Osteoporosis

🔍 When to Suspect

A patient presents with a fragility fracture (from a fall from standing height or less), has significant risk factors, or has developed height loss or kyphosis

From the full topic in The Ocean Library: Osteoporosis

🧭 When to suspect (targeted case finding)

Osteoporosis is a skeletal disorder of low bone mass and microarchitectural deterioration that weakens bone and raises fracture risk. It is clinically silent until a fragility fracture occurs, so the work in primary care is targeted case finding: deciding who to assess, calculating fracture risk before any scan, and treating those at highest risk.

A crucial point underpins the whole pathway – the majority of fragility fractures occur in people whose bone mineral density (BMD) is not in the osteoporotic range. Fracture risk, estimated with a validated tool, therefore drives decisions far more than a single BMD number. Use QFracture or FRAX (Fracture Risk Assessment Tool) first; reserve DXA (dual-energy X-ray absorptiometry) for those the tool flags.

Who to assess	Action
All women ≥ 65 and all men ≥ 75	Assess 10-year fracture risk (QFracture or FRAX).
Women < 65 / men < 75 with ≥ 1 risk factor	Assess 10-year fracture risk.
Anyone with a fragility fracture (any age)	Assess – and start treatment without DXA in clear high-risk groups (see Management).
Adults < 50 years	Do not routinely assess unless a major risk factor: current/frequent oral glucocorticoids, untreated premature menopause, or previous fragility fracture.
Adults < 40 years with major risk factors	Measure BMD by DXA directly; interpret with specialist input.

Risk factors that warrant assessment in the younger group: previous fragility fracture; current or frequent oral glucocorticoids; history of falls; low body mass index (< 18.5 kg/m²); smoking; alcohol > 14 units/week; parental history of hip fracture; and secondary causes – premature menopause, hypogonadism, rheumatoid arthritis (RA), inflammatory bowel disease (IBD), coeliac disease, type 1 diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD) or chronic liver disease. Certain drugs also raise risk: aromatase inhibitors, androgen-deprivation therapy, antiepileptics, and long-term proton pump inhibitors or SSRIs.

A fragility fracture is one sustained from a fall from standing height or less, or occurring spontaneously (a vertebral fracture may follow nothing more than bending or lifting). On DXA, osteoporosis is a T-score ≤ −2.5 at the femoral neck or spine; osteopenia is −1 to −2.5; and established (severe) osteoporosis is a T-score ≤ −2.5 together with a fragility fracture.

Source: NICE CG146 · NICE QS149 · NOGG 2024

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