Prevention and management of osteoporosis

Osteoporosis is a skeletal disorder characterized by compromised bone strength, predisposing individuals to an increased fracture risk. The diagnosis of osteoporosis in postmenopausal women and men over the age of 50 is confirmed in the presence of low bone density on a bone mineral density (BMD) dual energy xray absorptiometry (DXA) study. BMD is evaluated in g/cm² and expressed as standard deviation (T-score) above or below the mean BMD in the young adult female Caucasian population. A T-score of −2.5 or lower at the lumbar spine, femoral neck, total hip or one-third radius site confirm the diagnosis of osteoporosis by DXA technology. In postmenopausal women of any age and men over age 50, osteoporosis can also be diagnosed clinically in the presence of a low trauma fracture. Fracture risk assessment, incorporating the Fracture Risk Assessment Tool (FRAX), is crucial in guiding treatment decisions. Clinical evaluation should include a detailed history, physical examination and investigations to exclude secondary causes of osteoporosis, including endocrinopathies, gastrointestinal disorders, inflammatory conditions, malignancies as well as medication-related bone loss. Management strategies include ensuring adequate calcium, phosphate and vitamin supplementation. Pharmacological interventions are offered in the presence of an increased fracture risk.

Antiresorptive therapies include bisphosphonates, denosumab and selective oestrogen receptor modulators. They reduce bone turnover and fracture risk. Anabolic agents, include teriparatide, abaloparatide and romosozumab. These molecules promote bone formation and improve bone microstructure and dramatically improve bone density while significantly reducing fracture risk. The selection of individualized treatment is based on fracture risk as well as contraindications to therapy. In those at a moderate fracture risk with a major osteoporotic fracture (MOF) risk of 10–20% over the next 10 years a bisphosphonate can be offered for 5 years followed by a possible drug holiday. If the MOF is high (≥20%) or hip fracture risk is ≥3% then denosumab can be offered. If the MOF is very high (MOF>30% or hip fracture risk >4.5%) or in the presence of fragility fracture then an anabolic agent can be considered as first line therapy).