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.

The work in primary care is therefore targeted case finding:

• Deciding who to assess.

• Calculating fracture risk before any scan.

• Treating those at highest risk.

One 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 decides who needs a scan; treatment then rests on the T-score together with fractures and risk factors, not a single BMD number.

• Use QFracture or FRAX (Fracture Risk Assessment Tool) first.

• Reserve DXA (dual-energy X-ray absorptiometry) for a 10-year risk of 10% or more, or offer it directly after a hip or vertebral, recent or repeated fragility fracture (see Investigations).

Who to assess	Action
All women ≥ 65 and all men ≥ 75	Assess 10-year fracture risk (QFracture or FRAX).
Women < 65 or men < 75 with ≥ 1 risk factor	Assess 10-year fracture risk.
Anyone with a fragility fracture (any age)	• Assess – offer DXA directly after a hip or vertebral, recent or repeated fragility fracture • A long wait for DXA need not delay treatment (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	• Use QFracture at 30–39 years (FRAX covers 40–90) • Under 30, seek specialist advice

Risk factors that warrant assessment in the younger group:

• Previous fragility fracture.

• Current or frequent oral glucocorticoids.

• History of 2 or more falls in the last year.

• Low body mass index (< 18.5 kg/m²).

• Smoking.

• Alcohol > 14 units/week.

• Hip fracture in a first-degree relative (particularly if they were under 80 at the time).

• Secondary causes – premature menopause, hypogonadism, rheumatoid arthritis (RA), inflammatory bowel disease (IBD), coeliac disease, diabetes (type 1 and 2), chronic kidney disease (CKD) stage 4 and 5, 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.

• Established (severe) osteoporosis is a T-score ≤ −2.5 together with a fragility fracture.

Source: NICE NG259 · NICE QS149 · NOGG 2024

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