Osteoporosis: Management

Key points

• UK guidance is the National Osteoporosis Guideline Group (NOGG) 2024 update. Assess fracture risk with FRAX or QFracture in anyone aged 50+ with a clinical risk factor, or younger adults with major risk factors · confirm with DXA where it will change management · osteoporosis is a T-score ≤ −2.5 at hip or lumbar spine · any fragility fracture warrants assessment and usually treatment.
• All patients: ensure adequate calcium intake and vitamin D (typically 800-1000 IU/day) · weight-bearing exercise · falls assessment · address smoking, alcohol and secondary causes.
• First-line: an oral bisphosphonate — alendronate 70 mg weekly or risedronate 35 mg weekly. Etidronate is obsolete and no longer used.
• Oral bisphosphonate unsuitable or not tolerated (roughly a quarter have upper GI problems): IV zoledronate, or denosumab · other options include ibandronate, raloxifene, or HRT in postmenopausal women aged 60 or under · strontium ranelate is now only a last-line option, with restricted use because of cardiovascular risk and an intermittent UK supply.
• Very high fracture risk — recent vertebral fracture within 2 years, multiple vertebral fractures, T-score ≤ −3.5, or high-dose glucocorticoids — consider an ANABOLIC agent first: teriparatide, abaloparatide or romosozumab, followed by an antiresorptive to preserve the gains. Refer to a specialist osteoporosis service.
• Duration: oral bisphosphonates for at least 5 years, IV zoledronate for at least 3 years, then reassess · longer in those aged 70+, after hip or vertebral fracture, or on high-dose steroids · NEVER stop denosumab without follow-on therapy — rebound bone loss causes multiple vertebral fractures within months.

Decision points in this pathway

• Very high fracture risk (recent vertebral fracture within 2 years, multiple vertebral fractures, T-score ≤ −3.5, or high-dose glucocorticoids)?
• Oral bisphosphonate not tolerated or unsuitable?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.