Patient handout

Osteoporosis & fragility-fracture prevention (DXA/FRAX → treat-to-target)

PRODUCTION

1. Your condition

This handout is for osteoporosis & fragility-fracture prevention (dxa/frax → treat-to-target). Your care team identified this based on: postmenopausal woman or man ≥ 50 — screening / risk-assessment visit (bhof 2022 pmid 35478046).

Other reasons your team may use this plan: prior low-trauma (fragility) hip or clinical/morphometric vertebral fracture — clinical osteoporosis regardless of bmd (endo soc 2019 pmid 30907953); chronic glucocorticoid (≥ 2.5–7.5 mg prednisone-equivalent ≥ 3 months) — glucocorticoid-induced osteoporosis surveillance (aace/ace 2020 pmid 33577971); incidental vertebral fracture / low bone density on imaging (vfa, ct, plain film) (bhof 2022 pmid 35478046).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
cholecalciferol (vitamin D3)	800–2000 IU/day, titrate to 25-OH-D ≥ 30 ng/mL	PO	once daily	BHOF 2022 (PMID 35478046) — adjunct (NOT monotherapy); replete BEFORE a potent antiresorptive to avoid hypocalcaemia; Bischoff-Ferrari fall RR 0.81 (0.71–0.92) in deficient (PMID 19797342)
calcium carbonate (diet-first)	500–600 mg elemental BID with meals; total diet + supplement ~1000–1200 mg/day	PO	BID with meals	BHOF 2022 (PMID 35478046) — adequate calcium with vitamin D underpins every antifracture regimen
treat the identified secondary cause first (parathyroidectomy / control hyperthyroidism / replace gonadal axis / gluten-free diet / taper glucocorticoid / treat myeloma)	—	—	—	Endo Soc 2019 (PMID 30907953) — a reversible secondary cause is treated before (or with) the antiresorptive; route primary HPT to endo.hyperparathyroidism.v1

Plan: Osteoporosis treat-to-target ladder — foundation/secondary-cause → HIGH-risk antiresorptive-first → VERY-HIGH-risk anabolic-first → directional anabolic→antiresorptive sequencing + denosumab transition → SERM/MHT → drug-holiday logic (Endo Soc 2019 PMID 30907953; AACE/ACE 2020 PMID 33577971; ASBMR/BHOF 2024 PMID 39073912)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable, on treatment, risk controlled

If you have:

Taking your bone medicine and calcium/vitamin D as prescribed
No new back pain, height loss, or fractures
DXA and follow-up on schedule

Do this:

Take your osteoporosis medicine exactly as prescribed — oral bisphosphonate upright and fasting (BHOF 2022 PMID 35478046)
Keep calcium ~1000–1200 mg/day (food first) and vitamin D as prescribed (BHOF 2022 PMID 35478046)
Do weight-bearing + resistance exercise; do not smoke; limit alcohol
Keep your DXA and follow-up appointments; never miss a denosumab dose without a plan (Cummings PMID 29105841)
Tell your dentist you take a bone medicine before any extraction/implant (Shane PMID 23712442)

YELLOW — Caution — new symptoms or a missed/late dose

If you have:

New or worsening mid/low back pain or loss of height (possible vertebral fracture)
A denosumab injection that is overdue
New thigh or groin ache on a long-term bone medicine
A planned dental extraction / implant

Do this:

Contact your provider promptly — do not just wait for the next visit
If a denosumab dose is overdue, arrange it (or a transition) NOW — stopping it abruptly raises spine-fracture risk (Cummings PMID 29105841)
Report new thigh/groin pain — it can precede an atypical thigh-bone fracture (Shane PMID 23712442)
Coordinate dental work with your bone-medicine provider (BHOF 2022 PMID 35478046)

Call your provider if:

New back pain / height loss (possible vertebral fracture) (BHOF 2022 PMID 35478046)
Denosumab dose overdue (Cummings PMID 29105841)
New thigh/groin pain on long-term bisphosphonate/denosumab (Shane PMID 23712442)

RED — Emergency — acute fracture or nerve signs

If you have:

Sudden severe back pain after minimal or no trauma, especially with leg weakness, numbness, or loss of bowel/bladder control
A fall with hip/groin pain and inability to bear weight
Sudden thigh fracture, sometimes after prodromal thigh pain

Do this:

Go to the emergency department / call emergency services now
Bring your medication list including your osteoporosis medicine and last dose date
Cord/cauda signs with a vertebral fracture are a surgical emergency (BHOF 2022 PMID 35478046)

Call your provider if:

Always seek emergency care for an acute fracture or any new leg weakness / numbness / bladder-bowel change with back pain

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Acute vertebral fracture with cord / cauda-equina signs (leg weakness, sensory level, bowel/bladder dysfunction) (BHOF 2022 PMID 35478046)(life-threatening)
New thigh / groin prodromal pain on long-term bisphosphonate or denosumab — possible incomplete / impending atypical femoral fracture (Shane ASBMR PMID 23712442)
Low BMD / fragility fracture with anaemia, weight loss, hypercalcaemia, lytic lesions, or abnormal SPEP — myeloma / malignancy mimic of osteoporosis (Endo Soc 2019 PMID 30907953)
Recent (< 12–24 mo) fracture, multiple vertebral fractures, very low BMD (e.g. T ≤ −3.0) with fracture, very high FRAX, or fracture ON antiresorptive therapy — very-high-risk stratum (Endo Soc 2020 PMID 32068863; AACE/ACE 2020 PMID 33577971)
Denosumab being stopped / a dose lapsing without a planned bisphosphonate transition (Cummings JBMR 2018 PMID 29105841)

5. Follow-up

Drug-holiday logic: reassess oral bisphosphonate at ~5 years / IV zoledronate at ~3 years (FLEX PMID 17190893) — continue if still high/very-high risk, holiday if risk reduced; denosumab has NO holiday (transition to a bisphosphonate on stopping). Re-stratify very-high-risk patients; sustain calcium/vitamin D, weight-bearing/resistance exercise, smoking/alcohol counselling and a falls-prevention programme; lifelong surveillance — the diagnosis persists even if T-score rises above −2.5 (BHOF 2022 PMID 35478046; AACE/ACE 2020 PMID 33577971)

6. Sources

Guideline: Endocrine Society 2019 Pharmacological Management of Osteoporosis in Postmenopausal Women (Eastell, JCEM) + 2020 update (Shoback/Eastell) + AACE/ACE 2020 (Camacho) + BHOF 2022 Clinician’s Guide (LeBoff) + ACP 2023 living guideline (Qaseem) + ASBMR/BHOF 2024 goal-directed treat-to-target position statement; reconciled with the landmark RCTs (FIT, VERT-NA, HORIZON-PFT, FREEDOM, FPT, ACTIVE, FRAME, ARCH, FLEX) and the ASBMR atypical-femoral-fracture task force