Questionnaire/history: Female + 65+ years? Man + 75+ years? Female aged 50-64 and male aged 50-74 + following risk factor: Previous osteoporotic fragility fracture? Current use or frequent use of oral corticosteroids? History of falls? Low body mass index (< 18.5 kg/m2)? Smoker? Alcohol intake > 14 units per week? Secondary cause of osteoporosis? - Hypogonadism? ----- Untreated premature menopause (menopause before 40 years of age)? ----- Treatment with aromatase inhibitors (such as Exemastane)? ----- treatment with gonadotrophin-releasing hormone agonists (such as Goserelin)? Endocrine conditions? - Diabetes mellitus? - Cushing's disease? - Hyperthyroidism? - Hyperparathyroidism? - Hyperprolactinaemia? Conditions associated with malabsorption? - Inflammatory bowel disease? - Coeliac disease? - Chronic pancreatitis? Rheumatoid arthritis and other inflammatory arthropathies? Haematological conditions? - Multiple myeloma? - Haemoglobinopathies? Chronic obstructive pulmonary disease? Chronic liver failure? Chronic kidney disease? Immobility? Younger than 50 years + following risk factors: Current or frequent use of oral corticosteroids? Untreated premature menopause? Previous fragility fracture? Younger than 40 years + following risk factors: Current or recent use of high-dose oral corticosteroids equivalent to, or more than, 7.5 mg prednisolone daily for 3 months or more? Previous fragility fracture of the spine, hip, forearm, or proximal humerus? History of multiple fragility fractures? Consider assessing fracture risk for people taking the following medication, especially in the presence of other risk factor: Selective serotonin reuptake inhibitors? Antiepileptic medication - particularly enzyme-inducing drugs, such as carbamazepine? Aromatase inhibitors, such as Exemestane? Gonadotropin-releasing hormone agonists, such as Goserelin? Proton pump inhibitors? Thiazolidinediones, such as Pioglitazone? Past medical history? Current medication? Drug allergies? Investigations: Dual-energy X-ray absorptiometry (DXA) without calculating the fragility fracture risk if: - Over 50 years of age with a history of fragility fracture - Younge than 40 year who have a major risk factor for fragility fracture (- depending on the BMD T-score, refer to specialist experienced in the treatment of osteoporosis) For all other people with risk factors for osteoporosis: QFracture® (preferred) or FRAX® (interpretation) If 10-year fracture risk of 10% (or close to 10% + risk factors that may be underestimated by FRAX®) dual-energy X-ray absorptiometry (DXA) with measurement of the BMD at the spine and hip Vitamin D deficiency (if 65+ years or not exposed to much sunlight)? Inadequate calcium intake (< 1000 mg/day) (Steps to estimate calcium intake)? Fall – risk assessment Management: Vertebral fracture? Consideration of bone-sparing drug treatment without a DXA scan If T-score ≤ -2.5? Bone-sparing drug treatment - Alendronate 70 mg once weekly ----- Offered advice on the use of bisphosphonates and explained about possible adverse effects - Calcium intake adequate (≥ 700 mg/day)? ----- Vitamin D 10 mcg (400 IU) for people not exposed to much sunlight - Calcium intake inadequate? ----- Vitamin D 10 mcg (400 IU) + at least calcium 1000 mg daily - Elderly people who are housebound or living in a nursing home? ------Vitamin D 20 mcg (800 IU) + at least calcium 1000 mg daily - Younger postmenopausal women? ------ Considered HRT If T-score > -2.5? - Risk factor modification where possible - Treatment of underlying conditions - Repeated DXA at an interval using clinical judgement (but usually within 2 years) If low risk of fragility fracture? Offered lifestyle advice and follow up within 5 years Advised: - To take regular (tailored) exercise to improve muscle strength - Walking, especially outdoors with increased exposure to sunlight - Strength training (such as weight training) of different muscle groups (for example hip, wrist, and spine) - Combination of exercise types, for example balance, flexibility, stretching, endurance, and progressive strengthening exercises - Balanced diet - To stop smoking if applicable - To drink alcohol within recommended limits - Sources of information and support: ----- The Royal Osteoporosis Society ----- Healthtalkonline: Osteoporosis ----- NHS Health A to Z: Osteoporosis Reference(s): NICE CKS: Osteoporosis – prevention of fragility fractures Information for parents/carers: Healthtalkonline: Osteoporosis NHS Health A to Z: Osteoporosis Royal Osteoporosis Society