Primary prevention
The identification of decreased bone mineral density in people with any risk factors for osteoporosis suggests a greater risk of osteoporotic fracture. Primary prevention of osteoporotic spinal compression fractures requires optimisation of peak bone mass in childhood, which is influenced mainly by:
Genetic factors
Adequate nutrition
Exercise.
Thereafter, primary prevention depends on minimising loss of bone mass and maintaining skeletal trabeculae microarchitecture and cortical thickness. Important factors to consider are:[11]
Supplementing diet with calcium and vitamin D
Avoiding excess alcohol consumption
Stopping smoking.
In the UK, oral bisphosphonates (e.g., alendronic acid, ibandronic acid, and risedronate) are recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of osteoporosis.[42] Medications such as bisphosphonates have been shown to significantly reduce the incidence of new vertebral fractures, by almost 50%.[43] When bisphosphonates are not tolerated or contraindicated, NICE recommends denosumab for primary prevention.[44]
NICE guidance assumes that women who receive treatment have an adequate calcium intake and are vitamin D replete. If the latter is not the case, calcium and/or vitamin D supplementation should be considered.
Hormone therapy prevents bone loss and reduces fracture risk in healthy postmenopausal women, with dose-related effects on bone density.[45] The benefit-risk ratio of hormone therapy appears favourable for the prevention of bone loss or fracture among women (without contraindications) who are aged under 60 years or are within 10 years of menopause onset.[45] The US Food and Drugs Administration (FDA) recommends that the lowest effective doses of oestrogen therapy for the shortest duration should be used, and that if oestrogen therapy or hormone therapy is intended to be prescribed solely for prevention of osteoporosis, approved non-oestrogen treatments should be carefully considered first.[11] Discontinuation of hormone therapy results in rapid bone loss and eventual loss of anti-fracture efficacy.
In the US, FDA-approved pharmacological options for the prevention and/or treatment of postmenopausal osteoporosis include:[11]
Bisphosphonates
Calcitonin
Oestrogen-related therapy (oestrogen and/or hormone therapy, raloxifene, conjugated oestrogens/bazedoxifene)
Parathyroid hormone analogues (teriparatide, abaloparatide)
Denosumab
Romosozumab.
The European Medicines Agency no longer recommends calcitonin for the treatment of osteoporosis due to an increased risk of various types of cancer in patients using the drug long-term.[46][47] Calcitonin is still approved in the US but is infrequently used and is considered second-line therapy reserved for women in whom alternative treatments are not suitable.[11]
The FRAX tool, developed by the World Health Organization (WHO) is widely used to identify decreased bone mineral density (BMD) in people with risk factors for osteoporosis, therefore suggesting a greater risk of osteoporotic fracture. FRAX®: WHO fracture risk assessment tool Opens in new window Q-fracture is also used in some regions, e.g., in the UK (as recommended by NICE), to estimate 10-year predicted absolute fracture risk.[48] ClinRisk: QFracture®-2016 risk calculator Opens in new window
The Bone Health and Osteoporosis Foundation (BHOF) recommends BMD testing in women aged 65 years or older, and men aged 70 years or older. They also recommend BMD testing in postmenopausal women and men aged 50-69 years, based on risk profile, and in postmenopausal women and men aged 50 years or older with a history of adult-age fracture.[11] The US Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women aged 65 years or older, and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.[49] The USPSTF does not recommend routine osteoporosis screening in men since current evidence is insufficient to assess the balance of benefits and harms of screening in this population.[49] In the UK, NICE recommends to assess fracture risk in all women aged 65 years and over and all men aged 75 years and over. NICE also recommends to assess fracture risk in women aged under 65 years and men aged under 75 years in the presence of risk factors (e.g., previous fragility fracture, current use or frequent recent use of oral or systemic glucocorticoids, history of falls, family history of hip fracture, other causes of secondary osteoporosis, low body mass index [less than 18.5 kg/m²], smoking, and alcohol intake of more than 14 units per week for men and women).[48] See Osteoporosis.
Secondary prevention
Post-fracture patient care should be co-ordinated via fracture liaison service and multi-disciplinary programmes comprising osteoporosis evaluation and treatment, rehabilitation, and transition management.[11]
The occurrence of a spinal compression fracture should trigger a review and optimisation of treatment of the underlying osteoporosis.[11] See Osteoporosis.
Supplementing the diet with calcium and vitamin D, avoiding excess alcohol consumption, and stopping smoking are advised to minimise loss of bone mass and maintain skeletal trabeculae microarchitecture and cortical thickness.[11][94]
The evidence for exercise overall is inconclusive, although some trials have reported some benefit for pain relief, physical function, and quality-of-life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution.[103]
Annual influenza vaccines (to reduce risk of illness-associated immobility, coughing, and sneezing) are recommended.
For information on the prevention and/or pharmacological treatment of osteoporosis see Primary prevention.
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