Osteoporosis: Common Questions and Answers

Kira Harris; Christopher A. Zagar; Kelley V. Lawrence

KIRA HARRIS, PharmD, CHRISTOPHER A. ZAGAR, MD, AND KELLEY V. LAWRENCE, MD

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.^4–6	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.^4–6	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.^4,5,13–16	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.^{4,14,15,20–22,24,25}	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

Recommendation	Sponsoring 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).^4–6 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 DEXA^4–6 (Table 2^4,5). 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.^7–10 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.

Population	AACE/ACE	Bone Health and Osteoporosis Foundation	USPSTF
Women	All 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
Men	—	All men 70 years and older Men 50 to 69 years of age with clinical fracture risk	Insufficient evidence to assess benefit
Any adult	—	People 50 years and older with fracture Any condition or medication associated with low bone mass or bone loss	—

Type of osteoporosis	Risk factors
Primary	Early menopause Excessive alcohol intake Family history of osteoporotic fracture Low body weight (< 57.6 kg [127 lb]) Smoking
Secondary	Medical 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

Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014;29(11):2520-2526.

Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22(3):465-475.

Brauer CA, Coca-Perraillon M, Cutler DM, et al. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302(14):1573-1579.

Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis –2020 update. Endocr Pract. 2020;26(suppl 1):1-46.

LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. April 28, 2022. Accessed May 25, 2022. https://link.springer.com/content/pdf/10.1007/s00198-021-05900-y.pdf

Curry SJ, Krist AH, Owens DK, et al.; US Preventive Services Task Force. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(24):2521-2531.

Kanis JA, Cooper C, Dawson-Hughes B, et al.; International Osteoporosis Foundation. FRAX and ethnicity. Osteoporos Int. 2020;31(11):2063-2067.

Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight – reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874-882.

Pecina JL, Romanovsky L, Merry SP, et al. Comparison of clinical risk tools for predicting osteoporosis in women ages 50–64. J Am Board Fam Med. 2016;29(2):233-239.

Cass AR, Shepherd AJ, Asirot R, et al. Comparison of the Male Osteoporosis Risk Estimation Score (MORES) with FRAX in identifying men at risk for osteoporosis. Ann Fam Med. 2016;14(4):365-369.

Shepstone L, Lenaghan E, Cooper C, et al.; SCOOP Study Team. Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet. 2018;391(10122):741-747.

Cass AR, Shepherd AJ. Validation of the Male Osteoporosis Risk Estimation Score (MORES) in a primary care setting. J Am Board Fam Med. 2013;26(4):436-444.

Barrionuevo P, Kapoor E, Asi N, et al. Efficacy of pharmacological therapies for the prevention of fractures in postmenopausal women: a network meta-analysis [published correction appears in J Clin Endocrinol Metab. 2021; 106(3): e1494]. J Clin Endocrinol Metab. 2019;104(5):1623-1630.

Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622.

Shoback D, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society guideline update. J Clin Endocrinol Metab. 2020;105(3):587-594.

Albert SG, Wood E. Meta-analysis of clinical fracture risk reduction of antiosteoporosis drugs: direct and indirect comparisons and meta-regressions. Endocr Pract. 2021;27(11):1082-1092.

Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, et al.; Clinical Guidelines Committee of the American College of Physicians. Pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults: a living clinical guideline from the American College of Physicians. Ann Intern Med. 2023. Accessed February 10, 2023. https://www.acpjournals.org/doi/full/10.7326/M22-1034

Ayers C, Kansagara D, Lazur B, et al. Effectiveness and safety of treatments to prevent fractures in people with low bone mass or primary osteoporosis: a living systematic review and network meta-analysis for the American College of Physicians [published online January 3, 2023]. Ann Intern Med. 2023. Accessed February 10, 2023. https://www.acpjournals.org/doi/10.7326/M22-0684

Saag KG, Petersen J, Brandi ML, et al. Romosozumab or alendronate for fracture prevention in women with osteoporosis. N Engl J Med. 2017;377(15):1417-1427.

Black DM, Geiger EJ, Eastell R, et al. Atypical femur fracture risk versus fragility fracture prevention with bisphosphonates. N Engl J Med. 2020;383(8):743-753.

Black DM, Schwartz AV, Ensrud KE, et al.; FLEX Research Group. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006;296(24):2927-2938.

Black DM, Reid IR, Boonen S, et al. The effect of 3 versus 6 years of zoledronic acid treatment of osteoporosis: a randomized extension to the HORIZON-Pivotal Fracture Trial (PFT). J Bone Miner Res. 2012;27(2):243-254.

Fink HA, MacDonald R, Forte ML et al. Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review. Agency for Healthcare Research and Quality; 2019. AHRQ Publication no.: 19-EHC016-EF.

Schilcher J, Koeppen V, Aspenberg P, et al. Risk of atypical femoral fracture during and after bisphosphonate use. Acta Orthop. 2015;86(1):100-107.

Adler RA, El-Hajj Fuleihan G, Bauer DC, et al. Managing osteoporosis in patients on long-term bisphosphonate treatment: report of a task force of the American Society for Bone and Mineral Research [published correction appears in J Bone Miner Res. 2016; 31(10): 1910]. J Bone Miner Res. 2016;31(1):16-35.

Leder BZ, Mitlak B, Hu MY, et al. Effect of abaloparatide vs. alendronate on fracture risk reduction in postmenopausal women with osteoporosis [published correction appears in J Clin Endocrinol Metab. 2020; 105(8): e3053]. J Clin Endocrinol Metab. 2020;105(3):938-943.

Jeremiah MP, Unwin BK, Greenawald MH, et al. Diagnosis and management of osteoporosis. Am Fam Physician. 2015;92(4):261-268.

Sweet MG, Sweet JM, Jeremiah MP, et al. Diagnosis and treatment of osteoporosis. Am Fam Physician. 2009;79(3):193-200.

South-Paul JE. Osteoporosis: part I. Evaluation and assessment. Am Fam Physician. 2001;63(5):897-908.

Ullom-Minnich P. Prevention of osteoporosis and fractures. Am Fam Physician. 1999;60(1):194-202.

What Are the Current Screening Recommendations for Osteoporosis?

EVIDENCE SUMMARY

How Is Osteoporosis Diagnosed?

EVIDENCE SUMMARY

Continue Reading

More in AFP

More in Pubmed

What Are the Current Screening Recommendations for Osteoporosis?

EVIDENCE SUMMARY

How Is Osteoporosis Diagnosed?

EVIDENCE SUMMARY

Subscribe

Issue Access

Article Only

Continue Reading

More in AFP

More in Pubmed