🔑 Key Learning

  • T-score < -2.5 on DEXA = osteoporosis
  • Assess fracture risk using age and clinical risk factors
  • Initiate bone-sparing treatment if DEXA T-score ≤ -2.5
  • Oral bisphosphonates (alendronic acid) are first-line; consider denosumab or others used if not tolerated
  • Supplement with calcium + vitamin D if deficient (e.g. adcal d3)

🧬 Pathophysiology

  • Imbalance in bone remodelling: increased osteoclastic resorption vs osteoblastic formation
  • BMD ≤ 2.5 SD below young adult mean (T-score < -2.5 on DEXA)
  • Fragility fractures: occur from minimal trauma (e.g. fall from standing height)

👀 Clinical Features

  • Often asymptomatic until fracture
  • Common sites: wrist, spine (vertebral crush fractures), and hip
  • May present with kyphosis or height loss (vertebral fractures)

🧪 Investigations & Diagnosis

When to Offer DEXA (Dual-energy X-ray Absorptiometry):

Offer DEXA without prior fracture risk score in:

  • Anyone >50 with a fragility fracture
  • Anyone <40 with a major risk factor:
    • Vertebral fracture
    • High-dose corticosteroids (≥7.5mg prednisolone daily ≥3 months)
    • ≥2 fragility fractures

In all others:

  1. Calculate QFracture (preferred) or FRAX 10-year risk
  2. If high or borderline risk → proceed to DEXA

DEXA T-score Interpretation:

  • -1.0 = Normal
  • -1.0 to -2.5 = Osteopenia
  • < -2.5 = Osteoporosis

🧪 Bloods (if concern for secondary causes)

  • Calcium, phosphate, ALP, vitamin D, PTH, TFTs, FBC
  • Consider SPEP/UPEP (myeloma), coeliac screen if high suspicion

🧮 Fracture Risk Stratification

NICE recommends assessment in:

  • All women ≥65, all men ≥75
  • Women <65 and men <75 with risk factors:
    • Prior fragility fracture
    • Corticosteroid use
    • Family hx of hip fracture
    • Low BMI (<18.5), smoker, alcohol >14 units/wk
    • Conditions: early menopause, hypogonadism, endocrine (e.g. hyperthyroid, DM), GI malabsorption (IBD, coeliac), RA, CKD, COPD, CLD, myeloma
  • Assess:
    • Preferred tool: QFracture (NICE recommends QFracture over FRAX)
    • Alternative: FRAX (used in some localities or if QFracture not available)
  • Both estimate 10-year risk of hip fracture or major osteoporotic fracture (hip, spine, wrist, shoulder). In high-risk patients, consider commencing treatment and follow-up w/ DEXA if needed. 

💊 Management

Bone-Sparing Treatment

Offer if:

  • DEXA T-score ≤ -2.5
  • Or vertebral fracture diagnosed clinically/radiologically

1st Line:

  • Oral bisphosphonates: alendronate 70 mg weekly or risedronate 35 mg weekly
    • Consider ibandronate 150 mg monthly if not tolerated
    • Use with PPI in patients at GI risk
    • Counsel thoroughly. SE - oesophagitis, jaw osteonecrosis etc. 

If bisphosphonates contraindicated → consider referral for:

  • Zoledronic acid (IV annually)
  • Denosumab (SC 60mg every 6 months)
  • Raloxifene, strontium ranelate, teriparatide
  • HRT (in younger postmenopausal women)

Vitamin D & Calcium Supplementation

  • If intake adequate → vitamin D 10 mcg (400 IU) daily
  • If inadequate intake or institutionalised → prescribe combo:
    • Adcal-D3 (calcium + vitamin D)
    • 800 IU vitamin D if elderly/housebound

🏋️ Lifestyle Measures

  • Smoking cessation / Alcohol moderation / Nutrition
  • Weight-bearing/resistance exercises

🔁 Follow-Up & Monitoring

After Starting Treatment

  • Check adherence & side effects at 3 months and 12 months
  • Monitor for atypical femoral fracture symptoms (e.g. thigh pain)
  • Reassess at 5 years (earlier if new fracture)

If still high risk:

  • Continue for at least 10 years if:
    • Age ≥70
    • Vertebral/hip fracture
    • Multiple clinical risk factors

If low/moderate risk at 5 years:

  • DEXA to guide:
    • T-score ≤ -2.5 → continue treatment
    • T-score > -2.5 → pause for 1.5–3 years, then reassess

📝 Exam Clues & Clinchers

  • Elderly woman with vertebral crush fracture from minor trauma
  • T-score < -2.5 on DEXA confirms diagnosis
  • Start bisphosphonates + calcium/vitamin D supplementation
  • Use QFracture to guide initial risk estimation
  • Counsel on osteonecrosis of the jaw risk 

🔗 Useful Links and References