Osteoporosis: case finding and treatment (over 50)
Postmenopausal women and men over 50. Not for children, premenopausal women, men under 50 or pregnancy: T-scores do not apply; seek specialist advice.
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Osteoporosis Case Finding & Management (RACGP/HBA 2024, USPSTF 2025)
Osteoporosis Case Finding & Management (RACGP/HBA 2024, USPSTF 2025): Osteoporosis: case finding and treatment (over 50) → Minimal-trauma fracture after...
Pathway Overview
25 steps
Algorithm Steps
25 total
01Start 02Decision Minimal-trauma fracture after age 50?
Fracture from a fall from standing height or less, or a vertebral fracture seen on imaging.
- If Yes
03Action Yes: fracture = presumptive osteoporosis
Assess and treat. Hip or vertebral fracture: treat whatever the T-score.
- Any minimal-trauma fracture is presumptive osteoporosis; hip or vertebral fracture: treat whatever the T-score
- Any minimal-trauma fracture: DXA for baseline where feasible (MBS 12306); do not delay treatment to get it
- Fracture in the past 12 months: very high risk; refer promptly to a bone specialist
- Single mild vertebral deformity, especially under age 60: take care before you diagnose
04Action Before treatment: look for secondary causes
Tests for everyone who starts drug treatment.
- FBC, albumin-adjusted calcium, phosphate, magnesium, creatinine and eGFR, LFTs
- 25(OH) vitamin D and PTH
- Men 50-69 years: total testosterone and LH/FSH
- Selected patients: TSH, coeliac serology, serum protein electrophoresis and free light chains
- High risk of osteonecrosis of the jaw (poor dentition, planned extraction): dental review before starting
05Warning Before any bone drug: check calcium, kidneys, oesophagus
Hypocalcaemia is a contraindication to bisphosphonates, denosumab and romosozumab.
- Low calcium or 25(OH)D <50 nmol/L: correct first (risk of severe hypocalcaemia)
- CrCl <35 mL/min: no alendronate or zoledronic acid; CrCl <30 mL/min: no risedronate, and denosumab carries a high risk of severe hypocalcaemia; seek specialist advice
- Oesophageal stricture or achalasia, or cannot stay upright for 30 min: no oral bisphosphonate
06Decision Very high fracture risk?
Any of: fracture in the past 12 months; T-score below -3.0; fractures while on treatment; drugs that harm bone; FRAX major fracture risk 30% or more, or hip fracture risk above 4.5%.
- If Yes
07Warning Very high risk: anabolic drug exclusions (past MI or stroke; bone tumour risk)
Check these before romosozumab or teriparatide.
- Romosozumab: contraindicated after any past myocardial infarction or stroke; weigh cardiovascular risk first
- Teriparatide: not with Paget disease, hyperparathyroidism, unexplained high ALP, prior skeletal radiation, bone cancer or metastases, hypercalcaemia or severe renal impairment
- Romosozumab: correct low calcium first; stop if MI or stroke occurs
08Action Very high risk: bone specialist for anabolic drug first
Adult doses. Refer promptly. PBS authority criteria apply.
- Romosozumab 210 mg SC (2 x 105 mg injections) once a month for 12 doses
- Teriparatide 20 micrograms SC once daily; maximum 24 months in a lifetime (PBS: 18 months)
- AU PBS romosozumab first line: T-score -2.5 or lower with a symptomatic minimal-trauma fracture and a hip or symptomatic vertebral fracture, or 2 or more fractures, in the past 24 months
- After the anabolic course: start an antiresorptive at once (bisphosphonate or denosumab)
09Action Antiresorptive treatment (first line for most)
Adult doses. Bisphosphonate, or denosumab for osteoporosis or fracture (not PBS-listed for osteopenia). Denosumab must never be stopped without follow-on treatment.
- Alendronate 70 mg orally once weekly (not if CrCl <35 mL/min)
- Risedronate 35 mg orally once weekly or 150 mg once monthly (not if CrCl <30 mL/min)
- Zoledronic acid 5 mg IV over at least 15 min once yearly; hydrate first; not if CrCl <35 mL/min
- Denosumab 60 mg SC every 6 months; check calcium before each dose; do not stop or delay a dose by more than 4 months (rebound vertebral fractures)
- Stopping denosumab: give a bisphosphonate for at least 12 months (oral, or zoledronic acid)
- Oral bisphosphonates: take as the product directs; stay upright for 30 min
- AU PBS: minimal-trauma fracture; or age 70 or older with T-score -2.5 or lower (zoledronic acid: -3.0 or lower); or prednisolone 7.5 mg/day or more for 3 months or more with T-score -1.5 or lower (not denosumab)
- Women within 10 years of menopause: MHT, or raloxifene for mainly vertebral risk, may suit; both raise VTE risk: not after VTE; no MHT with breast cancer
10Action Review and monitoring on treatment
Review 3-6 months after starting, then every 6-12 months for side effects and adherence.
- Repeat DXA 1-2 years after starting or changing treatment (MBS 12306: once in 24 months)
- Bisphosphonate: reassess after 5 years oral or 3 years IV; a break may suit if T-score is above -2.5 and there is no new fracture
- Continue if T-score is -2.5 or lower or a new fracture occurs; restart after bone loss or fracture
- Denosumab: no drug holiday
- New fracture on treatment: check adherence and secondary causes; refer to a bone specialist
- New thigh, hip or groin pain: assess for atypical femur fracture (image both femurs)
11Action Bone health measures (everyone)
Continue with or without drug treatment.
- Resistance training at least twice a week; weight-bearing impact exercise most days; challenging balance training
- Falls risk assessment and prevention
- Stop smoking; limit alcohol
- Calcium 1000 mg/day for adults; 1300 mg/day for women over 50 and men over 70; diet first
- Vitamin D: aim for 25(OH)D above 50 nmol/L; if a supplement is needed, 800-1000 IU/day
- Frail older people: protein 1-1.2 g/kg/day
12Outcome Ongoing: reassess fracture risk regularly
Reassess after a new fracture, a new risk factor or a change in treatment, including in people not on treatment who remain at increased risk.
If No13Action No: high (not very high) risk: start an antiresorptive
Osteoporosis or minimal-trauma fracture: bisphosphonate or denosumab. Low bone mass (osteopenia): prefer a bisphosphonate. See the antiresorptive treatment step (doses and cautions).
- Path rejoins step 09Shared downstream outcome
If No14Action No fracture: assess clinical risk factors
Ask about each factor. Enter them in FRAX (fraxplus.org) to estimate 10-year fracture risk.
- Age, female sex, low body weight (kg) or low BMI
- Parental hip fracture; falls in the past year
- Current smoking; alcohol 3 or more drinks a day
- Glucocorticoids for 3 months or more; rheumatoid arthritis
- Early menopause or hypogonadism; aromatase inhibitor or androgen deprivation therapy
- Other causes: type 1 diabetes, hyperthyroidism, hyperparathyroidism, malabsorption, chronic liver disease
15Action Who needs DXA (no fracture)
Australia: case finding, not population screening (RACGP/HBA 2024). US: screen women (USPSTF 2025).
- AU: over 50 with a disease or drug that causes bone loss (eg glucocorticoids 3 months or more): DXA
- AU: over 50 with other risk factors: FRAX first; DXA if 10-year major fracture risk is 10% or more
- AU: age 70 or older: use the FRAX rule above; Medicare funds DXA at this age (MBS 12320)
- Starting an aromatase inhibitor or androgen deprivation therapy: baseline DXA
- US: all women 65 or older: DXA
- US: postmenopausal women under 65 with 1 or more risk factors: risk tool (eg OST, FRAX); DXA if risk is increased
- Men: evidence for screening is insufficient (USPSTF); use clinical judgement
16Decision DXA indicated?
Meets one of the criteria in the step above.
- If Yes
17Action Yes: DXA of lumbar spine and hip
Measure at least 2 sites. Use the lowest T-score for diagnosis.
- Lumbar spine and hip (femoral neck, total hip); forearm if a site is unsuitable (eg hip prosthesis)
- T-score: postmenopausal women and men 50 or older
- Z-score: premenopausal women, men under 50 and children (specialist)
- After DXA, recalculate FRAX with the femoral neck BMD
18Decision T-score result (lowest site)
WHO categories. Each next step states its T-score range.
- -1.0 or higher
19Action T-score -1.0 or higher: normal BMD
No drug treatment. Do not repeat DXA routinely. Reassess after a fracture or a new risk factor.
- Path rejoins step 11Shared downstream outcome
- -1.0 to -2.5
20Action T-score between -1.0 and -2.5: low bone mass (osteopenia)
Use FRAX with BMD to decide on drug treatment.
- AU: treat if T-score -1.5 to -2.5 and FRAX major fracture risk 20% or more, or hip fracture risk 3% or more
- US (BHOF): treat if T-score -1.0 to -2.5 and FRAX hip fracture risk 3% or more, or major fracture risk 20% or more
- AU: aromatase inhibitor and age 70 or older with T-score -2.0 or lower: start an antiresorptive
- Women 10 or more years after menopause: consider a bisphosphonate to prevent vertebral fracture
- AU PBS at this T-score: only with prednisolone 7.5 mg/day or more for 3 months or more and T-score -1.5 or lower
21Decision Low bone mass: above the treatment threshold?
FRAX threshold met; aromatase inhibitor criterion met; or a bisphosphonate is chosen 10 or more years after menopause.
- If Yes
22Action Yes: above threshold: plan drug treatment
Do the secondary-cause tests and check the drug warnings, then start treatment (see those steps).
- Path rejoins step 04Shared downstream outcome
If No23Action No: below threshold, no drug now
Bone health measures. Repeat FRAX and DXA based on risk. MBS pays DXA every 2 years at age 70 or older with T-score -1.5 to -2.5 (item 12322).
- Path rejoins step 11Shared downstream outcome
- -2.5 or lower
24Action T-score -2.5 or lower: osteoporosis
Drug treatment is indicated. Exclude secondary causes first.
- T-score below -3.0: very high fracture risk (specialist)
- Path rejoins step 04Shared downstream outcome
If No25Action No: DXA not needed now
Bone health measures. Reassess risk after a fracture, a new risk factor, or at age 70 (AU) or 65 (US women).
- Path rejoins step 11Shared downstream outcome
Guideline Source
RACGP and Healthy Bones Australia guideline for osteoporosis management and fracture prevention in postmenopausal women and men over 50 (2024) + USPSTF 2025 Screening for Osteoporosis to Prevent Fractures
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Thresholds differ by country: Australia uses RACGP/HBA 2024 and PBS criteria; the US uses USPSTF 2025 and BHOF 2022.
- Not for children, premenopausal women, men under 50, pregnancy, or CKD stage 4-5 or dialysis: seek specialist advice.
- Anabolic therapy, treatment sequencing and drug holidays need specialist input.
- Glucocorticoid-induced, cancer-therapy-related and other secondary osteoporosis are covered only briefly.
- FRAX does not include falls history or glucocorticoid dose; use clinical judgement.
Contraindicated Populations
children and adolescentspremenopausal women (use Z-score; specialist)men under 50 (use Z-score; specialist)pregnancy or breastfeedingCKD stage 4-5 or dialysis (specialist)
Applicable Regions
AUUS
AU: RACGP/HBA 2024: case finding, not population screening. DXA if FRAX 10-year major fracture risk is 10% or more, or a disease or drug that causes bone loss. PBS: minimal-trauma fracture, age 70+ with T-score -2.5 or lower (zoledronic acid -3.0), or glucocorticoid criteria. MBS 12320 pays DXA at age 70+.
US: USPSTF 2025: screen women 65+ and postmenopausal women under 65 at increased risk on a risk tool (grade B); men: I statement. Treatment thresholds from BHOF 2022.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Osteoporosis Case Finding & Management (RACGP/HBA 2024, USPSTF 2025)?
The Osteoporosis Case Finding & Management (RACGP/HBA 2024, USPSTF 2025) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on RACGP and Healthy Bones Australia guideline for osteoporosis management and fracture prevention in postmenopausal women and men over 50 (2024) + USPSTF 2025 Screening for Osteoporosis to Prevent Fractures.
What guideline is the Osteoporosis Case Finding & Management (RACGP/HBA 2024, USPSTF 2025) based on?
This algorithm is based on RACGP and Healthy Bones Australia guideline for osteoporosis management and fracture prevention in postmenopausal women and men over 50 (2024) + USPSTF 2025 Screening for Osteoporosis to Prevent Fractures (DOI: 10.5694/mja2.52637).
What are the limitations of the Osteoporosis Case Finding & Management (RACGP/HBA 2024, USPSTF 2025)?
Known limitations include: Thresholds differ by country: Australia uses RACGP/HBA 2024 and PBS criteria; the US uses USPSTF 2025 and BHOF 2022.; Not for children, premenopausal women, men under 50, pregnancy, or CKD stage 4-5 or dialysis: seek specialist advice.; Anabolic therapy, treatment sequencing and drug holidays need specialist input.; Glucocorticoid-induced, cancer-therapy-related and other secondary osteoporosis are covered only briefly.; FRAX does not include falls history or glucocorticoid dose; use clinical judgement.. Individual patient factors may require deviation from these recommendations.
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