Osteoporosis Screening & Management (USPSTF/NOF)

Algorithm Steps

1. ▶

   Start

   Osteoporosis Risk Assessment

   Identify candidates for bone density testing

   1. ◆

      Decision

      USPSTF Screening Criteria

      Who should be screened

      • Women ≥65 years: Screen all
      • Postmenopausal women <65: Screen if 10-year fracture risk ≥ 65-year-old white woman (FRAX ~9.3%)
      • Men: No universal recommendation; consider if risk factors
      1. ●

         Action

         Risk Factor Assessment

         Identify increased risk

         • Advanced age, female sex
         • Low body weight (<127 lbs)
         • Current smoking, excess alcohol
         • Personal or parental hip fracture
         • Glucocorticoid use (≥3 months)
         • Rheumatoid arthritis, secondary causes
         1. ●

            Action

            DXA Bone Density

            Central DXA of hip and spine

            • Measure femoral neck and lumbar spine
            • Use lowest T-score for diagnosis
            • Report T-score (postmenopausal/men ≥50)
            • Report Z-score (premenopausal/men <50)
            1. ◆

               Decision

               T-Score Classification

               WHO criteria

               • Normal: T-score ≥ -1.0
               • Osteopenia: T-score -1.0 to -2.5
               • Osteoporosis: T-score ≤ -2.5
               1. ✓

                  Outcome

                  Normal Bone Density

                  Reassess in 10-15 years; lifestyle counseling

               2. ●

                  Action

                  Osteopenia

                  Calculate 10-year fracture risk

                  • Use FRAX calculator
                  • Treat if: Hip fracture risk ≥3% OR major osteoporotic fracture risk ≥20%
                  • Otherwise: lifestyle, rescreen 2-5 years
                  1. ●

                     Action

                     Pharmacologic Treatment

                     First-line agents

                     • Alendronate 70mg weekly or 10mg daily
                     • Risedronate 150mg monthly or 35mg weekly
                     • Zoledronic acid 5mg IV yearly
                     • Take with water, remain upright 30-60 min
                     • Ensure adequate Ca (1000-1200mg) and Vit D (800-1000 IU)
                     1. ●

                        Action

                        Treatment Monitoring

                        Follow-up strategy

                        • Repeat DXA 1-2 years after starting treatment
                        • Stable or improved = continue
                        • Consider drug holiday after 5 years oral / 3 years IV if not high risk
                        • Reassess fracture risk annually
               3. ⚠

                  Warning

                  Osteoporosis

                  Initiate treatment

                  • T-score ≤ -2.5 at any site
                  • OR prior fragility fracture (clinical osteoporosis)
                  • Secondary workup: Ca, Vit D, PTH, TSH, CBC, CMP
                  1. ●

                     Action

                     Very High Risk Options

                     Anabolic agents first

                     • Consider if: T-score ≤ -3.0, multiple fractures, very high FRAX
                     • Romosozumab 210mg SQ monthly x 12 months
                     • Teriparatide 20mcg SQ daily x 2 years
                     • Must follow with bisphosphonate
            2. ●

               Action

               Lifestyle Measures (All)

               Non-pharmacologic interventions

               • Weight-bearing exercise
               • Fall prevention assessment
               • Smoking cessation
               • Limit alcohol (<3 drinks/day)
               • Calcium 1000-1200mg, Vit D 800-2000 IU daily