The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group

TLDR

Osteoporosis is a common bone‑strength disorder that markedly increases fracture risk in older adults, with diagnosis traditionally based on a T‑score ≤ −2.5 at the spine, femur neck, or total hip. The authors aim to broaden osteoporosis diagnosis beyond T‑scores, endorsing hip fractures, osteopenia‑related fractures, and FRAX‑derived risk thresholds, and to facilitate ICD‑10 coding of high‑risk patients. A National Bone Health Alliance–appointed working group of 17 clinicians and scientists evaluated how to expand diagnostic criteria for osteoporosis. The group concluded that postmenopausal women and men ≥50 should be diagnosed with osteoporosis when they exhibit an elevated fracture risk, defined by a T‑score ≤ −2.5, a hip fracture, osteopenia‑related fractures, or a FRAX risk of ≥3 % hip or ≥20 % major fracture over 10 years.

Abstract

Osteoporosis causes an elevated fracture risk. We propose the continued use of T-scores as one means for diagnosis but recommend that, alternatively, hip fracture; osteopenia-associated vertebral, proximal humerus, pelvis, or some wrist fractures; or FRAX scores with ≥3 % (hip) or 20 % (major) 10-year fracture risk also confer an osteoporosis diagnosis. Osteoporosis is a common disorder of reduced bone strength that predisposes to an increased risk for fractures in older individuals. In the USA, the standard criterion for the diagnosis of osteoporosis in postmenopausal women and older men is a T-score of ≤ −2.5 at the lumbar spine, femur neck, or total hip by bone mineral density testing. Under the direction of the National Bone Health Alliance, 17 clinicians and clinical scientists were appointed to a working group charged to determine the appropriate expansion of the criteria by which osteoporosis can be diagnosed. The group recommends that postmenopausal women and men aged 50 years should be diagnosed with osteoporosis if they have a demonstrable elevated risk for future fractures. This includes having a T-score of less than or equal to −2.5 at the spine or hip as one method for diagnosis but also permits a diagnosis for individuals in this population who have experienced a hip fracture with or without bone mineral density (BMD) testing and for those who have osteopenia by BMD who sustain a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture. Finally, the term osteoporosis should be used to diagnose individuals with an elevated fracture risk based on the World Health Organization Fracture Risk Algorithm, FRAX. As new ICD-10 codes become available, it is our hope that this new understanding of what osteoporosis represents will allow for an appropriate diagnosis when older individuals are recognized as being at an elevated risk for fracture.