Osteoporosis

Clinical guidelines

• The Royal Australian College of General Practitioners (RACGP): Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age, second edition 
• RACGP: Osteoporosis risk assessment, diagnosis and management flow chart 
• Healthy Bones Australia: Position statement of the management of osteoporosis 

Tools

• University of Sheffield: Fracture Risk Assessment Tool (FRAX®) for the Australian setting, recommended in Australian guidelines 
• Garvan Institute: Bone fracture risk calculator 

General information

• International Osteoporosis Foundation: Prevention 
• Healthy Bones Australia: Exercise guidelines for preventing and treating osteoporosis 
• Healthy Bones Australia: Sun exposure recommendations 

Background

A healthy diet and adequate physical activity that start in childhood set the foundation for good bone health. A diet rich in calcium, vitamin D and protein in the early years provides the nutritional basis for building bone mass.⁷ This is particularly important during periods of rapid bone growth. Peak bone mass is achieved around the age of 20 years and is maintained by weight-bearing exercise and good nutrition during adulthood.⁷ Bone density reduces as people age due to a reduction in sex hormones, reduced physical activity and increased sedentary behaviour, low bodyweight and certain medications and medical comorbidities.² Given the importance of nutritious dietary intake, the affordability and accessibility of foods affect musculoskeletal health. Data from the 2012–13 National Aboriginal and Torres Strait Islander Nutrition and Physical Activity Survey suggested that 22% of respondents had run out of food and could not afford to buy more during the previous 12 months.⁸

Osteoporosis is a chronic systemic skeletal disease characterised by low bone mass and deterioration of bone microarchitecture, causing bone fragility and increasing the risk of fracture.⁷ Osteoporosis affects both trabecular and cortical bone.⁷

Osteoporosis is associated with minimal trauma fractures. A minimal trauma fracture (also called a fragility fracture) is a fracture that occurs from standing height or less, excluding fractures of the phalanges.³ Minimal trauma fractures can occur in the context of a fall or collision and typically affect the wrist, humerus or femur. Vertebral fractures can also signal bone fragility and may not have any identified precipitating injury. Vertebral fractures are defined by at least a 20% loss of vertebral body height and are associated with significant long-term disability related to pain and kyphosis (curvature of the spine).² Screening for vertebral fracture is recommended if there is a greater than 3 cm height loss, kyphosis or prolonged glucocorticoid treatment.^2,9 Primary and secondary prevention of minimal trauma fractures is a key preventive health goal for older adults.³ Osteoporosis is underdiagnosed and undertreated in Australia and internationally.^3,4 Underdiagnosis and undertreatment of osteoporosis mean that opportunities for fracture prevention are being missed.

Osteoporosis is common in older adults, with women in the general population having approximately double the lifetime risk than men, and a family history of minimal trauma fracture is significant.² In 2023, the Australian Bureau of Statistics reported an estimated that 924,000 Australians live with osteoporosis.¹⁰ The National strategic action plan for osteoporosis suggests that 80% of the population aged over 70 years in Australia has osteoporosis or osteopenia.¹¹ In the 2018–19 Aboriginal and Torres Strait Islander Health Survey, 2.3% of people (ie ~18,900 people) self-reported osteoporosis, with women affected twice as much as men.¹⁰

It is estimated that 50% of postmenopausal women and 30% of men aged over 60 years will experience a minimal trauma fracture in their lifetime.¹¹ In 2020–21, there were 107,000 hospitalisations for minimal trauma fractures in people aged 45 years and over in Australia, with the highest rates of hospitalisation in those aged 85 years and older.¹⁰ A cascade of injury can occur after a minimal trauma fracture, with the strongest risk factor for a future fracture being a previous fracture.¹¹ Minimal trauma fractures are associated with loss of independence, disability and increased risk of mortality.² Therefore, minimal trauma fractures, particularly in older people, can have significant personal and economic costs.

There is conflicting evidence as to whether minimal trauma hip fractures occur more frequently for Aboriginal and Torres Strait Islander people. However, Brennan-Olsen et al¹² conducted a systemic review of fracture rates in indigenous peoples in several countries and found an approximately three-fold greater risk of osteoporotic fractures in indigenous than non-indigenous populations after adjusting for sociodemographic and clinical risk factors. The review also observed that the hip fracture rate was continent-specific, with lower rates of hip fracture on all continents except Canada and Australia.¹² Aggregated data from Australian studies revealed higher rates of hip fractures for Aboriginal and Torres Strait Islander women and men.¹² Hospital data in Western Australia between 1999 and 2009 showed a higher rate of hip fracture due to minimal trauma in both Aboriginal men and women, with Aboriginal men having more than twice the age-standardised risk of fracture than non-Indigenous Australian men.¹³

In a 2021 study using New South Wales hospital data, minimal trauma hip fractures occurred at an earlier age in Aboriginal and Torres Strait Islander people. Of all the Aboriginal and Torres Strait Islander people admitted to hospital for hip fracture, 52% were aged 40–75 years (versus 19% of non-Indigenous Australians in the same age bracket).¹⁴ Aboriginal and Torres Strait Islander people aged 45–49 were threefold as likely to sustain a minimal trauma hip fracture as non-Indigenous people in the same age group.¹⁴

Risk factors for osteoporosis

The risk factors for osteoporosis are summarised in Box 1. The primary risk factor for reduced bone density is age.² Other factors include a parental history of fracture and previous falls. Medical conditions that increase the risk of osteoporosis include chronic kidney disease, chronic liver disease, hyperthyroidism, hyperparathyroidism, hypogonadism, rheumatoid arthritis, premature menopause, coeliac disease, diabetes, multiple myeloma and HIV infection.² For people with chronic kidney disease, a long duration of dialysis is associated with increased osteoporosis risk, and renal osteodystrophy may also be present.⁹ Conditions that affect nutritional status, such as inflammatory bowel disease, coeliac disease and anorexia nervosa, affect bone health, particularly if bone health is further compromised by corticosteroids.² Certain medications reduce bone density, especially corticosteroids, but also anti-androgen therapy, aromatase inhibitors, excess thyroid replacement, selective serotonin reuptake inhibitors, thiazolidinediones, protein pump inhibitors and antipsychotic and anti-epileptic drugs.^2,4

Diabetes was found to be an independent risk factor for osteoporotic and hip fractures in a study of Canadian indigenous people.¹² Diabetes can have a variable effect on the skeleton and certain medications are associated with a risk of fracture. For example, an increased fracture risk has been associated with the use of insulin (indirectly), sulphonylureas (indirectly) and thiazolidinediones (directly).¹⁵ There are multiple confounding factors that affect the increased risk associated with diabetes and medications, including the duration of diabetes, the level of glycaemic control and the presence of microvascular complications.¹⁵

Modifiable risk factors include excessive alcohol consumption, smoking, low body mass index, immobility/inactivity and vitamin D deficiency.^2,16 Smoking has a detrimental effect on bone health, including a direct effect on osteoblast and osteoclast activity. Smoking interferes with hormonal modulators of bone density (sex hormones, adrenal hormones and the parathyroid hormone/vitamin D axis) and is associated with a reduced body mass index.¹⁷ Considering that 41% of Aboriginal people (aged 15 years and over) self-identified as current smokers in the 2018–19 health survey, this is a significant modifiable risk factor. A meta-analysis showed that daily alcohol consumption or the consumption of >10 standard drinks per week increases the risk of fracture in men.¹⁶ That analysis also found a history of falls within the past year, diabetes and stroke were statistically significant risk factors for fracture.¹⁶

Long-term exposure to air pollution appears to be associated with reduced bone density, particularly exposure to nitrogen oxides (NO and NO₂) based on the results of a prospective cohort study of postmenopausal women in the US.¹⁸ In that study, participants underwent bone mineral density (BMD) testing at study enrolment and at Years 1, 3 and 6. Corresponding air pollution data, including particulate matter, sulphur dioxide, nitric oxide and nitrogen dioxide, were obtained based on the residential address of participants.¹⁸ In addition, a systemic review and meta-analysis of nine studies found an increased risk of osteoporosis (total body BMD and hip fracture), particularly with exposure to particulate matter and nitrogen dioxide.⁶ 

Diagnosis

Osteoporosis may be diagnosed on the detection of a minimal trauma fracture or diagnosed before a fracture occurs based on the DEXA score. DEXA measures bone density at the hip, spine and radius, expressed as a T-score. A T-score of –2.5 or lower is diagnostic of osteoporosis, and a T-score between –1.0 and –2.5 is diagnostic of osteopenia.

The following policy documents have informed the recommendations in this guide:

• RACGP and Osteoporosis Australia: Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age²
• Healthy Bones Australia: Position statement on the management of osteoporosis³ 

Recognising people who are at risk

Risk factors for osteoporosis should be identified and taken into account when considering a person’s fracture risk.¹⁶ Aboriginal and Torres Strait Islander people should undergo risk assessment for osteoporosis with active case finding from the age of 50 years. This is consistent with advice for all Australians.¹⁹ Annual health checks provide a structured opportunity to identify risk factors, including asking about falls and minimal trauma fractures.
Calculating the risk of fracture can provide additional information about whether to commence treatment, particularly in the scenario of a non-vertebral, non-hip minimal trauma fracture with a DEXA greater than –2.5.^2,3 If a person has a 10-year risk of fracture of >20% for any fracture or >3% for hip fracture, treatment is recommended.³ Two fracture risk calculators used in the Australian context include FRAX® and the Garvan Institute’s bone fracture risk calculator (see Useful resources).² FRAX® was developed at The University of Sheffield in conjunction with the World Health Organization, and uses country-specific data (selecting the country when using the tool) to calculate the 10-year risk of major osteoporotic fracture and hip fracture.²⁰ The Garvan Institute’s bone fracture risk calculator is an Australian calculator that includes the number of falls in the past 12 months and can estimate risk of fracture. Both tools can calculate fracture risk with or without BMD values, which may also provide guidance on who should have BMD measured.²¹

It is recommended that all Australians aged 70 years and older and most people aged 50 years and over with a history of minimal trauma fracture undergo a baseline DEXA study to check their BMD.³ A Medicare rebate for a DEXA scan is available after the age of 70 years with no additional risk factors, or at a younger age with the most significant risk factors (see Box 1) or after minimal trauma fracture.² There are other groups of people who are at increased risk of fracture but do not qualify for Medicare Benefit Schedule reimbursement for a DEXA scan (see the RACGP/Osteoporosis Australia algorithm for testing and treatment in Useful resources). Access to BMD, particularly in regional and remote areas, may be a barrier to screening older Aboriginal and Torres Strait Islander people for osteoporosis. 

Optimising bone health

Calcium intake

The Australian recommended dietary intake of calcium is 1300 mg/day for women aged 50 years and above and 1000 mg/day for men aged 50–70 years.² For men aged older than 70 years, a dietary intake of 1300 mg/day calcium is recommended.² The evidence around dietary/supplemental calcium levels and fracture risk does not support the use of calcium for the primary or secondary prevention of falls or fractures.²² In addition, concerns have been raised about the adverse effects of calcium supplementation, including constipation, renal calculi and the risk of myocardial infarction.^22,23 The dietary calcium intake should be assessed in people who are commencing antiresorptive treatment, and supplementation should be considered to counter the risk of hypocalcaemia with treatment.² Calcium is not listed on the PBS and is therefore not covered by the PBS Closing the Gap co-payment program.
 

Vitamin D

Vitamin D refers to either cholecalciferol or ergocalciferol (coming from plant sources). Cholecalciferol is formed when ultraviolet B radiation acts on 7-dehydrocholesterol in the skin. There are dietary sources of vitamin D (eg liver, eggs and fortified foods [ie margarine]), but sunlight exposure is the primary mechanism for vitamin D synthesis.⁵ People with darker skin pigmentation and people with increased body mass index require longer sun exposures to achieve equivalent vitamin D levels. People who are at risk of vitamin D deficiency include those in residential care settings with reduced mobility and restricted access to natural sunlight. Housebound people and people who avoid sun exposure are similarly at risk.⁵
 
Aboriginal and Torres Strait Islander peoples experience vitamin D insufficiency and deficiency. Using data from the 2012–13 National Aboriginal and Torres Strait Islander Health Survey, Black et al identified that 27% of participants had vitamin D levels <50 nmol/L and 5% of participants had vitamin D levels <30 nmol/L.²⁴ Vitamin D deficiency was more marked in remote areas (39%), with a higher prevalence in the southern states of South Australia and Tasmania.²⁴ The collection of these data occurred with seasonal variation, which would have affected the results because vitamin D levels tend to be lower at the end of winter and higher during summer months.²⁴ The length of sunlight exposure required is dependent on the season and geographical location. To achieve the required one-third of a minimal erythema dose in summer, a six- to seven-minute walk mid-morning or mid-afternoon, with arms exposed, is probably adequate for people with moderately fair skin.⁵ For people with pigmented skin, exposure times that are three to six times longer may be required; this is because melanin absorbs ultraviolet radiation.⁵
 
In the RACGP/Osteoporosis Australia guidelines published in 2017, routine vitamin D supplementation was not recommended, except for people experiencing severe immobility or in a residential care facility.² However, updated recommendations by Healthy Bones Australia (previously Osteoporosis Australia) acknowledged the benefit of vitamin D on muscle function and reduced fracture risk in individuals with vitamin D deficiency.²⁵ Vitamin D supplementation (dose 800–1000 IU) is recommended for people with vitamin D levels less than 50 nmol/L.²⁵
There is inconsistency in the literature about the benefit and harms associated with vitamin D supplementation. In a pooled analysis of vitamin D supplementation across 11 trials (31,022 people), high doses of vitamin D (>800 IU daily) were significant in reducing the risk of hip fracture (30% reduction) and non-vertebral fracture (14% reduction).²⁶ That study also suggested that dosing interval may be important, with longer-interval regimes showing less effectiveness in reducing fracture risk.²⁶ In a 2020 meta-analysis of randomised controlled trials, vitamin D supplementation showed reduced falls risk compared with placebo (risk ratio [RR] 0.948; 95% confidence interval [CI] 0.914–0.984; P=0.004);²⁷ however, the overall fracture risk reduction was not statistically significant (RR 0.949; 95% CI 0.846–1.064; P=0.37).²⁷ In subgroup analysis, vitamin D supplementation was effective in reducing fracture risk for residents in health and residential care settings (RR 0.517; 95% CI 0.286–0.935; P=0.03).²⁷ Furthermore, the coadministration of calcium may reduce both falls and fracture risk (RR 0.859; 96% CI 0.895-1.230; P=0.55).²⁷ (For vitamin D supplementation for falls prevention, refer to Chapter 8: The health of older people, Mobility, balance and coordination: Falls prevention.)
The benefits of specific anti-osteoporotic therapies have been demonstrated in the context of adequate vitamin D levels. Patients who are to be started on specific antiresorptive medication should have their vitamin D levels checked and should commence supplementation if their vitamin D level is less than 50 nmol/L.² Vitamin D (cholecalciferol) is not listed on the PBS Closing the Gap co-payment program. 

Physical activity

Primary prevention of osteoporosis is supported by physical activity at all ages that includes brief weight-bearing, high-impact exercise and high-intensity progressive resistance training.¹ Regular progressive resistance training targeting the major muscle groups attached to the hip and spine has been shown to slow bone density loss in postmenopausal women and older men.² Impact loading should be dynamic, with fewer cycles (repetitions) and in short bursts.¹ This could include activities such as hopping, skipping rope and bench stepping with a variable intensity according to the individual’s risk factors. A high-risk individual may need to start with progressive resistance training to have adequate strength for impact-loading activities.¹ Balance training involves ‘standing and moving exercises with gradual reduction in base of support to standing on one foot, perturbing the centre of mass’.¹ Dual-task training may improve functional mobility because falls can occur when the person is attempting a secondary activity.¹ For those people who have sustained an osteoporotic fracture, depending on the type of fracture, a formal rehabilitation program may be indicated, when available.

Physical activity needs to be balanced against falls risk and injury. A physiotherapist, exercise physiologist or other appropriately trained professional should supervise the introduction of an exercise program for people with osteoporosis or increased falls risk.² Access to allied health may be supported with Medicare rebates following GP management plans and annual health checks, and where appropriate services are available. 

Hip protectors

Hip protectors are either foam pads (soft) or plastic shields (hard) worn over the hips in specially designed underwear and act to protect the hips in case of a fall to the side. Hip protectors have been shown to reduce the risk of hip fracture in older people living in aged care facilities, although the number needed to treat for one year to prevent one fracture is 91.² Hip protectors have not been shown to reduce the risk of hip fracture among people living in the community, probably because people choose not to wear them.²

Smoking and alcohol

Smoking cessation is strongly recommended.

High alcohol intake has been associated with an increased risk of minimal trauma fracture.² Advising not having more than 10 drinks per week and not more than four on any one day is recommended.
For more information, refer to Chapter 2: Healthy living and health risks, Smoking and Alcohol.
 

Medical treatments for osteoporosis for the primary and secondary prevention of minimal trauma fractures

Antiresorptive treatment should be commenced following the diagnosis of osteoporosis.^2,3 Commencing antiresorptive treatment is time sensitive following a minimal trauma fracture because of the increased risk of subsequent fracture within 12–24 months.³ The decision to treat can be guided by the absolute fracture risk determined using FRAX® or the Garvan Institute’s risk calculator (see Useful resources).
 
PBS-funded treatment (authority streamlined) is available for individuals in the following circumstances:

• after minimal trauma fracture
• a DEXA score in the osteoporosis range and age 70 years or older
• long-term treatment with high-dose steroids (at least 7.5 mg prednisolone or equivalent) with a DEXA score of ≤1.5 (alendronate and risedronate only).

 
Eligibility criteria for PBS-funded treatments vary over time and should be checked at the time of prescribing to make sure medications are accessible and affordable.

Bisphosphonates

Bisphosphonates, such as risedronate and alendronate, bind to calcium hydroxyapatite in bone, inhibiting osteoclast function.²⁸ Bisphosphonates are listed on the PBS for the treatment of osteoporosis following minimal trauma fracture (secondary prevention), in those with a low BMD and age over 70 years, and those on long-term corticosteroids with a DEXA score of 1.5 or less. Uncommon adverse effects of oral bisphosphate therapy include medication-related osteonecrosis of the jaw and atypical femur fractures. Therefore, good dental hygiene is recommended and a dental review should be considered prior to commencement of therapy.^2,29

Denosumab

Denosumab is a human monoclonal antibody and may be used for women and men diagnosed with osteoporosis, given as a six-monthly injection. In people with renal impairment, there is an increased risk of hypocalcaemia with denosumab.² Dietary calcium and serum vitamin D levels should be replete during treatment with denosumab. There is evidence of rapid decrease in BMD on discontinuation of denosumab therapy that is associated with an increased risk of vertebral fracture 6–18 months after the last dose.^30,31 The longer the duration of denosumab treatment, the more significant the rebound effect. Alternative antiresorptive treatment (eg an oral bisphosphonate) should be commenced immediately to buffer these discontinuation effects.³ 

Hormone therapy

Menopausal hormonal therapy (MHT) is effective in improving BMD and reducing the risk of fractures in postmenopausal women. MHT has been shown to be effective in primary prevention and for treating established osteoporosis.² However, there are adverse effects, including an increased risk of breast cancer, stroke and thromboembolic events.² These risks appear lower in women started on hormone replacement therapy within 10 years of the menopause, and younger women in general have a lower baseline risk of vascular events.² Tibolone has been shown to decrease the risk of vertebral and non-vertebral fracture.² Raloxifene is a selective oestrogen receptor modulator and is effective in reducing vertebral fractures, and is most suitable for postmenopausal women.² Raloxifene may exacerbate menopausal symptoms and is associated with an increased risk of thromboembolism, including stroke.² 

Anabolic agents

In the event of treatment failure despite first-line therapy, a referral is recommended for specialist assessment.³ This may result in the prescription of anabolic agents. Teriparatide is a recombinant human parathyroid hormone that acts to stimulate new bone formation and enhance bone microarchitecture.²⁹ Romosozumab is a monoclonal antibody, administered as a monthly subcutaneous injection, that binds to and inhibits sclerostin, which is produced by osteocytes.² Sclerostin would usually act to increase bone resorption and decrease bone formation.³²