Adults
Osteoporosis: complex or refractory
Fracture on treatment, very high fracture risk needing anabolic therapy, glucocorticoid-induced osteoporosis, or intolerance.
What to look for
- Fragility fracture while on therapy, or multiple vertebral fractures
- T-score of −3.0 or lower, or very high FRAX risk
- Glucocorticoid-induced osteoporosis needing advanced therapy
- Atypical femoral fracture, osteonecrosis of the jaw, or bisphosphonate intolerance
What to do
- Most osteoporosis is treated in primary care. Send DXA results, fracture history, prior and current treatment, and calcium, 25-OH vitamin D, creatinine and PTH if checked.
- Never stop denosumab without a plan. Follow it with a bisphosphonate to prevent rebound vertebral fractures.
- In advanced CKD or on dialysis, decide on denosumab with nephrology: an FDA boxed warning (2024) highlights severe, sometimes fatal hypocalcemia.
About this urgency level
These benefit from rheumatology input but are not time-critical. Treatment can often begin, or continue, in primary care while the patient waits.
Timeframes are typical targets. Local pathways, capacity and clinical judgment come first.