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 Management


Aim of monitoring is to increase adherence and to verify response to therapy

Bone Mineral Density (BMD) Measurement 

  • Recommended every 1-2 years after initiation of therapy and every 1-3 years thereafter
  • BMD measurement done while on treatment correlates with patient’s current fracture risk
  • Central DXA of the spine or hip is the gold standard for serial BMD assessment
    • Should be done every 2 years
    • If spine, hip or both cannot be assessed, 33% radius site can be used
  • Patient follow-up ideally should be done within the same facility using the same machine
  • Age-, disease- and treatment-related BMD changes can be monitored using QCT measurement of trabecular BMD 

Bone Turnover Markers

  • Bone resorption markers (eg fasting serum C-terminal crosslinking telopeptide of type I collagen) may be measured before starting therapy and 3 or 6 months after starting treatment
  • Bone formation markers (eg serum procollagen type I N-terminal propeptide) may be measured before starting therapy and 6 months later
  • High levels of bone resorption markers are associated with an increased risk of osteoporotic fractures
    • Resorption markers may be used for assessing fracture risk in selected patients when BMD and clinical risk factors are not sufficient to make treatment decisions

Vertebral Imaging

  • Repeat vertebral imaging is indicated for patients with the following:
    • Documented height loss
    • Presence of vertebral pain
    • Changes in posture
    • Chest X-ray abnormalities
    • Due for re-evaluation of treatment with possible withdrawal of therapy
    • Presence of vertebral fracture during off-treatment interval

Reassessment of Postmenopausal Women on Long-Term Bisphosphonate Therapy 

  • Postmenopausal women who have been taking oral bisphosphonates for ≥5 years or IV bisphosphonates for ≥3 years should be reassessed for presence of fractures prior to initiation and during therapy
    • Bisphosphonate therapy can be continued beyond 3-5 years in patients ≥75 years old, on high-dose oral glucocorticoid treatment, with prior history of hip or vertebral fracture, or who sustained a low-trauma fracture during therapy
  • If fractures occurred, treatment with bisphosphonates may be continued or may consider the use of other agents
  • If fracture-free, assess BMD T-score or fracture risk
    • If with hip BMD T-score of ≤-2.5 or with high fracture risk, consider continuing bisphosphonate therapy or may change into other alternative agents
    • If with normal bone mass and still no fractures, may consider withholding treatment and advise patient to follow-up every 2-3 years

Monitoring Therapy in Men with Osteoporosis

  • Patients can be monitored with BMD measurements as recommended for postmenopausal women
    • There may be limitations to the use of spine DXA in aging men due to interference from osteophytes and vascular calcifications on the spine measurement

Treatment Failure

  • Defined as (after excluding secondary osteoporosis or maximal treatment adherence) ≥2 incident fragility fractures; or one incident fracture and elevated serum CTX or P1NP at baseline with no significant reduction during treatment or a significant decrease in BMD or both; or no significant decrease in serum CTX or P1NP but a significant decrease in BMD  
  • Treatment modifications may include replacing a weaker antiresorptive agent with a more potent one from the same class, replacing an oral drug with an injectable one, or replacing a strong antiresorptive agent with an anabolic agent
  • Evaluate patient’s adherence to therapy and address factors associated with poor treatment adherence, eg inadequate patient/caregiver education, presence of adverse events

Specialist Referral 

  • Consider referral to a specialist if:
    • Fragility fractures are experienced
    • A non-major trauma fracture is sustained by a patient with normal BMD
    • Continued bone loss or recurrent fractures happen in a patient on therapy but has no clear causes of bone loss that are treatable
    • Osteoporosis has uncommon features, is severe, or rare secondary conditions are present, eg hyperparathyroidism, increased prolactin
    • A condition is present that makes management difficult, eg chronic kidney disease, malabsorption
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