women and men.
All patients treated with teriparatide, abaloparatide, denosumab, or romosozumab should receive sequential therapy with antiresorptive osteoporosis treatment to prevent rapid bone loss.
In postmenopausal women, estrogen is considered only for those at high risk for whom nonestrogen medications are inappropriate.
Osteoporosis is a complex skeletal disease characterized by low bone density and microarchitectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture.
History and exam
Key diagnostic factors
Other diagnostic factors
- back pain
- vertebral tenderness
- prior fragility fracture
- female sex
- white ancestry
- older age (>50 years for women and >65 years for men)
- low BMI
- loss of height
- family history of maternal hip fracture
- secondary amenorrhea
- primary hypogonadism
- tobacco use
- excessive alcohol use
- prolonged immobilization
- low calcium intake
- vitamin D deficiency
- glucocorticoid excess
- corticosteroid use
- proton-pump inhibitors
- heparin use
- anticonvulsant use
- androgen deprivation treatment (men)
- aromatase inhibitor treatment (women)
1st investigations to order
- dual-energy x-ray absorptiometry (DXA)
Investigations to consider
- Fracture Risk Assessment Tool (FRAX)
- quantitative ultrasound (QUS) of the heel
- x-ray (wrist, heel, spine, and hip)
- quantitative CT
- biochemical markers of bone resorption and bone formation
- serum alkaline phosphatase
- serum calcium
- serum albumin
- serum creatinine
- serum phosphate
- serum 25-hydroxy vitamin D
- serum parathyroid hormone
- thyroid function tests
- urinary free cortisol
- serum testosterone (men)
- urine protein electrophoresis
- serum protein electrophoresis
not glucocorticoid-induced: women
not glucocorticoid-induced: men
- Multiple myeloma
- Chronic kidney disease-bone and mineral disorder
- Pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults
- 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis
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Osteoporosis: what treatments work?More Patient leaflets
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