Metabolic Bone Disease and Vitamin D Disorders

Meet the patient

Meet a 72-year-old woman referred six weeks after a low-impact wrist fracture — she tripped on a curb and put out her hand. DXA shows a femoral-neck T-score of −2.8, she had a wrist fracture five years ago, her FRAX ten-year hip-fracture probability is 5 per cent, and she takes a proton-pump inhibitor for reflux. The real decision is not which bisphosphonate, but whether an oral agent is right for her at all.^[1][12]

Two questions settle every metabolic bone case before any prescription: what is the mechanism (high-turnover osteoporosis, low-turnover adynamic bone, defective mineralisation, localised Paget disease, or parathyroid-driven resorption), and what is the absolute fracture risk over ten years by FRAX? Answer those two and the drug ladder writes itself.^[5][12]

References13ShowHide

1. [1]Black DM, Delmas PD, Eastell R, Reid IR, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis N Engl J Med, 2007.PMID 17476007
2. [2]Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis N Engl J Med, 2009.PMID 19671655
3. [3]Bone HG, Wagman RB, Brandi ML, Brown JP, et al. 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension Lancet Diabetes Endocrinol, 2017.PMID 28546097
4. [4]Cummings SR, Ferrari S, Eastell R, Gilchrist N, et al. Vertebral Fractures After Discontinuation of Denosumab: A Post Hoc Analysis of the Randomized Placebo-Controlled FREEDOM Trial and Its Extension J Bone Miner Res, 2018.PMID 29105841
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10. [10]Reid IR, Miller P, Lyles K, Fraser W, et al. Comparison of a single infusion of zoledronic acid with risedronate for Paget's disease N Engl J Med, 2005.PMID 16135834
11. [11]Bilezikian JP Primary Hyperparathyroidism J Clin Endocrinol Metab, 2018.PMID 30060226
12. [12]Compston J, Cooper A, Cooper C, Gittoes N, et al. The 2024 UK clinical guideline for the prevention and treatment of osteoporosis Arch Osteoporos, 2025.PMID 40921943
13. [13]Cianferotti L Osteomalacia Is Not a Single Disease Int J Mol Sci, 2022.PMID 36499221