-
Postmenopausal pts <65 yo Assess risk factors1-4 for low bone density/fx, including for transgender and gender nonconforming individuals5 - Evaluate for condition/meds assoc w/ low bone mass/bone loss (NOF6)
- If risk of vit D deficiency:7 Check serum 25(OH)D levels (NOF8)
- Check ht annually; wall-mounted stadiometer preferred, w/o shoes (NOF9)
If osteoporosis risk factors:1-4 Check BMD +/- vertebral imaging - Check BMD w/ DEXA @ hip + spine;9-14 use DEXA @ forearm in selected pts (ISCD,15 ACR16)
- Lateral vertebral fx assessment on DEXA equipment or lateral T + L-spine x-ray indicated if:
◦ NOF:9 ≥50 yo and postmenopausal w/ the following risk factors: fx during adulthood (any cause); historical ht loss ≥1.5" (peak ht – current ht); prospective ht loss ≥0.8" (last documented ht − current ht); recurrent or ongoing long-term GC tx (≥5 mg prednisone or equivalent daily for ≥3mo6); hyperparathyroidism
◦ ISCD:12 BMD T-score <−1 + at least one of the following: historical ht loss >4 cm (>1.5"); self-reported but undocumented prior vertebral fx; GC tx equivalent to ≥5 mg prednisone daily for ≥3mo
◦ AACE:3 unexplained ht loss, self-reported but undocumented prior spine fx, GC tx equivalent to ≥5 mg prednisone daily for ≥3mo
- Use FRAX tool to estimate osteoporosis-assoc fx risk (ACOG,10 NOF17)
Recommend measures to ↓ osteoporosis/fx risk for all pts - Adequate Ca++ (1,000 mg/day for 19-50 yo; 1,200 mg/day for ≥51 yo)18 + vit D (recs vary by org and range from 600-2,000 IU/day for adults 50-70 yo; 800-2,000 IU/day for those ≥71 yo); supplement if needed (NOF,8 ACOG,18 AACE19)
- Adequate protein intake of 0.8 g/kg (AACE20)
- Regular wt-bearing/muscle-strengthening exercise and routine aerobic physical activity (mod to high impact) to maintain bone health and prevent bone loss21 recommended (e.g., walking 30-40min/session w/ back & posture exercises 3-4x/wk)20 (ACOG,21 NOF,22 AACE23)
- Stop smoking, limit EtOH to ≤2 drinks/day (NOF,9 AACE23); limit caffeine to <1-2 servings/day (AACE24)
- Assess/manage fall risk factors (NOF,25 ACOG,26 AACE27)
- Fall-prevention strategies for pts at ↑risk include wt-bearing and muscle-strengthening exercises along w/ individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification)26
Footnotes 1 ACOG 2021. Selected risk factors for osteoporosis include increasing age, parental hx of hip or spine fx, BMI <20 kg/m 2 or body wt <127 lb, smoking, and excessive EtOH use (i.e., >3 drinks/day).
Conditions, diseases assoc w/ 2° osteoporosis include AIDS and HIV, anorexia nervosa, T1DM and T2DM, diminished ovarian reserve, gastric bypass, hyperparathyroidism, hypocalcemia, premature menopause (induced, surgical, or spontaneous), primary ovarian insufficiency, renal impairment, RA, Turner syndrome, and vit D deficiency.
Meds assoc w/ 2° osteoporosis include antiepileptics (e.g., phenytoin, carbamazepine, primidone, and phenobarbital), antiretrovirals, aromatase inhibitors, chemo-tx, DMPA, GCs, GnRH agonists and antagonists, and heparin.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
2 ISCD 2019. Risk factors include low body wt, prior fx, high-risk medication use, dz or condition assoc w/ bone loss.
2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
3 AACE 2020. Risk factors for osteoporosis/osteoporosis-related fx include prior fx w/o major trauma after 50 yo, body wt <127 lb, smoking, excessive EtOH intake (≥3 drinks/day), FHx osteoporosis or fx, early menopause, 2° osteoporosis, corticosteroid use.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
4 ACR 2022. Perform BMD testing in asymptomatic women ≥65 yo and in women <65 yo w/ the following risk factors: estrogen deficiency; h/o maternal hip fx >50 yo; wt <127 lb; amenorrhea hx (>1y before 42 yo); current smoker; loss of ht/thoracic kyphosis; osteopenia/fragility fx; minimal-no trauma wrist/hip/spine/proximal humerus fx (if ≥50 yo); insufficiency fx; on or being considered for osteoporosis drug tx.
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
5 ISCD 2019. Baseline BMD testing is indicated for transgender and gender nonconforming individuals if they have any of the following conditions:
• Hx of gonadectomy or tx that lowers endogenous gonadal steroid levels prior to hormone tx initiation
• Hypogonadism w/ no plan to take gender-affirming hormone tx
• Existing ISCD indications for BMD testing, such as GC use and hyperparathyroidism
2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
6 NOF 2022. Diseases assoc w/ bone loss include RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia nervosa, osteogenesis imperfecta, multiple myeloma. (See Table 1 for full list.)
Meds assoc w/ bone loss include aluminum (antacids), androgen deprivation tx, anticoagulants (unfractionated heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, cyclosporine A and tacrolimus, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for ≥3mo), GnRH agonists and antagonists, methotrexate, PPIs, SSRIs, tamoxifen (premenopausal use for breast CA tx), TZDs, thyroid replacement hormone (in excess).
Other factors assoc w/ bone loss include EtOH (>2 drinks/day), excessive thinness, excess vit A, frequent falling, high NaCl intake, immobilization, inadequate physical activity, calcium and vit D deficiencies, smoking, prior fx, parenteral nutrition.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
7 NOF 2022. Many conditions prevalent in older pts contribute to vit D deficiency, such as chronic renal insufficiency and limited sun exposure due to disability. Vit D deficiency is highly prevalent in pts w/ advanced OA presenting for total hip replacement as well as in hip fx pts w/ osteoporosis (including those on anti-fx meds). Vit D deficiency should be corrected to optimize surgical/pharmacologic outcomes.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
8 NOF 2022. NOF recommends 800-1,000 IU/day for adults ≥50 but also cites the Institute of Medicine recs of 600 IU/day until age 70, then 800 IU/day for ages ≥71.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
9 NOF 2022. LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
10 ACOG 2021 [ACOG-S][ACOG-H]. Refer for DEXA in pts w/ elevated risk for osteoporosis. Use formal, validated risk assessment tools to estimate fx risk to determine whether DEXA would be useful. USPSTF recommends FRAX tool to calculate risk in pts w/ ≥1 risk factor; 10-yr risk of osteoporotic fx >8.4% (fx risk in 65-yo Caucasian women w/o major risk factors for osteoporosis) justifies referral for BMD testing.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
11 USPSTF 2010. BMD screening recommended in women <65 yo whose fx risk is greater than or equal to that of 65-yo White woman w/o additional risk factors. Based on the U.S. FRAX tool, a 65-yo White woman w/o other risk factors has a 9.3% 10-yr risk for any osteoporotic fx. The FRAX tool also predicts 10-yr fx risks for Black, Asian, and Hispanic women in the U.S. (generally lower than for White women of the same age).
Nelson HD, et al. Screening for Osteoporosis: An Update for the U.S. Preventive Services Task Force. Ann Intern Med. 2010 Jul 20;153(2):99-111. Accessed online 8/16/23
12 ISCD 2019. 2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
13 AACE 2020 [B][2]. BMD screening recommended in postmenopausal women <65 yo if any of:
• hx of low-trauma fx
• long-term GC tx
• radiographic osteopenia
• clinical risk factor for osteoporosis (low body wt, cigarette smoking, FHx of spine/hip fractures, early menopause, or 2° osteoporosis)
Use central DEXA measurement (total hip, femoral neck, total lumbar spine, or combo).
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
14 ACR 2022. In asymptomatic pts or suspected low BMD, DEXA of lumbar spine/hips is usually appropriate [7-9]; quantitative CT scan of lumbar spine and hip [4-6]/DEXA of distal forearm [4-6]/trabecular bone score + DEXA may be appropriate.
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
15 ISCD 2019. Forearm BMD should be measured under the following circumstances:
• Hip or spine can’t be measured or interpreted
• Hyperparathyroidism
• Very obese pts (over wt limit for DXA table)
2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
16 ACR 2022. Add distal forearm DEXA [4-6]in pts w/ hyperparathyroidism (causes ↓mineralization @ hip & midradius).
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
17 NOF 2022. USA-adapted FRAX tool calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors, including BMD at femoral neck; validated for women and men 40-90 yo; femoral neck preferred; nonhip sites not recommended. Data validating the relative weight of some known risk factors aren’t yet available, so they’re not included in the algorithm: risks assoc w/ falls, non-DXA bone density, rapidity of bone loss, specific 2° causes of osteoporosis, multiple fractures in a short time. Other risks important in older adults and not included: frailty, multiple comorbid conditions, multiple meds assoc w/ falls/fractures, life expectancy. Most useful in low femoral neck BMD.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
18 ACOG 2021 [GPP]. Although Ca++ and vit D supplementation don’t appear to be effective for preventing osteoporotic fx in avg-risk individuals, counsel pts to consume the RDAs of dietary Ca++ and vit D for bone and general health. ACOG references National Academy of Medicine (Institute of Medicine) recs of 1,000 mg/day of Ca++ for 19- to 50-yr-olds and 1,200 mg/day for pts ≥51 yo; for vit D, 600 IU/day for ≤70-yr-olds and 800 IU thereafter.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
19 AACE 2020 [A][1]. 1,000-2,000 IU/day typically needed for optimal serum vit D level. Higher doses may be required in presence of obesity, malabsorption, transplant pts, older pts.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
20 AACE 2020. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
21 ACOG 2021. Regular aerobic physical activity (mod to high impact) and wt-bearing exercises (muscle-strengthening or resistance) are recommended to maintain bone health and prevent bone loss [ACOG-S][ACOG-M]. CDC recommends ≥150-300min/wk of mod-intensity activity or 75-150min/wk of vigorous-intensity aerobic physical activity (or combination of both).
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
22 NOF 2022. Wt-bearing: walking, jogging, tai chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Evaluate pts before they start a new exercise program, esp. one involving compressive or contractile stressors (e.g., running, wt-lifting).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
23 AACE 2020 [B][2]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
24 AACE 2020. Limit caffeine to <1-2 drinks/day. Observational studies show assoc w/ fx; may contribute to inadequate Ca++ intake by replacing milk in diet.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
25 NOF 2022. Risk factors for falls include medical (advanced age, arthritis, female gender, poor vision, urinary urgency or incontinence, previous fall, orthostatic hypotension, impaired transfer and mobility, meds that cause dizziness/sedation (narcotic analgesics, anticonvulsants, psychotropics), malnutrition/parenteral nutrition (vit D deficiency, insufficient protein)); neuro/musculoskeletal (poor balance, weak muscles/sarcopenia, gait disturbances, kyphosis, ↓proprioception, diseases and therapies that cause sedation/dizziness/weakness/lack of coordination, Alzheimer dz/other dementia, delirium, Parkinson dz, stroke); environmental (low-level lighting, obstacles in walking path, loose throw rugs, stairs, lack of assistive devices in bathrooms, slippery outdoor conditions); and psychological (anxiety/agitation, depression, diminished cognitive acuity, fear of falling).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
26 ACOG 2021. Assess risk of falls in postmenopausal pts w/ low BMD or osteoporosis. Fall-prevention strategies for those at ↑risk include wt-bearing and muscle-strengthening exercises as well as individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification) [GPP].
Important risk factors for falls include:
• older age
• hx of falls
• impairments in mobility, gait, and balance
• environmental factors (e.g., loose throw rugs, low-level lighting)
• medical conditions (e.g., anxiety, depression, vit D deficiency, kyphosis, orthostatic hypotension, poor vision, hx of stroke)
• meds that cause sedation
Consider referral to or consultation w/ a specialist in fall prevention (PT or OT) to provide further risk assessment and targeted interventions for pts at ↑fall risk.
NOF recommends multifactorial interventions, including tai chi and other exercise programs, home safety assessment and appropriate modification, removal of psychotropic meds, and correction of visual impairment for pts at ↑fall risk.
AACE recommends similar multifactorial fall-prevention strategies, esp. exercises for balance and ↑ trunk muscle strength, such as walking, jogging, tai chi, stairclimbing, wt training, and other activities w/ resistance.
European guidelines recommend fall risk assessment, regular wt-bearing exercise tailored to the individual, and interventions to address modifiable risk factors for those at ↑risk.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
27 AACE 2020 [A][1]. Counsel on fall-prevention measures: Anchor rugs, minimize clutter/loose wires, use nonskid mats, install handrails in bathroom/stairs, lighting in hallways/stairs/entrances, wear low-heeled footwear, avoid use of stepstools. Consider PT.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
Postmenopausal pts ≥65 yo Check BMD +/- vertebral imaging - Evaluate for condition/meds assoc w/ low bone mass/bone loss (NOF1)
- If risk of vit D deficiency:2 Check serum 25(OH)D levels (NOF3)
- Check BMD w/ DEXA @ hip + spine;4-9 use DEXA @ forearm in selected pts (ACOG,10 ISCD,11 ACR12)
- Lateral vertebral fx assessment on DEXA equipment or lateral T + L-spine x-ray indicated if:
◦ NOF:4 ≥65 yo if T-score ≤−1 at femoral neck; ≥70 yo if T-score ≤−1 at lumbar spine, total hip, or femoral neck; ≥50 yo and postmenopausal w/ the following risk factors: fx during adulthood (any cause); historical ht loss ≥1.5" (peak ht – current ht); prospective ht loss ≥0.8" (last documented ht − current ht); recurrent or ongoing long-term GC tx (≥5 mg prednisone or equivalent daily for ≥3mo1); hyperparathyroidism
◦ ISCD:7 BMD T-score <−1 + at least one of the following: ≥70 yo; historical ht loss >4 cm (>1.5"); self-reported but undocumented prior vertebral fx; GC tx equivalent to ≥5 mg prednisone daily for ≥3mo
◦ AACE:13 unexplained ht loss, self-reported but undocumented prior spine fx, GC tx equivalent to ≥5 mg prednisone daily for ≥3mo
- Use FRAX tool to estimate osteoporosis-assoc fx risk (ACOG,10 NOF14)
- Check ht annually; wall-mounted stadiometer preferred, w/o shoes (NOF4)
Recommend measures to ↓ osteoporosis/fx risk for all pts - Adequate Ca++ (1,000 mg/day for 19-50 yo; 1,200 mg/day for ≥51 yo)15 + vit D (recs vary by org and range from 600-2,000 IU/day for adults 50-70 yo; 800-2,000 IU/day for those ≥71 yo); supplement if needed (NOF,3 ACOG,15 AACE16)
- Adequate protein intake of 0.8 g/kg (AACE13)
- Regular wt-bearing/muscle-strengthening exercise and routine aerobic physical activity (mod to high impact) to maintain bone health and prevent bone loss17 recommended (e.g., walking 30-40min/session w/ back & posture exercises 3-4x/wk)13 (ACOG,17 NOF,18 AACE19)
- Stop smoking, limit EtOH to ≤2 drinks/day (NOF,4 AACE13); limit caffeine to <1-2 servings/day (AACE20)
- Assess/manage fall risk factors (NOF,21 ACOG,22 AACE23)
- Fall-prevention strategies for pts at ↑risk include wt-bearing and muscle-strengthening exercises along w/ individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification)22
Footnotes 1 NOF 2022. Diseases assoc w/ bone loss include RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia nervosa, osteogenesis imperfecta, multiple myeloma. (See Table 1 for full list.)
Meds assoc w/ bone loss include aluminum (antacids), androgen deprivation tx, anticoagulants (unfractionated heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, cyclosporine A and tacrolimus, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for ≥3mo), GnRH agonists and antagonists, methotrexate, PPIs, SSRIs, tamoxifen (premenopausal use for breast CA tx), TZDs, thyroid replacement hormone (in excess).
Other factors assoc w/ bone loss include EtOH (>2 drinks/day), excessive thinness, excess vit A, frequent falling, high NaCl intake, immobilization, inadequate physical activity, calcium and vit D deficiencies, smoking, prior fx, parenteral nutrition.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
2 NOF 2022. Many conditions prevalent in older pts contribute to vit D deficiency, such as chronic renal insufficiency and limited sun exposure due to disability. Vit D deficiency is highly prevalent in pts w/ advanced OA presenting for total hip replacement as well as in hip fx pts w/ osteoporosis (including those on anti-fx meds). Vit D deficiency should be corrected to optimize surgical/pharmacologic outcomes.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
3 NOF 2022. NOF recommends 800-1,000 IU/day for adults ≥50 but also cites the Institute of Medicine recs of 600 IU/day until age 70, then 800 IU/day for ages ≥71.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
4 NOF 2022. LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
5 ACOG 2021. BMD screening is recommended for ages ≥65 yo to prevent osteoporotic fx [ACOG-S][ACOG-H]. When hip and spine sites cannot be evaluated (e.g., bilateral hip replacements, lumbar spine surgery, or both), BMD measurement @ forearm (distal one third of radius) can be used for dx.
Diagnostic criteria for postmenopausal pt include:
• BMD T-score ≤−2.5 establishes osteoporosis dx
• BMD T-score −1.0 to −2.5 indicates low bone density (or osteopenia)
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
6 USPSTF 2010. BMD screening recommended in women ≥65 yo. Based on the U.S. FRAX tool, a 65-yo White woman w/ no other risk factors has a 9.3% 10-yr risk for any osteoporotic fx.
Nelson HD, et al. Screening for Osteoporosis: An Update for the U.S. Preventive Services Task Force. Ann Intern Med. 2010 Jul 20;153(2):99-111. Accessed online 8/16/23
7 ISCD 2019. 2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
8 AACE 2020 [B][2]. BMD screening recommended in postmenopausal women ≥65 yo. Use central DEXA measurement (total hip, femoral neck, total lumbar spine, or combo).
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
9 ACR 2022. In asymptomatic pts or suspected low BMD, DEXA of lumbar spine/hips is usually appropriate [7-9]; quantitative CT scan of lumbar spine and hip [4-6]/DEXA of distal forearm [4-6]/trabecular bone score + DEXA may be appropriate.
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
10 ACOG 2021. American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
11 ISCD 2019. Forearm BMD should be measured under the following circumstances:
• Hip or spine can’t be measured or interpreted
• Hyperparathyroidism
• Very obese pts (over wt limit for DXA table)
2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
12 ACR 2022. Add distal forearm DEXA [4-6]in pts w/ hyperparathyroidism (causes ↓mineralization @ hip & midradius).
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
13 AACE 2020. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
14 NOF 2022. USA-adapted FRAX tool calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors, including BMD at femoral neck; validated for women and men 40-90 yo; femoral neck preferred; nonhip sites not recommended. Data validating the relative weight of some known risk factors aren’t yet available, so they’re not included in the algorithm: risks assoc w/ falls, non-DXA bone density, rapidity of bone loss, specific 2° causes of osteoporosis, multiple fractures in a short time. Other risks important in older adults and not included: frailty, multiple comorbid conditions, multiple meds assoc w/ falls/fractures, life expectancy. Most useful in low femoral neck BMD.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
15 ACOG 2021 [GPP]. Although Ca++ and vit D supplementation don’t appear to be effective for preventing osteoporotic fx in avg-risk individuals, counsel pts to consume the RDAs of dietary Ca++ and vit D for bone and general health. ACOG references National Academy of Medicine (Institute of Medicine) recs of 1,000 mg/day of Ca++ for 19- to 50-yr-olds and 1,200 mg/day for pts ≥51 yo; for vit D, 600 IU/day for 70-yr-olds and 800 IU thereafter.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
16 AACE 2020 [A][1]. 1,000-2,000 IU/day typically needed for optimal serum vit D level. Higher doses may be required in presence of obesity, malabsorption, transplant pts, older pts.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
17 ACOG 2021. Regular aerobic physical activity (mod to high impact) and wt-bearing exercises (muscle-strengthening or resistance) are recommended to maintain bone health and prevent bone loss [ACOG-S][ACOG-M]. CDC recommends ≥150-300min/wk of mod-intensity activity or 75-150min/wk of vigorous-intensity aerobic physical activity (or combination of both). For older pts who cannot do 150min/wk of mod-intensity activity or bone-strengthening exercises (e.g., d/t mobility issues or chronic dz), CDC recommends being as physically active as possible.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
18 NOF 2022. Wt-bearing: walking, jogging, tai chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Evaluate pts before they start a new exercise program, esp. one involving compressive or contractile stressors (e.g., running, wt-lifting).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
19 AACE 2020 [A][1]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
20 AACE 2020. Limit caffeine to <1-2 drinks/day. Observational studies show assoc w/ fx; may contribute to inadequate Ca++ intake by replacing milk in diet.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
21 NOF 2022. Risk factors for falls include medical (advanced age, arthritis, female gender, poor vision, urinary urgency or incontinence, previous fall, orthostatic hypotension, impaired transfer and mobility, meds that cause dizziness/sedation (narcotic analgesics, anticonvulsants, psychotropics), malnutrition/parenteral nutrition (vit D deficiency, insufficient protein)); neuro/musculoskeletal (poor balance, weak muscles/sarcopenia, gait disturbances, kyphosis, ↓proprioception, diseases and therapies that cause sedation/dizziness/weakness/lack of coordination, Alzheimer dz/other dementia, delirium, Parkinson dz, stroke); environmental (low-level lighting, obstacles in walking path, loose throw rugs, stairs, lack of assistive devices in bathrooms, slippery outdoor conditions); and psychological (anxiety/agitation, depression, diminished cognitive acuity, fear of falling).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
22 ACOG 2021. Assess risk of falls in postmenopausal pts w/ low BMD or osteoporosis. Fall-prevention strategies for those at ↑risk include wt-bearing and muscle-strengthening exercises as well as individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification) [GPP].
Important risk factors for falls include:
• older age
• hx of falls
• impairments in mobility, gait, and balance
• environmental factors (e.g., loose throw rugs, low-level lighting)
• medical conditions (e.g., anxiety, depression, vit D deficiency, kyphosis, orthostatic hypotension, poor vision, hx of stroke)
• meds that cause sedation
Consider referral to or consultation w/ a specialist in fall prevention (PT or OT) to provide further risk assessment and targeted interventions for pts at ↑fall risk.
USPSTF recommends exercise interventions for community-dwelling adults ≥65 yo who are at ↑fall risk.
NOF recommends multifactorial interventions, including tai chi and other exercise programs, home safety assessment and appropriate modification, removal of psychotropic meds, and correction of visual impairment for pts at ↑fall risk.
AACE recommends similar multifactorial fall-prevention strategies, esp. exercises for balance and ↑ trunk muscle strength, such as walking, jogging, tai chi, stairclimbing, wt training, and other activities w/ resistance.
European guidelines recommend fall risk assessment, regular wt-bearing exercise tailored to the individual, and interventions to address modifiable risk factors for those at ↑risk.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
23 AACE 2020 [A][1]. Counsel on fall-prevention measures: Anchor rugs, minimize clutter/loose wires, use nonskid mats, install handrails in bathroom/stairs, lighting in hallways/stairs/entrances, wear low-heeled footwear, avoid use of stepstools. Consider PT.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
-
Assess/address low bone density/fx risk factors,1-4 including for transgender and gender nonconforming individuals;5 consider vertebral imaging - Lateral vertebral fx assessment on DEXA equipment or lateral T + L-spine x-ray indicated if:
◦ NOF:6 ≥50 yo and postmenopausal w/ the following risk factors: fx during adulthood (any cause); historical ht loss ≥1.5" (peak ht – current ht); prospective ht loss ≥0.8" (last documented ht − current ht); recurrent or ongoing long-term GC tx (≥5 mg prednisone or equivalent daily for ≥3mo1); hyperparathyroidism
◦ AACE:7 unexplained ht loss, self-reported but undocumented prior spine fx, GC tx equivalent to ≥5 mg prednisone daily for ≥3mo - Use FRAX tool to estimate osteoporosis-assoc fx risk (NOF,8 ACOG9)
- Adequate Ca++ (1,000 mg/day for 19-50 yo; 1,200 mg/day for ≥51 yo)10 + vit D (recs vary by org and range from 600-2,000 IU/day for adults 50-70 yo; 800-2,000 IU/day for those ≥71 yo); supplement if needed (ACOG,10 NOF,11 AACE12)
- Adequate protein intake of 0.8 g/kg (AACE7)
- Regular wt-bearing/muscle-strengthening exercise and routine aerobic physical activity (mod to high impact) to maintain bone health and prevent bone loss13 recommended (e.g., walking 30-40min/session w/ back & posture exercises 3-4x/wk)7 (ACOG,13 NOF,14 AACE15)
- Stop smoking, limit EtOH to ≤2 drinks/day (NOF,6 AACE15); limit caffeine to <1-2 servings/day (AACE16)
- Assess/manage fall risk factors (NOF,17 ACOG,18 AACE19)
- Fall-prevention strategies for pts at ↑risk include wt-bearing and muscle-strengthening exercises along w/ individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification)18
- Check ht annually; wall-mounted stadiometer preferred, w/o shoes (NOF6)
Footnotes 1 ACOG 2021. Selected risk factors for osteoporosis include increasing age, parental hx of hip or spine fx, BMI <20 kg/m 2 or body wt <127 lb, smoking, and excessive EtOH use (i.e., >3 drinks/day).
Conditions, diseases assoc w/ 2° osteoporosis include AIDS and HIV, anorexia nervosa, T1DM and T2DM, diminished ovarian reserve, gastric bypass, hyperparathyroidism, hypocalcemia, premature menopause (induced, surgical, or spontaneous), primary ovarian insufficiency, renal impairment, RA, Turner syndrome, and vit D deficiency.
Meds assoc w/ 2° osteoporosis include antiepileptics (e.g., phenytoin, carbamazepine, primidone, and phenobarbital), antiretrovirals, aromatase inhibitors, chemo-tx, DMPA, GCs, GnRH agonists and antagonists, and heparin.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
2 ISCD 2019. Risk factors include low body wt, prior fx, high-risk medication use, dz or condition assoc w/ bone loss.
2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
3 AACE 2020. Risk factors for osteoporosis/osteoporosis-related fx include prior fx w/o major trauma after 50 yo, body wt <127 lb, smoking, excessive EtOH intake (≥3 drinks/day), FHx osteoporosis or fx, early menopause, 2° osteoporosis, corticosteroid use.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
4 NOF 2022. Diseases assoc w/ bone loss include RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia nervosa, osteogenesis imperfecta, multiple myeloma. (See Table 1 for full list.)
Meds assoc w/ bone loss include aluminum (antacids), androgen deprivation tx, anticoagulants (unfractionated heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, cyclosporine A and tacrolimus, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for ≥3mo), GnRH agonists and antagonists, methotrexate, PPIs, SSRIs, tamoxifen (premenopausal use for breast CA tx), TZDs, thyroid replacement hormone (in excess).
Other factors assoc w/ bone loss include EtOH (>2 drinks/day), excessive thinness, excess vit A, frequent falling, high NaCl intake, immobilization, inadequate physical activity, calcium and vit D deficiencies, smoking, prior fx, parenteral nutrition.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
5 ISCD 2019. F/u BMD testing in transgender and gender nonconforming individuals should be done when results are likely to influence pt mgmt. Examples include:
• Individuals taking tx to suppress puberty, such as GnRH analogs
• Nonadherence w/ or inadequate doses of gender-affirming hormone tx
• Plan to d/c gender-affirming hormone tx
• Presence of other risks for bone loss or fragility fx
• Individualize BMD testing intervals based on pt’s clinical status: typically, q1-2y until BMD is stable or improved is appropriate, w/ longer intervals thereafter
2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
6 NOF 2022. LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
7 AACE 2020. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
8 NOF 2022. USA-adapted FRAX tool calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors, including BMD at femoral neck; validated for women and men 40-90 yo; femoral neck preferred; nonhip sites not recommended. Data validating the relative weight of some known risk factors aren’t yet available, so they’re not included in the algorithm: risks assoc w/ falls, non-DXA bone density, rapidity of bone loss, specific 2° causes of osteoporosis, multiple fractures in a short time. Other risks important in older adults and not included: frailty, multiple comorbid conditions, multiple meds assoc w/ falls/fractures, life expectancy. Most useful in low femoral neck BMD.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
9 ACOG 2021 [ACOG-S][ACOG-H]. Refer for DEXA in pts w/ elevated risk for osteoporosis. Use formal, validated risk assessment tools to estimate fx risk to determine whether DEXA would be useful. USPSTF recommends FRAX tool to calculate risk in pts w/ ≥1 risk factor; 10-yr risk of osteoporotic fx >8.4% (fx risk in 65-yo Caucasian women w/o major risk factors for osteoporosis) justifies referral for BMD testing.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
10 ACOG 2021 [GPP]. Although Ca++ and vit D supplementation don’t appear to be effective for preventing osteoporotic fx in avg-risk individuals, counsel pts to consume the RDAs of dietary Ca++ and vit D for bone and general health. ACOG references National Academy of Medicine (Institute of Medicine) recs of 1,000 mg/day of Ca++ for 19- to 50-yr-olds and 1,200 mg/day for pts ≥51 yo; for vit D, 600 IU/day for 70-yr-olds and 800 IU thereafter.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
11 NOF 2022. NOF recommends 800-1,000 IU/day for adults ≥50 but also cites the Institute of Medicine recs of 600 IU/day until age 70, then 800 IU/day for ages ≥71.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
12 AACE 2020 [A][1]. 1,000-2,000 IU/day typically needed for optimal serum vit D level. Higher doses may be required in presence of obesity, malabsorption, transplant pts, older pts.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
13 ACOG 2021. American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
14 ACOG 2021. Regular aerobic physical activity (mod to high impact) and wt-bearing exercises (muscle-strengthening or resistance) are recommended to maintain bone health and prevent bone loss [ACOG-S][ACOG-M]. CDC recommends ≥150-300min/wk of mod-intensity activity or 75-150min/wk of vigorous-intensity aerobic physical activity (or combination of both). For older pts who cannot do 150min/wk of mod-intensity activity or bone-strengthening exercises (e.g., d/t mobility issues or chronic dz), CDC recommends being as physically active as possible.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
15 NOF 2022. Wt-bearing: walking, jogging, tai chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Evaluate pts before they start a new exercise program, esp. one involving compressive or contractile stressors (e.g., running, wt-lifting).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
16 AACE 2020 [A][1]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
17 AACE 2020. Limit caffeine to <1-2 drinks/day. Observational studies show assoc w/ fx; may contribute to inadequate Ca++ intake by replacing milk in diet.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
18 NOF 2022. Risk factors for falls include medical (advanced age, arthritis, female gender, poor vision, urinary urgency or incontinence, previous fall, orthostatic hypotension, impaired transfer and mobility, meds that cause dizziness/sedation (narcotic analgesics, anticonvulsants, psychotropics), malnutrition/parenteral nutrition (vit D deficiency, insufficient protein)); neuro/musculoskeletal (poor balance, weak muscles/sarcopenia, gait disturbances, kyphosis, ↓proprioception, diseases and therapies that cause sedation/dizziness/weakness/lack of coordination, Alzheimer dz/other dementia, delirium, Parkinson dz, stroke); environmental (low-level lighting, obstacles in walking path, loose throw rugs, stairs, lack of assistive devices in bathrooms, slippery outdoor conditions); and psychological (anxiety/agitation, depression, diminished cognitive acuity, fear of falling).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
19 ACOG 2021. Assess risk of falls in postmenopausal pts w/ low BMD or osteoporosis. Fall-prevention strategies for those at ↑risk include wt-bearing and muscle-strengthening exercises as well as individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification) [GPP].
Important risk factors for falls include:
• older age
• hx of falls
• impairments in mobility, gait, and balance
• environmental factors (e.g., loose throw rugs, low-level lighting)
• medical conditions (e.g., anxiety, depression, vit D deficiency, kyphosis, orthostatic hypotension, poor vision, hx of stroke)
• meds that cause sedation
Consider referral to or consultation w/ a specialist in fall prevention (PT or OT) to provide further risk assessment and targeted interventions for pts at ↑fall risk.
USPSTF recommends exercise interventions for community-dwelling adults ≥65 yo who are at ↑fall risk.
NOF recommends multifactorial interventions, including tai chi and other exercise programs, home safety assessment and appropriate modification, removal of psychotropic meds, and correction of visual impairment for pts at ↑fall risk.
AACE recommends similar multifactorial fall-prevention strategies, esp. exercises for balance and ↑ trunk muscle strength, such as walking, jogging, tai chi, stairclimbing, wt training, and other activities w/ resistance.
European guidelines recommend fall risk assessment, regular wt-bearing exercise tailored to the individual, and interventions to address modifiable risk factors for those at ↑risk.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
20 AACE 2020 [A][1]. Counsel on fall-prevention measures: Anchor rugs, minimize clutter/loose wires, use nonskid mats, install handrails in bathroom/stairs, lighting in hallways/stairs/entrances, wear low-heeled footwear, avoid use of stepstools. Consider PT.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
Abnormal BMD (T-score <−1): tx-naive Eval osteoporosis/osteopenia - Evaluate for 2° causes of osteoporosis (NOF,1,2 ACOG,3 AACE4)
- Lateral vertebral fx assessment on DEXA equipment or lateral T + L-spine x-ray indicated if:
◦ NOF:5 ≥65 yo if T-score ≤−1 at femoral neck; ≥70 yo if T-score ≤−1 at lumbar spine, total hip, or femoral neck; ≥50 yo and postmenopausal w/ the following risk factors: fx during adulthood (any cause); historical ht loss ≥1.5" (peak ht – current ht); prospective ht loss ≥0.8" (last documented ht − current ht); recurrent or ongoing long-term GC tx (≥5 mg prednisone or equivalent daily for ≥3mo1); hyperparathyroidism
◦ ISCD, ACR:6,7 BMD T-score <−1 + at least one of the following: ≥70 yo; historical ht loss >4 cm (>1.5"); self-reported but undocumented prior vertebral fx; GC tx equivalent to ≥5 mg prednisone daily for ≥3mo
◦ AACE:8 unexplained ht loss, self-reported but undocumented prior spine fx, GC tx equivalent to ≥5 mg prednisone daily for ≥3mo - Use FRAX tool to estimate osteoporosis-assoc fx risk + need for tx (NOF,9 ACOG10)
- F/u BMD testing in transgender and gender nonconforming individuals should be done when results are likely to influence pt mgmt. Examples include:6
◦ Low bone density
◦ Individuals taking tx to suppress puberty, such as GnRH analogs
◦ Nonadherence w/ or inadequate doses of gender-affirming hormone tx
◦ Plan to d/c gender-affirming hormone tx
◦ Presence of other risks for bone loss or fragility fx
◦ Individualize BMD testing intervals based on pt’s clinical status: typically, q1-2y until BMD is stable or improved is appropriate, w/ longer intervals thereafter
Consider pharmacologic tx11-15 if: - Low-trauma hip/vertebral fx (NOF,5 ES,11 AACE16)
- @ high risk of fx, esp. if recent fx (w/in the past 2y) (ES11)
- T-score ≤−2.5 (NOF,5 ACP,15 AACE16)
- T-score −1.0 to −2.5 Consider tx in pts w/ FRAX 10-yr hip fx probability ≥3% or 10-yr major osteoporosis-related fx probability ≥20% or proximal humerus/pelvis/distal forearm fx (NOF,5 ACOG,10 AACE16); ACP suggests taking individualized approach to starting BP if osteopenia and >65 yo15
Medication Choices | Comparison of Recent Guidelines If starting tx: - If osteoporosis: Treat w/ BPs x5y (ACP17); treat w/ teriparatide or abaloparatide x2y, followed by antiresorptive tx; treat w/ romosozumab x1y, followed by antiresorptive tx (ES11)
- Check bone turnover markers (CTX, NTX, BSAP, OC, PINP) at 3-6mo (NOF,18 AACE19)
- Check BMD w/ DEXA @ hip + spine q1-2y (NOF,5 AACE,19 ACR20); monitor BMD (by DEXA @ spine and hip) of high-risk pts w/ low BMD q1-3y (ES21)
Recommend nonpharmacologic measures for all pts - Adequate Ca++ (1,000 mg/day for 19-50 yo; 1,200 mg/day for ≥51 yo)22 + vit D (recs vary by org and range from 600-2,000 IU/day for adults 50-70 yo; 800-2,000 IU/day for those ≥71 yo); supplement if needed (ACOG,22 NOF,23 AACE,24 ES25)
- Adequate protein intake of 0.8 g/kg (AACE8)
- Regular wt-bearing/muscle-strengthening exercise and routine aerobic physical activity (mod to high impact) to maintain bone health and prevent bone loss26 recommended (e.g., walking 30-40min/session w/ back & posture exercises 3-4x/wk)8 (AACE,19 ACOG,26 NOF27)
- Stop smoking, limit EtOH to ≤2 drinks/day (NOF,5 AACE19); limit caffeine to <1-2 servings/day (AACE28)
- Manage fall risk factors (NOF,29 AACE30); assess/address fall risk factors in pts w/ low BMD or osteoporosis (ACOG31)
- Fall-prevention strategies for pts at ↑risk include wt-bearing and muscle-strengthening exercises along w/ individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification)31
- Check ht annually; wall-mounted stadiometer preferred, w/o shoes (NOF5)
Footnotes 1 NOF 2022. Diseases assoc w/ bone loss include RA, SLE, ankylosing spondylitis, DM, thyrotoxicosis, hyperparathyroidism, celiac dz, gastric bypass, IBD, hypogonadal states, ESRD, post-transplant, sickle cell dz, anorexia nervosa, osteogenesis imperfecta, multiple myeloma. (See Table 1 for full list.)
Meds assoc w/ bone loss include aluminum (antacids), androgen deprivation tx, anticoagulants (unfractionated heparin), anticonvulsants, aromatase inhibitors, barbiturates, chemo-tx, cyclosporine A and tacrolimus, depo-medroxyprogesterone, steroids (≥5 mg/day prednisone or equivalent for ≥3mo), GnRH agonists and antagonists, methotrexate, PPIs, SSRIs, tamoxifen (premenopausal use for breast CA tx), TZDs, thyroid replacement hormone (in excess).
Other factors assoc w/ bone loss include EtOH (>2 drinks/day), excessive thinness, excess vit A, frequent falling, high NaCl intake, immobilization, inadequate physical activity, calcium and vit D deficiencies, smoking, prior fx, parenteral nutrition.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
2 NOF 2022. Consider in all pts: CBC, albumin, albumin-adjusted Ca++, phos, magnesium, renal/hepatic fxn, 25(OH)D, PTH, 24-hr urinary Ca++ and Cr excretion. Consider in selected pts: serum protein electrophoresis, serum immunofixation, serum free kappa and lambda light chains, TSH +/- free T 4, tissue transglutaminase antibodies (and IgA), Fe studies, homocysteine, prolactin, tryptase, bone turnover markers, protein electrophoresis and kappa and lambda light chains, salivary and/or urinary free cortisol, urinary histamine.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
3 ACOG 2021. Clinical eval for osteoporosis includes medical hx, physical exam, and measurement of changes in ht. Medical hx should assess for significant risk factors and conditions, diseases, and meds assoc w/ 2° osteoporosis.
Conditions, diseases assoc w/ 2° osteoporosis include AIDS and HIV, anorexia nervosa, T1DM and T2DM, diminished ovarian reserve, gastric bypass, hyperparathyroidism, hypocalcemia, premature menopause (induced, surgical, or spontaneous), primary ovarian insufficiency, renal impairment, RA, Turner syndrome, and vit D deficiency.
Meds assoc w/ 2° osteoporosis include antiepileptics (e.g., phenytoin, carbamazepine, primidone, and phenobarbital), antiretrovirals, aromatase inhibitors, chemo-tx, DMPA, GCs, GnRH agonists and antagonists, and heparin.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
4 AACE 2020 [B][1]. To evaluate for 2° causes, consider CBC, Ca++, phos, total protein/albumin, liver enzymes, alkaline phosphatase, creatinine, electrolytes, 25(OH)D, TSH, 24-hr urine for Ca++, sodium, and creatinine excretion. Consider additional tests if clinical suspicion: thyrotropin, PTH, serum protein electrophoresis (myeloma), tissue transglutaminase abs (celiac dz), urinary free cortisol (adrenal hypersecretion), acid-base studies, serum tryptase & urinary N-methyl-histamine (mastocytosis), bone marrow aspiration/bx, undecalcified iliac crest bone bx w/ double tetracycline labeling.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
5 NOF 2022. LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
6 ISCD 2019. 2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
7 ACR 2022. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
8 AACE 2020 Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
9 NOF 2022. USA-adapted FRAX tool calculates 10-yr probability of hip/other major osteoporotic fx based on clinical risk factors, including BMD at femoral neck; validated for women and men 40-90 yo; femoral neck preferred; nonhip sites not recommended. Data validating the relative weight of some known risk factors aren’t yet available, so they’re not included in the algorithm: risks assoc w/ falls, non-DXA bone density, rapidity of bone loss, specific 2° causes of osteoporosis, multiple fractures in a short time. Other risks important in older adults and not included: frailty, multiple comorbid conditions, multiple meds assoc w/ falls/fractures, life expectancy. Most useful in low femoral neck BMD.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
10 ACOG 2021 [ACOG-S][ACOG-H]. Refer for DEXA in pts w/ elevated risk for osteoporosis. Use formal, validated risk assessment tools to estimate fx risk to determine whether DEXA would be useful. USPSTF recommends FRAX tool to calculate risk in pts w/ ≥1 risk factor; 10-yr risk of osteoporotic fx >8.4% (fx risk in 65-yo Caucasian women w/o major risk factors for osteoporosis) justifies referral for BMD testing. FRAX can also be used to determine whether to initiate pharmacologic tx in a pt w/ a BMD T-score between −1.0 and −2.5.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
11 ES 2020. Consider the following tx in women who are at high risk for osteoporotic fx:
• BPs (alendronate, risedronate, zoledronic acid, and ibandronate*) as 1st-line tx for postmenopausal women at high fx risk [ES-S][ES-H](except ibandronate is not recommended to reduce nonvertebral or hip fx risk).
• denosumab as alternative initial tx (60 mg SC q6mo) [ES-S][ES-H]administered w/o interruptions, since denosumab’s effects on bone remodeling reverse after 6mo if not taken on schedule; don’t delay/stop w/o subsequent antiresorptive (e.g., BP, hormone tx, or SERM) or other tx administered to prevent rebound in bone turnover and to ↓ risk of rapid BMD loss and heightened risk of fx (Ungraded Good Practice Statement).
Consider the following tx in women who are at very high risk for osteoporotic fx, such as those w/ severe or multiple vertebral fx:
• teriparatide or abaloparatide tx for up to 2y for reduction of vertebral/nonvertebral fx [ES-S][ES-M]or
• romosozumab tx for up to 1y for reduction of vertebral/hip/nonvertebral fx, unless ASCVD or CVA risk [ES-M]
• plus antiresorptive osteoporosis tx after completion of course of teriparatide, abaloparatide, or romosozumab to maintain bone density gains [ES-S][ES-L]
Consider the following tx in women at high risk for osteoporotic fx who also have low DVT risk, aren’t eligible for BPs/denosumab, or have a high risk of breast CA:
• raloxifene or bazedoxifene to reduce the risk of vertebral fx [ES-S][ES-H]
Suggest the following tx in postmenopausal women at high risk for osteoporotic fx who are also: <60 yo or <10y past menopause, low DVT risk, not eligible for BPs/denosumab, w/ bothersome vasomotor/additional climacteric sx but w/o contraindications/prior MI/stroke/breast CA:
• menopausal hormone tx, using estrogen only in women w/ hysterectomy, to prevent all types of fractures [ES-C][ES-M]
Suggest the following tx in postmenopausal women at high risk for osteoporotic fx who can't tolerate raloxifene, BPs, estrogen, denosumab, abaloparatide, or teriparatide or for whom these treatments aren’t appropriate:
• calcitonin (nasal spray) [ES-C][ES-VL]
Recommend the following tx in women at high risk of fx w/ osteoporosis who can’t tolerate BPs, estrogen, selective estrogen response modulators, denosumab, teriparatide, or abaloparatide:
• daily calcium and vit D supplementation to prevent hip fx [ES-S][ES-M]
Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3):587-594. Accessed online 8/16/23
12 ACOG 2012 [ACOG-A]. Use FDA-approved options for women (individualize based on fx hx, severity, comorbid conditions, cost):
• BPs (alendronate, risedronate, zoledronic acid, ibandronate); 1st-line tx, benefits persist after tx d/c
• estrogen agonist/antagonist (raloxifene); good initial tx for younger women, risk of VTE/stroke
• PTH (1-34) (teriparatide); may only be used x2y; reserved for pts w/ fx or severe osteoporosis
• RANKLi (denosumab); useful in pts w/ high fx risk
• calcitonin; do not use until 5y postmenopause, reserve for less severe cases when other tx not tolerated
• HRT; benefit dose related, ↑risk of breast CA assoc w/ use for >3-5y; bone benefits lost w/in 1-2y of d/c
ACOG Practice Bulletin N. 129. Osteoporosis. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120(3):718-34.
13 NOF 2022. Use FDA-approved options for postmenopausal women:
• BPs (alendronate, alendronate/cholecalciferol, ibandronate, risedronate, zoledronic acid)
• estrogens (estrogen +/or HRT)
• estrogen agonist/antagonist (raloxifene)
• tissue-selective estrogen complex (conjugated estrogens/bazedoxifene)
• PTH (1-34) (teriparatide)
• PTHrP (1-34) (abaloparatide)
• RANKLi (denosumab)
• sclerostin inhibitor (romosozumab)
• calcitonin
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
14 AACE 2020 [A][1]. Use alendronate, risedronate, zoledronic acid, or denosumab as 1st-line tx; consider raloxifene or ibandronate for initial tx in pts requiring spine-specific efficacy; consider teriparatide, denosumab, romosozumab, or zoledronic acid for pts unable to take oral tx or w/ very high fx risk.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
15 ACP 2024 [C][L]. Ayers C, et al. Update Alert: 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. Ann Intern Med. 2024 May 7. doi: 10.7326/L24-0118. Online ahead of print. Full-text article
Qaseem A, et al. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians (Version 1, Update Alert). Ann Intern Med. 2024 May 7. doi: 10.7326/L24-0113. Online ahead of print. Full-text article
Qaseem A, et al. 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 Feb;176(2):224-238. Epub 2023 Jan 3. Free, full-text PDF at PubMed® Central
16 AACE 2020. Indications for drug tx:
• Pts w/ osteopenia/low bone mass & h/o low trauma hip/vertebral fx [A][1]
• T-score ≤−2.5 in spine, femoral neck, total hip or 33% (one third) radius site [A][1]
• T-score −1.0 to −2.5 (osteopenia) + FRAX 10-yr hip fx probability ≥3%, or 10-yr major osteoporosis-related fx probability ≥20% [B][1]
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
17 ACP 2024. Offer tx w/ alendronate, risedronate, or zoledronic acid to ↓ hip/vertebral fx risk [S][H]x5y.
Ayers C, et al. Update Alert: 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. Ann Intern Med. 2024 May 7. doi: 10.7326/L24-0118. Online ahead of print. Full-text article
Qaseem A, et al. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians (Version 1, Update Alert). Ann Intern Med. 2024 May 7. doi: 10.7326/L24-0113. Online ahead of print. Full-text article
Qaseem A, et al. 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 Feb;176(2):224-238. Epub 2023 Jan 3. Free, full-text PDF at PubMed® Central
18 NOF 2022. Includes bone resorption markers (CTX=serum C-telopeptide, NTX=urinary N-telopeptide) + bone formation markers (BSAP=serum bone-specific alkaline phosphatase, OC=osteocalcin, PINP=aminoterminal propeptide of type I procollagen). Obtain samples in early AM after overnight fast. In treated pts, markers may predict extent of fx risk reduction (when repeated after 3-6mo of tx), + predict magnitude of BMD ↑ w/ tx. Helps assess adequacy of tx compliance/persistence. In untreated pts, markers predict fx risk independently of bone density, and predict rapidity of bone loss.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
19 AACE 2020 [B][1]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
20 ACR 2022. Scan pts on same DEXA scanner. Rescan q2y; q1y w/ accelerated loss (e.g., GC-use pts). Quantitative CT scans can be used for monitoring. Vertebral fx assessment and DEXA are complementary and performed concomitantly, at the same visit where BMD measurement is obtained.
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
21 ES 2020 [ES-C][ES-VL]. Alternative way of identifying poor response/nonadherence: Monitor bone tumor markers (serum C-terminal crosslinking telopeptide for antiresorptive tx, or procollagen type 1 N-terminal propeptide for bone anabolic tx).
Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3):587-594. Accessed online 8/16/23
22 ACOG 2021 [GPP]. Although Ca++ and vit D supplementation don’t appear to be effective for preventing osteoporotic fx in avg-risk individuals, counsel pts to consume the RDAs of dietary Ca++ and vit D for bone and general health. ACOG references National Academy of Medicine (Institute of Medicine) recs of 1,000 mg/day of Ca++ for 19- to 50-yr-olds and 1,200 mg/day for pts ≥51 yo; for vit D, 600 IU/day for 70-yr-olds and 800 IU thereafter.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
23 NOF 2022. NOF recommends 800-1,000 IU/day for adults ≥50 but also cites the Institute of Medicine recs of 600 IU/day until age 70, then 800 IU/day for ages ≥71.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
24 AACE 2020 [A][1]. 1,000-2,000 IU/day typically needed for optimal serum vit D level. Higher doses may be required in presence of obesity, malabsorption, transplant pts, older pts.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
25 ES 2020. Suggest calcium and vit D as adjunct to osteoporosis tx in postmenopausal women w/ low BMD and @ high risk of fx [ES-C][ES-L]; recommend daily calcium and vit D supplementation to prevent hip fx in those @ high risk of fx who can’t tolerate BPs, estrogen, SERMs, denosumab, teriparatide, and abaloparatide [ES-S][ES-M]. ES notes that expert opinion recommends ≤1,000 mg/day in the form of supplements, whereas overall rec from NOF and Institute of Medicine for women >50 yo is a total calcium intake of 1,200 mg/day.
Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3):587-594. Accessed online 8/16/23
26 ACOG 2021. Regular aerobic physical activity (mod to high impact) and wt-bearing exercises (muscle-strengthening or resistance) are recommended to maintain bone health and prevent bone loss [ACOG-S][ACOG-M]. CDC recommends ≥150-300min/wk of mod-intensity activity or 75-150min/wk of vigorous-intensity aerobic physical activity (or combination of both). For older pts who cannot do 150min/wk of mod-intensity activity or bone-strengthening exercises (e.g., d/t mobility issues or chronic dz), CDC recommends being as physically active as possible.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
27 NOF 2022. Wt-bearing: walking, jogging, tai chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Evaluate pts before they start a new exercise program, esp. one involving compressive or contractile stressors (e.g., running, wt-lifting).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
28 AACE 2020. Limit caffeine to <1-2 drinks/day. Observational studies show assoc w/ fx; may contribute to inadequate Ca++ intake by replacing milk in diet.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
29 NOF 2022. Risk factors for falls include medical (advanced age, arthritis, female gender, poor vision, urinary urgency or incontinence, previous fall, orthostatic hypotension, impaired transfer and mobility, meds that cause dizziness/sedation (narcotic analgesics, anticonvulsants, psychotropics), malnutrition/parenteral nutrition (vit D deficiency, insufficient protein)); neuro/musculoskeletal (poor balance, weak muscles/sarcopenia, gait disturbances, kyphosis, ↓proprioception, diseases and therapies that cause sedation/dizziness/weakness/lack of coordination, Alzheimer dz/other dementia, delirium, Parkinson dz, stroke); environmental (low-level lighting, obstacles in walking path, loose throw rugs, stairs, lack of assistive devices in bathrooms, slippery outdoor conditions); and psychological (anxiety/agitation, depression, diminished cognitive acuity, fear of falling).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
30 AACE 2020 [A][1]. Counsel on fall-prevention measures: Anchor rugs, minimize clutter/loose wires, use nonskid mats, install handrails in bathroom/stairs, lighting in hallways/stairs/entrances, wear low-heeled footwear, avoid use of stepstools. Consider PT.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
31 ACOG 2021. Assess risk of falls in postmenopausal pts w/ low BMD or osteoporosis. Fall-prevention strategies for those at ↑risk include wt-bearing and muscle-strengthening exercises as well as individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification) [GPP].
Important risk factors for falls include:
• older age
• hx of falls
• impairments in mobility, gait, and balance
• environmental factors (e.g., loose throw rugs, low-level lighting)
• medical conditions (e.g., anxiety, depression, vit D deficiency, kyphosis, orthostatic hypotension, poor vision, hx of stroke)
• meds that cause sedation
Consider referral to or consultation w/ a specialist in fall prevention (PT or OT) to provide further risk assessment and targeted interventions for pts at ↑fall risk.
USPSTF recommends exercise interventions for community-dwelling adults ≥65 yo who are at ↑fall risk.
NOF recommends multifactorial interventions, including tai chi and other exercise programs, home safety assessment and appropriate modification, removal of psychotropic meds, and correction of visual impairment for pts at ↑fall risk.
AACE recommends similar multifactorial fall-prevention strategies, esp. exercises for balance and ↑ trunk muscle strength, such as walking, jogging, tai chi, stairclimbing, wt training, and other activities w/ resistance.
European guidelines recommend fall risk assessment, regular wt-bearing exercise tailored to the individual, and interventions to address modifiable risk factors for those at ↑risk.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506. Abnormal BMD (T-score <−1): tx-experienced F/u at least annually while on meds; 1-yr f/u while on GC tx (ACOG1); check bone turnover markers (CTX, NTX, BSAP, OC, PINP)2 3-6mo after initiation (NOF,3 AACE4); check BMD q1-2y (ACOG,1 NOF,3 AACE,4 ACR5); repeat screen ≥2y after initial screening;1 individualize tx duration - Routinely reassess fx risk, pt satisfaction, tx adherence, need for continued/modified tx6
- Monitor diet/supplements (Ca++, vit D),7 exercise,8 smoking/EtOH, fall risk factors9
- Check ht annually; wall-mounted stadiometer preferred, w/o shoes6
- Check BMD w/ DEXA @ hip + spine q1-2y (NOF,3 AACE,4 ACR10). If hip, spine, or both aren’t evaluable, or if an additional site is needed in pts w/ primary hyperparathyroidism, or according to clinical judgment, consider 1/3 radius.3,4
- F/u BMD testing in transgender and gender nonconforming individuals should be done when results are likely to influence pt mgmt. Examples include:11
◦ Low bone density
◦ Individuals taking tx to suppress puberty, such as GnRH analogs
◦ Nonadherence w/ or inadequate doses of gender-affirming hormone tx
◦ Plan to d/c gender-affirming hormone tx
◦ Presence of other risks for bone loss or fragility fx
◦ Individualize BMD testing intervals based on pt’s clinical status: typically, q1-2y until BMD is stable or improved is appropriate, w/ longer intervals thereafter - Recheck vertebral imaging if: new ht loss; back pain/posture change; suspicious CXR finding; or if considering discontinuing meds6
After 3-5y of initial bisphosphonate (BP) tx, individualize ongoing tx based on comprehensive risk assessment (NOF,6 ASBMR,12 AACE13) - If hip/spine/multiple other osteoporotic fx before/during tx: Continue BP tx or change to alternative tx (NOF,6 ASBMR12)
- If hip BMD T-score ≤−2.5/high fx risk (age >70 yo, other strong fx risk factors, FRAX score above country-specific threshold6,12): Continue tx (ES14); consider continued BP tx for up to 10y or change to alternative tx (NOF,6 ASBMR12)
- If no fx before/during tx + hip BMD T-score >−2.5/no high fx risk:
◦ ASBMR, NOF:12,15 Consider d/c of meds (drug holiday)
◦ ES:14 Temporarily d/c BPs for up to 5y (or longer depending on BMD and individual pt clinical circumstances)
◦ AACE:13 Consider drug holiday from oral BPs after 5y of stability in moderate-risk pts or 6-10y of stability in high-risk pts [B][2] - Reassessment
◦ NOF, ASBMR: Reassess BMD in all pts q2-3y,6,12 but use shorter interval if new fx or if accelerated bone loss anticipated (e.g., due to GC/aromatase inhibitor tx)12
◦ ES:14 Reassess fx risk at 2- to 4-yr intervals. Consider reinitiating osteoporosis tx earlier than 5-yr suggested max if significant decline in BMD, an intervening fx, or other changes to clinical risk status.
If pt has been on denosumab x5-10y: Reassess fx risk (ES16) - Continue denosumab tx for women who remain at high fx risk or treat w/ other osteoporosis tx16
- Avoid drug holiday or tx interruption w/ denosumab;16,17 don’t delay or stop tx w/o subsequent antiresorptive tx (BP, hormone tx, or SERM) or other tx to prevent rebound in bone turnover and ↓ risk of BMD loss and fx16
If pt has been on romosozumab x1y: Reassess fx risk (ES,16 AACE18) - D/c romosozumab and start other antiresorptive tx (BPs, denosumab have strongest evidence)
If pt has been on IV zoledronic acid [A][1]:13 - Moderate-risk pts: Consider drug holiday after 3 annual doses
- High-risk pts: Consider drug holiday after 6 annual doses
If pt on teriparatide: Limit tx to 2y [A][1]13 Recommend nonpharmacologic measures for all pts - Adequate Ca++ (1,000 mg/day for 19-50 yo; 1,200 mg/day for ≥51 yo)19 + vit D (recs vary by org and range from 600-2,000 IU/day for adults 50-70 yo; 800-2,000 IU/day for those ≥71 yo); supplement if needed (ACOG,19 NOF,20 AACE,21 ES22)
- Adequate protein intake of 0.8 g/kg (AACE13)
- Regular wt-bearing/muscle-strengthening exercise and routine aerobic physical activity (mod to high impact) to maintain bone health and prevent bone loss1 recommended (e.g., walking 30-40min/session w/ back & posture exercises 3-4x/wk)13 (ACOG,1 NOF,8 AACE23)
- Stop smoking, limit EtOH to ≤2 drinks/day (NOF,6 AACE23); limit caffeine to <1-2 servings/day (AACE24)
- Manage fall risk factors (NOF,9 AACE25); assess/address fall risk factors in pts w/ low BMD or osteoporosis (ACOG26)
- Fall-prevention strategies for pts at ↑risk include wt-bearing and muscle-strengthening exercises along w/ individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification)26
Footnotes 1 ACOG 2021. ACOG suggests repeat BMD in those w/ initial test results near tx thresholds or w/ significant changes in risk factors. For most, repeat BMD ≥2y after initial screening. ACR recommends 2-yr monitoring interval based on expected rate of change of bone mineralization. One-yr f/u is recommended in pts at risk of substantial short-term decreases in demineralization, such as those on GC tx. Serial BMD measurements should be performed at lumbar spine, total hip, or femoral neck. Pts should have f/u measurements on the same DEXA device as their prior measurement [ACOG-C][ACOG-L].
Regular aerobic physical activity (mod to high impact) and wt-bearing exercises (muscle-strengthening or resistance) are recommended to maintain bone health and prevent bone loss [ACOG-S][ACOG-M]. CDC recommends ≥150-300min/wk of mod-intensity activity or 75-150min/wk of vigorous-intensity aerobic physical activity (or combination of both). For older pts who cannot do 150min/wk of mod-intensity activity or bone-strengthening exercises (e.g., d/t mobility issues or chronic dz), CDC recommends being as physically active as possible.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
2 NOF 2022. Includes bone resorption markers (CTX=serum C-telopeptide, NTX=urinary N-telopeptide) + bone formation markers (BSAP=serum bone-specific alkaline phosphatase, OC=osteocalcin, PINP=aminoterminal propeptide of type I procollagen). Obtain samples in early AM after overnight fast. In treated pts, markers may predict extent of fx risk reduction (when repeated after 3–6mo of tx), + predict magnitude of BMD ↑ w/ tx. Helps assess adequacy of tx compliance/persistence. In untreated pts, markers predict fx risk independently of bone density, and predict rapidity of bone loss.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
3 NOF 2022. Check BMD 1-2y after initiating or changing tx and at appropriate intervals thereafter, based on clinical circumstances.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
4 AACE 2020. Repeat BMD q1-2y until findings stable, then q1-2y or less frequent [B][2]. F/u should be at same facility, on same machine, pref w/ same technologist [C][2].
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
5 ACR 2022. Vertebral fx assessment w/ DEXA usually appropriate [7-9]in pts w/ T-score <−1.0 w/ any of: age ≥70 yo; h/o ht loss >1.5 in (4 cm); self-reported but undocumented prior vertebral fx; GC tx (e.g., ≥5 mg prednisone/day) for ≥3mo.
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
6 NOF 2022. LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
7 NOF 2022. Adequate Ca++ intake: Women ≥51 yo=1,200 mg/day. Adequate vit D intake: 800-1,000 IU/day; vit D-deficient adults: Treat w/ 50,000 IU vit D2 or D3 once/wk (or 7,000 IU vit D2 or D3 daily) x5-8wk to achieve 25(OH)D blood level of ≈30 ng/mL. Follow w/ maintenance tx of 1,000-2,000 IU/day or as required for target blood levels.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
8 NOF 2022. Wt-bearing: walking, jogging, tai chi, stairclimbing, dance, tennis. Muscle-strengthening: wt training, yoga, Pilates, boot camps. Evaluate pts before they start a new exercise program, esp. one involving compressive or contractile stressors (e.g., running, wt-lifting).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
9 NOF 2022. Risk factors for falls include medical (advanced age, arthritis, female gender, poor vision, urinary urgency or incontinence, previous fall, orthostatic hypotension, impaired transfer and mobility, meds that cause dizziness/sedation (narcotic analgesics, anticonvulsants, psychotropics), malnutrition/parenteral nutrition (vit D deficiency, insufficient protein)); neuro/musculoskeletal (poor balance, weak muscles/sarcopenia, gait disturbances, kyphosis, ↓proprioception, diseases and therapies that cause sedation/dizziness/weakness/lack of coordination, Alzheimer dz/other dementia, delirium, Parkinson dz, stroke); environmental (low-level lighting, obstacles in walking path, loose throw rugs, stairs, lack of assistive devices in bathrooms, slippery outdoor conditions); and psychological (anxiety/agitation, depression, diminished cognitive acuity, fear of falling).
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
10 ACR 2022. Scan pts on same DEXA scanner. Rescan q2y; q1y w/ accelerated loss (e.g., GC-use pts). Quantitative CT scans can be used for monitoring. Vertebral fx assessment and DEXA are complementary and performed concomitantly, at the same visit where BMD measurement is obtained.
Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S417-S432. Revised 2022. PDF
11 ISCD 2019. 2019 ISCD Official Positions: Adult. International Society for Clinical Densitometry. Updated June 2019. Accessed November 29, 2023
12 ASBMR 2016. Adler RA, 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. J Bone Miner Res. 2016 Jan;31(1):16-35. PDF
13 AACE 2020. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
14 ES 2020 [ES-S][ES-L]. Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3):587-594. Accessed online 8/16/23
15 NOF 2022. The rationale for a BP holiday is the expectation that prolonged skeletal retention will confer anti-fx benefits for some period of time, perhaps several years, in appropriately selected pts. Non-BP effects wane rapidly w/ d/c. If considering drug holiday: Recheck vertebral imaging, as d/c not recommended if recent vertebral fx. During a BP holiday, bone turnover markers may help determine drug-holiday duration.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
16 ES 2020 [ES-C][ES-VL]. Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3):587-594. Accessed online 8/16/23
17 AACE 2020 [A][1]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
18 AACE 2020 [B][1]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
19 ACOG 2021 [GPP]. Although Ca++ and vit D supplementation don’t appear to be effective for preventing osteoporotic fx in avg-risk individuals, counsel pts to consume the RDAs of dietary Ca++ and vit D for bone and general health. ACOG references National Academy of Medicine (Institute of Medicine) recs of 1,000 mg/day of Ca++ for 19- to 50-yr-olds and 1,200 mg/day for pts ≥51 yo; for vit D, 600 IU/day for 70-yr-olds and 800 IU thereafter.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
20 NOF 2022. NOF recommends 800-1,000 IU/day for adults ≥50 but also cites the Institute of Medicine recs of 600 IU/day until age 70, then 800 IU/day for ages ≥71.
LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2022 Oct;33(10):2049-2102. Full-text article
21 AACE 2020 [A][1]. 1,000-2,000 IU/day typically needed for optimal serum vit D level. Higher doses may be required in presence of obesity, malabsorption, transplant pts, older pts.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
22 ES 2020. Suggest calcium and vit D as adjunct to osteoporosis tx in postmenopausal women w/ low BMD and @ high risk of fx [ES-C][ES-L]; recommend daily calcium and vit D supplementation to prevent hip fx in those @ high risk of fx who can’t tolerate BPs, estrogen, SERMs, denosumab, teriparatide, and abaloparatide [ES-S][ES-M]. ES notes that expert opinion recommends ≤1,000 mg/day in the form of supplements, whereas overall rec from NOF and Institute of Medicine for women >50 yo is a total calcium intake of 1,200 mg/day.
Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3):587-594. Accessed online 8/16/23
23 AACE 2020 [B][2]. Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
24 AACE 2020. Limit caffeine to <1-2 drinks/day. Observational studies show assoc w/ fx; may contribute to inadequate Ca++ intake by replacing milk in diet.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
25 AACE 2020 [A][1]. Counsel on fall-prevention measures: Anchor rugs, minimize clutter/loose wires, use nonskid mats, install handrails in bathroom/stairs, lighting in hallways/stairs/entrances, wear low-heeled footwear, avoid use of stepstools. Consider PT.
Camacho PM, 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 May;26(Suppl 1)1-46. PubMed® abstract
26 ACOG 2021. Assess risk of falls in postmenopausal pts w/ low BMD or osteoporosis. Fall-prevention strategies for those at ↑risk include wt-bearing and muscle-strengthening exercises as well as individualized multifactorial interventions (e.g., vision assessment and tx, balance training, and environmental assessment and modification). [GPP]
Important risk factors for falls include:
• older age
• hx of falls
• impairments in mobility, gait, and balance
• environmental factors (e.g., loose throw rugs, low-level lighting)
• medical conditions (e.g., anxiety, depression, vit D deficiency, kyphosis, orthostatic hypotension, poor vision, hx of stroke)
• meds that cause sedation
Consider referral to or consultation w/ a specialist in fall prevention (PT or OT) to provide further risk assessment and targeted interventions for pts at ↑fall risk.
USPSTF recommends exercise interventions for community-dwelling adults ≥65 yo who are at ↑fall risk.
NOF recommends multifactorial interventions, including tai chi and other exercise programs, home safety assessment and appropriate modification, removal of psychotropic meds, and correction of visual impairment for pts at ↑fall risk.
AACE recommends similar multifactorial fall-prevention strategies, esp. exercises for balance and ↑ trunk muscle strength, such as walking, jogging, tai chi, stairclimbing, wt training, and other activities w/ resistance.
European guidelines recommend fall risk assessment, regular wt-bearing exercise tailored to the individual, and interventions to address modifiable risk factors for those at ↑risk.
American College of Obstetricians and Gynecologists. Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506.
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