What are the criteria for treating osteoporosis?

Treatment Criteria for Osteoporosis

Pharmacologic treatment for osteoporosis should be initiated in postmenopausal women and men ≥50 years with a T-score ≤-2.5 at the hip, femoral neck, or lumbar spine, OR in those with a history of fragility fracture, OR in patients with osteopenia (T-score between -1.0 and -2.5) who have a 10-year fracture risk ≥20% for major osteoporotic fracture or ≥3% for hip fracture based on FRAX assessment. 1

Diagnostic Thresholds for Treatment

Primary Osteoporosis Criteria

• T-score ≤-2.5: Treatment is recommended for any patient with bone mineral density (BMD) at the femoral neck, lumbar spine, or total hip that is ≥2.5 standard deviations below the mean BMD value for a young woman 1

• History of fragility fracture: Treatment should be considered in patients who have had a low-trauma fracture, even if DEXA does not indicate osteoporosis 1

• Osteopenia with elevated fracture risk: For patients with T-scores between -1.0 and -2.5, use FRAX to calculate 10-year fracture risk. Treat if major osteoporotic fracture risk ≥20% OR hip fracture risk ≥3% 1

Glucocorticoid-Induced Osteoporosis (GIOP) Criteria

Adults ≥40 years on glucocorticoids ≥2.5 mg/day prednisone equivalent for >3 months:

• High risk: History of osteoporotic fracture OR T-score ≤-2.5 OR FRAX 10-year major osteoporotic fracture risk ≥20% OR hip fracture risk ≥3% 1

• Very high risk: FRAX 10-year major osteoporotic fracture risk >30% OR hip fracture risk >4.5% OR very high-dose glucocorticoids (≥30 mg/day prednisone for >30 days or cumulative annual dose ≥5 grams) 1

Adults <40 years on glucocorticoids:

• History of osteoporotic fracture OR Z-score <-3 at hip or spine with prednisone >7.5 mg/day OR bone loss ≥10%/year at hip or spine with prednisone >7.5 mg/day 1

Screening Recommendations

• Women: DEXA screening for all women ≥65 years; postmenopausal women <65 years with risk factors (history of fragility fracture, weight <127 lb, medications/diseases causing bone loss, parental history of hip fracture) 1

• Men: The American College of Rheumatology recommends screening men ≥70 years and men with clinical risk factors, though evidence is limited 1

Special Population Criteria

Low Bone Mass (Osteopenia) Without Osteoporosis

• Females ≥65 years with low bone mass: Consider treatment with bisphosphonates (specifically zoledronate showed benefit in reducing clinical and vertebral fractures in older females with baseline fracture risk of 2.3%) 1

• Males with low bone mass: Evidence is insufficient to make firm recommendations for or against treatment 1

Women of Childbearing Potential

• Treatment criteria are the same as above, but medication selection differs. Oral bisphosphonates are preferred if not planning pregnancy and using effective contraception 1

Baseline Assessment Requirements

Before initiating treatment, assess:

• Bone mineral density via DEXA at femoral neck, total hip, and lumbar spine 1
• History of fractures (particularly fragility fractures from standing height or less) 1
• Secondary causes of osteoporosis: hypogonadism, vitamin D deficiency (target level ≥20 ng/mL), hypercalciuria, malabsorption, medications (especially glucocorticoids), thyroid disorders 1
• Fracture risk calculation using FRAX (glucocorticoid-adjusted for GIOP patients) 1
• Vertebral fracture assessment via radiography or DXA vertebral fracture assessment software in patients with height loss or osteopenia, as silent vertebral fractures trigger treatment regardless of FRAX score 1, 2

Universal Non-Pharmacologic Interventions

All patients meeting treatment criteria should receive:

• Calcium: 1,000-1,200 mg/day for adults 19-50 years; 1,200 mg/day for those ≥51 years 1
• Vitamin D: 600-800 IU/day (target serum 25(OH)D ≥20-30 ng/mL, some guidelines recommend ≥30-50 ng/mL for GIOP) 1
• Lifestyle modifications: weight-bearing exercise, smoking cessation, alcohol limitation (≤1-2 drinks/day), fall prevention strategies 1

Common Pitfalls

• Do not wait for a fracture to occur before treating patients with T-scores ≤-2.5 1
• Do not rely solely on T-scores in patients with osteopenia; always calculate FRAX to identify those who would benefit from treatment 1, 2
• Do not overlook secondary causes of osteoporosis, as these are present in 44-90% of cases and may require specific interventions beyond standard osteoporosis treatment 1
• Do not forget to screen for silent vertebral fractures in patients with height loss, as these change management even with osteopenia 1, 2
• FRAX has not been validated in HIV-infected persons and may underestimate fracture risk in this population 1