Guideline

Summary of recommendations

Osteoporosis management and fracture prevention in post-menopausal women and men > 50 years of age
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Summary of recommendations

*Recommendations underwent a focused and detailed published literature search during which multiple databases were interrogated to identify publications subsequent to the previous edition (ie since 2016). Refer to Appendix B for a full explanation.

These were then reviewed by a subject matter adviser (see Appendix D) with subspeciality expertise in the topic and the relevant chapter(s) updated. The final draft of the chapter(s) underpinning relevant recommendation(s) was then reviewed by the National Osteoporosis Guideline Review Committee (see Appendix D) and discussed at several face-to-face and online meetings.

All other recommendations have been updated by at least one subject matter adviser with subspeciality expertise in the area and reviewed by the National Osteoporosis Guideline Review Committee at two face-to-face meetings.

Section No. Recommendation Grade
1.1 Identifying patients to investigate for osteoporosis 1 All individuals over the age of 50 years who sustain a fracture following minimal trauma (such as a fall from standing height, or less) should be considered to have a presumptive diagnosis of osteoporosis. A
2 * Conduct a clinical risk factor assessment in postmenopausal women and men over the age of 50 years with one or more major risk factors for minimal trauma fracture to guide bone mineral density (BMD) measurement and prompt timely referral and/or drug treatment. A
3 A presumptive diagnosis of osteoporosis can be made in a patient with a vertebral fracture or hip fracture in whom there is no history of significant trauma.

Caution regarding diagnosis and treatment should be exercised if only a single mild vertebral deformity (height loss) is detected, especially in a patient under the age of 60 years.

 B
1.2 Measurement of bone mineral density 4 * Measure BMD by dual energy X-ray absorptiometry (DXA) scanning on at least two skeletal sites, including the lumbar spine and hip, unless these sites are unsuitable (eg hip prosthesis). A
1.3 Assessment of absolute fracture risk 5 * Assessment of absolute fracture risk, using the Fracture Risk Assessment Tool (FRAX®; https://fraxplus.org) may be useful in assessing the need for treatment in individuals who do not clearly fit established criteria. B
6 * Patients with a very high and/or imminent fracture risk should be promptly referred to a specialist for consideration of osteoanabolic therapy as first-line treatment. C
1.4 Case-finding 7 Those aged >50 years with a current or prior minimal trauma fracture should be assessed and appropriately treated. A
8 * For those aged >50 years with lifestyle and non-modifiable risk factors (eg parent with hip fracture), use FRAX® to calculate absolute fracture risk.
When FRAX® risk for major osteoporotic fracture (MOF) is ≥10%, refer for DXA. If the risk of MOF is <10%, DXA is not recommended.
Re-stratify risk with FRAX® after DXA using BMD reading and treat when:
  • BMD T-score is ≤–2.5
  • BMD T-score is between –1.5 and –2.5 and the FRAX® risk for MOF is ≥20% and/or the hip fracture risk is ≥3%.
 D
9 * For those aged >50 years with diseases/chronic conditions/medications associated with increased fracture risk, refer for BMD assessment by DXA.
Re-stratify risk with FRAX® after DXA using BMD reading and treat when:
  • BMD T-score is ≤–2.5
  • BMD T-score is between –1.5 and –2.5 and the FRAX® risk for MOF is ≥20% and/or the hip fracture risk is ≥3%.
 C
10 There is insufficient evidence to recommend population-based systematic screening with BMD measurement for reduction of osteoporotic fractures in Australia, and case finding is recommended. B
Section No. Recommendation Grade
2.1 Calcium, protein, and vitamin D 11 * For generally healthy older people:
Although the absolute benefit of calcium and vitamin D supplements in short-term (less than six years) studies for fracture reduction is low, there is good evidence that adequate calcium intake and vitamin D status are important for long-term maintenance of bone and muscle function.		 C
12 * For frail and institutionalised older people:
Calcium and vitamin D supplementation, together with adequate protein intake, are recommended for fracture prevention. Optimisation of calcium and vitamin D should be the standard of care for this group of people.		 B
13 * For people taking osteoporosis treatments:
  • Calcium supplements should be recommended if their dietary calcium intake is less than 1300 mg per day.
  • Vitamin D supplements should be recommended to correct low serum vitamin D levels (25-hydroxyvitamin D <50 nmol/L).
 C
14 * For most people with olive or pale brown skin, no other risk factors and who are at intermediate risk of skin cancer, a few minutes of sunlight exposure towards the middle of the day, with time depending on latitude, season and skin area exposed, followed by further sun protection measures should maintain vitamin D levels. People with dark skin at low risk of skin cancer have less need for sun protection, but require more time outdoors to avoid vitamin D deficiency. People at high risk of skin cancer need sun protection most of the year, which may limit vitamin D synthesis. The use of sunscreen, in practice, does not greatly affect vitamin D status. B
2.2 Reducing falls 15 Opportunistic case finding should be undertaken as per the recommended algorithm1 to identify older people at risk of falls and fall-related injury. A
16 Offer further assessment and/or interventions to prevent falls based on the level of risk identified. A
2.3 Exercise 17 Exercises recommended to reduce fracture risk:
  • Muscle resistance (strength) training should be regular (at least twice a week), moderate–vigorous and progressive.
  • Weight-bearing impact exercises should be performed most days (at least 50 moderate impacts) and include moderate-to-high loads in a variety of movements in different directions.
  • Balance training activities should be challenging.
Limit prolonged sitting (sedentary behaviour).		 B
18 Exercise programs for very frail older institutionalised people and those with a high vertebral fracture risk should be supervised, modified and tailored to minimise the potential to increase the risk of falls, injury and vertebral fractures. C
19 Prescribe extended and supervised exercise therapy, including targeted resistance and challenging balance training, after hip fracture to improve mobility, strength and physical performance and to reduce falls risk. B
20 Evidence for the benefits of exercise after vertebral and non-hip fractures is limited, but suggests supervised resistance training will build bone once a fracture has healed to the same extent as in non-fractured patients. For people with a vertebral fracture, exercises to strengthen back muscles, enhance flexibility and improve posture, as well as to reduce falls risk, should be considered. D
Section No. Recommendation Grade
3.1 Bisphosphonates 21 * Bisphosphonate therapy (alendronate, risedronate or zoledronate) should be considered for the primary prevention of vertebral fractures in women with osteopenia who are at least 10 years postmenopause. B
22 * Bisphosphonate therapy is recommended for reducing the risk of vertebral and non-vertebral fractures in postmenopausal women and men over the age of 50 years at high risk of fracture (those with osteoporosis by BMD criteria, or prior minimal trauma fracture). A (women)
C (men)
23 * Reconsider the need to continue bisphosphonate therapy after 5–10 years in postmenopausal women and men over the age of 50 years with osteoporosis who have responded well to treatment (T-score ≥–2.5 and no recent fractures). If BMD remains low (T-score ≤–2.5) and/or there are incident fragility fractures, continue treatment. Treatment should be restarted if there is bone loss, especially at the hip, or if a further minimal trauma fracture is sustained. D
3.2 Denosumab 24 * Denosumab is recommended for the treatment of osteoporosis in postmenopausal women at high risk of minimal trauma fracture. A
25 * Denosumab may be considered as an alternative to bisphosphonates for the treatment of men at increased risk of minimal trauma fracture. B
26 * Denosumab therapy should not be interrupted. If denosumab needs to be ceased, patients should be transitioned to bisphosphonate therapy for a minimum of 12 months. C
3.3 Romosozumab 27 * Romosozumab is recommended as first-line therapy for osteoporosis treatment in postmenopausal women at very high risk of minimal trauma fracture. A
28 * Romosozumab is recommended as first-line therapy for osteoporosis treatment in men at very high risk of minimal trauma fracture. C
3.4 Menopausal hormone therapy 29 * Consider oestrogen replacement therapy to reduce the risk of fragility fractures in postmenopausal women within 10 years of menopause. The increased risk of adverse events associated with treatment should be carefully weighed against benefits. A
30 * Selective oestrogen receptor modulators (SERMs) should be considered as a treatment option for postmenopausal women with osteoporosis where vertebral fractures are the major osteoporosis risk (based on low spine BMD and/or an existing vertebral fracture) and where other agents are poorly tolerated. SERMs may be particularly useful in younger postmenopausal women at risk of vertebral fracture with a prior or family history of breast cancer. A
3.5 Recombinant human parathyroid hormone 31 Recombinant human parathyroid hormone (teriparatide) treatment is recommended to reduce fracture risk in postmenopausal women with osteoporosis who have sustained a subsequent fracture while on antiresorptive therapy, or in those at very high fracture risk. A
32 Recombinant human parathyroid hormone (teriparatide) treatment is recommended to reduce fracture risk in men aged over 50 years with osteoporosis who have sustained a subsequent fracture while on antiresorptive therapy, or in those at very high fracture risk. C
Section No. Recommendation Grade
4.1 Ongoing monitoring 33 Regularly reassess fracture risk and the requirement for anti-osteoporotic therapy in patients not receiving therapy, but who remain at increased fracture risk. C
34 Clinically review all patients 3–6 months after initiating pharmacological therapy for osteoporosis, and 6–12 monthly thereafter for medication side effects and therapy adherence. C
35 Measurement of bone turnover markers should be confined to specialist practice. Measurement of bone turnover markers may be useful for monitoring medication adherence and efficacy and for evaluation of secondary causes of bone loss. D
Section No. Recommendation Grade
5.1 Management of osteoporosis in frail and older people (over 75 years of age) 36 Consider a multifactorial approach (environment, pharmacological treatments, exercise, nutrition) to reduce falls and fracture risk. C
5.2 Bone loss associated with aromatase inhibitor therapy for breast cancer and androgen deprivation therapy for prostate cancer 37 All women commencing aromatase inhibitor therapy should have baseline assessment of fracture risk prior to commencing therapy, including clinical risk factors, biochemistry and BMD (DXA) measurement, with ongoing monitoring based on risk factors. A
38 Women commencing aromatase inhibitor therapy who fall within one of the following two categories should commence antiresorptive therapy unless contraindicated:
  • age ≥70 years with BMD T-score ≤–2.0
  • age >50 years with a minimal trauma fracture (including radiological vertebral fracture) or a high estimated 10-year fracture risk.
There is limited evidence specific to women receiving aromatase inhibitors to guide firm recommendations outside these criteria, especially in premenopausal women.		 A
39 The duration of antiresorptive treatment in women undergoing, or who have completed, aromatase inhibitor therapy should be individualised and based on absolute fracture risk. D
40 General measures to prevent bone loss should be implemented in all women commencing aromatase inhibitor therapy. C
41 All men commencing androgen deprivation therapy (ADT) should have a baseline assessment of fracture risk, including BMD assessment by DXA. A
42 All men receiving ADT with a history of minimal trauma fracture should be commenced on antiresorptive therapy, unless contraindicated. A
43 Bone health should be reviewed 1–2 yearly in men on continuous ADT. C
44 General measures to prevent bone loss should be implemented in all men commencing ADT. C
5.3 Medication-related osteonecrosis of the jaw (MRONJ) 45 * MRONJ is a rare complication of osteoporosis therapy and most patients will not be at increased risk of MRONJ. Consider patient risk of MRONJ prior to starting osteoporosis therapy and ensure high-risk patients receive dental review prior to therapy initiation. Given the long in vivo half-life of bisphosphonates, there is little benefit to their cessation prior to dental extraction. Invasive dental procedures in patients on denosumab should be performed just prior to the next six-monthly injection because the in vivo effect on bone suppression will be waning.  C
  1. Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 2022;51(9):afac205. doi: 10.1093/ageing/afac205.
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