This protocol covers the management of osteoporosis in patients who carry a high fracture risk but have not yet experienced a pathological fracture and do not meet very-high-risk criteria — a clinically distinct sub-group where first-line anti-resorptive intervention is indicated.
The population addressed here has a bone mineral density T-score of ≤−2.5 at any skeletal site, or a FRAX 10-year major osteoporotic fracture probability of ≥20%. Very-high-risk features are absent: no multiple vertebral fractures and no fragility fracture within the previous two years.
Major guidelines — including AACE, the Endocrine Society, and BHOF — recognise these thresholds as the indication for structured pharmacological intervention at the high-risk tier.
First-line management is built around anti-resorptive therapy, combined with calcium and vitamin D supplementation and a structured weight-bearing and resistance exercise programme — the specific agent, eligibility criteria, and complete regimen are detailed in the full protocol.
The primary target is a personalised total hip T-score of ≥−2.5 — total hip bone mineral density is the best specific monitoring site. Clinically meaningful response includes an improvement in total hip T-score of at least 0.2 units (3%) and in lumbar spine T-score of at least 0.5 units (6%) over three years. Bone mineral density is reassessed every one to three years while on therapy.
DOI: 10.1136/bmj‑2024-081250
All recommend anti-resorptives as first line therapy for patients at high risk and osteoanabolics for those at very high risk.
AACE, Endocrine Society, and BHOF recommend a T-score based strategy when T ≤−2.5 at any site or a fixed risk threshold when T-score is between −2.5 and −1.0 if FRAX 10 year MOF is ≥20% or 10 year HF is ≥3%.
Anti-resorptives first line for most people at high risk: alendronate, risedronate, zoledronate, denosumab.
For patients at high risk, AACE, Endocrine Society, BHOF, and NOGG recommend alendronate, risedronate, or zoledronate as first line therapy.
For postmenopausal women and older men, aim for total elemental calcium 1000–1200 mg/day and vitamin D 800–1000 IU/day.
Weight bearing, resistance, balance training; 2–3 sessions per week, for at least 12 weeks.
In patients with low T-scores, a target of T ≥−2.5 is generally adopted as an appropriate threshold for discontinuation of therapy, on the basis of the FLEX (alendronate) and HORIZON-PFT (zoledronate) trials, and endorsed by the latest American Society of Bone and Mineral Research guidance on goal directed osteoporosis treatment.
Experts recommend an improvement in total hip T-score of at least 0.2 units (3%) and in lumbar spine T-score of at least 0.5 units (6%), on the basis of reasonable chances of attaining such increments over three years by most therapies, including anti-resorptives.
BMD every 1–3 years on therapy.
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