Predisposing Factors, Prevention and Management of Osteoporosis

Constitutional: advancing age, female sex, postmenopausal state, prior fragility fracture (doubles future risk), parental hip fracture, small frame, and Caucasian or Asian ethnicity.

Nutritional: low dietary calcium (Indian intake frequently under 400 mg/day against a requirement of 1000 mg/day), vitamin D deficiency, low protein intake, low BMI below 20 kg/m², and undernutrition.

Lifestyle: physical inactivity and immobilisation, smoking, alcohol above 3 units/day, excess caffeine, and inadequate sun exposure.

Endocrine: early or surgical menopause, hypogonadism in men, hyperthyroidism including over-replacement with levothyroxine, primary hyperparathyroidism, Cushing’s syndrome, type 1 and type 2 diabetes, and acromegaly.

Gastrointestinal and nutritional disease: coeliac disease, inflammatory bowel disease, bariatric surgery, chronic liver disease, pancreatic insufficiency and anorexia nervosa.

Drugs: glucocorticoids (the commonest secondary cause), aromatase inhibitors, androgen deprivation therapy, anticonvulsants (phenytoin, carbamazepine), long-term heparin, proton pump inhibitors, SSRIs, thiazolidinediones and loop diuretics.

Chronic disease: rheumatoid arthritis, CKD-MBD, multiple myeloma, COPD, HIV and antiretroviral therapy, post-transplant state, and immobility from stroke or Parkinson’s disease.

Geriatric amplifiers: sarcopenia, frailty, falls, poor vision, orthostatic hypotension, cognitive impairment and polypharmacy — these convert low bone density into an actual fracture. Osteoporosis breaks bones only when the patient falls.

Primordial prevention: peak bone mass is attained by about age 30; adequate childhood and adolescent calcium, protein, sunlight and impact exercise determine the “bone bank” available for later life.

Nutrition: calcium 1000–1200 mg/day preferably from diet (milk, curd, paneer, ragi, sesame, green leafy vegetables, small fish with bones), protein ≥1 g/kg/day, and vitamin D 800–1000 IU/day with 15–30 minutes of sun exposure without sunblock.

Exercise: progressive resistance and weight-bearing impact exercise at least 3 days a week, plus balance training such as Tai Chi. Swimming and cycling do not load bone. Long-term exercise training reduces falls, fractures, hospitalisation and mortality.

Lifestyle modification: stop smoking, restrict alcohol to ≤2 units/day, and maintain BMI above 20 kg/m².

Falls prevention: home hazard modification, adequate lighting, grab rails, correct footwear, vision and hearing correction, treatment of orthostatic hypotension, deprescribing fall-risk-increasing drugs using STOPPFall, vitamin D correction, and hip protectors in selected institutionalised patients.

Case-finding and screening: DXA in women ≥65 and men ≥70, earlier with risk factors; FRAX-based intervention thresholds to decide who to treat. The SCOOP trial showed that community FRAX-based screening of older women reduced hip fractures.

Secondary prevention: actively identify and treat secondary causes. In glucocorticoid therapy, start bone protection with any dose in patients ≥70 or with prior fracture, and at ≥7.5 mg prednisolone daily for ≥3 months in others.

Tertiary prevention: Fracture Liaison Service after every fragility fracture, orthogeriatric care of hip fracture, early mobilisation, and rehabilitation to prevent post-fracture disability and institutionalisation.

Foundation for all: calcium, vitamin D, protein, exercise, falls prevention and medication review — continued even after drug therapy starts.

High risk: oral bisphosphonate (alendronate/risedronate), IV zoledronate 5 mg yearly, or denosumab 60 mg 6-monthly.

Very high or imminent risk: romosozumab, teriparatide or abaloparatide first, then an antiresorptive to consolidate the gain.

Special situations: denosumab or teriparatide in CKD (avoid bisphosphonates if eGFR <30–35 mL/min); raloxifene or MHT in younger postmenopausal women; vertebral augmentation only for refractory painful acute vertebral fracture.

Monitoring: DXA at 1–2 years on the same machine, interpreting change only if it exceeds the least significant change (about 3% spine, 5% hip); CTX or P1NP at 3–6 months for adherence; annual height measurement as a simple marker of new vertebral fracture.

Adherence is poor — under 50% at one year. Use gastro-resistant or less frequent formulations, patient education, group education programmes and reminder systems.

Indian service delivery: osteoporosis care is delivered through NPHCE geriatric clinics and district hospitals; hip fracture surgery is covered under AB-PMJAY; assistive devices come through ADIP and Rashtriya Vayoshri Yojana; and calcium/vitamin D are widely available in the essential medicines list.