Treatment Guideline Chart
Osteoporosis is a progressive, systemic skeletal disease characterized by decreased bone mass and micro-architectural deterioration of bone tissue leading to increased bone fragility and susceptibility to fractures.
The more risk factors (eg history of fracture, advanced age, comorbidities, etc) that are present, the greater the risk of fracture.

Osteoporosis Diagnosis


Indications for Bone Mineral Density (BMD) Measurements 

  • 2014 National Osteoporosis Foundation (NOF)
    • Women ≥65 years; postmenopausal women >50 years with risk factors for fracture
    • Men ≥70 years, or >50 years with risk factors for fracture
  • 2015 International Society for Clinical Densitometry (ISCD)  
    • Women ≥65 years; postmenopausal women <65 years with a risk factor for low bone mass
    • Women during menopausal transition with risk factors for fracture
    • Men ≥70 years, or <70 years with a risk factor for low bone mass
    • Adults:
      • With a fragility fracture
      • With a condition or who are taking medications associated with low bone mass/bone loss
      • Being considered for pharmacological therapy
      • Receiving treatment to monitor effect
      • Not on treatment in whom evidence of bone loss would require treatment 
  • 2018 US Preventive Services Task Force (USPSTF)
    • Women ≥65 years; postmenopausal women <65 years considered at increased risk for osteoporosis based on formal clinical risk assessment tool  
  • Some authorities recommend that patients >65 years old with multiple risk factors or prevalent osteoporotic fracture be started on treatment for osteoporosis without BMD measurements

Glucocorticoid-induced Osteoporosis

  • BMD testing within 6 months of starting glucocorticoid therapy is performed in:
    • Adults <40 years old with history of osteoporotic fracture OR other significant osteoporosis risk factors
    • Adults ≥40 years old with FRAX with glucocorticoid dose correction
      • The risk generated with FRAX is increased by 1.15 for major osteoporotic fracture and 1.2 for hip fracture if glucocorticoid therapy is >7.5 mg/day

Osteoporosis Self-Assessment Tool for Asians (OSTA)

  • Formula combines patient’s age and body weight 
  • Useful for identifying young postmenopausal women for BMD testing 
    • Can support detecting a postmenopausal woman’s risk for osteoporosis

World Health Organization (WHO) Fracture Risk Assessment Model (FRAX™)

  • Developed to calculate the 10-year risk of osteoporosis fracture, with or without BMD values, based on individual factors (eg sex, age, ethnicity, family history, previous fracture, glucocorticoid treatment, smoking status, alcohol consumption, rheumatoid arthritis, BMI)
    • Level of fracture probability will vary between countries
  • Useful in identifying among the group of patients with osteopenia those at higher risk of fracture
  • Limitations of FRAX™ include lack of detail on some risk factors (eg smoking, prior fracture, effects of glucocorticoids), non-inclusion of other known risk factors (eg biochemical markers, falls)

Fracture Risk Categories

  • Low risk: BMD T-score at both hip and spine >-1.0, and 10-year hip fracture risk <3%, and 10-year risk of major osteoporotic fractures <20%, with no prior hip or spine fractures
  • Moderate risk: BMD T-score at both hip and spine >-2.5, or 10-year hip fracture risk <3%, or 10-year risk of major osteoporotic fractures <20%, with no prior hip or spine fractures
  • High risk: BMD T-score at hip or spine of ≤-2.5, or 10-year hip fracture risk ≥3%, or 10-year risk of major osteoporotic fracture risk ≥20%, with a prior hip or spine fracture
  • Very high risk: BMD T-score at hip or spine ≤-2.5 with multiple spine fractures
Fracture Risk Adults <40 Years Old Adults ≥40 Years Old
FRAX** 10-year Risk of Major Osteoporotic Fracture FRAX** 10-year Risk of Hip Fracture
Low No risk factors other than glucocorticoid therapy <10% ≤1%
Moderate Hip or spine BMD Z-score < -3 or rapid bone loss at a rate of ≥10% at the hip or spine in over 1-2 years and continuing glucocorticoid therapy at ≥7.5 mg/day for ≥6 months ≥10% and <20% >1% and <3%
High Previous osteoporotic fracture/s or glucocorticoid therapy ≥30 mg/day or cumulative glucocorticoid doses ≥5 g/year ≥20% ≥3%
Previous osteoporotic fracture/s
Hip or spine BMD T-score ≤-2.5 in men ≥50 years old and postmenopausal women
Glucocorticoid therapy ≥30 mg/day or cumulative glucocorticoid doses ≥5 g/year 
*For patients not yet receiving treatment for osteoporosis
**With glucocorticoid dose correction
Reference: 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) summary. https:/www.rheumatology.org.

Physical Examination

  • Measure patient’s height and weight
    • Decrease in patient's height >4 cm (>1.5 in)
  • Evaluate patient’s muscle strength and balance and for the presence of kyphosis 
  • Tenderness over the anterior tibia or thoracic vertebrae may indicate focal bone disease or osteomalacia; presence of blue sclerae or joint laxity may indicate osteogenesis imperfecta


BMD Measurements
  • Give an accurate reflection of bone mass and confirm diagnosis of osteoporosis
  • An excellent predictor of future fracture risk
    • For each SD reduction in BMD, there is approximately a 2-fold increased risk fracture
  • Recommended when results would affect management
  • Identify patients for possible pharmacologic therapy
  • Used for therapeutic monitoring in patients with glucocorticoid-induced osteoporosis (GIOP)
Methods of BMD Measurement
  • DXA of hip and spine
    • Gold standard
    • Diagnose osteoporosis with a hip and/or spine DXA BMD T-score of ≤-2.5
    • Monitor therapeutic response based on BMD of the spine
    • Fracture risk assessment based on DXA measurement at the hip in patients with GIOP

Bone Mineral Density (BMD) T-Score1

WHO Recommended Values2 for Diagnosis of Osteoporosis
BMD T-score (SD) Definition
T ≥ -1 Normal
-2.5 < T < -1 Osteopenia (low bone mass)
T ≤ -2.5 Osteoporosis
T ≤ -2.5 + fragility fracture Severe/established osteoporosis

1Should be used for postmenopausal women and men ≥50 years old
2Values are based on DXA 
T-score: A comparison with young normal adult mean of the same sex

                       BMD Z-Score3

 BMD Z-score (SD)  Definition
 ≥ -2.0  Within the expected range for age
 ≤ -2.04  Below the expected range for age
3Should be used for premenopausal women, men <50 years old and children
4For premenopausal women and men <50 years old, consider screening for secondary causes of osteoporosis

  • Quantitative CT scan (QCT)
    • Used as an alternative technique when DXA is not available
    • Measures bone strength in the axial skeleton and volumetric bone density of the vertebra and hip
    • Has higher radiation dose compared to DXA
  • Trabecular Bone Score (TBS)
    • Evaluates microarchitectural texture of the bone
    • Highly sensitive in predicting fracture risk
Screening Methods (Not for Diagnosis or Monitoring)
  • Peripheral DXA (pDXA)
  • CT-based assessments: Peripheral QCT
  • Quantitative ultrasound densitometry (QUS) of heel, tibia, patella and other peripheral skeletal sites
If fracture is present, physical exam, lab tests and radiologic tests should also be conducted to exclude underlying diseases that mimic, aggravate or cause osteoporosis eg secondary osteoporosis (metabolic or endocrine causes, GI or nutritional conditions, collagen metabolism disorders, medications, AIDS/HIV, immobilization, organ transplantation, myeloma and some malignancies)

Laboratory Tests

  • Complete blood count (CBC), erythrocyte sedimentation rate (ESR)
  • Renal function tests (eg blood urea nitrogen [BUN], creatinine), liver function tests (LFTs) 
  • Electrolytes (eg ionized calcium, phosphate, magnesium)
  • Serum 25-hydroxyvitamin D, total protein, albumin, aspartate aminotransferase (AST), alkaline phosphatase
  • Urinalysis, urinary N-telopeptide (uNTX), 24-hour urinary calcium
  • Bone turnover markers
    • May be considered in the primary evaluation and follow-up of patients with osteoporosis
    • Elevated levels indicate rapid bone loss and identify patients at high risk for fractures
    • Used to evaluate efficacy and compliance to current treatment
    • Eg serum C-telopeptide (CTX), osteocalcin, N-terminal propeptide of type 1 procollagen (P1NP), tissue transglutaminase antibodies (IgA and IgG), serum protein electrophoresis (SPEP)
  • Others (eg thyroid function as indicated, parathyroid hormone, total and free testosterone)


  • Scintigraphic bone studies, X-ray of lateral thoraco-lumbar spine or hip (as indicated)
    • Bone loss of >30% is seen as radiological osteopenia in plain X-rays
Vertebral Imaging
  • Recommended for the following:
    • Women ≥70 years and men ≥80 years with bone mineral density (BMD) T-score ≤-1.0 at the spine, total hip, or femoral neck
    • Women 65-69 years and men 70-79 years with BMD T-score ≤-1.5 at the spine, total hip, or femoral neck
    • Postmenopausal women and men ≥50 years with low-trauma fracture during adulthood, historical height loss (current height - peak height at 20 years) by >1.5 in, prospective height loss (current height - recently documented height) by ≥0.8 in, and/or currently or previously on long-term glucocorticoid treatment
    • Other BMD measurements are unavailable
Diagnosis of Postmenopausal Osteoporosis
  • A T-score of ≤-2.5 in the femoral neck, lumbar spine, total proximal femur and/or 33% radius
  • Low-trauma fracture of the hip or spine (regardless of BMD)
  • Osteopenia or low bone mass with a fragility fracture of pelvis, proximal humerus or distal forearm or with multiple fractures at other sites
  • Osteopenia or low bone mass and high probability of FRAX™ fracture based on country-specific cutoffs
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