Managing Osteoporosis

Documents to Request

• DXA scan report with T-scores at lumbar spine (L1-L4), femoral neck, and total hip
• FRAX calculation output (with or without BMD; specify country)
• Vertebral fracture assessment (VFA) or lateral thoracolumbar X-ray
• Labs: calcium (corrected), 25-OH vitamin D, phosphorus, alkaline phosphatase, PTH, BMP
• CBC, TSH, total testosterone (men), celiac panel (if suspected)
• 24-hour urine calcium (to assess absorption and renal calcium handling)
• Prior DXA scans for trend analysis
• Medication list including glucocorticoids, aromatase inhibitors, anticonvulsants, PPIs, SSRIs
• Fall risk assessment (Timed Up and Go, balance testing)

Step 1: Screening and DXA Interpretation

USPSTF screening recommendations:

• Women ≥65: DXA screening (Grade B)
• Postmenopausal women <65: screen if FRAX 10-year major osteoporotic fracture risk ≥9.3% (equivalent to 65-year-old white woman)
• Men: USPSTF states insufficient evidence (Grade I) for routine screening; however, NOF recommends DXA for men ≥70 or men 50-69 with risk factors
• Repeat DXA: every 2 years while on treatment; sooner if new risk factor or treatment change

DXA T-score classification (WHO):

DXA interpretation pitfalls:

• Degenerative changes at lumbar spine can falsely elevate T-score; use femoral neck if >2 level discordance
• T-scores are validated only for postmenopausal women and men ≥50; use Z-scores for premenopausal women and men <50
• Z-score ≤ -2.0 in younger patients: evaluate for secondary causes

Step 2: FRAX Risk Assessment

Calculate 10-year fracture probability at https://frax.shef.ac.uk using:

• Age, sex, BMI, prior fracture, parental hip fracture, smoking, alcohol (≥3 units/day), glucocorticoids, rheumatoid arthritis, secondary osteoporosis, femoral neck BMD (optional)

NOF treatment thresholds (for osteopenia with FRAX):

• 10-year hip fracture probability ≥3% → treat
• 10-year major osteoporotic fracture probability ≥20% → treat

FRAX limitations:

• Does not account for fall risk, dose-response for glucocorticoids, or number of prior fractures
• Underestimates risk in patients with multiple vertebral fractures or very high glucocorticoid doses
• Trabecular Bone Score (TBS) can be applied as a FRAX adjustment in some calculators

Step 3: First-Line Pharmacotherapy

Treatment selection framework:

• Mild-moderate osteoporosis, no recent fracture → oral bisphosphonate (first-line)
• Severe osteoporosis (T-score ≤ -3.0, multiple fractures) → anabolic agent first (teriparatide, abaloparatide, or romosozumab) followed by antiresorptive
• Bisphosphonate intolerance or contraindication → denosumab or IV zoledronic acid
• Glucocorticoid-induced osteoporosis → bisphosphonate; consider teriparatide for high risk (per ACR 2022)

Step 4: Calcium, Vitamin D, and Lifestyle

Lifestyle interventions:

• Weight-bearing and resistance exercise 3-5 days/week (reduces fall and fracture risk)
• Balance training (tai chi) for fall prevention in elderly
• Fall risk assessment: home safety evaluation, vision correction, medication review (sedatives, antihypertensives)
• Smoking cessation and alcohol moderation (<3 drinks/day)

Step 5: Monitoring and Drug Holiday Decision

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Has the DXA been interpreted correctly with T-scores at all sites documented?
2. Is the FRAX calculation documented with treatment decision aligned to NOF thresholds?
3. Has a secondary cause workup been considered (labs ordered or documented as not indicated)?
4. Is the treatment selection appropriate for osteoporosis severity and patient risk profile?
5. Is the monitoring plan documented with DXA interval and drug holiday considerations?

Quality Audit

• DXA screening performed per USPSTF recommendation (women ≥65 or younger with risk equivalent)
• T-scores reported at lumbar spine, femoral neck, and total hip
• WHO classification applied (normal, osteopenia, osteoporosis)
• FRAX calculated with treatment decision documented
• Secondary causes of bone loss evaluated (vitamin D, calcium, PTH, TSH minimum)
• Fragility fracture history documented (including morphometric vertebral fractures via VFA)
• First-line treatment selected with rationale documented
• Bisphosphonate administration instructions provided to patient
• Calcium and vitamin D intake assessed and supplementation prescribed if inadequate
• Fall risk assessment performed (Timed Up and Go or equivalent)
• Exercise prescription documented (weight-bearing + balance training)
• DXA follow-up interval scheduled (2 years on treatment; per risk if untreated)
• Drug holiday eligibility assessed after 3-5 years of bisphosphonate therapy
• Denosumab discontinuation risks documented if patient on Prolia
• Dental clearance recommended before initiating bisphosphonate or denosumab (ONJ risk)

Guidelines

• Never initiate bisphosphonate therapy without first ensuring adequate vitamin D levels (25-OH ≥20 ng/mL, ideally ≥30 ng/mL) and calcium intake; hypocalcemia can result
• Denosumab must NEVER be stopped without transitioning to a bisphosphonate; rebound vertebral fractures occur within 12-18 months of the last dose, sometimes causing multiple simultaneous vertebral fractures
• Oral bisphosphonates must be taken on an empty stomach with 8oz plain water, remaining upright for 30 minutes to prevent esophageal erosion
• Bisphosphonates and denosumab carry a rare risk of osteonecrosis of the jaw (ONJ); dental evaluation before starting therapy is recommended, especially for denosumab
• Atypical femoral fractures are associated with long-term bisphosphonate use (>5-7 years); prodromal thigh pain should prompt X-ray evaluation
• Z-scores (not T-scores) should be used for premenopausal women and men under 50; the diagnosis of "osteoporosis" in these populations requires a Z-score ≤ -2.0 plus a secondary cause or fragility fracture
• Glucocorticoid-induced osteoporosis should be addressed proactively: start bisphosphonate if prednisone ≥2.5mg/day expected for ≥3 months per ACR guidelines
• Vertebral fracture assessment (VFA) or lateral spine X-ray should be obtained in women ≥70 and men ≥80 to detect asymptomatic compression fractures that change management