brand logo

Am Fam Physician. 2023;107(3):238-246

Patient information: See related handout on osteoporosis, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Osteoporosis affects 10.2% of adults older than 50 years and is expected to increase to 13.6% by 2030. Osteoporotic fractures, specifically hip fractures, significantly affect morbidity, mortality, and quality of life. Screening for osteoporosis with dual energy x-ray absorptiometry should be considered for all women 65 years and older or women who are postmenopausal with clinical risk factors. The Bone Health and Osteoporosis Foundation recommends screening men 70 years and older and men with clinical risk factors; however, the U.S. Preventive Services Task Force did not find sufficient evidence to support routine screening in men. Osteoporosis can be diagnosed by a T-score of −2.5 or less or the presence of a fragility fracture. All patients with osteoporosis should be counseled on weight-bearing exercise, smoking cessation, moderation of alcohol intake, and calcium and vitamin D supplementation. Treatment of osteoporosis is influenced by the patient’s fracture risk, the effectiveness of fracture risk reduction, and medication safety. Patients at high risk of fracture should consider treatment with antiresorptive therapy, including bisphosphonates and denosumab. Anabolic agents such as teriparatide, abaloparatide, and romosozumab should be considered for patients at very high risk or with previous vertebral fractures.

In 2010, the incidence of osteoporosis was 10.2% in people older than 50 years and is expected to reach 13.6% by 2030 based on projected population demographics.1 Approximately 2 million to 3 million osteoporotic fractures occur annually in the United States, which can significantly affect morbidity, mortality, and quality of life.2 Hip fractures can be especially debilitating and have a one-year mortality risk of 21% to 24%.3 Adequate detection and management can decrease risks and associated comorbidities.

Clinical recommendation Evidence rating Comments
All women 65 years and older should have dual energy x-ray absorptiometry of the hip and lumbar spine to measure bone mineral density.46 B USPSTF recommendations, consensus guidelines, and epidemiologic studies showing increased fracture risk
Women who are postmenopausal and younger than 65 years with a high risk of fracture should receive bone mineral density testing.46 B USPSTF recommendations, consensus guidelines, and studies that show decreased hip fracture risk
All patients with osteoporosis should receive adjunctive therapy with calcium and vitamin D supplementation to decrease hip fracture risk.4,5,13,14 B Consensus guidelines and meta-analyses showing reduced hip fracture risk
Patients with a T-score of −2.5 or less, a previous hip or vertebral fracture, or a T-score between −1 and −2.5 and a 10-year risk of at least 20% for a major osteoporotic fracture or at least 3% for a hip fracture should receive pharmacologic treatment.4,5,1316 A Consensus guidelines and meta-analyses showing reduced osteoporotic fracture risk
Patients at very high risk of fracture may benefit from therapy with anabolic agents to decrease vertebral fracture risk.4,13,15,16,19 B Consensus guidelines, meta-analyses, and clinical trials showing decreased incidence of vertebral fracture
A drug holiday should be considered in patients who have received oral bisphosphonate therapy for five years or intravenous bisphosphonate therapy for three years.4,14,15,2022,24,25 B Consensus guidelines and clinical trials showing increased risk of atypical femoral fractures with long-term therapy, decreased risk of atypical femoral fractures after discontinuation with no increase in fracture risk
RecommendationSponsoring organization
Do not use DEXA screening for osteoporosis in women younger than 65 years or men younger than 70 years with no risk factors.American Academy of Family Physicians
Do not routinely repeat DEXA more often than once every two years.American College of Rheumatology

What Are the Current Screening Recommendations for Osteoporosis?

Dual energy x-ray absorptiometry (DEXA) is recommended for all women 65 years and older or women who are postmenopausal and younger than 65 years with clinical risk factors for osteoporotic fracture. Although the U.S. Preventive Services Task Force (USPSTF) does not recommend routine screening for men, the Bone Health and Osteoporosis Foundation recommends screening for men 70 years and older.

EVIDENCE SUMMARY

The USPSTF, the Bone Health and Osteoporosis Foundation, and the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommend bone mineral density (BMD) measurement by DEXA for all women 65 years and older (Table 1).46 Women younger than 65 years who are postmenopausal should undergo an osteoporosis risk assessment, including an evaluation of clinical risk factors and fracture risk assessment to determine the need for DEXA46 (Table 24,5). The most used assessment tool is the Fracture Risk Assessment Tool (FRAX; https://www.sheffield.ac.uk/FRAX); however, there is some controversy about the underestimation of risk in some races (Black, Asian, Hispanic) and a relatively low sensitivity. FRAX estimates a 10-year risk of major osteoporotic and hip fractures and should be used as part of the overall risk assessment.710 In a clinical trial, using the FRAX score to determine the need for DEXA improved the percentage of patients receiving therapy at one year and decreased hip fractures by 28% (P = .002).11 The USPSTF did not find benefit in routine BMD screening in men; however, the Bone Health and Osteoporosis Foundation recommends screening men 70 years and older and men with high clinical risk.5,6 The Male Osteoporosis Risk Estimation Score uses age, weight, and a history of chronic obstructive pulmonary disease to assess risk, may help determine the need for DEXA in men, and is more sensitive but less specific than the FRAX score.10,12 The American Academy of Family Physicians supports the USPSTF screening recommendations for osteoporosis.

PopulationAACE/ACEBone Health and Osteoporosis FoundationUSPSTF
WomenAll women 65 years and older
Women who are postmenopausal with:
 History of fragility fracture
 Long-term treatment with glucocorticoids
 Radiographic osteopenia
 Clinical risk factors
All women 65 years and older
Women who are postmenopausal and 50 to 64 years of age with clinical fracture risk
All women 65 years and older
Women who are postmenopausal and younger than 65 years with an increased risk of osteoporosis
MenAll men 70 years and older
Men 50 to 69 years of age with clinical fracture risk
Insufficient evidence to assess benefit
Any adultPeople 50 years and older with fracture
Any condition or medication associated with low bone mass or bone loss
Type of osteoporosisRisk factors
PrimaryEarly menopause
Excessive alcohol intake
Family history of osteoporotic fracture
Low body weight (< 57.6 kg [127 lb])
Smoking
SecondaryMedical causes
 Alcoholism
 Ankylosing spondylitis
 Chronic kidney disease
 Chronic obstructive pulmonary disease
 Hyperparathyroidism
 Hyperthyroidism (or on thyroid replacement therapy)
 Malabsorption disorders (celiac disease, Crohn disease, gastric bypass)
 Rheumatoid arthritis
 Type 1 or type 2 diabetes mellitus
 Vitamin D deficiency
Medications associated with osteoporosis
 Antiepileptics
 Aromatase inhibitors
 Glucocorticoids
 Gonadotropin-releasing hormone agents
 Heparin
 Lithium
 Medroxyprogesterone (Depo-Provera)
 Proton pump inhibitors
 Selective serotonin reuptake inhibitors
 Thiazolidinediones (pioglitazone [Actos])
 Thyroid hormones

How Is Osteoporosis Diagnosed?

Osteoporosis is diagnosed based on BMD (T-score of −2.5 or less on DEXA) or the presence of a fragility fracture or vertebral fracture.

EVIDENCE SUMMARY

Osteoporosis is diagnosed based on central DEXA BMD measurements at the hip and lumbar spine.6 BMD should be measured at the forearm (1/3 radius) when the hip and lumbar spine cannot be accurately measured due to structural changes (i.e., osteophytes).5 In women who are postmenopausal and men 50 years and older, BMD is classified using the World Health Organization diagnostic T-score criteria based on a young adult reference population (Table 3).5 The International Society of Clinical Densitometry recommends that ethnicity- or race-adjusted z scores (also adjusted for age or sex norms) should be used for patients 20 to 50 years of age with z scores of −2.0 or less for the expected range for age being diagnostic of osteoporosis.5

Already a member/subscriber?  Log In

Subscribe

From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available
Subscribe

Issue Access

$59.95
  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

$25.95
  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Continue Reading

More in AFP

More in Pubmed

Copyright © 2023 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.