*Risk of Fracture |
Lifestyle and nutritional optimization especially Calcium & Vitamin D |
1st Line Treatment |
2nd Line Treatment |
Reassessment |
Drug Holiday |
Low
|
|
|
Reassess fracture risk in 2-4 yrs |
|
|
Moderate
|
Calcium & Vitamin D ± Bisphosphonates (BPs)
|
|
Reassess fracture risk –
|
|
|
High
|
BPs/ Denosumab/ Teriparatide (for 2 years, followed by BPs/denosumab) + Calcium & Vitamin D |
If intolerant/inappropriate to BPs/ Denosumab therapy
|
|
||
Very high
|
*Low- no prior hip or spine fracture, T-score at the hip and spine > -1.0, hip fracture FRAX <3% and major osteoporotic fracture FRAX <20%,
Moderate- no prior hip or spine fracture, T-score at the hip and spine > -2.5, hip fracture FRAX <3% and major osteoporotic fracture FRAX <20%,
High- a prior hip or spine fracture, T-score at the hip and spine ≤ -2.5, hip fracture FRAX ≥3% and major osteoporotic fracture FRAX ≥20%,
Very high- multiple prior hip or spine fracture, T-score at the hip and spine ≤ -2.5;
#No uterusàEstrogen; with uterus à Estrogen+ Progestin
SERM- Selective Estrogen Receptor Modulator; HT- Hormone Therapy; VTE – Venous Thromboembolism
Reference:
Shoback D, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020 Mar 1;105(3).