How should I manage a patient with osteoporosis who has a history of fragility fractures?

Management of a patient with osteoporosis and a history of fragility fractures:

• Offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) without first calculating fracture risk, as a history of fragility fracture in people over 50 years is an indication for DXA assessment NICE CKS.
• If the DXA scan shows a T-score of -2.5 or lower, initiate bone-sparing drug treatment, typically starting with oral bisphosphonates such as alendronate 70 mg once weekly or risedronate 35 mg once weekly, unless contraindicated or not tolerated NICE CKS.
• If the T-score is above -2.5, modify risk factors where possible, treat any underlying conditions, and repeat DXA at an interval based on clinical judgement, usually within 2 years NICE CKS.
• Assess and address secondary causes of osteoporosis, including endocrine, gastrointestinal, rheumatological, haematological, respiratory, metabolic, chronic renal disease, and immobility causes, especially if fragility fractures occur despite low risk NICE CKS,NICE CG146.
• Evaluate and manage risk factors for falls, as these contribute to fracture risk NICE CKS.
• Ensure adequate calcium intake (at least 1000 mg/day) and assess for vitamin D deficiency, particularly in those over 65 or with limited sunlight exposure NICE CKS.
• Consider referral to an osteoporosis specialist for people at very high risk, such as those with recent vertebral fractures, multiple vertebral fractures, very low BMD (T-score ≤ -3.5), or those on high-dose glucocorticoids NICE CKS.
• Provide verbal and written information about the condition, treatment expectations, rehabilitation, and self-care to support patient involvement in management decisions NICE NG38.