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Osteoporosis

Guidelines for preventive activities in general practice
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Women

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Men

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The goal of the prevention and treatment of osteoporosis is to reduce a person’s overall fracture risk, not just to maintain bone density.

Review of fracture risk factors for postmenopausal women aged >45 years and men aged >50 years is recommended (Practice Point). Those with increased risk should have bone density assessed (Practice Point).

Osteoporosis is a disease characterised by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and increased fracture risk.1 It is diagnosed on the presence of a fragility fracture (fracture from the equivalent of a fall from standing height or less, or a fracture that under normal circumstances would not be expected in a healthy young man or woman). For epidemiological and clinical purposes, osteoporosis is defined by bone mineral density (BMD) as a T-score of ≤–2.5. However, age, lifestyle factors, family history, and some medications and diseases contribute to bone loss and increased risk of fragility fractures. Furthermore, it is important to note that in an individual who has sustained a fragility fracture, a T-score of ≤–2.5 is not also required to make the diagnosis of osteoporosis, the presence of a fragile fracture is sufficient. Thus, the goal of prevention and treatment is to reduce a person’s overall fracture risk (not just maintain bone density).

Two of the most widely validated methods to estimate absolute fracture risk for osteoporotic fractures relevant to the Australian population are available at:

These calculators can be used with and without measuring BMD, though the Garvan fracture risk calculator has not been validated in an external cohort when BMD has not been used in the calculator.2 Risk estimation is imperfect, with the tools being modest predictors of fracture risk.3,4 Risk factors (eg falls, glucocorticoid use) not included in one or the other risk algorithm require clinical judgement to modify the risk estimate.

To date, there are no randomised controlled trials (RCTs) directly evaluating screening effectiveness, harms and intervals, and whether screening is performed by bone density screening by dual-energy X-ray absorptiometry (DXA) or by estimating absolute fracture risk.4 The place of absolute fracture risk assessment in the prevention and management of osteoporosis requires further clarification as its effectiveness is yet to be tested.

Table 14.1

Table 14.1

Osteoporosis: Identifying risk
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Osteoporosis: Preventive interventions

Table 14.2

Osteoporosis: Preventive interventions
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An alternative imaging technique for assessing fracture risk is quantitative ultrasound, which measures parameters such as speed of sound (SOS) and broadband ultrasound attenuation (BUA), with these values being combined into composite parameters such as stiffness index. These parameters predict fracture to a similar degree as DXA measures of BMD. However, there is no agreed definition of osteoporosis using quantitative ultrasound, and it cannot be used to assess the response to osteoporosis treatment.22Moreover, intervention trials have predominantly been based on cases identified through DXA assessment, so their results cannot readily be applied to individuals identified by other means.1,3 For this reason, DXA remains the recommended method of assessment.

Several Australian studies have shown an evidence–practice gap, where the majority of people with a fragility fracture tend to have their fracture treated, but not the underlying osteoporosis.23,24 Those with a previous fragility fracture have a very high risk of further fracture, and have greatest benefit from specific anti-osteoporosis treatment. Fracture risk reductions with optimal therapy are substantial and treatment according to current guidelines is recommended unless absolutely contraindicated. This is unlikely given the range of treatments now available. Optimal treatment necessitates the use of a specific anti-osteoporosis treatment such as a bisphosphonate, but also includes ensuring adequate calcium intake and correcting vitamin D deficiency.

There are inequities in the use of BMD measurement with relative underuse in men and people from rural and remote locations.25

There is insufficient evidence to support population screening of younger women by DXA. However, if a DXA is performed for a clinical indication, the results could be used opportunistically to improve bone health via feedback of relative fracture risk. In women aged 25–45 years, written feedback of being at high risk compared to not at high risk of fracture in later life (based on mean DXA hip and lumbar spine T-score being less than or greater than or equal or zero) resulted in improved osteoporosis preventive behaviours and femoral neck BMD at two26 and 12 years.27

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