Guidelines for preventive activities in general practice

Musculoskeletal disorders

Osteoporosis

      1. Osteoporosis

Musculoskeletal disorders | Osteoporosis

Screening age bar - women

0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Osteoporosis is a disease characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to bone fragility and increased fracture risk.1 For information about preventing falls, see Falls.

Generally, osteoporosis is underdiagnosed. Because osteoporosis has no overt symptoms, it is often not diagnosed until a fracture occurs. It is therefore difficult to determine the true prevalence of the condition. Information about ‘diagnosed cases’ is likely to underestimate the actual prevalence of the condition. An estimated 924,000 Australians have osteoporosis, based on self-reported data from the Australian Bureau of Statistics (ABS) 2017–18 National Health Survey,2 and 20% of people aged ≥75 years have osteoporosis.3 The definition of osteoporosis given above includes people who were told by a doctor or nurse that they had osteoporosis or osteopenia.3

Osteoporosis is more common in women than in men, with 29% of women aged ≥75 years having osteoporosis in 2017–18 compared with 10% of men.3 The proportion of women with osteoporosis increases with age, with those aged ≥75 years being most affected.

The goal of the prevention and treatment of osteoporosis is to reduce a person’s overall fracture risk, not just to maintain bone density. Approximately 70% of fragility fractures occur in women,4 and comprehensive treatment can halve (30–70%) the risk of subsequent fragility fracture.5 The absolute risk reduction and value of treatment is highest in those at highest risk (eg those with a previous fragility fracture), but the majority remain untreated in general practice and hospital settings.6,7

Osteoporosis is diagnosed on the presence of a fragility fracture (a 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 an increased risk of fragility fractures. A presumptive diagnosis of osteoporosis can be made without BMD measurement if an individual has a fragility fracture not from another cause.

Screening

Recommendation Grade How often References
Screening for osteoporosis with bone mineral density (BMD) measurement in the general population is not recommended at any age. Not recommended (Strong) N/A 8,9
Use FRAX® to calculate absolute fracture risk in people aged ≥50 years with lifestyle and non-modifiable risk factors (eg parent with hip fracture). When the FRAX® risk for major osteoporotic fracture (MOF) is ≥10%, refer for dual energy X-ray absorptiometry (DXA). If the risk for MOF is <10%, DXA is not recommended.
 
Refer for BMD assessment by DXA for people aged ≥50 years with diseases/chronic conditions/medications associated with increased fracture risk.
 
Restratify risk with FRAX® after DXA using BMD reading and treat when: the BMD T-score is ≤–2.5, or when the 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%.
 
Conditionally recommended Do not routinely repeat BMD + FRAX® within 2 years except in special circumstance. 9,10

Preventive activities and advice

Recommendation Grade How often References
Encourage regular weight-bearing and resistance exercise for the prevention of falls, bone loss and fracture risk reduction. For additional advice on falls prevention refer to falls. Recommended (Strong) N/A 11,12
Calcium and vitamin D supplements should not be used routinely in non-institutionalised elderly people. The absolute benefit of calcium and vitamin D supplements in terms of fracture reduction is low. There is evidence of significant benefit in people at risk of deficiency, particularly institutionalised individuals. Calcium and vitamin D supplements should be offered to people taking osteoporosis treatments if their dietary calcium intake is <1300 mg/day.* Vitamin D supplements should be recommended to correct low serum vitamin D concentrations (25-hydroxyvitamin D concentrations <50 nmol/L).
 
*There is an average of 1300 mg calcium/day in an older adult’s diet.13 For more information on calcium intake and bone health in older adults, refer to the Healthy Bones Australia website.
Conditionally Recommended N/A 1,10
Encourage a healthy lifestyle (eg adequate protein intake, smoking cessation and limiting alcohol intake). Practice Point N/A 11,12

There have been three recent large population-based randomised control trials of screening in women for the prevention of osteoporotic fractures: Screening in the Community to Reduce Fractures in Older Women (SCOOP) in the UK,14 Risk-stratified Osteoporosis Strategy Evaluation (ROSE) in Denmark15 and SALT Osteoporosis Study (SOS) in the Netherlands.16 The optimal thresholds of absolute fracture risk and implementation strategies are inadequately defined for the Australian context and there are no data on screening for men. Accordingly, there is currently insufficient evidence to support a population-based osteoporosis screening program in Australia.

Two of the most widely validated methods to estimate absolute fracture risk for osteoporotic fractures relevant to the Australian population are the Garvan bone fracture risk calculator and the Fracture Risk Assessment tool (FRAX®).These calculators can be used with and without BMD measurement, although the Garvan bone fracture risk calculator has not been validated in an external cohort when BMD has not been used in the calculator.17 Risk estimation is imperfect, with the tools being modest predictors of fracture risk.18,19 Risk factors (eg falls, glucocorticoid use) not included in one or the other risk algorithm require clinical judgement to modify the risk estimate.

If BMD is indicated, then it should be measured by bone density (DXA) scanning performed on two sites, preferably anteroposterior spine and hip. Without bone-losing medical conditions (eg hypogonadism, antigonadal therapy or corticosteroid use), BMD is unlikely to change significantly in <2 years. The average decrease in T-score is usually approximately 0.1/year if there are no specific bone-losing medical conditions.

Although there appears to be little or no effect of increased protein in healthy adults, for institutionalised older adults a recent Australian study of the effectiveness of increasing calcium and protein intake (<1 g/kg body weight protein per day) by providing residents with additional milk, yoghurt and cheese showed a 11% reduction in the risk of falls, a 48% reduction in hip fractures and a 30% reduction in all fractures.10

There is insufficient evidence to recommend a different screening or treatment approach in Aboriginal and Torres Strait Islander peoples.

  1. The Royal Australian College of General Practitioners (RACGP). Clinical practice guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. RACGP, 2010.
  2. Australian Bureau of Statistics (ABS). National health survey: First results, 2017–18. ABS, 2018 [Accessed 21 February 2024].
  3. Australian Institute of Health and Welfare (AIHW). Chronic musculoskeletal conditions: Osteoporosis and minimal trauma fractures. AIHW, 2023 [Accessed 12 July 2023].
  4. Watts JJ, Abimanyi-Chom J, Sanders KM. Osteoporosis costing all Australians: A new burden of disease analysis – 2012 to 2022. Osteoporosis Australia, 2013 [Accessed 30 October 2023].
  5. Stevenson M, Lloyd-Jones M, De Nigris E, Brewer N, Davis S, Oakley J. A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis. Health Technol Assess 2005;9(22):1–160. doi: 10.3310/hta9220.
  6. Naik-Panvelkar P, Norman S, Elgebaly Z, et al. Osteoporosis management in Australian general practice: An analysis of current osteoporosis treatment patterns and gaps in practice. BMC Fam Pract 2020;21(1):32. doi: 10.1186/s12875-020-01103-2.
  7. Teede HJ, Jayasuriya IA, Gilfillan CP. Fracture prevention strategies in patients presenting to Australian hospitals with minimal-trauma fractures: A major treatment gap. Intern Med J 2007;37(10):674–79. doi: 10.1111/j.1445-5994.2007.01503.x.
  8. Scottish Intercollegiate Guidelines Network (SIGN). Management of osteoporosis and the prevention of fragility fractures. SIGN, 2021 [Accessed 30 October 2023].
  9. Canadian Task Force on Preventive Health Care. Fragility fractures. Canadian Task Force on Preventive Health Care, 2023 [Accessed 31 January 2024].
  10. The Royal Australian College of General Practitioners (RACGP); Healthy Bones Australia. Osteoporosis management and fracture prevention in post-menopausal women and men over 50 years of age. 3rd edn. RACGP, 2023.
  11. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014;25(10):2359–81. doi: 10.1007/s00198-014-2794-2.
  12. Ebeling PRDR, Daly RM, Kerr DA, Kimlin MG. Building healthy bones throughout life: An evidence-informed strategy to prevent osteoporosis in Australia. Med J Aust 2013;199(S7):S1–46. doi: 10.5694/mjao12.11363.
  13. Healthy Bones Australia. Calcium & bone health. Healthy Bones Australia, 2023. Available at Shepstone L, Lenaghan E, Cooper C, et al. Screening in the community to reduce fractures in older women (SCOOP): A randomised controlled trial. Lancet 2018;391(10122):741–47. doi: 10.1016/S0140-6736(17)32640-5.
  14. Rubin KH, Rothmann MJ, Holmberg T, et al. Effectiveness of a two-step population-based osteoporosis screening program using FRAX: The randomized Risk-stratified Osteoporosis Strategy Evaluation (ROSE) study. Osteoporos Int 2018;29(3):567–78. doi: 10.1007/s00198-017-4326-3.
  15. Merlijn T, Swart KM, van Schoor NM, et al. The effect of a screening and treatment program for the prevention of fractures in older women: A randomized pragmatic trial. J Bone Miner Res 2019;34(11):1993–2000. doi: 10.1002/jbmr.3815.
  16. Marques A, Ferreira RJ, Santos E, Loza E, Carmona L, da Silva JA. The accuracy of osteoporotic fracture risk prediction tools: A systematic review and meta-analysis. Ann Rheum Dis 2015;74(11):1958–67. doi: 10.1136/annrheumdis-2015-207907.
  17. Nelson HD, Haney EM, Chou R, Dana T, Fu R, Bougatsos C. Screening for osteoporosis: Systematic review to update the 2002 U.S. Preventive Services Task Force Recommendation. Report No.: 10-05145-EF-1. Agency for Healthcare Research and Quality, 2010 [Accessed 31 January 2024].
  18. Rubin KH, Friis-Holmberg T, Hermann AP, Abrahamsen B, Brixen K. Risk assessment tools to identify women with increased risk of osteoporotic fracture: Complexity or simplicity? A systematic review. J Bone Miner Res 2013;28(8):1701–17. doi: 10.1002/jbmr.1956.
  19. Healthy Bones Australia. Calcium & bone health. Healthy Bones Australia, 2023 [Accessed 12 October 2023].
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