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endo.osteoporosis.core.v1

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

endocrinologychronicadultgeriatric
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Osteoporosis is a SILENT fragility state: name it before the fracture (primary) or act on the sentinel fracture (secondary). Spine = (1) diagnose via 3 non-hierarchical routes [T ≤ −2.5 / fragility hip-or-vertebral fracture / FRAX above threshold], (2) EXCLUDE secondary causes before the primary label (osteoporosis vs osteomalacia vs CKD-MBD vs myeloma — pivots: vit D, PTH, ALP, Z-score, SPEP), (3) treat-to-target risk-stratified with DIRECTIONAL anabolic→antiresorptive sequencing (Endo Soc 2019 PMID 30907953; BHOF 2022 PMID 35478046; ASBMR/BHOF 2024 PMID 39073912)

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Scope set to chronic ambulatory bone-fragility with the 3-decision cascade explicit

Patient inputs (22)

FRAX input and age-stratified treat threshold; oldest-old re-frame treatment goals (FRAX PMID 18292978; BHOF 2022)

Male osteoporosis is under-diagnosed and skews secondary-cause prior (hypogonadism); FRAX sex-specific

Postmenopausal estrogen loss is the dominant primary mechanism; sets pre-test prior

Prior hip/vertebral fragility fracture is diagnostic regardless of BMD and ≈ 2–5× refracture (highest in first 12 months) (BHOF 2022)

Glucocorticoid dose/duration is independently bone-toxic and is under-weighted by raw FRAX → very-high-risk overlay (AACE/ACE 2020)

Hyperparathyroidism, hyperthyroidism, hypogonadism, coeliac, myeloma, Cushing, CKD, malabsorption — must be excluded BEFORE labelling primary osteoporosis (Endo Soc 2019)

Glucocorticoid, aromatase inhibitor, ADT, PPI, SSRI, anticonvulsant, long-term heparin are bone-toxic; reconcile and time antiresorptive vs dental work

Lowest of LS / total hip / femoral neck T-score is a diagnostic route (≤ −2.5) and treat-to-target metric (ISCD; BHOF 2022)

Low 25-OH-D with high ALP pivots toward OSTEOMALACIA (MECE) and must be repleted before potent antiresorptive (BHOF 2022)

Ca/PO4/ALP pattern separates osteoporosis (normal) from osteomalacia (ALP ↑) and CKD-MBD; hypocalcaemia must be corrected pre-antiresorptive

High PTH → primary hyperparathyroidism (route out) or CKD-MBD (MECE pivot — do NOT just give a bisphosphonate)

eGFR (CKD-EPI 2021, race-neutral) gates bisphosphonate use (avoid < 30–35) and is the CKD-MBD pivot (calc.ckd_epi_2021)

Z-score ≤ −2.0 raises the SECONDARY-cause prior and forces the secondary work-up branch

SPEP / serum free light chains — myeloma is a malignant mimic of osteoporosis (MECE pivot)

Hypogonadism is the leading secondary cause in male osteoporosis

Coeliac disease is a common occult malabsorptive secondary cause

24-h urinary calcium screens idiopathic hypercalciuria / malabsorption

Fracture = bone fragility × fall energy; falls programme is a non-pharmacologic pillar (BHOF 2022)

A morphometric/clinical vertebral fracture is a stand-alone osteoporosis diagnosis and ~5× further-vertebral-fracture risk (BHOF 2022)

Hyperthyroidism / over-replacement is a reversible secondary cause of accelerated bone loss

CTX / P1NP baseline + on-treatment change drives adherence/response and treat-to-target

New thigh/groin pain on long-term bisphosphonate/denosumab = possible impending ATYPICAL FEMORAL FRACTURE — bilateral femoral imaging (Shane PMID 23712442)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningvertebral_fracture_with_neuro_compromise
    Acute vertebral fracture with cord / cauda-equina signs (leg weakness, sensory level, bowel/bladder dysfunction) (BHOF 2022 PMID 35478046)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereimpending_atypical_femoral_fracture
    New thigh / groin prodromal pain on long-term bisphosphonate or denosumab — possible incomplete / impending atypical femoral fracture (Shane ASBMR PMID 23712442)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremalignancy_myeloma_mimic_before_antiresorptive
    Low BMD / fragility fracture with anaemia, weight loss, hypercalcaemia, lytic lesions, or abnormal SPEP — myeloma / malignancy mimic of osteoporosis (Endo Soc 2019 PMID 30907953)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevery_high_fracture_risk_anabolic_first
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredenosumab_discontinuation_rebound_risk
    Denosumab being stopped / a dose lapsing without a planned bisphosphonate transition (Cummings JBMR 2018 PMID 29105841)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateosteomalacia_or_ckd_mbd_pivot
    Low 25-OH vitamin D + high alkaline phosphatase (osteomalacia) OR low eGFR + high PTH + abnormal Ca×PO4 (CKD-MBD / renal osteodystrophy) — NOT primary osteoporosis (Endo Soc 2019 PMID 30907953)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatethyroid_driven_secondary_bone_loss
    Suppressed TSH (< 0.45; especially < 0.10 mIU/L) — endogenous subclinical/overt hyperthyroidism OR levothyroxine over-replacement as a reversible secondary cause of accelerated bone loss (Blum IPD JAMA 2015 PMID 26010634; Zhu meta PMID 31721088)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateestrogen_deficiency_overlap_menopause_or_pcos
    Premature/early menopause, primary ovarian insufficiency, or chronic hypoestrogenic amenorrhoea (lean-PCOS / functional-hypothalamic overlap) driving low BMD in a younger woman — an estrogen-deficiency secondary pathway (Endo Soc 2019 PMID 30907953; WHI RCT PMID 12117397)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateglucocorticoid_induced_osteoporosis
    Chronic glucocorticoid ≥ 2.5–7.5 mg prednisone-equivalent ≥ 3 months — glucocorticoid-induced bone loss (FRAX under-weights dose) (AACE/ACE 2020 PMID 33577971)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemale_osteoporosis_secondary_cause
    Male osteoporosis — under-diagnosed; high prior for a secondary cause (hypogonadism, alcohol, glucocorticoid, hypercalciuria) (Endo Soc 2019 PMID 30907953)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_low_egfr_bisphosphonate_unsuitable
    eGFR < 30–35 (CKD-EPI 2021) — oral / IV bisphosphonate contraindicated; denosumab pathway with hypocalcaemia vigilance (BHOF 2022 PMID 35478046)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildbisphosphonate_drug_holiday_reassessment
    Oral bisphosphonate ~5 years / IV zoledronate ~3 years reached — drug-holiday vs continuation decision (FLEX PMID 17190893; AACE/ACE 2020 PMID 33577971)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

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)
axis: osteoporosis_risk_stratified_treat_to_target_ladderstep 1 - Step 1 — Universal foundation + treat the secondary cause (no osteoporosis-specific drug yet if a reversible cause dominates)
Selected step "Step 1 — Universal foundation + treat the secondary cause (no osteoporosis-specific drug yet if a reversible cause dominates)" — Every patient before/with any antiresorptive or anabolic
  • cholecalciferol (vitamin D3)
    first line
    fat_soluble_vitamin
    800–2000 IU/day, titrate to 25-OH-D ≥ 30 ng/mL • PO • once daily
    triggers: vitamin_d_insufficiency, before_or_with_potent_antiresorptive
    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)
    rxcui 2418
  • calcium carbonate (diet-first)
    first line
    mineral_supplement
    500–600 mg elemental BID with meals; total diet + supplement ~1000–1200 mg/day • PO • BID with meals
    triggers: inadequate_dietary_calcium
    BHOF 2022 (PMID 35478046) — adequate calcium with vitamin D underpins every antifracture regimen
    rxcui 1897
  • treat the identified secondary cause first (parathyroidectomy / control hyperthyroidism / replace gonadal axis / gluten-free diet / taper glucocorticoid / treat myeloma)
    first line
    secondary_cause_treatment
    triggers: primary_hyperparathyroidism, hyperthyroidism, hypogonadism, coeliac_disease, glucocorticoid_excess, myeloma
    Endo Soc 2019 (PMID 30907953) — a reversible secondary cause is treated before (or with) the antiresorptive; route primary HPT to endo.hyperparathyroidism.v1

outpatient playbook — drug actions (6)

  1. 1. calcium + vitamin D foundation + treat the secondary cause
    vitamin D to 25-OH-D ≥ 30 ng/mL; calcium ~1000–1200 mg/day total; treat the named secondary cause • PO • daily
    trigger: Every patient before/with antiresorptive or anabolic
    Adjunct foundation; replete before potent antiresorptive (BHOF 2022 PMID 35478046)
  2. 2. oral bisphosphonate (alendronate/risedronate) — HIGH risk
    Alendronate 70 mg weekly (risedronate 35 mg weekly alternative) • PO • weekly
    trigger: Treat-threshold osteoporosis, eGFR ≥ 30–35, not very-high-risk
    FIT/VERT vertebral RR ~0.53–0.59, hip RR ~0.49 (PMID 8950879; 10527181)
  3. 3. IV zoledronate or denosumab — HIGH risk, oral unsuitable
    Zoledronate 5 mg IV yearly OR denosumab 60 mg SC q6mo • IV/SC • yearly / q6 months
    trigger: Oral intolerance / adherence concern / eGFR < 30–35 (denosumab)
    HORIZON vert HR 0.30 / hip HR 0.59 (PMID 17476007); FREEDOM vert RR 0.32 / hip HR 0.60 (PMID 19671655)
  4. 4. anabolic-first (teriparatide/abaloparatide/romosozumab) — VERY-HIGH risk
    Teriparatide 20 µg SC daily / abaloparatide 80 µg SC daily (≤ 2 yr) / romosozumab 210 mg SC monthly (12 mo) • SC • daily / monthly
    trigger: Recent/multiple/severe fracture, very low BMD with fracture, very high FRAX, fracture on therapy
    FPT/ACTIVE/FRAME vert RR 0.35/0.14/0.27 (PMID 11346808; 27533157; 27641143); romosozumab CV contraindication (PMID 28892457)
  5. 5. mandatory antiresorptive consolidation after any anabolic
    Alendronate 70 mg weekly OR zoledronate 5 mg IV • PO/IV • weekly / single then reassess
    trigger: Anabolic course complete
    Anabolic gain lost without consolidation; NEVER reverse the sequence (ASBMR/BHOF 2024 PMID 39073912)
  6. 6. raloxifene / menopausal hormone therapy — selected
    Raloxifene 60 mg PO daily • PO • daily
    trigger: Postmenopausal vertebral-predominant / breast-cancer-risk / vasomotor context, other agents unsuitable
    Vertebral (not hip) fracture reduction; VTE caution (Endo Soc 2019 PMID 30907953)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Postmenopausal woman or man ≥ 50 — screening / risk-assessment visit (BHOF 2022 PMID 35478046); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Osteoporosis & fragility-fracture prevention (DXA/FRAX → treat-to-target)** (endo.osteoporosis.core.v1).
Phenotype framing: MECE terminal split: PRIMARY osteoporosis (postmenopausal / age-related / idiopathic) vs SECONDARY osteoporosis (glucocorticoid, hyperparathyroidism, hyperthyroidism / levothyroxine over-replacement, hypogonadism, coeliac/malabsorption, myeloma) vs OSTEOMALACIA (vit D ↓ + ALP ↑) vs CKD-MBD / renal osteodystrophy (eGFR ↓ + PTH ↑) vs MALIGNANCY/MYELOMA (SPEP, lytic). Discriminators (named): vitamin D, PTH, alkaline phosphatase, Z-score, SPEP. QUANTITATIVE Bayes layer (verified): per −1 SD hip BMD RR 2.6 (2.0–3.5) / spine BMD for vertebral RR 2.3 (1.9–2.8) (Marshall meta BMJ 1996 PMID 8634613) → a ~3-SD-low hip (≈ T ≤ −3.0) carries a cumulative ~2.6³ ≈ 17–18× gradient; a prior moderate/severe morphometric vertebral fracture independently RR 4.23 (3.58–5.00) for a further vertebral fracture, mild RR 2.17 (1.70–2.76) (Johansson/Kanis meta PMID 23974856) — the very-low-BMD + prior-vertebral-fracture cluster is the wired strongest LR+ (≈ 20–30, multiplicative gradient × prior-fracture). Subclinical hyperthyroidism / TSH < 0.10 raises spine-fracture HR up to 3.57 (1.88–6.78) (Blum IPD JAMA 2015 PMID 26010634) → pivots toward endo.hyperthyroidism.core.v1 / levothyroxine over-replacement (endo.hypothyroidism.core.v1) (Endo Soc 2019 PMID 30907953)
Scope: Osteoporosis is a SILENT fragility state: name it before the fracture (primary) or act on the sentinel fracture (secondary). Spine = (1) diagnose via 3 non-hierarchical routes [T ≤ −2.5 / fragility hip-or-vertebral fracture / FRAX above threshold], (2) EXCLUDE secondary causes before the primary label (osteoporosis vs osteomalacia vs CKD-MBD vs myeloma — pivots: vit D, PTH, ALP, Z-score, SPEP), (3) treat-to-target risk-stratified with DIRECTIONAL anabolic→antiresorptive sequencing (Endo Soc 2019 PMID 30907953; BHOF 2022 PMID 35478046; ASBMR/BHOF 2024 PMID 39073912)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — Universal foundation + treat the secondary cause (no osteoporosis-specific drug yet if a reversible cause dominates)".
1. cholecalciferol (vitamin D3) 800–2000 IU/day, titrate to 25-OH-D ≥ 30 ng/mL PO once daily (fat_soluble_vitamin, first line) — 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)
2. calcium carbonate (diet-first) 500–600 mg elemental BID with meals; total diet + supplement ~1000–1200 mg/day PO BID with meals (mineral_supplement, first line) — BHOF 2022 (PMID 35478046) — adequate calcium with vitamin D underpins every antifracture regimen
3. treat the identified secondary cause first (parathyroidectomy / control hyperthyroidism / replace gonadal axis / gluten-free diet / taper glucocorticoid / treat myeloma) (secondary_cause_treatment, first line) — Endo Soc 2019 (PMID 30907953) — a reversible secondary cause is treated before (or with) the antiresorptive; route primary HPT to endo.hyperparathyroidism.v1

Setting playbook (outpatient) — Diagnose via the 3 routes, EXCLUDE secondary causes before the primary label, risk-stratify high vs very-high, treat-to-target with directional anabolic→antiresorptive sequencing, and manage CKD / glucocorticoid / male / denosumab-transition / drug-holiday special cases (Endo Soc 2019 PMID 30907953; BHOF 2022 PMID 35478046; ASBMR/BHOF 2024 PMID 39073912)
4. calcium + vitamin D foundation + treat the secondary cause vitamin D to 25-OH-D ≥ 30 ng/mL; calcium ~1000–1200 mg/day total; treat the named secondary cause PO daily — Every patient before/with antiresorptive or anabolic (Adjunct foundation; replete before potent antiresorptive (BHOF 2022 PMID 35478046))
5. oral bisphosphonate (alendronate/risedronate) — HIGH risk Alendronate 70 mg weekly (risedronate 35 mg weekly alternative) PO weekly — Treat-threshold osteoporosis, eGFR ≥ 30–35, not very-high-risk (FIT/VERT vertebral RR ~0.53–0.59, hip RR ~0.49 (PMID 8950879; 10527181))
6. IV zoledronate or denosumab — HIGH risk, oral unsuitable Zoledronate 5 mg IV yearly OR denosumab 60 mg SC q6mo IV/SC yearly / q6 months — Oral intolerance / adherence concern / eGFR < 30–35 (denosumab) (HORIZON vert HR 0.30 / hip HR 0.59 (PMID 17476007); FREEDOM vert RR 0.32 / hip HR 0.60 (PMID 19671655))
7. anabolic-first (teriparatide/abaloparatide/romosozumab) — VERY-HIGH risk Teriparatide 20 µg SC daily / abaloparatide 80 µg SC daily (≤ 2 yr) / romosozumab 210 mg SC monthly (12 mo) SC daily / monthly — Recent/multiple/severe fracture, very low BMD with fracture, very high FRAX, fracture on therapy (FPT/ACTIVE/FRAME vert RR 0.35/0.14/0.27 (PMID 11346808; 27533157; 27641143); romosozumab CV contraindication (PMID 28892457))
8. mandatory antiresorptive consolidation after any anabolic Alendronate 70 mg weekly OR zoledronate 5 mg IV PO/IV weekly / single then reassess — Anabolic course complete (Anabolic gain lost without consolidation; NEVER reverse the sequence (ASBMR/BHOF 2024 PMID 39073912))
9. raloxifene / menopausal hormone therapy — selected Raloxifene 60 mg PO daily PO daily — Postmenopausal vertebral-predominant / breast-cancer-risk / vasomotor context, other agents unsuitable (Vertebral (not hip) fracture reduction; VTE caution (Endo Soc 2019 PMID 30907953))

Non-pharmacologic actions:
- Weight-bearing + resistance exercise; smoking cessation; limit alcohol (BHOF 2022 PMID 35478046)
- Multifactorial falls-prevention programme (home hazards, vision, medication review) (BHOF 2022 PMID 35478046)
- Dental review before / during long-term antiresorptive (ONJ) (Shane PMID 23712442)
- Fracture-liaison-service enrolment; bidirectional loop with msk.fracture-triage.core.v1 (BHOF 2022 PMID 35478046)
- Route a confirmed primary hyperparathyroidism to endo.hyperparathyroidism.v1 (Endo Soc 2019 PMID 30907953)

AVOID / contraindication checks:
- Bisphosphonate_avoid_if_eGFR_lt_30_35_use_denosumab_pathway (BHOF 2022 PMID 35478046; AACE/ACE 2020 PMID 33577971)
- Replete_calcium_and_vitamin_D_before_any_potent_antiresorptive_hypocalcaemia_risk (BHOF 2022 PMID 35478046)
- Denosumab_has_NO_drug_holiday_must_transition_to_bisphosphonate_on_stopping_rebound_multiple_vertebral_fracture (Cummings PMID 29105841)
- Sequence_is_anabolic_then_antiresorptive_NEVER_antiresorptive_then_anabolic_blunts_anabolic_gain (ASBMR/BHOF 2024 PMID 39073912)
- Romosozumab_contraindicated_within_12_months_of_MI_or_stroke (ARCH PMID 28892457; Endo Soc 2020 PMID 32068863)
- Oral_bisphosphonate_upright_fasting_dosing_and_dental_review_to_reduce_ONJ; new_thigh_groin_pain_on_long_term_antiresorptive_is_impending_atypical_femoral_fracture (Shane ASBMR PMID 23712442)
- Teriparatide_abaloparatide_max_lifetime_~2_years; romosozumab_12_months (Endo Soc 2019 PMID 30907953)
- Exclude_secondary_cause_osteomalacia_CKD_MBD_myeloma_before_labelling_primary_osteoporosis (Endo Soc 2019 PMID 30907953)

Monitoring

Regimen monitoring:
- DXA q1–2 years toward the T-score treat-to-target goal (ASBMR/BHOF 2024 PMID 39073912)
- bone turnover markers (CTX/P1NP) at ~3–6 months for response and adherence (ASBMR/BHOF 2024 PMID 39073912)
- serum calcium / 25-OH vitamin D after potent antiresorptive (hypocalcaemia) (BHOF 2022 PMID 35478046)
- dental review pre- and during long-term antiresorptive; AFF prodrome (thigh/groin pain) surveillance (Shane PMID 23712442)
- denosumab — confirm next dose is given on time or a transition is planned; no lapse (Cummings PMID 29105841)
- bisphosphonate drug-holiday reassessment at ~3 (IV) / ~5 (oral) years (FLEX PMID 17190893)

Setting (outpatient) monitoring:
- DXA q1–2 years to the T-score target (ASBMR/BHOF 2024 PMID 39073912)
- Bone-turnover markers (CTX/P1NP) at ~3–6 months for adherence/response (ASBMR/BHOF 2024 PMID 39073912)
- Serum calcium / vitamin D after potent antiresorptive; AFF prodrome + dental surveillance (Shane PMID 23712442)
- Denosumab dosing-interval vigilance (no lapse without transition) (Cummings PMID 29105841)
- Bisphosphonate drug-holiday reassessment at ~3 (IV) / ~5 (oral) years (FLEX PMID 17190893)

Follow-up plan: 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)
- Close-out criterion: Drug-holiday / continuation decision made, falls + lifestyle plan and lifelong surveillance booked

Monitoring phase: Treat-to-target: DXA q1–2 years toward the T-score goal; bone-turnover markers (CTX / P1NP) at ~3–6 months to confirm response and adherence; serum calcium / vitamin D after potent antiresorptive (hypocalcaemia); dental review and atypical-femoral-fracture prodrome surveillance on long-term bisphosphonate/denosumab; never let a denosumab dose lapse without a transition plan (ASBMR/BHOF 2024 PMID 39073912; Shane PMID 23712442; Cummings PMID 29105841)

Disposition

Current setting: outpatient — Diagnose via the 3 routes, EXCLUDE secondary causes before the primary label, risk-stratify high vs very-high, treat-to-target with directional anabolic→antiresorptive sequencing, and manage CKD / glucocorticoid / male / denosumab-transition / drug-holiday special cases (Endo Soc 2019 PMID 30907953; BHOF 2022 PMID 35478046; ASBMR/BHOF 2024 PMID 39073912)

Disposition criteria:
- Continue outpatient endocrinology / FLS once on a risk-appropriate treat-to-target regimen (BHOF 2022 PMID 35478046)
- Refer for vertebral augmentation / atypical-femoral-fracture surgery, or route the secondary cause to its own engine, as indicated (Endo Soc 2019 PMID 30907953)

Escalation triggers (move to higher acuity):
- Vertebral fracture with neurologic deficit (cord/cauda) → emergent spine imaging + surgery (BHOF 2022 PMID 35478046)
- Malignancy/myeloma pattern (anaemia, hypercalcaemia, lytic lesions, abnormal SPEP) → oncology before antiresorptive (Endo Soc 2019 PMID 30907953)
- New thigh/groin prodromal pain on long-term bisphosphonate/denosumab → bilateral femoral imaging, hold drug, orthopaedics (Shane PMID 23712442)
- Severe symptomatic hypocalcaemia → correct before any potent antiresorptive (BHOF 2022 PMID 35478046)
- Fracture while on adherent therapy → re-stratify to very-high-risk, switch to anabolic-first (ASBMR/BHOF 2024 PMID 39073912)

Patient Action Plan

**Osteoporosis bone-health & fracture-prevention plan**
Personalised values: fracture_risk_tier, osteoporosis_medication, drug_holiday_status, denosumab_next_dose_date, calcium_vitamin_d_target.

**Stable, on treatment, risk controlled** (green):
Triggers:
- Taking your bone medicine and calcium/vitamin D as prescribed
- No new back pain, height loss, or fractures
- DXA and follow-up on schedule
Actions:
- 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)

**Caution — new symptoms or a missed/late dose** (yellow):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- 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)

**Emergency — acute fracture or nerve signs** (red):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- Always seek emergency care for an acute fracture or any new leg weakness / numbness / bladder-bowel change with back pain

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute vertebral fracture with cord / cauda-equina signs (leg weakness, sensory level, bowel/bladder dysfunction) (BHOF 2022 PMID 35478046)
- [SEVERE] New thigh / groin prodromal pain on long-term bisphosphonate or denosumab — possible incomplete / impending atypical femoral fracture (Shane ASBMR PMID 23712442)
- [SEVERE] Low BMD / fragility fracture with anaemia, weight loss, hypercalcaemia, lytic lesions, or abnormal SPEP — myeloma / malignancy mimic of osteoporosis (Endo Soc 2019 PMID 30907953)

Citations

- 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 [PMID:30907953](https://pubmed.ncbi.nlm.nih.gov/30907953/)
- Cited evidence (PMID 32068863) [PMID:32068863](https://pubmed.ncbi.nlm.nih.gov/32068863/)
- Cited evidence (PMID 33577971) [PMID:33577971](https://pubmed.ncbi.nlm.nih.gov/33577971/)
- Cited evidence (PMID 35478046) [PMID:35478046](https://pubmed.ncbi.nlm.nih.gov/35478046/)
- Cited evidence (PMID 36592456) [PMID:36592456](https://pubmed.ncbi.nlm.nih.gov/36592456/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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 — PMID:30907953
  • Cited evidence (PMID 32068863) — PMID:32068863
  • Cited evidence (PMID 33577971) — PMID:33577971
  • Cited evidence (PMID 35478046) — PMID:35478046
  • Cited evidence (PMID 36592456) — PMID:36592456