For a 68-year-old woman with a history of prior fragility fractures, the current treatment approach for osteoporosis involves prompt assessment and initiation of bone-sparing therapy, prioritising bisphosphonates such as alendronate or risedronate as first-line pharmacologic agents if there are no contraindications NICE CKS. Since she is over 50 with prior fragility fractures, a dual-energy X-ray absorptiometry (DXA) scan should be arranged to confirm diagnosis and guide treatment decisions NICE CKS.
Risk assessment and diagnosis: Her prior fracture already places her at high risk, warranting treatment consideration even before DXA results NICE CKS. Fracture risk calculators like FRAX or QFracture should be used to estimate her 10-year fracture risk and refine management plans, incorporating clinical risk factors such as prior fractures, age, and other comorbidities NICE CKSHashimoto et al. 2009.
Pharmacologic treatment: Oral bisphosphonates (alendronate, risedronate) are generally first-line treatments in primary care due to their efficacy in increasing bone mineral density and reducing the risk of vertebral and non-vertebral fractures NICE CKSMun et al. 2025. For patients at very high fracture risk or with contraindications to bisphosphonates, other agents such as denosumab or anabolic therapies (teriparatide, abaloparatide, romosozumab) may be considered, noting that anabolic agents may provide superior fracture risk reduction, especially in those with previous fractures NICE CKSMun et al. 2025.
Adjunctive management and monitoring: Correctable secondary causes of osteoporosis (e.g., vitamin D deficiency, corticosteroid use) should be identified and addressed NICE CKS. Vitamin D and calcium supplementation are advised if deficiencies exist, though calcium alone without vitamin D supplementation is not recommended for fracture prevention in the absence of deficiency Trulson et al. 2026. Fall risk factors and lifestyle contributors such as smoking or excessive alcohol use should be optimised to reduce fracture risk NICE CKS.
Follow-up: Patients should have regular follow-up to monitor adherence, assess for adverse effects of therapy, and determine the need for continued bisphosphonate treatment beyond 5 years NICE CKS. Secondary fracture prevention remains suboptimal globally, so ensuring treatment initiation and adherence are critical Trulson et al. 2026.
In summary, for this patient, after confirming osteoporosis diagnosis via DXA and clinical risk assessment, initiation of bisphosphonate therapy combined with appropriate vitamin D supplementation and lifestyle interventions represents the standard approach, with consideration of more potent antiresorptive or anabolic agents if fracture risk is very high or bisphosphonates are contraindicated NICE CKSMun et al. 2025Trulson et al. 2026.
Key References
- CKS - Osteoporosis - prevention of fragility fractures
- CG146 - Osteoporosis: assessing the risk of fragility fracture
- CKS - Menopause
- CG124 - Hip fracture: management
- (McClung, 2006): Do current management strategies and guidelines adequately address fracture risk?
- (Hashimoto et al., 2009): [Usefulness of FRAX and future issues in women's health].
- (Burch et al., 2014): Systematic review of the use of bone turnover markers for monitoring the response to osteoporosis treatment: the secondary prevention of fractures, and primary prevention of fractures in high-risk groups.
- (Mun et al., 2025): Individualized Fracture Prevention for Postmenopausal Women with Osteopenia.
- (Trulson et al., 2026): Impact of osteoporosis pharmacotherapy and vitamin d supplementation on fracture morphology and treatment of pelvic fragility fractures: a retrospective cohort study of 1493 patients from the German Pelvic Trauma Registry.
- (Cuadra-Llopart et al., 2026): Temporal trends in osteoprotective treatment after hip fracture in Spain: data from the Spanish National Hip Fracture Registry (2017-2024).