How should I manage a patient with osteoporosis who has a history of fragility fractures?

Management of a patient with osteoporosis and a history of fragility fractures:

• Offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) without first calculating fracture risk, as a history of fragility fracture in people over 50 years is an indication for DXA assessment ¹.
• If the DXA scan shows a T-score of -2.5 or lower, initiate bone-sparing drug treatment, typically starting with oral bisphosphonates such as alendronate 70 mg once weekly or risedronate 35 mg once weekly, unless contraindicated or not tolerated ¹.
• If the T-score is above -2.5, modify risk factors where possible, treat any underlying conditions, and repeat DXA at an interval based on clinical judgement, usually within 2 years ¹.
• Assess and address secondary causes of osteoporosis, including endocrine, gastrointestinal, rheumatological, haematological, respiratory, metabolic, chronic renal disease, and immobility causes, especially if fragility fractures occur despite low risk ¹,².
• Evaluate and manage risk factors for falls, as these contribute to fracture risk ¹.
• Ensure adequate calcium intake (at least 1000 mg/day) and assess for vitamin D deficiency, particularly in those over 65 or with limited sunlight exposure ¹.
• Consider referral to an osteoporosis specialist for people at very high risk, such as those with recent vertebral fractures, multiple vertebral fractures, very low BMD (T-score ≤ -3.5), or those on high-dose glucocorticoids ¹.
• Provide verbal and written information about the condition, treatment expectations, rehabilitation, and self-care to support patient involvement in management decisions ³.