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 optimization of peak bone mass in childhood, which is influenced mainly by:
Genetic factors
Adequate nutrition
Exercise
Thereafter, primary prevention depends on minimizing 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
Food and Drug Administration (FDA)-approved pharmacologic options for the prevention and/or treatment of postmenopausal osteoporosis in the US include:[11]
Bisphosphonates
Calcitonin
Estrogen-related therapy (estrogen and/or hormone therapy, raloxifene, conjugated estrogens/bazedoxifene)
Parathyroid hormone analogs (teriparatide, abaloparatide)
Denosumab
Romosozumab
In the UK, oral bisphosphonates (e.g., alendronate, ibandronate, 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.
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.[45][46] 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]
Hormone therapy prevents bone loss and reduces fracture risk in healthy postmenopausal women, with dose-related effects on bone density.[47] The benefit-risk ratio of hormone therapy appears favorable 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.[47] The FDA recommends that the lowest effective doses of estrogen therapy for the shortest duration should be used, and that if estrogen therapy or hormone therapy is intended to be prescribed solely for prevention of osteoporosis, approved nonestrogen treatments should be carefully considered first.[11] Discontinuation of hormone therapy results in rapid bone loss and eventual loss of anti-fracture efficacy.
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 ages 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.
The table that follows summarizes recommendations on prevention and treatment of osteoporotic fractures from the Bone Health and Osteoporosis Foundation (BHOF).[11]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Man ages ≥50 years, or postmenopausal woman
All
Intervention
Advice on balance training, muscle-strengthening exercise, and safe movement strategies
Counsel or refer patients for advice and instruction on:
Balance training
Muscle-strengthening exercise, e.g., weight training and resistive exercises such as yoga, Pilates, and boot camp calisthenics
Safe movement strategies
Supervision is recommended to ensure physical activities are safe and sustainable given an individual’s health status and overall fitness. To avoid injury, it is recommended that patients are evaluated before initiating a new exercise program, particularly one involving compressive or contractile stressors (such as running or weightlifting).
Consultation with a trained physical therapist and/or participation in group exercise led by certified fitness personnel may help ensure patient safety, motivate daily participation, and promote social engagement.
Providing principles of safe movement are followed, walking and daily activities such as housework and gardening are practical ways to contribute to maintenance of fitness and bone mass.
Goal
Prevention of fracture(s) in the activities of daily life
Maintaining independence by preventing an injury that could lead to nursing home admission is likely to be a priority for many individuals.
Adherence with a recommended lifestyle change may be challenging; linking the change to something of value to an individual may help to improve motivation.
With osteoporosis or osteopenia meeting criteria for treatment
Intervention
Treatment of osteoporosis or osteopenia
Offer treatment for osteoporosis or osteopenia using lifestyle interventions with or without medication in line with published clinical guidance on management of osteoporosis/osteopenia.
Medication for osteoporosis/osteopenia:
Management plans are highly individualized and recommendations may differ according to sex, investigation findings, personalized fracture risk assessment results, and whether or not glucocorticoid use is a contributing factor to bone mineral density loss.
It is recommended that treatment is stratified according to fracture risk; combination or sequential treatment with different classes of medication may be required to lower risk to acceptable levels in people at particularly high risk of future fracture.
Patient adherence to prescribed treatment is key. An estimated 25-30% of people with osteoporosis do not start taking their prescribed medication and 50% or more do not continue treatment after 1 year; nonadherence to treatment is associated with higher morbidity and mortality.
Ensure a good foundation for treatment is in place, including focused support and monitoring early in treatment, which may help improve a patient’s long-term adherence with prescribed treatment and, consequently, fracture outcomes.
Ask questions about patient preferences and address fears and misconceptions as part of the medication selection process, as this can not only promote better adherence to prescribed treatment but also lead to better outcomes in terms of prevention of fractures and disability.
Lifestyle interventions for osteoporosis:
A multicomponent program is recommended, encompassing:
Progressive resistance training
Balance training
Back extensor strengthening
Core stabilizers
Cardiovascular conditioning
Impact or ground-reaction forces to stimulate bone
Note that recreational pursuits and athletic activities that exert intense forces on weakened bone and/or involve abrupt or high-impact loading can break bones in people with osteoporosis.
For safety, it is recommended that any program of physical activity is developed and supervised by certified fitness personnel experienced with skeletal fragility in older adults.
See Osteoporosis.
Goal
Increased bone mineral density; improved falls outcomes; reduced fracture risk
Like any lifelong chronic disease, osteoporosis is most successfully managed with continued therapy and monitoring.
Recommended duration of treatment varies according to patient characteristics and the type of medication used.
Periodically review pharmacotherapy to determine whether treatment should be continued, changed, stopped, or resumed. It is reasonable to evaluate patients every 1 to 2 years during any hiatus from active bisphosphonate treatment.
For patients on pharmacologic therapy, a reasonable 3-year target outcome could be to increase the T-score from −2.8 to > −2.5 and have no fractures.
Stable bone mineral density and a year with no new fractures could be a measurable goal for someone with low bone mineral density and prior fragility fractures.
If the patient is not on track to reach their target or does not reach their target, consider clinical reassessment and possibly a change in therapy.
With insufficient intake of calcium
Intervention
Advice on increased calcium intake ± calcium supplementation
Adequate total calcium intake is defined as:
1000 mg/day for men ages 50-70 years and women ages 50 years
1200 mg/day for women ages ≥51 years and men ages ≥71 years
Increasing dietary calcium is the first-line approach when there is inadequate calcium intake.
Advise people to eat a balanced diet rich in foods that provide calcium as well as numerous nutrients needed for good health:
low-fat dairy products;
select dark greens;
fish with bone;
fruits;
vegetables; and
fortified foods (e.g., nondairy supplemented beverages including orange juice, and soy and almond milk).
Calcium supplements are recommended when an adequate dietary intake cannot be achieved.
Supplemental calcium is most widely available as calcium carbonate and calcium citrate:
Calcium citrate is useful for people with achlorhydria, inflammatory bowel disease, absorption disorders, and those on proton-pump inhibitors that reduce gastric acid as it doesn't require stomach acid for absorption and can be taken on an empty stomach.
Doses may need to be split to ensure optimal absorption.
Goal
Achieve targets for recommended calcium intake according to sex and age; fracture prevention
Goals are the following:
1000 mg/day for men ages 50-70 years and women ages 50 years
1200 mg/day for women ages ≥51 years and men ages ≥71 years
There is no evidence that calcium intake in excess of recommended amounts confers additional bone benefit.
Supplemental calcium intake above 1200-1500 mg/day can increase risk for developing kidney stones in at-risk individuals.
With vitamin D deficiency or insufficiency
Intervention
Vitamin D supplementation
Vitamin D sufficiency is defined as 30-50 ng/mL.
Prescribe supplemental vitamin D as needed for individuals ages 50 years and older to achieve a sufficient vitamin D level.
Higher doses may be necessary in some adults, especially those with malabsorption.
See Vitamin D deficiency.
Goal
Maintenance of serum vitamin D sufficiency; fracture prevention
Maintain serum vitamin D sufficiency (30-50 ng/mL).
In healthy individuals a serum 25(OH) vitamin D level ≥20 ng/mL may be sufficient, but in the setting of known or suspected metabolic bone disease ≥30 ng/mL is appropriate.
With tobacco use
Intervention
Smoking cessation advice ± referral
Provide guidance for smoking cessation; advise the patient that use of tobacco products is detrimental to the skeleton as well as to overall health.
Refer for smoking cessation care as appropriate.
See Smoking cessation.
Goal
Cessation of smoking; fracture prevention
With alcohol intake＞two drinks/day (in women) or＞three drinks/day (in men)
Intervention
Advice on avoidance of excessive alcohol intake ± substance use referral
Provide guidance for avoidance of excessive alcohol intake; advise the patient that alcohol intake of more than two drinks a day for women or three drinks a day for men may be detrimental to bone health, and that it has been associated with reduced calcium absorption and increased risk for falls.
Identify patients at risk for chronic heavy drinking and/or binge drinking who require further evaluation and treatment.
See Alcohol use disorder.
Goal
Alcohol intake within safe drinking limits
In women: ≤ two drinks/day is recommended.
In men: ≤ three drinks/day is recommended.
With major risk factors for falls
Intervention
Fall prevention strategies
Identify and address modifiable risk factors associated with falls, such as:
Sedating medications
Polypharmacy
Hypotension
Gait or vision disorders
Out-of-date prescription glasses
In community-dwelling patients, refer for at-home fall hazard evaluation and remediation.
Many risk factors for falls are modifiable: muscle strength and balance can be improved through targeted exercise; visual impairment can be addressed; fall hazards in the home and work environment can be remediated; medications that induce dizziness and disorientation can be replaced or reduced.
Goal
Reduced risk of future falls and fractures
Secondary prevention
Post-fracture patient care should be coordinated via fracture liaison service and multidisciplinary programs comprising osteoporosis evaluation and treatment, rehabilitation, and transition management.[11]
The occurrence of a spinal compression fracture should trigger a review and optimization 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 minimize loss of bone mass and maintain skeletal trabeculae microarchitecture and cortical thickness.[11][67]
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.[104]
Annual influenza vaccines (to reduce risk of illness-associated immobility, coughing, and sneezing) are recommended.
For information on the prevention and/or pharmacologic treatment of osteoporosis see Primary prevention.
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