Osteoporosis & Bone Health

Bone Remodelling

Bone is a living tissue undergoing constant remodelling through a tightly regulated cycle:

Osteoclasts — resorb old/damaged bone (activated by RANKL)
Osteoblasts — form new bone matrix (osteoid → mineralised)
Osteocytes — sense mechanical load; regulate both cell lines via sclerostin

In osteoporosis, resorption outpaces formation → net bone loss → microarchitectural deterioration → fragility.

Peak Bone Mass — achieved by approximately age 25–30. Higher peak = greater skeletal reserve. Nutrition, exercise, genetics and hormonal status in youth are the key determinants.

WHO T-Score Classification (DXA)

Normal T-score > −1.0

Osteopenia (low bone mass) −1.0 to −2.5

Osteoporosis ≤ −2.5

Severe Osteoporosis ≤ −2.5 + fragility fracture

Z-score — used for premenopausal women and men <50 (age-matched); T-score compares to young-adult reference population.

DXA Scan (DEXA)

Standard Sites Measured

Lumbar spine (L1–L4)
Femoral neck / total hip
Forearm (if above sites non-diagnostic)

Reporting

Lowest T-score of hip or spine used for diagnosis
Z-score reported for premenopausal women and men <50
VFA (Vertebral Fracture Assessment) — lateral spine imaging during DXA

Indications for DXA

Women ≥65 / Men ≥70 (screening)
Fragility fracture at any age
High FRAX score (intermediate zone)
Long-term glucocorticoid use (>3 months)
Secondary causes of osteoporosis
Monitoring response to treatment (repeat at 2 years)

FRAX Risk Factors (Clinical)

Advancing age
Female sex
Low BMI (<20 kg/m²)
Prior fragility fracture

Parental hip fracture (maternal or paternal)
Current smoking
Oral glucocorticoids ≥5mg prednisolone ≥3 months
Rheumatoid arthritis

Alcohol ≥3 units/day
Secondary osteoporosis (see below)
BMD (T-score at femoral neck — optional)

Secondary Causes of Osteoporosis

Endocrine

Hyperparathyroidism (primary)
Hypothyroidism / hyperthyroidism
Hypogonadism (male & female)
Cushing's syndrome
Diabetes mellitus type 1

GI / Nutritional

Coeliac disease
Inflammatory bowel disease
Malabsorption syndromes
Liver disease (chronic)
Post-bariatric surgery

Other

Chronic kidney disease (CKD)
Rheumatoid arthritis
Long-term glucocorticoids
Anticonvulsants (CYP450 inducers)
Aromatase inhibitors / androgen deprivation therapy

FRAX Tool

Calculates the 10-year probability of:

Hip fracture (standalone)
Major Osteoporotic Fracture (MOF) — hip, clinical spine, wrist, humerus

Can be calculated with or without BMD (femoral neck T-score). Adding BMD improves accuracy.

Access: www.sheffield.ac.uk/FRAX — select country-specific model (Saudi Arabia, UAE, etc. available)

UK NOGG Intervention Thresholds

Age-dependent thresholds — plot 10-year MOF probability:

Above upper threshold Treat directly

Between thresholds DXA → reassess with BMD

Below lower threshold Reassure / lifestyle advice

Thresholds increase with age (e.g. 15% at 50 → 30% at 70 for upper threshold)

Vertebral Fracture Assessment (VFA)

Lateral spine imaging performed alongside DXA. Uses semi-quantitative Genant grading:

Grade	Height Loss	Description
0	Normal	No deformity
I (mild)	20–25%	Mild deformity
II (moderate)	25–40%	Moderate deformity
III (severe)	>40%	Severe deformity

Indications for VFA

Height loss >4 cm
Kyphosis
Back pain in women >55 / men >50
T-score ≤ −1.0 (some guidelines)
Glucocorticoid use ≥5mg/day ≥3 months

Vertebral fracture on VFA = severe osteoporosis → triggers treatment regardless of T-score

Bone Turnover Markers (BTMs)

Resorption Marker

CTX (C-terminal telopeptide of type 1 collagen) — reflects osteoclast activity. Decreases with antiresorptive therapy (bisphosphonates, denosumab).

Sample fasted AM (diurnal variation); decreases 50–70% within 3–6 months on treatment = good adherence/response.

Formation Marker

P1NP (procollagen type 1 N-terminal propeptide) — reflects osteoblast activity. Increases with anabolic therapy (teriparatide, romosozumab).

Preferred formation marker by IOF. Useful at 3 months to confirm treatment adherence before repeat DXA at 2 years.

QFracture (Alternative Tool)

UK-based algorithm validated in primary care. Includes additional risk factors not in FRAX: type 2 diabetes, asthma/COPD, chronic liver disease, falls history, care home residence. Does not require BMD. Useful in GP settings.

Monitoring Protocol: Repeat DXA 2 years after initiating treatment. Earlier repeat if high-dose glucocorticoids or monitoring response to anabolic therapy.

First-Line Treatment: Bisphosphonates inhibit osteoclast-mediated bone resorption by binding to hydroxyapatite in bone matrix. They are pyrophosphate analogues incorporated during bone remodelling.

Alendronate — First-Line Oral

Dose: 70 mg once weekly (or 10 mg daily)

Indication: Post-menopausal osteoporosis, male osteoporosis, GIOP prevention

Administration Instructions (Critical)

Take on waking, before any food/drink/medication
Swallow with a full glass of plain water (200 mL)
Remain upright (sitting/standing) for at least 30 minutes
No food, drink or other medication for at least 30 minutes after
Do not lie down until after first meal

Contraindications

Oesophageal stricture / achalasia / inability to sit upright
Active upper GI disease (oesophagitis, gastric ulcer)
Hypocalcaemia (correct before starting)
eGFR <35 mL/min (oral bisphosphonates)

Side Effects

Oesophageal irritation / dysphagia / heartburn
GI upset — less with weekly vs daily dosing
Musculoskeletal pain (rare)

Risedronate

Dose: 35 mg once weekly or 150 mg once monthly

Note: Fewer GI side effects than alendronate. Same administration instructions apply.

Preferred in patients with upper GI sensitivity. Can be taken at any time of day with the monthly formulation (some evidence for flexibility).

Ibandronate

Oral: 150 mg once monthly

IV: 3 mg every 3 months (IV injection)

No spinal hip fracture data (only vertebral). Less evidence for hip fracture reduction compared to alendronate/risedronate/zoledronic acid.

IV Zoledronic Acid (Zoledronate)

Dose: 5 mg IV infusion once yearly (100 mL over at least 15 minutes)

Indications: Intolerance of oral bisphosphonates, poor adherence, post-hip fracture (given within 90 days reduces mortality), Ramadan preference

Pre-infusion Checks

Renal function: eGFR >35 mL/min (avoid if <35)
Serum calcium — correct hypocalcaemia before
Adequate hydration — 500 mL fluid before infusion
Calcium + vitamin D supplementation in place

First-Infusion Reaction (Acute Phase)

Flu-like symptoms (fever, myalgia, arthralgia, headache) — 10–30% of patients, usually resolves 48–72 hours. Much less common with subsequent infusions.

Management: Pre-medicate or treat with paracetamol 1g QID ± NSAID for 2–3 days. Hydrate well.

Long-Term Risks (all bisphosphonates)

Atypical femoral fracture (AFF) — after >5 years
Osteonecrosis of the jaw (ONJ) — rare at osteoporosis doses

Bisphosphonate Drug Holiday

Oral: After 5 years — review fracture risk. Consider holiday if T-score > −2.5 and no recent fracture.

IV Zoledronic Acid: After 3 years (due to longer skeletal retention).

During holiday, reassess annually. Restart if new fracture, significant bone loss, or rising BTMs. High-risk patients (T-score ≤ −2.5, prior vertebral fracture) should continue or switch to denosumab.

Calcium & Vitamin D Co-Prescribing

Calcium: 1000–1200 mg/day total (dietary + supplement)

Vitamin D: 800–1000 IU/day (colecalciferol)

Essential adjunct with all antiosteoporosis treatments. Correct vitamin D deficiency before starting bisphosphonates (risk of hypocalcaemia especially with IV zoledronic acid).

Loading dose if deficient: 300,000 IU over several weeks then maintenance. Check 25-OH vitamin D level 3 months after loading.

Denosumab (Prolia)

Mechanism: Human monoclonal antibody — inhibits RANKL → reduces osteoclast differentiation and activity

Dose: 60 mg SC injection every 6 months (subcutaneous — abdomen, thigh, upper arm)

Indications: Post-menopausal women at high fracture risk; men with prostate cancer on androgen deprivation therapy; renal impairment (no dose adjustment needed)

Advantages

No renal dose restriction (unlike bisphosphonates)
Reduces hip fracture by ~40%, vertebral ~68%
Effective in patients who cannot tolerate oral bisphosphonates

CRITICAL — Rebound Vertebral Fractures: Stopping denosumab abruptly causes rapid bone loss and multiple vertebral fractures within 12–18 months. Must transition to a bisphosphonate (oral or IV zoledronic acid) before or immediately upon stopping denosumab.

Monitoring

Calcium before each injection (risk of hypocalcaemia)
Do not delay injection beyond 7 months (rebound risk)
Dental check before starting (ONJ risk — higher than bisphosphonates for invasive dental procedures)

Teriparatide (Forsteo)

Mechanism: Recombinant PTH 1–34 fragment — anabolic agent, stimulates osteoblast bone formation (when given intermittently)

Dose: 20 mcg SC daily (pen device) — self-administered

Duration: Maximum 18–24 months lifetime (regulatory limit)

Indications

Very severe osteoporosis (multiple vertebral fractures)
Fracture despite bisphosphonate therapy
Intolerance of antiresorptives
T-score ≤ −3.0 + high fracture risk

Theoretical Osteosarcoma Risk: Seen in animal studies at high doses; not confirmed in humans. Contraindicated in Paget's disease, prior bone radiation, hypercalcaemia, bone metastases, unexplained raised ALP.

After Teriparatide

Bone gains are lost rapidly if no antiresorptive given after. Must follow with bisphosphonate or denosumab to preserve gains (sequential therapy).

Store in refrigerator 2–8°C. Inject thigh or abdomen. Sit or lie down after first injection (transient orthostatic hypotension possible).

Romosozumab (Evenity)

Mechanism: Anti-sclerostin monoclonal antibody — dual effect: stimulates bone formation (anabolic) AND inhibits bone resorption (antiresorptive)

Dose: 210 mg SC monthly (two 105 mg injections at same visit) × 12 months

Most potent agent for rapid bone density gain. Followed by antiresorptive therapy.

Cardiovascular Caution: Increased risk of MI and stroke in clinical trials. Contraindicated in patients with history of MI or stroke within previous year. Prescribe with caution in those with cardiovascular risk factors.

Sequence: Romosozumab → Alendronate shown superior to alendronate alone for fracture reduction in ARCH trial.

Glucocorticoid-Induced Osteoporosis (GIOP)

Threshold for prophylaxis: Prednisolone ≥7.5 mg/day for ≥3 months (or equivalent)

Prevention Protocol

Start bisphosphonate (alendronate 70mg weekly) prophylactically when starting glucocorticoids
Calcium 1000–1200 mg + Vitamin D 800 IU/day from day one
Baseline DXA scan
FRAX adjustment: glucocorticoid doses >7.5mg increase fracture risk beyond FRAX estimate — correct upwards

Bone loss is rapid in first 3–6 months of glucocorticoid use — do not delay prevention.

Males with Osteoporosis

~30% of hip fractures occur in men; often under-recognised and under-treated.

Assessment

Exclude secondary causes (especially hypogonadism — check testosterone)
Alcohol use disorder
Glucocorticoid use

Treatment

Testosterone replacement if hypogonadal (primary or secondary)
Bisphosphonate (alendronate/zoledronic acid) if eugonadal or testosterone insufficient
Same calcium/vitamin D supplementation
Teriparatide licensed for men with severe osteoporosis

HRT & Raloxifene

Hormone Replacement Therapy (HRT)

Effective for bone protection in peri/early post-menopausal women. Reduces vertebral and hip fractures. Primarily used for menopausal symptom control; bone protection is an additional benefit. Not first-line for osteoporosis treatment in older women.

Raloxifene (SERM)

Selective Oestrogen Receptor Modulator — reduces vertebral fractures (not hip). Reduces breast cancer risk. May worsen hot flushes. Increases VTE risk. Used in women <70 with predominantly vertebral fracture risk and breast cancer concern.

Fracture Liaison Service (FLS)

The FLS is a systematic, coordinator-led service that identifies, investigates and initiates treatment for all patients over 50 years who sustain a fragility fracture.

Evidence Base

SIGN Guideline 142 (Management of Osteoporosis)
Royal College of Physicians (RCP) recommendation
Reduces secondary fractures by ~30%
Cost-effective — pays for itself within 2 years

FLS Nurse Coordinator Role

Case finding: identify patients presenting with fragility fracture to ED/orthopaedic wards
Arrange DXA + baseline bloods
Risk assessment: FRAX/NOGG
Initiate appropriate pharmacological treatment
Educate patient on adherence, administration, falls prevention
Refer to falls prevention programme
Follow up at 3–6 months (BTMs) and 2 years (DXA)

Falls Assessment (NICE Guidance)

Annual Minimum Assessment

Lying and standing BP — postural hypotension (>20 mmHg systolic drop)
Timed Up and Go (TUG) — >12 seconds = high risk
Balance and gait assessment (Berg Balance Scale)
Muscle strength (lower limb)
Cognitive screen (confusion, dementia)

Environmental & Other

Footwear inspection (worn soles, poor fit)
Vision assessment — acuity, cataracts, contrast
Home hazard assessment (rugs, lighting, grab rails)
Medication review (see culprits below)
Fear of falling assessment (FES-I score)

Multifactorial Falls Intervention (MDTI)

Exercise

Otago Exercise Programme — home-based strength and balance (reduces falls ~35%)
Group balance classes (Tai Chi)
Progressive resistance training
Walking programmes

Medication Deprescribing

High-risk medications (falls culprits):

Sedatives / benzodiazepines / z-drugs
Antidepressants (TCAs, SSRIs)
Antihypertensives (overtreatment)
Diuretics (postural hypotension)
Opioids
Anticholinergics
Antiepileptics

Other Interventions

Vision correction (cataract surgery if appropriate)
Home modification: grab rails, remove rugs, improve lighting
Hip protectors — reduce hip fracture in care home residents (adherence is key limitation)
Footwear advice
Continence management (urgency → rushing)

Bone-Protective Lifestyle

Calcium-Rich Diet

Dairy: milk (300 mg/200 mL), yoghurt, cheese
Fortified plant milks
Tinned sardines / salmon with bones
Kale, pak choi, broccoli
Fortified breads and cereals
Tofu (calcium-set)

Weight-Bearing Exercise

Brisk walking
Dancing
Low-impact aerobics
Stair climbing
Resistance / strength training

Mechanical loading stimulates osteoblasts. Aim 30 min/day, 5 days/week.

Vitamin D — Sun Exposure

10–20 minutes of midday sun on forearms and face (without sunscreen) during spring/summer. Insufficient in GCC due to cultural and lifestyle factors (see Tab 6).

Avoid: Smoking (accelerates bone loss), excess alcohol (>14 units/week), carbonated drinks (phosphoric acid), very low body weight.

GCC Paradox: Despite abundant sunshine year-round, vitamin D deficiency is highly prevalent across the Gulf region — a major driver of bone disease.

GCC-Specific Epidemiology & Risk Factors

Vitamin D Deficiency in GCC

Covered clothing (abaya, hijab, niqab) limits sun exposure
Indoor lifestyle — air conditioning culture
High use of sunscreen when outdoors
Darker skin pigmentation — requires longer sun exposure for synthesis
Atmospheric dust scattering UV-B radiation

Prevalence of vitamin D deficiency in GCC women: up to 80–90% in some studies.

Dietary & Lifestyle Factors

Low dairy intake in traditional Arab diets (lactose intolerance common)
Rapid urbanisation → sedentary lifestyle, less walking
High rates of obesity (elevated DEXA false-negative risk)
Post-menopausal Arab women: particularly high fracture risk — early menopause, low dairy, VDD
Male osteoporosis under-recognised in GCC

Ramadan & Bisphosphonate Administration

Oral Bisphosphonates During Ramadan

Alendronate and other oral bisphosphonates require an empty stomach and upright posture for 30 minutes — challenging during fasting.

Practical solution: Alendronate can be taken with the pre-dawn Suhoor water — swallow with a large glass of water before the Suhoor meal, remain upright. Then the Suhoor meal provides the 30-min food break requirement.

Patient must understand: water only (not juice/tea) for the bisphosphonate dose; upright posture maintained.

IV Zoledronic Acid — Preferred in Ramadan

Annual IV infusion avoids the daily/weekly oral compliance challenge entirely during Ramadan. Many GCC clinicians schedule zoledronic acid infusions before or after Ramadan.

Calcium + Vitamin D supplements can be taken at Iftar (break-fast) or Suhoor without affecting absorption.

Denosumab During Ramadan

SC injection every 6 months — no food/water restriction. Fasting does not affect SC injection. Ensure 6-monthly schedule is maintained (do not delay >7 months).

DHA / DOH Osteoporosis Pathways

Dubai Health Authority (DHA)

DHA Clinical Practice Guideline: Osteoporosis Management
FLS implemented in major DHA hospitals (Rashid Hospital, Dubai Hospital)
VDD screening integrated into Well Woman programmes
FRAX-UAE model recommended
Bisphosphonate therapy follows NOGG-adapted thresholds

Abu Dhabi DOH / SEHA

National Bone Health Programme initiatives
Osteoporosis included in UAE National Health Agenda 2021–2031
Nurse-led bone health clinics in community settings
Mandatory reporting of hip fractures in patients >50

Saudi Arabia (MOH / SCFHS)

SCFHS bone health nursing competency framework
Saudi Osteoporosis Society guidelines align with IOF
National screening programme for women >60

SCFHS / DHA Exam Preparation — Key Topics

T-Score Interpretation (High-Yield)

T-Score	Diagnosis	Action
> −1.0	Normal	Lifestyle advice
−1.0 to −2.5	Osteopenia	FRAX + lifestyle
≤ −2.5	Osteoporosis	Pharmacotherapy
≤ −2.5 + fracture	Severe OP	Urgent treatment

Exam High-Yield Facts

Alendronate: 70 mg weekly — take with full glass of water, upright 30 min, no food 30 min before/after
Zoledronic acid: annual IV — check renal function + calcium pre-infusion
Denosumab: never stop abruptly — rebound vertebral fractures
GIOP: start bisphosphonate prophylaxis if prednisolone ≥7.5 mg ≥3 months
Teriparatide: maximum 18–24 months; follow with antiresorptive
FRAX calculates 10-year MOF and hip fracture probability
VFA Genant grading: I mild (20–25%), II moderate (25–40%), III severe (>40%)
CTX = resorption marker; P1NP = formation marker
Romosozumab: dual anabolic + antiresorptive; cardiovascular caution
FLS: identify all patients >50 post-fragility fracture (SIGN 142)
Otago programme: home exercise — reduces falls ~35%
TUG >12 seconds = high falls risk