Approach to osteoporosis diagnosis and fracture risk management in primary care

OBJECTIVE: To outline strategies to reduce osteoporosis-related fracture risk through pharmacologic and nonpharmacologic interventions; to examine the role of the Fracture Risk Assessment Tool (FRAX) and bone mineral density (BMD) testing in fracture risk evaluation and periodic monitoring; and to outline evidence-informed interventions for optimizing nutrition, exercise, and pharmacotherapy. SOURCES OF INFORMATION: Recent Canadian guidelines from Osteoporosis Canada, the Canadian Task Force on Preventive Health Care, and the Society of Obstetricians and Gynaecologists of Canada. MAIN MESSAGE: Both BMD testing and FRAX are endorsed by Canadian guidelines for fracture risk assessment. Guidelines support clinical evaluation of fracture risk, particularly in females 65 years or older, with variations in age- and sex-specific screening recommendations between 50 and 64 years. Effective bone health management integrates pharmacologic and nonpharmacologic strategies to prevent falls and fractures. CONCLUSION: Guidelines recommend prioritizing fracture risk screening in females 65 years or older with risk factor assessment and FRAX application. Evaluation should include assessment of fall risk and signs of undiagnosed vertebral fractures. Risk assessment and shared decision making should guide further evaluation with BMD testing. Osteoporosis Canada suggests targeting screening as per fracture risk in postmenopausal females 65 years or younger and males 50 years or older, noting limited supporting evidence. Adults 50 years or older should engage in balance, functional, and resistance training twice weekly, and follow Health Canada's recommendations for calcium and vitamin D intake, including a vitamin D supplement of 400 IU daily. Pharmacologic therapy is recommended for those with prior hip or vertebral fracture, 2 or more osteoporotic fractures, a 10-year fracture risk 20% or higher, or a T-score -2.5 or less and age 70 years or older, guided by patient values and preference.