Long-term osteoporosis management and monitoring in primary care?

Clinical answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Long-term management and monitoring of osteoporosis in primary care involves:

Regular assessment of fracture risk using tools such as FRAX or QFracture, especially in women aged 65 and over and men aged 75 and over, or younger people with risk factors like previous fragility fractures or glucocorticoid use .
Consideration of secondary causes of osteoporosis (e.g., endocrine, gastrointestinal, rheumatological, haematological, respiratory, metabolic, renal, and immobility-related causes) and addressing these where possible .
Initiation and continuation of pharmacological treatment such as bisphosphonates, with a review after 3 years to discuss the benefits and risks of continuing or stopping treatment, incorporating patient preferences, fracture risk, and life expectancy .
Development of an individualised management plan that includes non-pharmacological measures, medication review, prioritisation of healthcare appointments, and coordination of care among healthcare professionals .
Monitoring bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) scans at diagnosis and every 2 to 3 years to assess treatment response and fracture risk .
Regular clinical review to monitor adherence, side effects, and any new risk factors or fractures, with referral to specialist care if concerns arise or if secondary causes are suspected ,.
Providing information and support to patients to enable informed decision-making about their treatment and lifestyle modifications .

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