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Osteoporosis
Osteoporosis is diagnosed by a T-score of −2.5 or less or by a fragility fracture of the hip or spine; a bisphosphonate is first-line, and denosumab must not be stopped without follow-on treatment because of "rebound" vertebral fractures.
Why it matters in the exam
Questions present a postmenopausal woman with low bone density or a fracture after a fall from standing height, and ask about diagnosis, work-up or treatment. The definitions must be remembered: a T-score of −2.5 or less = osteoporosis, between −1 and −2.5 = osteopenia (treat by FRAX risk), and a fragility fracture of the hip or spine diagnoses osteoporosis even without a density test. Before treatment a secondary cause is sought: steroids (prednisone 5 mg or more for 3 months or more), overactive thyroid or parathyroid, hypogonadism, coeliac disease, vitamin D deficiency and myeloma.
Treatment questions: calcium (1000–1200 mg a day) and vitamin D for all; alendronate once a week on an empty stomach, standing or sitting for 30 minutes, and not with oesophageal disease or a low eGFR (below 35); intravenous zoledronic acid once a year as an alternative. After 5 years of oral treatment (3 years intravenous) a low-risk patient may have a "drug holiday". Denosumab is given every 6 months and does not depend on kidney function, but stopping it without a bisphosphonate afterwards causes multiple vertebral fractures. At very high risk, anabolic treatment (teriparatide or romosozumab) comes first. Rare complications: osteonecrosis of the jaw and atypical femoral fracture (thigh pain).
Key points
- Diagnosis: T-score −2.5 or less or a fragility fracture of hip or spine.
- Look for a secondary cause before treatment.
- First line: alendronate; alternative: zoledronic acid once a year.
- Denosumab every 6 months — do not stop without follow-on treatment.
- Very high risk: anabolic treatment first; calcium 1000–1200 mg and vitamin D for all.
Summary table
| Topic | Value / indication | Treatment | Exam note |
|---|---|---|---|
| Diagnosis | T-score −2.5 or less, or a fragility fracture of hip or spine | Drug treatment | Osteopenia: −1 to −2.5, by FRAX |
| Oral bisphosphonate | First line | Alendronate once a week, 30 minutes upright on an empty stomach | Not with oesophageal disease or eGFR below 35 |
| Intravenous bisphosphonate | Oral intolerance | Zoledronic acid once a year | Drug holiday after 3 years at low risk |
| Denosumab | CKD or intolerance | Injection every 6 months | Never stop without a bisphosphonate afterwards |
| Anabolic | Very high risk, multiple fractures | Teriparatide or romosozumab | Followed by antiresorptive treatment |
| Base for all | Every patient | Calcium 1000–1200 mg a day and vitamin D 800–1000 IU | Fall prevention and exercise |
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Sources
- Endocrine Society Clinical Practice Guideline: Pharmacological Management of Osteoporosis in Postmenopausal Women, 2019, with the 2020 update — Bisphosphonates, denosumab and anabolic therapy
- American College of Physicians Guideline: Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass, 2023 — First-line treatment and duration
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Osteoporosis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.