DEXA (dual-energy X-ray absorptiometry) scan
• T-score ≤ –2.5 → osteoporosis
• T-score –1 to –2.5 → osteopenia
• Z-score used in premenopausal women and younger men (age-matched)
FRAX score
• Calculates 10-year probability of major osteoporotic fracture and hip fracture
• Incorporates:
o Age
o Sex
o BMI
o Smoking, alcohol use
o Prior fractures
o Secondary causes
o Glucocorticoid use
• Endocrine
o Hyperthyroidism
o Hyperparathyroidism
o Diabetes mellitus (type 1 > type 2)
o Hypogonadism (e.g., anorexia nervosa, androgen deprivation therapy)
• Hematologic
o Multiple myeloma
o Mastocytosis
• Drugs
o Glucocorticoids (≥5 mg prednisolone for >3 months)
o Anticonvulsants (e.g., phenytoin, carbamazepine)
o Proton pump inhibitors (long-term)
• GI and liver
o Malabsorption (e.g., coeliac disease, IBD)
o Chronic liver disease
Bisphosphonates
• Alendronate, risedronate, zoledronic acid (IV)
• Inhibit osteoclast-mediated bone resorption
• Administration tips (oral agents):
o Take on empty stomach with water
o Stay upright ≥30 min
o Avoid food/drinks during this period to reduce risk of oesophagitis
• Side effects:
o Atypical femoral fractures (rare)
o Osteonecrosis of the jaw (rare, consider dental assessment before initiation)
Calcium and vitamin D supplementation
• Indicated if dietary intake inadequate
• Calcium ~1000–1200 mg/day, vitamin D ~800 IU/day
• Alone usually insufficient but used adjunctively
Denosumab
• RANKL inhibitor → inhibits osteoclast differentiation and activity
• Indications:
o Alternative if bisphosphonates contraindicated or not tolerated
• Administered subcutaneously every 6 months
• Risks: rebound vertebral fractures if stopped abruptly, hypocalcaemia
Other options
• Selective estrogen receptor modulators (SERMs) (e.g., raloxifene): reduce vertebral fractures, may increase VTE risk
• Teriparatide (recombinant PTH analog): reserved for severe osteoporosis or multiple fractures
• Strength and balance training (e.g., physiotherapy)
• Medication review → minimise sedatives, antihypertensives
• Home hazard assessment → remove rugs, improve lighting
• Vision and hearing correction
• Footwear assessment
• Vitamin D supplementation if deficient
Extra Revision Pearls
• Glucocorticoid-induced osteoporosis: bisphosphonates recommended at initiation if long-term therapy planned
• Vertebral fractures often asymptomatic — consider if unexplained back pain, height loss, kyphosis
• "High-turnover osteoporosis": e.g., in hyperparathyroidism; alkaline phosphatase often raised
• Re-evaluate need for bisphosphonates after 3–5 years (drug holiday considerations)
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
