The 2024 Australian National Osteoporosis Guidelines in Postmenopausal Women and Men Aged Over 50 Years: A Comparative Perspective Within the Asia–Pacific Region

Abstract

Osteoporosis is a major public challenge in the Asia–Pacific region where it affects ≤ 30% of women aged ≥ 40 years and ≤ 10% of men in developed economies [1]. Although many national guidelines within the Asia–Pacific region offer tailored strategies, differences in screening, risk assessment and treatment thresholds highlight the need for stronger, evidence-driven strategies to optimize patient outcomes and the importance of regional dialogue and knowledge exchange. This editorial explores Australia's recently released Osteoporosis Guidelines in the context of other Asia–Pacific recommendations, highlighting key similarities and differences in screening, risk assessment and treatment (Table 1).

The Royal Australian College of General Practitioners and Healthy Bones Australia published national guidelines for osteoporosis management in postmenopausal women and men aged ≥ 50 years in 2024 [2, 3]. Representative Asia–Pacific guidelines published in English chosen were the 2024 Osteoporosis Society of Hong Kong (HK) Guideline for Clinical Management of Postmenopausal Osteoporosis [5], the 2024 Guidelines for Osteoporosis—Korean Society of Menopause [4], the 2021 Indian Society for Bone and Mineral Research Position Statement for the Diagnosis and Treatment of Osteoporosis in Adults [6], the 2021 Clinical Standards for Fracture Liaison Services in New Zealand (NZ) [9] with the 2017 Guidance on the Diagnosis and Management of Osteoporosis in NZ [7], the 2018 Singaporean Appropriate Care Guide for Osteoporosis Identification and Management in Primary Care [8], and the 2021 Summary of the Thai Osteoporosis Foundation Clinical Practice Guidelines on the Diagnosis and Management of Osteoporosis [10]. (Of note, the Chinese guidelines were published in Mandarin and so not included in this Editorial [11].) Like the Australian guideline, the Thai document targeted postmenopausal women and men aged ≥ 50 years [10]. There was some variability in target population of the other guidelines, for example, the HK and Korean guidelines were directed as postmenopausal women [4, 5] and the Singaporean guideline targeted postmenopausal women and men aged ≥ 65 years [8]. Despite this, the principles discussed in the various guidelines were similar. It is not our intention to identify which guideline might be “better” as each document was written by local experts cognisant of the limitations and vagaries of their particular national healthcare system, funding envelope and at-risk population. There are obviously significant differences in national healthcare resources. This is particularly highlighted in the Indian guideline which was drafted specifically for a resource-constrained healthcare environment with a large at-risk population [6].

Although some countries have adopted age-based thresholds for bone health assessment, others prioritize risk-based approaches using the Fracture Risk Assessment Tool (FRAX) or other algorithms. This reflects the need for adaptable strategies that align with local healthcare priorities and funding. Australian guidelines recommend referral for bone density assessment by dual energy x-ray absorptiometry (DXA) in everyone ≥ 50 years of age with (i) a minimal trauma fracture (MTF), or (ii) in those without a fracture, who have risk factors for osteoporosis and a FRAX risk for major osteoporotic fracture (MOF) ≥ 10% [2]. None of the three large population-based randomized controlled trials (RCTs) of screening in women for prevention of osteoporotic fractures showed a reduction in the primary outcome of all fractures [12-14]. However, a significant reduction in hip fracture was found in a meta-analysis of these trials (n > 42 000 in total), with an absolute risk reduction of 0.47% over 5 years of treatment [15]. Due to inadequately defined Australian thresholds of absolute fracture risk and lack of data on screening in men, insufficient evidence was available to support a population-based-screening program in Australia [2].

This is mirrored in NZ where the presence of fragility fractures or osteoporosis risk factors directs case finding [7]. However, in HK [5], India [6], Korea [4], and Thailand, screening is based on age and risk factors. Ages for screening are men ≥ 70 years and women ≥ 65 years in HK [5] and Thailand [10], men ≥ 65 years and women ≥ 60 years in India [6], and women ≥ 65 years in Korea [4]. Singaporean guidelines suggest use of the Osteoporosis Self-Assessment Tool for Asians to inform the need for DXA assessment [8].

All the above guidelines recommend the use of FRAX (https://fraxplus.org) for absolute fracture risk assessment. However, in HK, a local alternative, such as the Chinese Osteoporosis Screening Algorithm (COSA) [5] may be appropriate, and NZ guidelines suggest either FRAX or the Garvan Fracture Risk Calculator (https://www.garvan.org.au/research/bone-fracture-risk-calculator) [7]. The Australian document suggests the latter may be of particular use in those at high falls risk, as this is not an input criterion for the current FRAX model [2]. Ongoing local validation studies are required to further refine the predictive value of fracture risk assessment tools.

Identification of patients at “very high” or “high” fracture risk is an evolving important concept allowing risk stratification for earlier access to bone anabolic agents. However, there is currently no internationally recognized definition for this. The 2024 Australian guidelines define very high fracture risk as a T-score ≤ −3.0 and fracture within 2 years, and/or (i) history of ≥ 2 fragility fractures, and/or (ii) presence of clinical risk factors, such as corticosteroid use, low body mass index (BMI), or recurrent falls, and/or (iii) a MOF FRAX risk of ≥ 30%, or hip fracture risk of ≥ 4.5% [2].

The HK guideline is broadly similar, substituting FRAX risk criteria for fractures sustained on anti-resorptive therapy [5]. The Thai guidelines define very high fracture risk as either (i) fragility hip or vertebral fracture within 12 months in individuals ≥ 65 years and T-score ≤ −2.5, or (ii) recurrent vertebral fracture or vertebral fractures at ≥ 2 levels with moderate-to-severe deformity, or (iii) bilateral hip fractures, hip and vertebral fractures, or multiple fractures (≥ 3 times, or ≥ 3 sites), (iv) T-score < −3.5 in men ≥ 70 years or women ≥ 65 years, or (v) fragility fracture after ≥ 2 years of bone protective therapy [10]. The Indian guidelines identify a fracture within 2 years as a marker for very high fracture risk [6] while the NZ, Singaporean and Korean guidelines do not specify a definition [4, 7, 8].

As this is an evolving concept, it is not surprising that heterogeneity in definition exists between countries—especially as there are funding differences for access to bone anabolic agents.

Although treatment thresholds are generally aligned across the Asia–Pacific Region, with the usual caveats about individualized clinical judgment, therapy initiation is guided by fracture risk and healthcare system factors. The Australian guidelines recommend initiation of bone protective pharmacological therapy in individuals with (i) very high fracture risk, or (ii) minimal trauma hip or vertebral fracture, or (iii) MTF at other sites and a T-score of ≤ −1.5 [2]. It further recommends treatment in individuals with risk factors, but no fracture with either a T-score of ≤ −2.5, or a T-score between −1.5 and-2.5 and a FRAX MOF risk of ≥ 20%, or hip fracture risk of ≥ 3%. The Indian guidelines note that these FRAX thresholds may underestimate fracture risk in Indians, and studies are underway to better inform local clinical practice [6]. Thai guidelines recommend treatment in the presence of a fragility vertebral or hip fracture, T-score of ≤ −2.5 or a T-score between −1.0 and −2.5 and a FRAX hip fracture risk of ≥ 3%, but also a T-score between −1.0 and −2.5 and a fragility fracture of the proximal humerus, pelvis, or distal forearm [10].

Access to osteoanabolic therapy is influenced by national healthcare policies and funding. Recent expansion of romosozumab access in Australia is a positive step and similar discussions are occurring in other parts of the Asia–Pacific Region. The Australian guidelines recommend consideration of bone anabolic agents (romosozumab or teriparatide) for those at very high fracture risk (see definition above). Until recently, this was only subsidized under the national Pharmaceutical Benefits Scheme for second-line therapy following fracture while on anti-resorptive therapy with a T-score ≤ −3.0 [2]. However, as of November 2024, romosozumab is available “first-line” for those with a T-score ≤ −2.5 with a symptomatic MTF and either ≥ 1 hip or symptomatic vertebral fracture in the previous 24 months, or a history of ≥ 2 fractures, including 1 symptomatic new fracture in the previous 24 months [16].

Early bone anabolic agent use for those at very high fracture risk is recommended in the HK and Thai guidelines [5, 10]. The Indian guidelines recommend teriparatide as first-line therapy in individuals with either vertebral fractures or very high fracture risk and intravenous zoledronic acid in hip fracture patients—preferably prior to hospital discharge [6]. The NZ guidelines recommend bisphosphonates as first-line therapy—although these were drafted prior to widespread use of bone anabolic therapy [7]. The Korean guidelines make no specific recommendation on the choice of bone protective therapy while the Singaporean guidelines make no demarcation between first and second-line therapies [4, 8].

Although exercise is widely recognized as a key component of osteoporosis management, widespread implementation and adherence to exercise regimes remain problematic. The Australian guidelines discuss the role of exercise for increasing or maintaining bone mass, for promotion of balance and falls prevention, and for fracture reduction [2]. Moderate-to-high-impact weight-bearing activities (jumping, hopping) and progressive resistance (strength) training are most effective for increasing or maintaining BMD, while there is minimal evidence of benefit for low-intensity resistance or low-impact weight-bearing aerobic exercises, such as walking and cycling [17, 18]. The role of the healthcare professional in adopting an encouraging approach to exercise is highlighted. The HK and Singaporean guidelines discuss falls prevention and the benefit of Tai-chi in balance training [5, 8], while the Korean guidelines discuss the importance of exercise on bone health, including exercises to avoid [4]. New Zealand guidelines mention 30 min of weight-bearing exercise per day [7], while the Thai and Indian guidelines do not specifically explore the role of exercise in bone protection [6, 10].

A Fracture Liaison Service (FLS) identifies and coordinates care for patients with a fragility fracture to reduce the risk of a subsequent fracture and is the most effective and cost-effective system-wide model of care to prevent refracture [19]. While there is widespread agreement regarding its importance, there are many barriers to widespread implementation—especially cost. Even in a relatively wealthy country like Australia, only New South Wales has a system-wide osteoporosis refracture program built around FLSs [2]. There has been widespread acceptance of this model of care in HK and NZ [4, 9]. Although FLSs are present in India [20], Thailand [21], and Singapore [22], there are no specific recommendations for widespread implementation in the relevant guidelines [4, 6, 8, 10]. Collaboration between countries may help optimize FLS models for broader adoption throughout the region.

The Asia–Pacific Region encompasses culturally and ethnically diverse populations with variations in healthcare resources, leading to heterogeneity in osteoporosis guidelines. A major reason for differences in recommendations is variation in the cost of osteoporosis medications and variable coverage of investigation and treatment costs by national healthcare systems. Australia, with a large migrant population, is a microcosm of the region at large, and dialogue, collaboration, and knowledge exchange with Asia–Pacific partners is important to produce guidelines representative of this diversity. The Asia–Pacific Consortium on Osteoporosis Framework was developed to establish clinical standards for osteoporosis management across the Region and is an important step toward harmonizing best practice [23]. As many countries refine osteoporosis management strategies, aligning national guidelines with evidence-based regional frameworks will drive more consistent and equitable osteoporosis care across the Asia–Pacific Region.

The initial draft was written by A.L. and P.K.K.W. All authors contributed to manuscript review.

Peter K. K. Wong is Honorary Medical Director and Board Member, Healthy Bones Australia, and an Associate Editor of the Journal. Manju Chandran has previously received travel grants and honoraria from Amgen Asia and Promedius AI solutions for speaking and chairing. Alwin Lian declares no relevant conflicts of interest.