Who should be screened for osteoporosis?

  • Women or men of any age with fractures after minimal trauma
  • All women over age 65
  • All men over 75
  • Younger women and men with major risk factors

What are the major risk factors for osteoporosis?

  • Low body weight (BMI <23)
  • Family history of osteoporosis
  • Significant history of smoking or alcohol excess
  • Premature menopause in women
  • Testosterone deficiency in men
  • Chronic glucocorticoid use

What are the major risk factors for fractures?

  • Prior fractures with minimal trauma, including asymptomatic vertebral fractures
  • Low bone mineral density
  • History of falls or impaired physical function
  • Frailty
  • Impaired cognition

How should patients be screened for osteoporosis?

  • Bone mineral densitometry of hip, with or without lumbar spine measurement
  • Use the lowest T-score to determine need for treatment (T-score provides a comparison to healthy young adults; negative scores reflect low bone mineral density)

What should be done to prevent osteoporosis?

  • Weight bearing exercise
  • Calcium (1,000 - 1,500 mg/day) & Vitamin D (400 - 800 IU/day)
  • Adequate calcium & vitamin D is essential for other therapies to be effective. Calcium is best taken in divided doses, with meals
  • Stop smoking
  • Avoid excess alcohol
  • Maintain a healthy body weight
  • Avoid thyroid hormone excess

When is drug treatment needed?

  • In addition to basic recommendations for prevention of osteoporosis, treatment is recommended for T scores < - 2.5
  • Consider treatment, if T-score is < -2 and other risk factors are present, or if there is documented bone loss over time
  • All patients on chronic glucocorticoids need drug treatment

Treatment Options

  • Bisphosphonates
  • Fosamax (Alendronate) (70 mg/week)
  • Actonel (Risedronate) (35 mg/week)
  • Additional potential benefits: none
  • Potential risks: esophageal ulcers
  • Side effects: GI distress, arthralgias/myalgias

Hormone Therapy

  • Estrogen or Estrogen/Progestin Therapy
  • Appropriate if primary indication is relief of vasomotor symptoms
  • Additional potential benefits: treatment of vasomotor symptoms and genitourinary atrophy
  • Potential risks: breast cancer, gallbladder disease, venous thrombosis, cardiovascular disease, stroke
  • Side effects: vaginal bleeding, breast tenderness


  • Evista (Raloxifene) (60 mg/day)
  • Additional potential benefits: reduced risk of breast cancer, LDL
  • Potential risks: venous thromboembolic events
  • Side effects: vasomotor symptoms, leg cramps

Anabolic Agents

  • Forteo (Teriparatide) (20 mcg/day by injection)
  • Additional potential benefits: none unless high risk of fracture
  • Potential risks: osteosarcoma after long-term use in rodents
  • Side effects: hypercalcemia, leg cramps

How can fractures be prevented in patients at increased risk? Fall prevention strategies:

  • Safety devices in home (e.g., non-skid rugs, night lights, tub or shower bars, stair banisters)
  • Balance, strength, gait and weight-bearing exercises
  • Proper footwear
  • Optimize vision
  • Minimize sedative and psychotropic drug use
  • Consider devices (e.g., canes, walkers, hip protectors)

How should patients be followed?

  • Assess compliance with recommended calcium and vitamin D intake, exercise program, and prescribed medications
  • Monitor bone mineral density every 2 years (or annually if osteoporosis is severe) until stable, then less frequently

When should patients be referred to a specialist?

  • Lack of response to conventional treatment, especially evidence of continued bone loss
  • New fracture on therapy
  • Inability to tolerate oral medications
  • Unexplained Z-score of < - 2, to rule out secondary causes of osteoporosis (Z-score provides comparison to age-matched adults)