Osteoporosis

Osteoporosis is a skeletal disorder in which bone mineral density is reduced and bone microarchitecture is disrupted, resulting in increased bone fragility and susceptibility to fracture. It is often described as a "silent" condition because bone loss occurs without symptoms until a fracture occurs. Fragility fractures — those resulting from low-energy trauma such as a fall from standing height — most commonly affect the vertebrae, hip, wrist and shoulder.

Osteoporosis affects an estimated 3.5 million people in the UK and is responsible for over 500,000 fragility fractures annually. Although more common in postmenopausal women — due to the decline in oestrogen that accompanies the menopause — it also affects men and younger individuals in the context of secondary causes such as corticosteroid use, inflammatory disease, malabsorption or hypogonadism.

Rheumatological conditions including rheumatoid arthritis, lupus and inflammatory bowel disease, as well as corticosteroid therapy used to treat them, substantially increase fracture risk. This means that osteoporosis assessment is an integral part of rheumatological practice and not merely a general medicine concern.

All patients with osteoporosis or significant fracture risk should optimise calcium and vitamin D intake — through diet and supplementation where dietary intake is insufficient. Weight-bearing and resistance exercise is strongly encouraged, as it helps to maintain bone density and reduce fall risk. Smoking cessation and reduction of alcohol intake are important modifiable risk factors. Falls prevention assessment is relevant for those at risk of fragility fractures.

Bisphosphonates — alendronate and risedronate (oral) and zoledronic acid (annual intravenous infusion) — are the most widely used first-line treatments and have robust evidence for fracture prevention at the hip, spine and wrist. They are safe and effective for the majority of patients. Denosumab is a monoclonal antibody given as a six-monthly subcutaneous injection and is particularly useful where bisphosphonates are not tolerated or contraindicated.

For patients at very high or imminent fracture risk — including those with recent vertebral fractures or on high-dose corticosteroids — anabolic therapies that stimulate new bone formation rather than simply reducing resorption may be appropriate. Teriparatide and romosozumab (an anti-sclerostin antibody) offer potent anabolic effects and substantial fracture risk reduction. These are administered by injection and are followed by antiresorptive treatment to maintain gains. Treatment choice is individualised based on fracture risk, tolerability, comorbidities and patient preference.