Osteoporosis
Thin, fragile bones that break too easily, often first noticed after a minor fall. Silent until it isn’t. The good news: exercise and modern medicines cut fractures a lot.
The osteoporosis ladder
Exercise, calcium and vitamin D are the foundation for everyone. After a minimal-trauma fracture, or with low bone density, medicine is usually the main event.
- Step 1 · Self-careStrength, impact and balance exerciseProgressive weights, impact (stepping, jumping if safe) and balance work, most days.
- Works
- Cuts falls by about a quarter; small gains in bone density
- Cost
- Free to a gym fee; exercise physiologist about $80–120 a session (Medicare rebates with a GP care plan)
- How long
- Ongoing
- Watch for
- Start supervised if you have had spine fractures. Avoid heavy forward bending and twisting.
Walking is lovely. Your bones want you to lift something heavier than a coffee.
- Step 2 · PharmacyCalcium and vitamin DFood first (dairy, tinned fish with bones, fortified foods); supplements if you fall short or are low in vitamin D.
- Works
- Cuts hip fractures by about 15%, mostly in aged care (about 9 fewer per 1000 a year); supports medicines
- Cost
- About $10–20 a month
- How long
- Ongoing
- Watch for
- Constipation from calcium tablets. More is not better.
Supplements aren’t a substitute for a treatment. They’re the scaffolding.
- Step 3 · PrescriptionBisphosphonate tablets (alendronate, risedronate)Slow bone breakdown. Weekly or monthly tablet.
- Works
- Cut spine fractures by about half, and hip fractures by up to a half
- Cost
- Under the $25 PBS co-payment, about $20–25 a month
- How long
- Usually 5 years, then review for a break
- Watch for
- Take on an empty stomach with a full glass of water, stay upright for 30 minutes. Heartburn. Rare jaw bone problems and thigh fractures.
The fussiest breakfast routine in medicine. Worth it.
- Step 4 · PrescriptionYearly infusion (zoledronic acid)A bisphosphonate given into a vein once a year.
- Works
- Cuts spine fractures by about two-thirds and hip fractures by about 40%
- Cost
- $25 per script on the PBS ($7.70 concession), plus infusion fees that vary
- How long
- Once a year, often for 3 years, then review
- Watch for
- Flu-like aches for a day or two after the first dose. Needs a kidney and vitamin D check.
Fifteen minutes once a year. Great for anyone who hates tablets or forgets them.
- Step 5 · Prescription6-monthly injection (denosumab)Blocks the cells that break down bone.
- Works
- Cuts spine fractures by about two-thirds and hip fractures by about 40%
- Cost
- $25 per injection on the PBS ($7.70 concession)
- How long
- Every 6 months, on time, long term
- Watch for
- Low calcium, so check levels. Stopping or running late causes rapid bone loss and spine fractures: never stop without a plan for the next medicine.
The one medicine where being 2 months late really matters. Book the next one before you leave.
- Step 6 · SpecialistBone-building medicines (romosozumab, teriparatide)Injections that build new bone, for very high fracture risk. Started by a specialist.
- Works
- Cut new spine fractures by about two-thirds or more
- Cost
- $25 per script on the PBS for those who qualify ($7.70 concession), plus specialist fees
- How long
- Romosozumab 12 months; teriparatide up to 18–24 months; then another medicine to lock it in
- Watch for
- Romosozumab: not after a recent heart attack or stroke. Teriparatide: daily injections, dizziness, leg cramps.
Bone renovation, not just maintenance. The heavy machinery.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Vibration platesSmall effects on bone density at best, and no good evidence they prevent fractures. A pricey way to stand still.
- Collagen supplementsSmall, low-quality studies, mostly funded by the people selling them.
- Alkaline diets and alkaline waterTrials show no benefit for bone. Your stomach is acid regardless.
- Big once-a-year vitamin D dosesOne large trial found a single yearly mega-dose increased falls and fractures. Regular modest doses are safer.
- Yearly bone density scansBone changes too slowly to measure reliably in a year, so scans are usually spaced 2 or more years apart.
What you can do
- Had a fracture from a fall at standing height or less? Ask about a bone density scan and treatment.
- Follow our bone health exercise handout: one printable page with sets and progressions.
- Make your home trip-proof: lights at night, no loose rugs, rails in the bathroom.
- Stop smoking, keep alcohol to 2 standard drinks a day or less.
- See your dentist before starting, and keep teeth in good shape.
- Don’t quietly stop your medicine. Talk to your GP first, especially denosumab.
See your GP if
- You’ve broken a bone from a minor fall or bump
- You’re over 70, went through early menopause, or take long-term steroid tablets
- New sudden back pain or loss of height
- New thigh, groin or jaw pain while on treatment
Get urgent help after a fall if you can’t stand or walk, or have severe hip or back pain: call 000 (Australia) or your local emergency number. From a mobile, 112 works in most countries.
Common questions
Who should have a bone density scan?
People who’ve had a minimal-trauma fracture, everyone 70 and over, and younger people with risk factors such as early menopause, long-term steroids or some medical conditions. Medicare covers scans for these groups.
Are osteoporosis medicines safe?
For people with osteoporosis, the fractures they prevent far outnumber the serious side effects. Jaw bone problems and unusual thigh fractures are rare. Good dental care lowers the jaw risk.
Can I stop denosumab injections?
Not without a plan. Stopping or delaying causes rapid bone loss and a risk of several spine fractures. Your doctor will usually switch you to another medicine first.
Is calcium enough to treat osteoporosis?
No. Calcium and vitamin D support treatment, but on their own they do little to prevent fractures in people living at home. Exercise and prescribed medicines do the heavy lifting.
Helpful resources
- Osteoporosis exercise handoutPrintable, one page, with sets and progressions. Free, from us.
- Know Your Bones5 to 10 minute online check of your bone health risk, with a report to take to your GP. Free, from Healthy Bones Australia and the Garvan Institute.
- Healthy Bones Australia: Exercise guideWeight-bearing, resistance and balance exercises you can do at home. Free, Australia.
- Royal Osteoporosis Society: BookletsFree downloadable booklets on exercise, treatment and living with fractures. UK.
Evidence and more information
- Healthy Bones Australia: Osteoporosis treatment
- RACGP and Healthy Bones Australia: Osteoporosis guidelines
- Healthdirect: Osteoporosis
- Cochrane: Vitamin D and calcium for preventing fractures (2014)
maladywise.com/osteoporosis/