GP · metabolic-and-endocrine-health
Osteoporosis
Also known as Osteopenia · Low bone mineral density · Fragility fracture prevention
GP-fellowship guide to osteoporosis: DXA T-scores and FRAX/NOGG intervention thresholds, vertebral fracture assessment, secondary-cause screening, bisphosphonates first-line with atypical femoral fracture and ONJ counselling, five-year drug holidays, the denosumab never-miss-a-dose danger, anabolic-first sequencing from DATA, romosozumab cardiovascular warning, and the honest limits of calcium and vitamin D.
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Target exams
Red flags
- A woman who stops denosumab must not simply drift — rebound vertebral fractures cluster in the months off drug; transition to a bisphosphonate deliberately
- New thigh, groin or hip pain on a bisphosphonate — atypical femoral fracture until imaged otherwise; stop the drug and image the femur
- A fragility fracture in a man or premenopausal woman is a secondary-cause screen, not just a bone-drug prescription
- New-onset back pain with height loss in an older adult — think vertebral fracture; plain X-ray or VFA, not reassurance
Overview
Osteoporosis is a skeletal disorder of reduced bone strength predisposing to fragility fracture — diagnosed at DXA T-score −2.5 or below at lumbar spine or hip, or clinically by any low-trauma fracture in an adult. The FREEDOM trial population defined the classic treatment target: women aged 60–90 with T-scores between −2.5 and −4.0.[1]
Treatment works. Alendronate cut new morphometric vertebral fractures from 15.0% to 8.0% over three years in the vertebral-fracture arm of FIT, and reduced clinical fractures by 36% (NNT 15) among women with femoral-neck osteoporosis in the low-BMD arm.[3][4] The clinical task in general practice is finding the right patients — the ones who fracture — and keeping them on effective therapy safely.
References12ShowHide
- [1]Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis (FREEDOM) N Engl J Med, 2009.PMID 19671655
- [2]Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis (HORIZON) N Engl J Med, 2007.PMID 17476007
- [3]Black DM, Thompson DE, Bauer DC, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures (FIT) Lancet, 1996.PMID 8950879
- [4]Cummings SR, Black DM, Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures JAMA, 1998.PMID 9875874
- [5]Tsai JN, Uihlein AV, Lee H, et al. Teriparatide and denosumab, alone or combined, in women with postmenopausal osteoporosis: the DATA study Lancet, 2013.PMID 23683600
- [6]Leder BZ, Tsai JN, Uihlein AV, et al. Denosumab and teriparatide transitions in postmenopausal osteoporosis (the DATA-Switch study) Lancet, 2015.PMID 26144908
- [7]Saag KG, Petersen J, Brandi ML, et al. Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis (ARCH) N Engl J Med, 2017.PMID 28892457
- [8]Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab Treatment in Postmenopausal Women with Osteoporosis (FRAME) N Engl J Med, 2016.PMID 27641143
- [9]Shane E, Burr D, Abrahamsen B, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research J Bone Miner Res, 2014.PMID 23712442
- [10]Bolland MJ, Grey A, Avenell A Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis Lancet Diabetes Endocrinol, 2018.PMID 30293909
- [11]Gregson CL, Armstrong DJ, Bowden J, et al. UK clinical guideline for the prevention and treatment of osteoporosis Arch Osteoporos, 2022.PMID 35378630
- [12]Gregson CL, Armstrong DJ, Avgerinou C, et al. The 2024 UK clinical guideline for the prevention and treatment of osteoporosis Arch Osteoporos, 2025.PMID 40921943