Guidelines for the management of osteoporosis

1) Over 75’s with a fragility fracture not previously on treatment

  • Check basic bloods (Calcium, ALP, phosphate) and any additional tests suggested by history and examination.
  • Treat empirically (unless contraindications) with Adcal D3 1 tablet bd and Alendronate 70mg weekly.

Evidence shows a 50% reduction in risk of vertebral, hip and wrist fractures with Alendronate. Many older people have subclinical Vitamin D deficiency and will benefit from supplementation. Treatment trials (bisphosphonates and Strontium) have been done with patients on Vitamin D and calcium.

  • If bisphosphonate intolerant (GI symptoms, oesophageal ulceration, erosion or stricture) use Strontium Ranelate 2g od as an alternative and in addition to Adcal D3. Please state clearly in notes and on EDL why strontium is being used instead of a bisphosphonate.

NB Renal Impairment –

Alendronate, Strontium and Zolendronic Acid are all only licensed for patients with a creatinine clearance of >30 mls/min. Residronate is licensed for a creatinine clearance down to 20 mls/min. If less than this it may be possible to give fortnightly; please discuss these patients with the orthogeriatricians.

2) Over 75’s with a fragility fracture previously on treatment

Treatment failure is usually due to poor compliance; only 40% of people continue to take their bisphosphonate after 1 year. If poor compliance is a factor treatment options include:

  • Strontium 2g od (if non-compliance is due to GI side effects).
  • Zolendronic Acid 5mg I.V once a year (refer to rheumatology for treatment initiation)
  • Dosette Box or NOMAD system (if non-compliance due to cognitive problems).

If patient is compliant with previous treatment and has been taking it for > 6 months this is treatment failure and the options for treatment are:

  • Strontium Ranelate 2g bd (this is on formulary for treatment failures in the over 80s).
  • Consideration of parathyroid hormone – Teriparatide.

Teriparatide has been recommended by NICE for women over 65 who have an unsatisfactory response to bisphonates, a very low Bone Mineral Density (BMD) and/or age independent risk factors. These patients should be discussed with the Orthogeriatrican first (even if young) and will require referral to the Rheumatologists.

3) Under 75’s with fragility fractures

These patients’s require investigation for secondary causes of osteoporosis. Check FBC, ESR, U&Es, LFTs, Ca, phos, ALP, TFTs, myeloma screen (serum electrophoresis and urine for Bence Jones Protein) and a PSA in men. If an abnormality is found treat or refer accordingly.

Use FRAX ( to calculate the 10 year probability for a further fragility fracture, follow the link to the NOGG and manage accordingly (either lifestyle advice, DEXA or treat). DEXA scans to assess Bone Mineral Density (BMD) are obtained by completing the standard referral letter and sending to Dr Jeremy McNally Consultant Rheumatologist.

Ensure lifestyle measures are addressed for all patients:

  • Stop smoking
  • Avoid excessive alcohol
  • Regular weight bearing exercise
  • Maintain adequate nutrient intake of Calcium and Vitamin D with supplements (Adcal D3).

Treatment depends on DEXA result which is inserted into the FRAX calculation tool. This result is likely to be available after patient is discharged so ask GP to review.

Please feel free to discuss any patients with the Orthogeriatricians (even if they are young) or the Rheumatologists.