Management of osteoporosis in the absence of fracture

Management of osteoporosis in the absence of fracture is based on individual fracture risk assessment; see Risk factors for minimal-trauma fracture. Measure bone mineral density (BMD) if the patient has significant risk factors for osteoporosis or minimal-trauma fracture. Measurement of BMD in patients 70 years and older (regardless of other risk factors) is also recommended.

Absolute fracture risk can be calculated using an online calculator (eg Fracture Risk Assessment Tool [FRAX], Garvan Institute Fracture Risk Calculator). The role of fracture risk calculators in practice is evolving; they are particularly useful to identify and reassure patients at low fracture risk who do not require drug therapy.

For patients aged 70 years and older, drug therapy for osteoporosis can be started for primary fracture prevention if the T-score is –2.5 or less. For younger patients, consider all risk factors for fracture—younger patients with a declining BMD or a high risk of fracture may benefit from treatment; seek specialist advice. For treatment decisions in patients taking glucocorticoid therapy, see Glucocorticoid-induced osteoporosis.

See Choice of drug therapy for osteoporosis for information about choosing the right treatment for each patient.

If a patient has risk factors for fracture but treatment is not yet warranted or desired, repeated measurement of BMD after 2 years and regular risk assessment is reasonable to monitor ongoing fracture risk.

For all patients, ensure calcium intake is sufficient and they are vitamin D replete. Provide advice about lifestyle measures to prevent minimal-trauma fracture.