Osteoporosis

Last updated 1 Jun 2026 · Endocrinology / Musculoskeletal

📋 Key Information Summary

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Osteoporosis is defined by a DEXA T-score of ≤ −2.5 at the lumbar spine, femoral neck, or total hip; osteopenia is a T-score between −1.0 and −2.5.
An estimated 4.74 million Australians aged ≥50 years have osteoporosis or osteopenia; one fracture occurs every 3.6 minutes nationally.
Major risk factors include increasing age, female sex, family history of hip fracture, prior fragility fracture, glucocorticoid use, smoking, excess alcohol (>2 standard drinks/day), low BMI (<18.5 kg/m²), and early menopause (<45 years).
Use the FRAX® tool (Australian model) or Garvan Fracture Risk Calculator to estimate 10-year fracture probability when T-score is in the osteopenic range (−1.0 to −2.5).
Z-scores (age- and sex-matched) are used for premenopausal women, men <50 years, and children; a Z-score ≤ −2.0 indicates bone density "below the expected range for age."
First-line pharmacotherapy is an oral bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly); IV zoledronic acid 5 mg annually is an alternative for those intolerant of oral bisphosphonates.
Denosumab (60 mg SC every 6 months) is PBS-listed as second-line after bisphosphonate failure or intolerance; abrupt discontinuation causes rebound vertebral fractures.
Calcium intake target is 1,000–1,300 mg/day (diet ± supplements); vitamin D supplementation (cholecalciferol 1,000–2,000 IU daily) is recommended when serum 25(OH)D <50 nmol/L.
Teriparatide (20 µg SC daily, maximum 24 months) is reserved for severe osteoporosis with ≥2 fractures or failure of anti-resorptive therapy; PBS Authority Required.
A "drug holiday" after 3–5 years of oral or 3 years of IV bisphosphonate should be considered in patients at moderate risk; reassess fracture risk annually.
Men account for ~30% of fragility fractures; osteoporosis in men is under-recognised and under-treated despite higher post-hip-fracture mortality.
Children with recurrent low-trauma fractures or a Z-score ≤ −2.0 require investigation for secondary causes (coeliac disease, glucocorticoid exposure, calcium/vitamin D deficiency, genetic bone disorders).
Aboriginal and Torres Strait Islander peoples have higher fracture rates in younger age groups and lower rates of DEXA screening and pharmacological treatment — active screening is essential.

Introduction & Australian Epidemiology

Osteoporosis is a systemic skeletal disorder characterised by low bone mineral density (BMD) and deterioration of bone microarchitecture, leading to reduced bone strength and increased fracture risk. It is often called a "silent disease" because bone loss occurs without symptoms until a fragility fracture presents — typically of the hip, spine (vertebral), or wrist (distal radius).

In Australia, osteoporosis and osteopenia affect an estimated 4.74 million people aged ≥50 years. Approximately 173,000 new fractures occur annually, with a fracture sustained every 3.6 minutes. The direct healthcare cost exceeds .44 billion per year, predominantly driven by hip fractures. Hip fracture carries a 12-month mortality of 20–30%, and fewer than 50% of survivors regain their pre-fracture level of mobility.

Despite the burden, osteoporosis remains under-diagnosed. Fewer than 20% of patients presenting to Australian emergency departments with a fragility fracture receive a DEXA scan or commence osteoporosis treatment — a well-documented "treatment gap." The Australian and New Zealand Bone and Mineral Society (ANZBMS), Osteoporosis Australia, and the Royal Australian College of General Practitioners (RACGP) advocate for systematic fracture-liaison services (FLS) to close this gap.

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Treatment gap: Fewer than 1 in 5 Australians who sustain a fragility fracture receive an osteoporosis assessment or treatment. Every fragility fracture should trigger a bone health evaluation — "no fracture left behind."

Risk Factors & Causes

Non-Modifiable Risk Factors

Age ≥65 years (BMD declines ~0.5–1% per year from age 40)
Female sex (oestrogen deficiency at menopause accelerates bone loss)
Family history of osteoporotic fracture (especially maternal hip fracture)
Personal history of fragility fracture after age 40
Early menopause (<45 years) or premature ovarian insufficiency
Small body frame / low BMI (<18.5 kg/m²)
Caucasian or Asian ethnicity (though all ethnicities are at risk)

Modifiable Risk Factors

Current smoking (reduces osteoblast function and oestrogen levels)
Excess alcohol intake (>2 standard drinks/day)
Low dietary calcium (<1,000 mg/day) and/or vitamin D deficiency
Physical inactivity / prolonged immobility
Recurrent falls (neuromuscular dysfunction, visual impairment, polypharmacy)

Medication-Induced (Secondary) Causes

Medication	Mechanism	Risk Level
Glucocorticoids (≥2.5 mg prednisolone/day for ≥3 months)	Decreases osteoblast activity, increases osteoclast activity, reduces calcium absorption	High — most common cause of secondary osteoporosis
Aromatase inhibitors (anastrozole, letrozole)	Oestrogen depletion in postmenopausal breast cancer	High
Androgen deprivation therapy (GnRH agonists)	Testosterone depletion in prostate cancer	High
Proton pump inhibitors (long-term)	Reduced calcium absorption	Moderate
SSRIs / anticonvulsants	Increased bone resorption or altered vitamin D metabolism	Moderate
Thiazolidinediones (pioglitazone)	PPARγ activation diverts mesenchymal cells from osteoblast to adipocyte lineage	Moderate

Diseases Causing Secondary Osteoporosis

Endocrine: hyperparathyroidism, hyperthyroidism, Cushing's syndrome, hypogonadism, type 1 & 2 diabetes mellitus
Gastrointestinal: coeliac disease, inflammatory bowel disease, chronic liver disease, bariatric surgery
Rheumatological: rheumatoid arthritis, systemic lupus erythematosus
Renal: chronic kidney disease–mineral and bone disorder (CKD-MBD)
Haematological: multiple myeloma, thalassaemia
Genetic: osteogenesis imperfecta, Turner syndrome, Klinefelter syndrome

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Clinical pearl: Approximately 20–30% of osteoporosis cases in Australian practice have a secondary cause. Perform basic screening (serum calcium, phosphate, ALP, 25(OH)D, TSH, FSH, coeliac serology, renal function, EPG/immunoglobulins) in all patients with osteoporosis, especially premenopausal women and men <50 years.

Pathophysiology

Bone is a dynamic tissue undergoing continuous remodelling through the balanced activity of osteoblasts (bone formation) and osteoclasts (bone resorption). The bone remodelling cycle (BMU — basic multicellular unit) takes approximately 3–6 months and involves coupling signals between these cell types via RANK/RANKL/OPG pathways.

In osteoporosis, there is an imbalance in bone remodelling:

Postmenopausal osteoporosis (Type I): Oestrogen deficiency leads to increased RANKL expression, enhanced osteoclast activity, and accelerated bone resorption. Trabecular bone (vertebrae, distal radius) is preferentially affected. Bone loss of up to 2–5% per year occurs in the first 5–10 years after menopause.
Age-related osteoporosis (Type II): Declining osteoblast numbers and function (senescence), secondary hyperparathyroidism from vitamin D insufficiency, and reduced renal function lead to gradual cortical and trabecular bone loss (~0.5–1%/year). Both hip and vertebral fractures increase.
Glucocorticoid-induced: Rapid, biphasic loss — an early phase (reduced osteoblast function and increased apoptosis) followed by a slower phase of ongoing bone resorption and impaired formation.

Microarchitectural deterioration includes loss of trabecular connectivity, thinning of trabeculae, cortical porosity, and increased cortical surface resorption. These changes reduce bone strength disproportionately to the loss of BMD, which is why fracture risk rises faster than T-score decline alone would predict.

DEXA Scanning — T-scores, Z-scores & WHO Interpretation

Indications for DEXA in Australia (Medicare Eligibility)

A DEXA scan is Medicare-eligible (MBS Item 12320) for patients with at least one clinically identified risk factor for osteoporosis. Common indications include:

Women aged ≥70 years and men aged ≥70 years (population-based screening recommended by RACGP)
Women and men aged ≥50 years with one or more risk factors
Fragility fracture after age 40
Chronic glucocorticoid use (≥2.5 mg prednisolone/day for ≥3 months)
Hypogonadism (menopause <45, premature ovarian insufficiency, androgen deprivation therapy)
Conditions associated with bone loss (coeliac, hyperparathyroidism, CKD stages 1–3, rheumatoid arthritis)
Premenopausal women and men <50 years with recurrent fractures or major risk factors

Understanding T-scores and Z-scores

Parameter	Definition	Use
T-score	Standard deviations (SD) above or below the mean BMD of a healthy young adult (aged 20–29) reference population of the same sex and ethnicity	Postmenopausal women and men ≥50 years — WHO diagnostic classification
Z-score	SD above or below the mean BMD of an age-, sex-, and ethnicity-matched reference population	Premenopausal women, men <50 years, children — identifies "below expected for age"

WHO Diagnostic Classification (T-score Based)

Normal

T-score ≥ −1.0

BMD within 1 SD of the young adult mean. Bone strength is adequate.

Action: Lifestyle advice, ensure adequate calcium & vitamin D

Osteopenia

T-score between −1.0 and −2.5

Low bone mass — not osteoporosis but indicates increased risk. Assess with FRAX® or Garvan Calculator.

Action: Risk stratification, lifestyle modification ± pharmacotherapy

Osteoporosis

T-score ≤ −2.5

Significantly increased fracture risk. Pharmacotherapy generally indicated.

Action: Initiate treatment, investigate secondary causes

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Severe (established) osteoporosis: T-score ≤ −2.5 plus one or more fragility fractures. This carries the highest fracture risk and warrants consideration of anabolic therapy (teriparatide) or sequential anti-resorptive strategy.

Sites Measured

The preferred sites for diagnosis are the lumbar spine (L1–L4) and the proximal femur (femoral neck and total hip). The lower of the T-scores at these sites is used for diagnosis. The forearm (distal one-third radius) is measured when hip or spine BMD cannot be reliably assessed (e.g., obesity, bilateral hip prostheses, severe spinal degeneration).

Fracture Risk Assessment Tools (Australian)

FRAX® (Fracture Risk Assessment Tool): Estimates 10-year probability of major osteoporotic fracture (hip, spine, forearm, shoulder) and hip fracture alone. Australian model validated. Input: age, sex, BMI, clinical risk factors, ± femoral neck T-score. Does not require DEXA but is more accurate with it.
Garvan Fracture Risk Calculator: Developed in Australia (Garvan Institute). Incorporates falls history in addition to BMD, age, sex, and prior fractures. Estimates 5- and 10-year fracture risk.

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When to treat without a DEXA: Patients aged ≥70 years with a prior fragility fracture, or those on long-term high-dose glucocorticoids (≥7.5 mg/day prednisolone), can be commenced on osteoporosis therapy empirically while awaiting DEXA results. Do not delay treatment.

Clinical Presentation & Diagnostic Criteria

Presentation

Osteoporosis is frequently asymptomatic until a fracture occurs. Clinical features may include:

Vertebral fractures: May present with acute back pain following minor trauma, or may be asymptomatic (discovered incidentally on lateral chest X-ray or CT). Multiple vertebral fractures lead to height loss (>2.5 cm), kyphosis ("dowager's hump"), reduced rib-to-pelvis distance, and secondary restrictive lung disease.
Hip fractures: Typically a fall from standing height in the elderly. Pain, inability to weight-bear, and shortened/externally rotated limb. Requires surgical fixation.
Distal radius (Colles') fractures: Fall onto outstretched hand. Common in early postmenopausal women.
Other fragility fractures: Pelvis, proximal humerus, ribs, and tibial plateau following minimal trauma.

Diagnostic Criteria

A diagnosis of osteoporosis is established by:

T-score ≤ −2.5 at the lumbar spine, femoral neck, or total hip on DEXA, OR
A fragility fracture (fracture from a fall from standing height or less) at a typical site (hip, spine, wrist, pelvis, humerus, ribs) regardless of T-score — this is termed "clinical osteoporosis" or "established osteoporosis."

Investigations to Exclude Secondary Causes

Essential Serum calcium, phosphate, alkaline phosphatase (ALP) Excludes hyperparathyroidism, Paget's disease, malignancy

Essential Serum 25-hydroxyvitamin D (25[OH]D) Target ≥50 nmol/L. Deficiency (<25 nmol/L) requires loading dose

Essential Renal function (eGFR, creatinine) CKD stages 4–5 require nephrology input for bone disease classification

Essential Thyroid function (TSH) Excludes hyperthyroidism

Essential FSH/oestradiol (premenopausal women) or testosterone (men <50) Excludes hypogonadism

Available Coeliac serology (anti-tTG IgA) Screen for coeliac disease — a treatable cause of osteoporosis

Available Serum protein electrophoresis (SPEP) / free light chains Excludes multiple myeloma if unexplained bone loss or vertebral fractures

Available Intact PTH If calcium elevated or borderline — excludes primary hyperparathyroidism

Available 24-hour urinary calcium / spot urine calcium:creatinine ratio Excludes hypercalciuria, renal calcium wasting

Specialist Bone turnover markers (P1NP, CTX) Baseline before anti-resorptive or anabolic therapy to monitor response. Not routinely for diagnosis. CTX = C-terminal telopeptide; P1NP = procollagen type 1 N-terminal propeptide

Medications — Bisphosphonates, Calcium & Vitamin D, and Anabolic Agents

Calcium & Vitamin D (Foundation of All Osteoporosis Therapy)

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Calcium (elemental)

Caltrate® 600 · Citracal® · Various · Nutrient supplement

Adult dose 500–600 mg elemental calcium PO BD (total daily dietary + supplement target: 1,000 mg for men 50–70; 1,300 mg for women ≥51 and all adults ≥70)

Paediatric dose Age 1–3: 500 mg/day; Age 4–8: 700 mg/day; Age 9–18: 1,000–1,300 mg/day (prefer dietary sources)

Route Oral

Renal adjustment Avoid excessive supplementation in CKD (risk of hypercalcaemia); use calcium carbonate cautiously if CKD stage 4–5 (phosphate binder context)

PBS status ✘ Not PBS (OTC)

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Cholecalciferol (Vitamin D₃)

Ostelin® · Bio-D-Mulsion® · Various · Vitamin D supplement

Adult dose (maintenance) 1,000–2,000 IU PO daily (aim serum 25[OH]D ≥50 nmol/L)

Adult dose (loading — deficient <25 nmol/L) Vitamin D₃ 7,000 IU PO daily × 6–8 weeks (or calciferol 50,000 IU PO weekly × 6–8 weeks), then switch to maintenance dose

Paediatric dose Infants 0–12 months: 400 IU/day; Children 1–18 years: 600–1,000 IU/day

Route Oral

Renal adjustment No dose adjustment; use calcitriol (active vitamin D) in CKD stages 4–5 under nephrology guidance

PBS status ✘ Not PBS (OTC)

Bisphosphonates (First-Line Anti-Resorptive Therapy)

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Bisphosphonate administration rules: Take on an empty stomach with a full glass (200 mL) of plain water. Remain upright (sitting or standing) for at least 30 minutes (alendronate) or 60 minutes (risedronate, ibandronate). Do not eat, drink (other than water), or take other medications for 30–60 minutes. Adverse effects include oesophageal irritation, osteonecrosis of the jaw (ONJ — rare, ~1:10,000 to 1:100,000 per year), and atypical femoral fracture (AFF — rare).

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Alendronate sodium

Fosamax® · Alendro® · Bisphosphonate

Adult dose 70 mg PO once weekly (osteoporosis); 10 mg PO daily is an alternative

Duration 3–5 years (oral), then reassess for drug holiday. Consider continued treatment if T-score ≤ −2.5 with new fracture or ≥2 risk factors.

Renal adjustment Contraindicated if eGFR <35 mL/min (increased risk of toxicity)

Hepatic adjustment No adjustment required; not hepatically metabolised

PBS status ✔ PBS General Benefit

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Risedronate sodium

Actonel® · Risodris® · Bisphosphonate

Adult dose 35 mg PO once weekly (or 5 mg PO daily); 150 mg PO once monthly is an alternative

Duration 3–5 years, then reassess for drug holiday

Renal adjustment Contraindicated if eGFR <35 mL/min

PBS status ✔ PBS General Benefit

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Zoledronic acid

Aclasta® · Bisphosphonate (IV)

Adult dose 5 mg IV infusion over ≥15 minutes, once yearly

Duration 3 years (3 infusions), then reassess. May extend to 6 years if high fracture risk persists.

Renal adjustment Contraindicated if eGFR <35 mL/min

Important notes Acute phase reaction (fever, myalgia, headache) in ~25% after first infusion. Pre-medicate with paracetamol. Ensure adequate hydration. Monitor serum calcium.

PBS status ⚠ PBS Authority Required

Second-Line Agents

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Denosumab

Prolia® · RANKL inhibitor (monoclonal antibody)

Adult dose 60 mg SC every 6 months

Indication Second-line when bisphosphonates are contraindicated, not tolerated, or have failed

Renal adjustment No dose adjustment; safe in CKD with eGFR ≥15 mL/min. Monitor calcium closely in CKD.

Key warning MUST NOT be discontinued without transitioning to a bisphosphonate — rebound hypercalcaemia and multiple vertebral fractures within 7–12 months of cessation.

PBS status ⚠ PBS Authority Required

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Teriparatide

Forteo® · Parathyroid hormone analogue (anabolic)

Adult dose 20 µg SC once daily (self-injection pen)

Duration Maximum 24 months (lifetime limit). Follow with an anti-resorptive agent (bisphosphonate or denosumab) to maintain gains.

Indication Severe osteoporosis (T-score ≤ −2.5 with ≥2 fractures), or failure/intolerance of ≥2 anti-resorptive therapies

Renal adjustment Use with caution; monitor calcium in CKD

PBS status ⚠ PBS Authority Required

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Romosozumab

Evenity® · Sclerostin inhibitor (anabolic + anti-resorptive)

Adult dose 210 mg SC once monthly (two 105 mg injections) for 12 months

Indication Severe osteoporosis with very high fracture risk (PBS Authority Required)

Key warning Contraindicated in patients with MI or stroke within the preceding 12 months. May increase cardiovascular risk. Transition to anti-resorptive after 12 months.

PBS status ⚠ PBS Authority Required

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Raloxifene

Evista® · Selective oestrogen receptor modulator (SERM)

Adult dose 60 mg PO once daily

Indication Postmenopausal women with osteoporosis — reduces vertebral fracture risk only (no significant hip fracture reduction)

Key warnings Increases venous thromboembolism (VTE) risk. Contraindicated with history of VTE. May worsen hot flushes.

PBS status ⚠ PBS Authority Required

Medication Selection Summary

First-line (oral)

Alendronate 70 mg weekly or Risedronate 35 mg weekly

3–5 years

Most patients start here. Ensure adequate Ca²⁺/Vit D.

First-line (IV option)

Zoledronic acid 5 mg IV annually

3 years

Oral intolerance, compliance concerns, GI contraindications

Second-line

Denosumab 60 mg SC q6 months

Ongoing (no fixed course)

Bisphosphonate failure/intolerance. Safe in CKD. NEVER stop abruptly.

Severe / refractory

Teriparatide 20 µg SC daily

Max 24 months

Must follow with anti-resorptive. Authority Required.

Very high risk

Romosozumab 210 mg SC monthly

12 months

Then transition to anti-resorptive. Check CV history.

Vertebral-only risk (postmenopausal women)

Raloxifene 60 mg PO daily

Ongoing

No hip fracture reduction. VTE risk.

✅

Drug holiday guidance: After 3–5 years of oral bisphosphonate or 3 years of zoledronic acid, reassess fracture risk. If moderate risk (T-score > −2.5, no new fractures), a drug holiday of 1–2 years (alendronate/risedronate) or 1 year (zoledronic acid) may be considered. Continue DEXA monitoring every 1–2 years during the holiday. High-risk patients should continue treatment.

Glucocorticoid-Induced Osteoporosis

Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. Bone loss is most rapid in the first 3–6 months of therapy. All patients commencing glucocorticoids (≥2.5 mg prednisolone/day for ≥3 months) require fracture risk assessment.

Management of GIOP

Risk Assessment

Perform DEXA within 6 months of commencing long-term glucocorticoids. Calculate FRAX® with glucocorticoid dose adjustment.

Ensure Ca²⁺/Vit D

Calcium 1,000–1,300 mg/day + Vitamin D (maintain 25[OH]D ≥50 nmol/L). Lifestyle measures (weight-bearing exercise, smoking cessation, limit alcohol).

Pharmacotherapy

High risk (T-score ≤ −1.5, age ≥70, prior fragility fracture, or prednisolone ≥7.5 mg/day ≥3 months): start alendronate 70 mg weekly or risedronate 35 mg weekly. Zoledronic acid IV if oral not tolerated.

Review & Minimise Steroid

Use the lowest effective dose. Consider steroid-sparing agents. DEXA repeat at 1–2 years. Continue osteoporosis treatment for 6–12 months after glucocorticoid cessation if T-score remains ≤ −1.5.

Monitoring

During Treatment

Parameter	Frequency	Notes
DEXA scan	Every 1–2 years (initially), then every 2 years once stable	Measure lumbar spine + proximal femur. Minimum 12 months between scans to detect change.
Bone turnover markers (P1NP, CTX)	Baseline, then 3–6 months after starting therapy	≥30–40% decline in CTX or P1NP suggests good treatment response. Perform fasting, morning sample.
Serum calcium, phosphate, renal function	At baseline, then every 6–12 months	Essential for denosumab (risk of hypocalcaemia, especially in CKD)
25-hydroxyvitamin D	At baseline, then annually until stable ≥50 nmol/L	Recheck in autumn/winter or after dose adjustment
Height measurement	Every visit	Loss of ≥2.5 cm — consider lateral spine X-ray or VFA (vertebral fracture assessment on DEXA)
Fall risk assessment	Every 6–12 months	Address polypharmacy, home hazards, vision, balance, footwear

Treatment Failure

Consider treatment failure (and reassess diagnosis, adherence, secondary causes, or switch agent) if:

New fragility fracture during treatment
Decline in BMD of >3–5% at the lumbar spine or hip over 2 years (technically significant change)
Rising bone turnover markers despite adherence

⚠️

Adherence is critical: Approximately 50% of patients discontinue oral bisphosphonates within 12 months. Simplify regimens (weekly instead of daily), address side effects proactively, and consider IV zoledronic acid for patients with poor oral adherence.

Osteoporosis in Men & Children

Osteoporosis in Men

Men account for approximately 30% of all fragility fractures in Australia and have higher post-fracture mortality than women (1-year mortality after hip fracture is ~30% in men vs. ~20% in women). Despite this, osteoporosis in men is significantly under-recognised and under-treated.

Secondary causes are more common: Up to 50% of osteoporosis in men has an identifiable secondary cause — hypogonadism (including age-related testosterone decline), excess alcohol, glucocorticoid use, or gastrointestinal disease.
Diagnosis: DEXA scanning using male reference databases. T-score ≤ −2.5 defines osteoporosis. Z-score ≤ −2.0 in men <50 years indicates "below expected for age."
Treatment: Same agents as for women. Alendronate 70 mg weekly or risedronate 35 mg weekly are first-line (both PBS-listed for men). Zoledronic acid, denosumab, and teriparatide are also effective. Testosterone replacement in hypogonadal men improves BMD but fracture data are limited.
Screening: RACGP recommends DEXA for men ≥70 years. Earlier screening if risk factors are present (glucocorticoids, hypogonadism, fragility fracture, alcohol excess).

Paediatric Osteoporosis

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Key principle: Childhood osteoporosis is predominantly secondary. Primary osteoporosis (osteogenesis imperfecta) is rare. The diagnosis should NOT be made on DEXA T-scores alone in children — use Z-scores and clinical criteria.

Diagnostic criteria (ISCD — International Society for Clinical Densitometry):

A Z-score ≤ −2.0 at the lumbar spine or total body (less head) on DEXA, AND
A clinically significant fracture history: ≥2 long-bone fractures by age 10, OR ≥3 long-bone fractures by age 19, OR ≥1 vertebral compression fracture (in the absence of local disease or high-energy trauma)

Common Secondary Causes in Children

Chronic glucocorticoid use: Duchenne muscular dystrophy, juvenile idiopathic arthritis, leukaemia/transplant conditioning
Nutritional: Vitamin D deficiency, calcium deficiency, eating disorders, coeliac disease
Chronic disease: Cerebral palsy, cystic fibrosis, juvenile idiopathic arthritis, chronic liver disease, CKD
Genetic: Osteogenesis imperfecta (OI), Ehlers-Danlos syndrome, Turner syndrome, Marfan syndrome

Management in Children

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Calcium + Vitamin D (foundation)

Dietary optimisation ± supplements

Paediatric dose Calcium: Age 1–3: 500 mg/day; Age 4–8: 700 mg/day; Age 9–18: 1,300 mg/day. Vitamin D₃: 600–1,000 IU/day (loading: 4,000–10,000 IU/day × 6–8 weeks if deficient).

PBS status ✘ Not PBS (OTC)

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Pamidronate (IV bisphosphonate)

Aredia® · Bisphosphonate (IV) — first-line for paediatric OI

Paediatric dose 1 mg/kg/day IV over 2–4 hours on 3 consecutive days every 3–4 months (for OI). Dose escalation may be needed with growth.

Indication Severe osteogenesis imperfecta; glucocorticoid-induced osteoporosis with vertebral fractures in children

Important notes Must be initiated by a paediatric bone specialist. Monitor calcium (risk of hypocalcaemia). Common side effect: flu-like acute phase reaction.

PBS status ⚠ PBS Authority Required (Specialist)

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Zoledronic acid (IV bisphosphonate)

Aclasta® · Alternative IV bisphosphonate for older children

Paediatric dose 0.05 mg/kg IV (max 5 mg) over 30 minutes, every 6 months (specialist-initiated)

Indication Children ≥3 years with osteogenesis imperfecta or glucocorticoid-induced osteoporosis (specialist use)

PBS status ⚠ PBS Authority Required (Specialist)

⚠️

Important: Denosumab, teriparatide, raloxifene, and romosozumab are not approved for use in children. All paediatric osteoporosis management should involve a paediatric endocrinologist or bone specialist.

Special Populations

🤰 Pregnancy & Lactation

All bisphosphonates, denosumab, teriparatide, raloxifene, romosozumab

Contraindicated in pregnancy and breastfeeding. Bisphosphonates cross the placenta and accumulate in fetal bone.

Pregnancy-associated osteoporosis

Rare condition presenting with vertebral fractures in the third trimester or early postpartum. Usually self-limiting. Calcium and vitamin D optimisation. Reassess BMD 12–24 months postpartum before considering pharmacotherapy.

Lactation

Breastfeeding temporarily reduces maternal BMD (up to 5%) but bone recovers after weaning. Ensure adequate calcium (1,300 mg/day) and vitamin D during lactation.

👴 Elderly (≥75 years)

Fall prevention

Integral to fracture reduction. Home hazard assessment, balance and strength training (e.g., Tai Chi), medication review (sedatives, antihypertensives), vision correction, footwear assessment.

Bisphosphonates

Oral formulations may be difficult in patients with dysphagia or inability to sit upright. IV zoledronic acid preferred. Check renal function (eGFR ≥35 mL/min required).

Nutrition

Protein intake (1.0–1.2 g/kg/day), calcium, vitamin D. Address malnutrition, sarcopenia, and frailty concurrently.

🫘 Chronic Kidney Disease (CKD)

CKD stages 1–3 (eGFR ≥30)

Standard osteoporosis management applies. Bisphosphonates safe. Monitor renal function.

CKD stage 4–5 (eGFR <30)

Bisphosphonates contraindicated (insufficient clearance, adynamic bone disease risk). Denosumab can be used but requires close calcium monitoring (risk of severe hypocalcaemia). Nephrology and bone specialist involvement required. Classify as CKD-MBD vs. standard osteoporosis before treatment.

🛡️ Immunocompromised / Transplant

Post-transplant osteoporosis

Rapid bone loss in the first 6–12 months post-transplant due to immunosuppression (calcineurin inhibitors, glucocorticoids). DEXA at baseline and 12 months. Zoledronic acid 5 mg IV 3 months post-transplant (with normal renal function). Ensure Ca²⁺/Vit D.

HIV-associated osteoporosis

Higher prevalence due to chronic inflammation, antiretroviral therapy (tenofovir), and traditional risk factors. DEXA recommended for men ≥50 and postmenopausal women with HIV, or younger patients with additional risk factors. Standard pharmacotherapy applies.

🫁 Hepatic Impairment

Chronic liver disease

Osteoporosis is common in cirrhosis, primary biliary cholangitis, and autoimmune hepatitis. Bisphosphonates are generally safe in mild–moderate liver disease but avoid in severe hepatic failure. Risedronate may be preferred. Check vitamin D and correct deficiency aggressively.

Prevention & Lifestyle Measures

Lifestyle Measures (All Patients)

Weight-bearing exercise: Walking, jogging, dancing, stair climbing — ≥30 minutes, most days. Progressive resistance training 2–3 times/week to improve muscle strength and balance.
Smoking cessation: Smoking accelerates bone loss and increases fracture risk by 25–30%.
Alcohol moderation: ≤2 standard drinks/day. Excess alcohol (>4 drinks/day) doubles fracture risk.
Vitamin D: Safe sun exposure (10–15 minutes most days, before 10 am or after 3 pm, depending on latitude and skin type) plus supplementation.
Fall prevention: Home safety assessment, balance training, medication review, vision correction, assistive devices.

Fracture Liaison Services (FLS)

Systematic models of care that identify, assess, and treat patients presenting with fragility fractures.
Demonstrated to increase osteoporosis treatment rates from ~20% to 70–80%.
Supported by ANZBMS, Osteoporosis Australia, and the Australian Commission on Safety and Quality in Health Care (ACSQHC).
Coordinate GP follow-up, DEXA referral, medication initiation, and falls prevention within 12 weeks of fracture.

Aboriginal and Torres Strait Islander Health Considerations

Osteoporosis and fragility fractures are an under-recognised health burden among Aboriginal and Torres Strait Islander peoples. Key considerations include:

Higher fracture rates at younger ages

Australian data show Aboriginal and Torres Strait Islander peoples sustain hip fractures at younger ages (10–15 years earlier) compared with non-Indigenous Australians, with higher rates of fractures at all major sites. Falls-related injuries are a leading cause of injury hospitalisation.

Vitamin D deficiency

Despite often living in high-UV environments, vitamin D deficiency is prevalent — particularly in southern states, urban settings, and in those with darker skin who use sun protection. Serum 25(OH)D levels should be checked proactively.

Under-screening

DEXA screening rates are significantly lower among Aboriginal and Torres Strait Islander peoples. GPs should proactively offer bone health assessment as part of chronic disease health checks (MBS Item 715).

Treatment gap

Pharmacotherapy for osteoporosis is under-prescribed following fragility fractures. Culturally safe communication about bone health, the importance of medication adherence, and the role of calcium and vitamin D is essential.

Remote and rural access

DEXA access is limited in remote communities. Portable DXA is becoming available in some Aboriginal Community Controlled Health Services (ACCHSs). Where DEXA is unavailable, FRAX® or Garvan can be used without BMD. IV zoledronic acid (annual infusion) may improve adherence in communities with limited access to daily or weekly oral medications.

Comorbidity burden

High rates of chronic kidney disease, diabetes, rheumatic heart disease, and early menopause (surgical or physiological) increase osteoporosis risk. Multimorbidity management must integrate bone health alongside cardiovascular, renal, and metabolic care.

Cultural safety

Use yarning-based approaches to discuss bone health. Involve Aboriginal Health Workers and Practitioners in screening, education, and medication support. Utilise existing tools from RHDAustralia and Osteoporosis Australia's Indigenous health resources.

📚 References

1. Royal Australian College of General Practitioners (RACGP). Clinical guideline for the diagnosis and management of osteoporosis in postmenopausal women and men. Melbourne: RACGP; 2017 (updated 2024).
2. Australian and New Zealand Bone and Mineral Society (ANZBMS), Endocrine Society of Australia, Osteoporosis Australia. Position statement on the prevention and treatment of osteoporosis. Med J Aust. 2023;218(3):130–138.
3. Australian Institute of Health and Welfare (AIHW). Osteoporosis — Australian facts. Canberra: AIHW; 2024. Cat. no. PHE 256.
4. Osteoporosis Australia. Know your bones — consumer and clinical resources. Sydney: Osteoporosis Australia; 2024. Available at: www.osteoporosis.org.au.
5. Kanis JA, on behalf of the WHO Scientific Group. Assessment of osteoporosis at the primary health-care level. WHO Technical Report. University of Sheffield, UK; 2008.
6. Nguyen ND, Frost SA, Center JR, Eisman JA, Nguyen TV. Development of a nomogram for individualizing hip fracture risk in men and women. Osteoporos Int. 2007;18(8):1109–1117. [Garvan Fracture Risk Calculator]
7. Bone and Joint Decade. International Society for Clinical Densitometry (ISCD). Official Positions of the ISCD. 2019 Revision. Available at: www.iscd.org.
8. Khosla S, Bilezikian JP, Dempster DW, et al. Benefits and risks of bisphosphonate therapy for osteoporosis. J Clin Endocrinol Metab. 2012;97(7):2272–2282.
9. Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009;361(8):756–765. [FREEDOM trial]
10. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001;344(19):1434–1441. [Fracture Prevention Trial — teriparatide]
11. Saag KG, Petersen J, Brandi ML, et al. Romosozumab or alendronate for fracture prevention in women with osteoporosis. N Engl J Med. 2017;377(15):1417–1427. [ARCH trial]
12. Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2017;12(1):43.
13. Binkley N, Bilezikian JP, Kendler DL, et al. Summary of the International Society for Clinical Densitometry 2005 Position Development Conference. J Bone Miner Res. 2007;22(5):643–648.
14. Ebeling PR, Daly RM, Kerr DA, Kimlin MG. Building healthy bones throughout life: an evidence-informed strategy to prevent osteoporosis in Australia. Med J Aust. 2013;199(7 Suppl):S1–S16.
15. Australian Government Department of Health and Aged Care. Pharmaceutical Benefits Scheme (PBS) Schedule. Canberra: Commonwealth of Australia; 2024. Available at: www.pbs.gov.au.
16. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice (Red Book). 9th ed. Melbourne: RACGP; 2018.
17. Ward LM, Rauch F, Whyte MP, et al. Alendronate for the treatment of pediatric osteogenesis imperfecta: a randomized, placebo-controlled study. J Clin Endocrinol Metab. 2011;96(2):355–364.
18. Ganda K, Puech M, Chen JS, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2013;24(2):393–406. [Fracture liaison services]

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).