Osteoporosis Guidelines

Updated: Jan 20, 2021
  • Author: Rachel Elizabeth Whitaker Elam, MD, MSc; Chief Editor: Herbert S Diamond, MD  more...
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Guidelines

Screening

The following organizations have issued recommendations on measurement of bone mineral density (BMD) for osteoporosis screening:

American Association of Clinical Endocrinologists 

The 2020 update of the American Association of Clinical Endocrinologists (AACE) guidelines recommends evaluation of all women age 50 or older for osteoporosis risk. The initial evaluation should include a detailed history, physical exam, and clinical fracture risk assessment with the Fracture Risk Assessment (FRAX) tool or other fracture risk assessment tool. [11]

BMD measurement should be considered, based on the patient's clinical fracture risk profile. For BMD measurement, axial dual-energy x-ray absorptiometry (DXA)(lumbar spine and hip; 1/3 radius if indicated) is recommended. [11]

The AACE recommends BMD testing in the following patients [11] :

  • Women age 65 or older
  • Postmenopausal women with a history of fracture(s) without major trauma, with osteopenia identified radiographically, or starting long-term systemic glucocorticoid therapy (≥3 months)
  • Perimenopausal or postmenopausal women with risk factors for osteoporosis if willing to consider pharmacologic interventions, with low body weight (< 127 lb or body mass index < 20 kg/m 2), taking long-term systemic glucocorticoid therapy (≥3 months), or with a family history of osteoporotic fracture

Other indications for BMD tesing include the following [11] :

  • Early menopause
  • Current smoking history
  • Excessive consumption of alcohol
  • Secondary osteoporosis 

National Osteoporosis Foundation

The 2014 NOF guidelines recommend BMD measurement in the following patients [4] :

  • Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors
  • Younger postmenopausal women and women in menopausal transition with clinical risk factors for fracture
  • Men age 50-69 years with clinical risk factors for fracture

International Society for Clinical Densitometry

The 2015 ISCD Official Positions recommend BMD testing in the following patients [5] :

  • Women aged 65 and older
  • Postmenopausal women younger than age 65 with a risk factor for low bone mass (eg, low body weight, prior fracture, high-risk medication use, disease or condition associated with bone loss)
  • Women during the menopausal transition with clinical risk factors for fracture (eg, low body weight, prior fracture, high-risk medication use)
  • Men age 70 years and older
  • Men younger than 70 years with a risk factor for low bone mass (eg, low body weight, prior fracture, high-risk medication use, disease or condition associated with bone loss)
  • Adults with a fragility fracture
  • Adults with a disease or condition associated with low bone mass or bone loss
  • Adults taking medications associated with low bone mass or bone loss
  • Anyone being considered for pharmacologic therapy
  • Anyone being treated, to monitor treatment effect
  • Anyone not receiving therapy in whom evidence of bone loss would lead to treatment

Women discontinuing estrogen should be considered for bone density testing according to the indications listed above.

US Preventive Services Task Force

The USPSTF recommends measuring BMD in the following patients [245]

  • Women age 65 years and older
  • Postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool

Suggested risk assessment tools include the following:

  • Fracture Risk Assessment Tool (FRAX)
  • Simple Calculated Osteoporosis Risk Estimation (SCORE)
  • Osteoporosis Risk Assessment Instrument (ORAI)
  • Osteoporosis Index of Risk (OSIRIS)
  • Osteoporosis Self-Assessment Tool (OST)

In contrast to the NOF and ISCD, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening to prevent osteoporotic fractures in men.

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Diagnosis

According to National Osteoporosis Foundation guidelines, a clinical diagnosis of osteoporosis may be made in a postmenopausal woman or in a man over age 50 years who is at an elevated risk for fracture, as indicated by any of the following [246] :

  • T-score of -2.5 or less at the spine or hip as determined by dual-energy x-ray absorptiometry (DXA)
  • Hip fracture, with or without bone mineral density (BMD) testing
  • Vertebral; proximal humerus; pelvis; or, in some cases, distal forearm fracture in the setting of low bone mass (osteopenia) confirmed by DXA
  • FRAX score with 10-year risk for hip fracture ≥3% or for major osteoporotic fracture ≥20% in a patient with osteopenia

The 2020 update of the American Association of Clinical Endocrinologists (AACE) guidelines provides the following criteria for the diagnosis of osteoporosis in postmenopausal women [11] :

  • T-score −2.5 or below in the lumbar spine, femoral neck, total proximal femur, or 1/3 radius
  • Low-trauma spine or hip fracture (regardless of BMD)
  • T-score between −1.0 and −2.5 and a fragility fracture of proximal humerus, pelvis, or distal forearm
  • T-score between −1.0 and −2.5 and high FRAX® fracture probability based on country-specific thresholds
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Treatment

The National Osteoporosis Foundation (NOF) recommends that pharmacologic therapy should be reserved for postmenopausal women and men aged 50 years or older who present with the following [4] :

  • A hip or vertebral fracture (vertebral fractures may be clinical or morphometric [ie, identified on a radiograph alone])

  • T-score of –2.5 or less at the femoral neck or spine after appropriate evaluation to exclude secondary causes

  • Low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture of 3% or greater or a 10-year probability of a major osteoporosis-related fracture of 20% or greater based on the US-adapted WHO algorithm

The 2020 updated guidelines from the American Association of Clinical Endocrinologists (AACE) are similar to NOF guidelines. The AACE strongly recommends pharmacologic treatment of osteoporosis for postmenopausal women with any of the following [11] :

  • T-score between −1.0 and −2.5 in the spine, femoral neck, total hip, or 1/3 radius and a history of fragility fracture of the hip or spine 
  • T-score of −2.5 or lower in the spine, femoral neck, total hip, or 1/3 radius
  • T-score between −1.0 and −2.5 in the spine, femoral neck, total hip, or 1/3 radius, if the FRAX® 10-year probability for major osteoporotic fracture is ≥20% or the 10-year probability of hip fracture is ≥3% (in the U.S.) or above the country-specific threshold in other countries or regions 

A clinical practice guideline from the American College of Physicians (ACP) recommends offering pharmacologic treatment to women with known osteoporosis, to reduce the risk of hip and vertebral fractures. [144] The ACP recommends use of any of the following agents:

  • Alendronate
  • Risedronate
  • Zoledronic acid
  • Denosumab

The ACP recommends against the use of estrogen or estrogen plus progestogen or raloxifene for the treatment of osteoporosis in postmenopausal women. Additional recommendations, based on low-quality evidence, include the following:

  • In women with osteoporosis, pharmacologic treatment should last for 5 years; generic drugs should be used when possible.

  • Monitoring of bone mineral density (BMD) during the 5 years of treatment in women with osteoporosis is not advised, as evidence suggests that fracture risk may be reduced regardless of BMD changes

  • For women aged 65 and older who have osteopenia and are at high fracture risk, decisions to treat should take into account patient preference, fracture-risk profile, benefits, harms, and price of medications

  • In men with clinically recognized osteoporosis, clinicians should offer bisphosphonate therapy to reduce the risk of vertebral fracture; evidence is lacking on BMD monitoring in men.

Guidelines from the American Association of Clinical Endocrinologists (AACE), updated in 2020, include the following recommendations for choosing drugs to treat osteoporosis in postmenopausal women [11] :

  • First-line agents for most high fracture risk patients: alendronate, risedronate, zoledronate, denosumab

  • First-line agents for high fracture risk patients unable to use oral therapy: abaloparatide, denosumab, romosozumab, teriparatide, and zoledronate

  • First-line agents for spine-specific indications in select patients: ibandronate and raloxifene

  • Sequential agents: anabolic agents (eg, abaloparatide, romosozumab, teriparatide) should be followed with a bisphosphonate or denosumab

Combination therapy with two or more agents has not been shown to have a greater effect on fracture reduction than single therapy. The AACE guidelines advise against the use of combination therapy, until the effect of combination therapy on fracture is better understood. [11]

A 2019 guideline from the Endocrine Society on pharmacological management of osteoporosis in postmenopausal women includes the following recommendations [247] :

  • Treat patients who are at high risk—particularly those with previous fracture.
  • Consider bisphosphonates as the first-line therapeutic choice for postmenopausal women at high risk of fracture.
  • Reassess fracture risk after patient has been on bisphosphonates for 3-5 years.
  • Following reassessment, prescribe a “bisphosphonate holiday” for women who are on bisphosphonates and are low-to-moderate risk of fracture.
  • Consider anabolic therapy (teriparatide or abaloparatide) for women at very high risk of fractures, including those with multiple fractures.
  • All women undergoing treatment with osteoporosis therapies other than anabolic therapy should consume calcium and vitamin D in their diet or via supplements.
  • Monitor the BMD of high-risk individuals with a low BMD every 1 to 3 years.

The American Society for Bone and Mineral Research (ASBMR), American Association of Clinical Endocrinologists (AACE), Endocrine Society, European Calcified Tissue Society (ECTS) and National Osteoporosis Foundation have created joint Guidance on Osteoporosis Management in the Era of COVID-19 that state the initiation of oral bisphosphonates for osteoporosis should not be delayed in patients at high risk for fracture and provide alternative methods of delivering parenteral osteoporosis treatments and specific recommendations for management of patients who are unable to receive ongoing non-oral osteoporosis medications during the COVID-19 pandemic.

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