Key recommendations
Do a FRAX assessment in any postmenopausal woman, or man aged 50 or over, with a clinical risk factor for fragility fracture, to guide bone density measurement, referral and treatment.
Fracture risk assessment and case finding
Offer drug treatment to people at high or very high fracture risk. Particularly in older people, consider treatment for anyone with a prior or recent fragility fracture.
Summary of main recommendations (6, 8)
For most people who need treatment, anti-resorptive therapy is first line: oral alendronate or risedronate, or intravenous zoledronate, are the most cost-effective options.
Pharmacological treatment options
Offer intravenous zoledronate as a first-line option after a hip fracture.
Pharmacological treatment options
Consider referring very-high-risk patients to an osteoporosis specialist to assess for parenteral treatment; some need anabolic treatment first, especially with multiple vertebral fractures.
Intervention thresholds and strategy
Diagnosis
Osteoporosis can be diagnosed from a DXA T-score of −2.5 or lower at the total hip, femoral neck or lumbar spine. Femoral neck T-scores in both men and women use the young female NHANES III reference.
Background; Measurement of bone mineral density
Most people who sustain a fragility fracture have a femoral neck T-score above −2.5, so decisions rest on fracture risk rather than bone density alone.
Background
Adjust FRAX for risks it does not capture: for example, increase major osteoporotic and hip fracture probability by about 30% with recurrent falls (two or more in the past year), and by about 15% and 20% respectively with high-dose glucocorticoids (over 7.5 mg a day).
Table 1
Quantitative ultrasound is not recommended for diagnosing osteoporosis.
Fracture risk assessment and case finding
Investigations
Investigate everyone with osteoporosis or a fragility fracture for underlying causes, including routine blood tests.
Fracture risk assessment and case finding
Vertebral fracture assessment is indicated with height loss of 4 cm or more, kyphosis, recent or current long-term oral glucocorticoids, a T-score of −2.5 or lower, or acute back pain with risk factors for osteoporosis.
Fracture risk assessment and case finding
If bone density measurement is unavailable or impractical — for example in frail people — offer treatment when there is a fragility fracture or FRAX-based risk exceeds the NOGG intervention threshold.
Intervention thresholds and strategy; Summary of main recommendations (7)
Treatment
Alternatives to bisphosphonates include denosumab, ibandronate, hormone replacement therapy, raloxifene and strontium ranelate.
Pharmacological treatment options
Before starting denosumab, agree a long-term plan: stopping it unplanned increases vertebral fracture risk. If it is stopped, give intravenous zoledronate 6 months after the last injection.
Pharmacological treatment options
Consider teriparatide or romosozumab first line for postmenopausal women at very high fracture risk, particularly with vertebral fractures (teriparatide for men aged 50 or over), followed by anti-resorptive treatment.
Pharmacological treatment options
Limit starting HRT for osteoporosis to women aged 60 or under at low risk of cancer and thromboembolism.
Pharmacological treatment options
Plan oral bisphosphonates for at least 5 years and intravenous zoledronate for at least 3 years, then reassess fracture risk. Longer courses suit people aged 70 or over, those with a previous hip or vertebral fracture, those on high-dose glucocorticoids, and those who fracture during treatment.
Summary of main recommendations (17); Duration of treatment
In lower-risk patients a treatment pause of 18–36 months can be considered after 5 years of an oral or 3 years of an intravenous bisphosphonate; reassess during the pause and restart if a new fracture occurs.
Summary of main recommendations (17, 21); Duration of treatment
Bone loss starts early on oral glucocorticoids, so start bone protection at the same time as glucocorticoids in people who need it, without waiting for a scan; oral bisphosphonates or intravenous zoledronate are first line.
Glucocorticoid-induced osteoporosis
Important geriatric considerations
Falls risk factors add substantially to fracture risk and overlap with risk factors for osteoporosis, so falls and fracture services should work together.
Background
Hip fracture is the most common cause of death after a fall. In the UK, only about half of people are living in their own home 120 days after a hip fracture, and about a quarter die within a year.
Background
For painful vertebral fractures, give analgesia by mouth where possible, at the weakest effective dose for the shortest time. Avoid NSAIDs in older people (if used, add a proton-pump inhibitor and monitor), and prescribe a laxative with opioids.
Management of symptomatic osteoporotic vertebral fractures
After a vertebral fracture, exercise should include progressive muscle strengthening, including the back extensors.
Strong recommendationManagement of symptomatic osteoporotic vertebral fractures
Review tolerance of and adherence to oral treatment regularly. If someone fractures on treatment, check adherence and look for secondary causes.
Summary of main recommendations (15); Reassessment of fracture risk
Drug doses
Calcium: the UK reference intake for adults is 700 mg a day. Dietary calcium is preferred; target supplements (with vitamin D) to people whose diet falls short.
Non-pharmacological management: calcium and vitamin D
Vitamin D: in the context of osteoporosis, 800 up to 2,000 IU a day may be appropriate (the general adult reference intake is 400 IU a day). People taking osteoporosis drugs should be vitamin D replete.
Non-pharmacological management: calcium and vitamin D
When to refer
Consider specialist referral for a vertebral fracture in the last 2 years, two or more vertebral fractures, a T-score of −3.5 or lower, high-dose glucocorticoids (7.5 mg a day or more of prednisolone or equivalent over 3 months — refer urgently and start an oral bisphosphonate meanwhile if there will be a delay), multiple risk factors with a recent fracture, or other signs of very high risk.
Intervention thresholds and strategy
Refer anyone who develops an atypical femoral fracture to an osteoporosis specialist, and stop the bisphosphonate or denosumab.
Rare adverse effects of long-term treatment
Fracture liaison services should systematically find and assess everyone with a fragility fracture.
Models of care for fracture prevention
Red flags
New thigh, groin or hip pain on bisphosphonate or denosumab treatment: image the whole femur, and the other femur too if an atypical fracture is found.
Rare adverse effects of long-term treatment
Loose teeth, oral pain or swelling on bisphosphonate or denosumab treatment should be reported; encourage good oral hygiene and routine dental check-ups.
Rare adverse effects of long-term treatment
Acute back pain, especially thoracic, in a postmenopausal woman or man aged 50 or over with risk factors for osteoporosis may be a vertebral fracture.
Models of care for fracture prevention
Recent updates
2022: a major update of the guideline first published in 2008 (updated 2013 and 2017), accredited by NICE. It covers diagnosis, risk assessment and intervention thresholds, vertebral fractures, drug and non-drug treatment including duration and monitoring, glucocorticoid-induced osteoporosis and models of care.
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