Synopsis
Estimate fragility-fracture risk, identify secondary causes and start timely bone protection with explicit duration, adherence and discontinuation planning.
- Osteoporosis is a disorder of reduced bone strength and fragility fracture risk; many fractures occur above a DXA T-score of minus 2.5, so density is not the whole diagnosis.
- Use FRAX without BMD initially for appropriate adults, then obtain DXA when the result will refine an intermediate decision or provide a useful baseline.
- A prior or recent fragility fracture, multiple vertebral fractures, very low BMD or high-dose glucocorticoids can define high or very high risk requiring prompt treatment.
- Look for secondary causes including glucocorticoids, hypogonadism, hyperthyroidism, hyperparathyroidism, coeliac disease, myeloma, CKD, malabsorption, alcohol and immobilisation.
- Oral alendronate or risedronate and intravenous zoledronate are cost-effective first-line options for many high-risk adults; renal, oesophageal and adherence factors guide route.
- Denosumab is effective but should not be delayed or stopped without a pre-arranged antiresorptive transition because rebound vertebral fractures can occur.
- Very-high-risk patients, particularly with vertebral fractures, need specialist consideration of anabolic treatment followed immediately by antiresorptive consolidation.
- Falls assessment, strength and balance work, smoking and alcohol advice, adequate calcium-protein-vitamin D and fracture liaison care remain necessary alongside medicines.
Investigation priorities
Estimate ten-year major osteoporotic and hip fracture probabilities from validated clinical risk factors, initially without BMD when appropriate.
Management branches
Age, risk factor, glucocorticoid exposure or low-trauma fracture raises concern for osteoporosis.
- Record fracture timing and mechanism, parental history, smoking, alcohol, glucocorticoid dose, comorbidity, falls and secondary-cause clues.
- Calculate FRAX and apply current NOGG thresholds, obtaining DXA and vertebral imaging when they will refine the risk category or treatment choice.
- Treat recent fracture promptly and refer very-high-risk disease for specialist anabolic consideration rather than waiting for routine serial BMD.
Key medicines
Alendronic acidUse the licensed once-weekly osteoporosis regimen, taken after an overnight fast with plain water while upright, delaying food and other medicines for the product-specified interval.Avoid or seek specialist advice in significant oesophageal disease, inability to sit upright, hypocalcaemia or renal impairment beyond the product limit. Review jaw risk and persistent thigh or groin pain.
Intravenous zoledronic acidGive the licensed osteoporosis infusion at the NOGG and local protocol interval after checking calcium, vitamin D, hydration and creatinine clearance; administer through a trained service.Acute-phase symptoms, hypocalcaemia and kidney injury occur. Avoid below the product renal threshold, review dental and atypical-femur risk, and do not confuse the osteoporosis regimen with oncology schedules.