Osteoporosis

Our Approach In Managing Osteoporosis

Diagnose Early. Strengthen Bone. Prevent Fractures.

 

At Shree Hospitals, we combine state-of-the-art bone density measurement with evidence-based medical therapy and targeted orthopaedic care to manage osteoporosis in Mumbai across all patient groups from perimenopausal women experiencing rapid early bone loss to elderly men with steroid-induced osteoporosis and to younger patients with secondary causes including malabsorption, inflammatory arthritis, and premature menopause.

 

Our bone health team treats osteoporosis as the serious, life-limiting medical condition it is  not as a normal part of ageing to be accepted.

 

The consequences of untreated osteoporosis are severe. A hip fracture in a patient over 70 carries a 20–30% one-year mortality rate comparable to many cancers. Vertebral compression fractures cause chronic pain, progressive kyphotic deformity, and significantly impaired quality of life.

 

Yet osteoporosis remains profoundly undertreated most patients receive their first diagnosis only after sustaining a fragility fracture, by which point bone loss is already advanced. Our approach is proactive: identifying at-risk patients through DEXA scan screening, initiating appropriate bisphosphonate treatment or bone-building therapy early, and implementing comprehensive fracture prevention strategies that protect every patient from preventable injury.

 

• DEXA scan (dual-energy X-ray absorptiometry) at the lumbar spine and hip — the gold standard for bone mineral density (BMD) measurement and osteoporosis diagnosis
• FRAX® (Fracture Risk Assessment Tool) calculation — 10-year probability of major osteoporotic and hip fracture, integrating BMD with clinical risk factors
• Full secondary osteoporosis screen — thyroid, parathyroid, vitamin D, calcium, renal, liver, and bone turnover markers
• Vertebral fracture assessment (VFA) on DEXA — identifies prevalent vertebral compression fractures that are silent but significantly elevate future fracture risk
• Trabecular Bone Score (TBS) — assesses bone microarchitecture quality independent of BMD
• Spinal X-rays for height loss or back pain to identify morphometric vertebral fractures

Evidence from international osteoporosis guidelines confirms that patients who sustain a fragility fracture without subsequent bone health assessment and treatment have a 2–3× higher risk of a second fracture within the following 2 years (International Osteoporosis Foundation, 2024).

 

Our Fracture Liaison Service (FLS) systematically identifies every patient admitted with a fragility fracture and initiates secondary prevention treatment before discharge.

 

• Personalised treatment plans based on fracture risk category, secondary causes, patient preferences, and co-morbidities
• Choice of oral, injection-based, or intravenous bone-strengthening medications
  Supervised physiotherapy and fall prevention programme
• Nutritional optimisation — calcium and vitamin D therapy as the non-negotiable foundation of all treatment
• Annual DEXA monitoring to assess treatment response and adjust therapy

Our bone health clinic provides a one-stop service — DEXA scanning, specialist consultation, medication initiation, and physiotherapy referral all within a single appointment pathway. 

1. Advanced Diagnosis — DEXA Scan & Bone Health Assessment

Osteoporosis diagnosis requires objective measurement of bone mineral density (BMD) clinical symptoms alone are insufficient and unreliable. Our diagnostic protocol follows the WHO and International Osteoporosis Foundation (IOF) standards.

DEXA Scan (Dual-Energy X-ray Absorptiometry):

• Measures BMD at the lumbar spine (L1–L4) and proximal femur (total hip and femoral neck) — the two most clinically relevant sites
• Results reported as T-score (comparison with young adult peak bone mass):
  • T-score ≥ −1.0: Normal bone density
  • T-score −1.0 to −2.5: Osteopenia (low bone density — pre-osteoporosis)
  • T-score ≤ −2.5: Osteoporosis
  • T-score ≤ −2.5 with one or more fragility fractures: Severe (established) osteoporosis
• Z-score (comparison with age-matched peers) — used in premenopausal women, men under 50, and children; a Z-score ≤ −2.0 indicates "below expected range for age" and mandates secondary cause investigation
• Forearm DEXA added for hyperparathyroidism, very obese patients, or where spine/hip are technically non-assessable
• Repeat DEXA every 1–2 years on treatment; every 2–3 years for monitoring in stable patients

FRAX® Fracture Risk Calculation:

• Validated WHO tool calculating 10-year probability of hip fracture and major osteoporotic fracture (spine, hip, wrist, humerus)
• Integrates BMD T-score with 11 clinical risk factors: age, sex, BMI, prior fragility fracture, parental hip fracture, current smoking, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis, alcohol ≥3 units/day
• Treatment thresholds: high fracture risk (FRAX hip ≥3% or major fracture ≥20%) — initiate pharmacological therapy
• Identifies patients at high fracture risk despite BMD in the osteopenic range — avoiding under-treatment
  

Secondary Osteoporosis Screen (Blood Tests):

• Serum calcium, phosphate, and alkaline phosphatase (ALP)
• 25-hydroxyvitamin D — deficiency is near-universal in osteoporosis patients and must be corrected before or alongside anti-resorptive therapy
• Parathyroid hormone (PTH) — elevated in primary hyperparathyroidism, a major secondary cause
• Thyroid function tests (TSH) — hyperthyroidism accelerates bone turnover
• Full blood count and ESR — anaemia and elevated ESR suggest myeloma (a malignancy mimicking osteoporosis)
• Serum protein electrophoresis and urine Bence Jones protein — to exclude myeloma in at-risk patients
• Renal and liver function — both affect bone metabolism and drug choice
• Testosterone (men), oestradiol, FSH/LH (premenopausal women with amenorrhoea)
• Coeliac serology (anti-tTG IgA) — malabsorption is an under-recognised secondary cause
  

Bone Turnover Markers:

• Serum CTX (C-terminal telopeptide) — marker of bone resorption; elevated in untreated osteoporosis, myeloma, and Paget's disease; suppressed by anti-resorptive therapy (confirms treatment efficacy)
• Serum P1NP (procollagen type 1 N-terminal propeptide) — marker of bone formation; elevated by anabolic therapy (teriparatide, romosozumab); used to monitor response

2. Nutritional & Lifestyle Management

Calcium, vitamin D, and bone-loading exercise are the non-negotiable foundation of osteoporosis management — without them, pharmacological therapy is significantly less effective. No drug works optimally in a calcium- or vitamin D-deficient patient.

Calcium:

• Recommended daily intake: 1,000 mg/day (adults under 50) and 1,200 mg/day (women over 50 and all adults over 70)
• Dietary sources prioritised over supplements — dairy products, fortified plant milks, green leafy vegetables (kale, broccoli), tofu, and sesame seeds
• Calcium carbonate supplementation (taken with food) or calcium citrate (can be taken fasting, preferred post-gastric surgery) for patients who cannot meet requirements through diet
• Calcium intake above 1,500 mg/day from supplements — no additional bone benefit; possible cardiovascular concerns with excessive supplementation
  

Vitamin D:

• Target serum 25-hydroxyvitamin D: ≥75 nmol/L (30 ng/mL) for optimal bone health; ≥50 nmol/L as minimum
• Daily supplementation: 800–2,000 IU cholecalciferol (D3) for most adults; higher doses (3,000–5,000 IU) for deficient patients until repletion
• Monthly or quarterly high-dose loading in severely deficient patients (25,000–300,000 IU oral or IM)
• Vitamin D toxicity (>250 nmol/L serum level) is rare but monitored annually in patients on high-dose supplementation

Exercise:

• Weight-bearing and resistance exercise are the only forms of exercise proven to maintain and modestly improve BMD — swimming and cycling do not load bone sufficiently to stimulate remodelling
• Recommended programme: 30 minutes of weight-bearing activity (walking, dancing, stair climbing) 5 days per week, combined with resistance training (weights, resistance bands) 2–3 times per week
• Progressive resistance training of the hip extensors and back extensors specifically proven to reduce vertebral and hip fracture risk
• Balance training (Tai Chi, single-leg standing, perturbation training) — addresses the fall risk component of fracture prevention
• High-impact exercise (jumping, jogging) in pre-osteoporosis patients with good bone quality; avoided in established osteoporosis with vertebral fractures
  

Lifestyle Modification:

• Smoking cessation — smoking reduces oestrogen levels, impairs calcium absorption, and directly inhibits osteoblast function; fracture risk in smokers is 25% higher than in non-smokers
• Alcohol reduction to ≤2 units/day — alcohol inhibits osteoblasts, reduces calcium absorption, impairs vitamin D activation, and elevates fall risk
• Review of bone-harmful medications — glucocorticoids (the single biggest preventable cause of secondary osteoporosis), proton pump inhibitors, aromatase inhibitors, anticonvulsants, thiazolidinediones, and GnRH agonists
• Optimisation of underlying conditions driving bone loss — coeliac disease, inflammatory bowel disease, rheumatoid arthritis, hypogonadism

3. Medical Therapy — Bone-Strengthening Medications

Pharmacological therapy is indicated for patients with osteoporosis (T-score ≤ −2.5), high FRAX fracture risk, or a prior fragility fracture. The choice of agent depends on fracture risk level, prior fracture sites, patient preference, renal function, and co-morbidities.

 

Anti-Resorptive Therapy — First Line:

Bisphosphonates:

• The most widely prescribed class of osteoporosis medication worldwide — inhibit osteoclast-mediated bone resorption, preserving bone microarchitecture and reducing fracture risk
• Alendronate (Fosamax) — 70 mg once weekly oral; reduces vertebral fracture risk by 47%, hip fracture risk by 51% (FIT trial). First-line choice for most patients. Must be taken fasting with plain water and patient remains upright for 30 minutes — to prevent oesophageal irritation
• Risedronate (Actonel) — 35 mg once weekly or 150 mg once monthly; similar efficacy to alendronate; better GI tolerability
• Ibandronate (Boniva) — 150 mg once monthly oral or 3 mg IV every 3 months; reduces vertebral but not non-vertebral fractures; option when weekly tablets are not tolerated
• Zoledronic Acid (Aclasta / Reclast) — 5 mg IV infusion once yearly; the most potent bisphosphonate; reduces vertebral fracture by 70%, hip fracture by 41% (HORIZON trial); ideal for patients with poor oral medication compliance, GI disease, or following hip fracture hospitalisation
• Bisphosphonate drug holidays (after 3–5 years): residual drug in bone provides ongoing protection; holiday reduces the rare risk of atypical femoral fracture and osteonecrosis of the jaw

Denosumab (Prolia):

• A monoclonal antibody against RANKL — inhibits osteoclast formation and activity; 60 mg subcutaneous injection every 6 months
• Reduces vertebral fracture by 68%, hip fracture by 40%, non-vertebral fracture by 20% (FREEDOM trial)
• No renal dose adjustment required — preferred over bisphosphonates in moderate-severe renal impairment (eGFR <30)
• Important: must not be stopped abruptly — rapid bone loss and rebound vertebral fractures occur if doses are missed without transitioning to a bisphosphonate
• Ideal for patients who cannot take or tolerate oral bisphosphonates, or who need a twice-yearly injectable option

Anabolic (Bone-Building) Therapy — High-Risk Patients:

Teriparatide (Forteo):

• Recombinant PTH(1-34) — stimulates osteoblast activity and new bone formation (anabolic mechanism), unlike anti-resorptive agents which prevent bone loss
• 20 mcg subcutaneous daily injection for 24 months
• Reduces vertebral fracture risk by 65%, non-vertebral by 53% — superior efficacy in severe osteoporosis with multiple prior vertebral fractures
• Reserved for patients at very high fracture risk, those who have failed anti-resorptive therapy, or those with glucocorticoid-induced osteoporosis
• Must be followed by an anti-resorptive agent after the 24-month course to preserve the gains

Abaloparatide (Tymlos):

• PTHrP analogue with similar anabolic mechanism to teriparatide; 80 mcg daily subcutaneous injection for 18 months
• Slightly faster onset of BMD gain; reduced hypercalcaemia risk compared to teriparatide

Romosozumab (Evenity):

• Sclerostin inhibitor — unique dual mechanism: stimulates bone formation AND inhibits bone resorption simultaneously
• 210 mg subcutaneous injection monthly for 12 months
• Most rapid and substantial BMD gains of any osteoporosis agent — 73% reduction in new vertebral fractures vs. placebo (FRAME trial); superior to alendronate in fracture prevention (ARCH trial)
• Reserved for patients at very high fracture risk — particularly those with prior hip fracture or multiple vertebral fractures
• Contraindicated within 12 months of myocardial infarction or stroke — due to a small cardiovascular signal in the ARCH trial
• Must be followed by anti-resorptive therapy after the 12-month course

Hormone Replacement Therapy (HRT):

• Oestrogen-based HRT is highly effective at preventing bone loss in perimenopausal and early postmenopausal women — particularly where menopausal symptoms co-exist with bone loss
• Not a first-line osteoporosis treatment in older women — cardiovascular, thromboembolic, and breast cancer risk considerations limit long-term use
• Testosterone replacement in hypogonadal men — significantly improves BMD; testosterone gel or injection under endocrinology co-management

4. Fracture Management & Vertebral Augmentation

When osteoporosis-related fractures occur particularly vertebral compression fractures and hip fractures prompt specialist intervention minimises pain, prevents deformity, and enables the fastest possible recovery.

 

Vertebral Compression Fracture Management:

• The most common osteoporotic fracture — approximately 1.4 million new vertebral fractures occur worldwide annually
• Most are managed conservatively: analgesia, short-term rest, thoracolumbar spinal orthosis (TLSO brace), and early mobilisation
• Persistent severe pain (>4–6 weeks) unresponsive to conservative management is the primary indication for vertebral augmentation

Vertebroplasty:

• Percutaneous injection of polymethylmethacrylate (PMMA) bone cement directly into the fractured vertebral body under fluoroscopic or CT guidance
• Stabilises the fracture, eliminates pain from micromotion, and provides immediate structural support
• Performed under local anaesthesia with sedation — day-care procedure; patient mobilised within hours
• Rapid and dramatic pain relief in 80–90% of patients — typically within 24–48 hours

Balloon Kyphoplasty:

• A refinement of vertebroplasty — an inflatable balloon tamp is inserted into the fractured vertebra and inflated to restore vertebral body height before cement injection
• Restores partial vertebral height, reduces kyphotic angulation, and creates a lower-pressure cavity for cement injection — reducing cement leakage risk compared to vertebroplasty
• Preferred for sub-acute fractures (2–6 weeks old) with height loss and kyphotic deformity
• Day-care or overnight stay procedure under local anaesthesia with sedation or general anaesthesia

Hip Fracture Surgery:

• Femoral neck fractures and intertrochanteric fractures in osteoporotic patients require urgent surgical fixation (within 36–48 hours of admission) — delay is directly associated with increased mortality
• Internal fixation (dynamic hip screw, cephalomedullary nail) for stable, reducible fractures
• Hemiarthroplasty or total hip replacement for displaced femoral neck fractures — particularly in patients over 65 where bone quality prevents reliable internal fixation
• Enhanced recovery protocols and early mobilisation (Day 1 post-surgery) to minimise immobility-related complications
• Every hip fracture patient is assessed by our Fracture Liaison Service before discharge — bone health treatment initiated in hospital

5. Long-Term Monitoring & Fall Prevention

Fracture prevention in osteoporosis is a two-part strategy: strengthening bone AND preventing falls. Bone strength alone is insufficient if patients continue to fall most hip fractures result from falls, not from the bone being too weak to withstand normal loading.

Medication Monitoring:

• Annual DEXA scan for the first 2–3 years of treatment — to confirm BMD is stable or improving
• Bone turnover markers at 3 and 12 months — CTX suppression confirms anti-resorptive therapy is working; P1NP rise confirms anabolic therapy is working
• Annual blood tests: serum calcium (hypercalcaemia on teriparatide), vitamin D level, renal function (bisphosphonates), and secondary osteoporosis markers
• Bisphosphonate drug holiday assessment after 3–5 years — continuing vs. holiday decision based on fracture risk recalculation
• Transition planning: all anabolic therapy (teriparatide, romosozumab) must be followed by an anti-resorptive agent; all denosumab courses must be transitioned to bisphosphonate on cessation
  

Fall Prevention Programme:

• Comprehensive fall risk assessment — Timed Up and Go (TUG) test, Berg Balance Scale, orthostatic blood pressure measurement
• Balance and strengthening physiotherapy — Tai Chi (level 1 evidence for fall reduction), progressive resistance training, vestibular rehabilitation
• Home hazard assessment — removing loose rugs, improving lighting, installing grab rails and non-slip mats, raising toilet seat and chair heights
• Footwear assessment — appropriate supportive shoes; referral for hip protector devices in very high-fall-risk elderly patients
• Medication review — identifying and rationalising bone-harmful and fall-risk-increasing medications (benzodiazepines, sedatives, antihypertensives causing postural hypotension, diuretics)
• Vision correction — cataract surgery referral where poor vision is contributing to fall risk
• Cardiac assessment — syncope and postural hypotension as reversible fall causes
  

Patient Education:

• Understanding osteoporosis as a chronic, manageable condition — not an inevitable consequence of ageing
• Correct medication administration technique (particularly for weekly bisphosphonates and self-injection with teriparatide or denosumab)
• Recognising vertebral fracture symptoms — acute back pain after minimal exertion, height loss measurement at home
• When to seek emergency care — sudden severe back pain, inability to weight-bear after a fall, neurological symptoms after a vertebral fracture