Become a Certified Prepared Patient
for Osteoporosis

Diagnostic Workup & Differential

• Diagnosis: DXA T-score ≤ -2.5 at hip or lumbar spine, OR any fragility fracture regardless of T-score. USPSTF recommends screening women 65+; postmenopausal women under 65 with FRAX 10-yr major-osteoporotic ≥9.3%. USPSTF says evidence insufficient for routine male screening; BHOF / AACE / Endocrine Society support broader screening (men 70+ or younger with risk factors).
• VFA on lateral DXA at diagnosis catches silent vertebral fractures (~2/3 are clinically silent) and often changes management.
• Secondary-cause workup mandatory after any fragility fracture: CBC, CMP, TSH, 25-OH vitamin D, intact PTH, 24-hr urine calcium, SPEP/UPEP (myeloma rule-out in older patients), celiac panel if suspected, testosterone in men, cortisol screening if Cushing suspected.
• Differential: osteoarthritis (joint cartilage), osteomalacia (defective mineralization — severe vit D deficiency, Fanconi syndrome, hypophosphatemia), Paget's disease (focal disordered remodeling), multiple myeloma, metastatic bone disease, primary hyperparathyroidism, hyperthyroidism.
• Survivorship overlap: aromatase-inhibitor-treated breast cancer survivors and ADT-treated prostate cancer survivors warrant baseline DXA + Q1–2 yr follow-up + often an antiresorptive (denosumab common). Coordinate with oncology.
• Always ask about height trend, falls / near-falls, prior fragility fractures, and adherence at every visit.
• Equity audit: AA / Latina / Asian women are screened and treated MUCH less despite real fracture risk; men with osteoporosis are massively undertreated (<20% start bone medication after a hip fracture). Build active prompts into your workflow.

Evidence-Based Treatment

• Bisphosphonates are first-line for most patients with osteoporosis or osteopenia + FRAX above threshold. Alendronate / risedronate oral weekly or monthly; zoledronic acid IV yearly (Reclast). Drug-holiday conversation typically after 3–5 yr oral or 3 doses IV if BMD has improved and ongoing risk is moderate/low.
• Denosumab (Prolia) Q6-month SC — strong fracture reduction. HONEST WARNING: never discontinue without a transition to a follow-on antiresorptive (typically a bisphosphonate). Rebound vertebral fractures within 7–18 months of stopping. Correct hypocalcemia before starting.
• Anabolic agents (teriparatide, abaloparatide, romosozumab) for severe or very-high-risk osteoporosis. Anabolic-first gives more BMD gain than antiresorptive-first in very-high-risk patients. All anabolics must be followed by an antiresorptive to lock in the gain. Romosozumab is contraindicated within 1 year of MI or stroke (CV signal in trials).
• Hormone therapy in early postmenopausal women with vasomotor symptoms reduces fracture risk; not first-line for osteoporosis alone. Raloxifene (SERM) reduces vertebral but not hip fractures.
• ONJ and atypical femoral fracture are real but rare: ONJ ~1:10,000–100,000 patient-years on oral bisphosphonate for osteoporosis; atypical femur ~1:1,000 patient-years after long-term use, with prodromal thigh pain. The math overwhelmingly favors treatment in high-risk patients.
• Pre-treatment dental evaluation is reasonable for high-risk dental work on bisphosphonate or denosumab; not mandatory for routine dentistry.
• Resistance training 2–3×/week + weight-bearing impact most days + balance training 2–3×/week has strong evidence (ACSM, BHOF, LIFTMOR / LIFTMOR-M). Walking alone is not enough.
• Calcium 1,000–1,200 mg/day from food first; supplements only to close a gap (calcium-supplement-cardiovascular controversy). Vitamin D 800–1,000 IU/day with 25-OH-D target ≥30 ng/mL. Protein 1.0–1.2 g/kg/day in older adults.
• Refer to behavioral health if depression / anxiety — depression doubles fracture risk; treating mood is bone-health work. SSRIs do raise fracture risk modestly, but treated depression lowers it more.

The Osteoporosis "NEVER" / "ALWAYS" List — Patient + Pharmacist + ER + Inpatient Nursing + Dentist

• NEVER discontinue denosumab without a transition to a follow-on antiresorptive — rebound vertebral fractures within 7–18 months. Plan the transition before stopping.
• NEVER walk on a possibly fractured hip after a fall — occult hip fractures show on MRI even with a negative X-ray.
• NEVER start denosumab or IV bisphosphonate in a hypocalcemic patient — correct calcium and vitamin D first.
• ALWAYS work up a secondary cause after any fragility fracture.
• ALWAYS document yearly standing height and act on loss >1.5 in from peak or >0.8 in/yr (VFA or thoracic/lumbar X-ray).
• ALWAYS close the post-fracture treatment gap — make sure the patient does not leave the hospital after a fragility fracture without a bone-health plan.
• ALWAYS audit for bone-loss-risk meds (steroids, AI, ADT, SSRIs, anticonvulsants, long-term PPIs, thiazolidinediones).

What Quality Metrics Should Look Like for a Prepared Patient · Osteoporosis

• DXA + FRAX + 25-OH-D + height trend at every visit; one-page numbers card patient-owned; secondary-cause workup complete after any fragility fracture; adherence tracked.
• Bone-health referrals: PCP coordinates most uncomplicated osteoporosis; Endocrinology for complex / anabolic / hyperparathyroidism / multiple secondary causes; Rheumatology if autoimmune + chronic steroids; osteoporosis-trained PT for resistance + balance + posture; OT for home safety; Pharmacist for adherence + dosing routine + bone-loss-risk medication audit; Dentist for pre-clearance on bisphosphonate/denosumab high-risk dental work; Behavioral Health for mood; Oncology if survivor; Nephrology if CKD; BHOF peer; family Ambassador; RRPS-certified community member if available.
• Post-fracture treatment-initiation rate: HEDIS measure — target ≥80% within 6 months of fragility fracture. Track it.
• Equity tracking: DXA rates and treatment-initiation rates by race/ethnicity and sex; close the AA / Latina / Asian and male gaps.