2023 Asia-Pacific Consensus on Osteoporotic Fracture Prevention in Postmenopausal Women With Low Bone Mass or Osteoporosis but No Fragility Fractures

I. Ten Core Consensus Statements (Expert Consensus)

1. Fracture Risk Assessment: Use FRAX (with country-specific databases) + BMD (T-score) to stratify risk; consider age, prior fracture, parental hip fracture, low BMI, smoking, alcohol use, glucocorticoid use, and rheumatoid arthritis.
2. Pharmacotherapy Eligibility: Recommend pharmacotherapy for high-risk women (FRAX 10-year major osteoporotic fracture risk ≥20% or hip fracture risk ≥3%; T-score ≤-2.5); conditional for moderate-risk (FRAX major 10–20% or hip 1–3%; T-score -1.0 to -2.5).
3. First-Line Pharmacotherapy: Alendronate, risedronate, and raloxifene are well-recognized options; zoledronic acid is effective for fracture prevention.
4. Denosumab & Teriparatide: Denosumab is a first-line alternative; teriparatide is reserved for severe osteoporosis (T-score ≤-3.0) or high fracture risk with failed bisphosphonates.
5. Calcium & Vitamin D Supplementation: Target 1000–1200mg calcium/day (diet + supplements) and 800–1000 IU vitamin D/day; monitor 25(OH)D levels (target ≥30ng/mL).
6. Lifestyle Interventions: Mandatory for all women—weight-bearing exercise (3×/week), resistance training (2×/week), smoking cessation, alcohol <10g/day, fall prevention.
7. Hormone Therapy (HT): Consider HT in early postmenopausal women (≤60 years or <10 years since menopause) with low fracture risk and no contraindications; avoid in high CV/GI risk patients.
8. Monitoring Strategy: BMD every 2 years; switch therapy if BMD declines >4% at spine/hip or new morphometric vertebral fracture occurs.
9. Adherence Enhancement: Use simplified regimens (e.g., weekly bisphosphonates, 6-month denosumab injections); educate on fracture risk reduction benefits.
10. Health Policy Advocacy: Reimburse pharmacotherapy for high-risk women to improve access and reduce fracture burden.

II. Risk Stratification & Intervention Framework

(1) Risk Stratification (FRAX + BMD)

(2) Stepwise Intervention Protocol

1. Base: Lifestyle optimization (exercise, smoking/alcohol cessation, fall prevention)+Ca/D supplementation (1200mg Ca, 800 IU D/day).
2. High Risk: Add bisphosphonate (alendronate 70mg/week or risedronate 35mg/week) or denosumab 60mg every 6 months.
3. Severe/Refractory: Switch to teriparatide 20mcg/day (max 2 years) or romosozumab (120mg/month ×12 months) followed by anti-resorptive therapy.
4. Monitoring: BMD at 2 years; 25(OH)D and calcium at baseline, 6 months, and annually.

III. Pharmacotherapy: Efficacy & Safety Summary

IV. Lifestyle & Nutritional Interventions (Expert Consensus)

1. Exercise:
   • Weight-bearing: Brisk walking, stair climbing, dancing (3×30min/week).
   • Resistance: Weight training, elastic bands (2×30min/week); focus on core and lower limbs.
   • Balance: Tai Chi, single-leg stands (daily) to reduce fall risk.
    
2. Nutrition:
   • Calcium: Dairy, tofu, leafy greens (avoid oxalate-rich veggies raw); supplements if diet <1000mg/day.
   • Vitamin D: Sunlight (15–30min/day, face/arms), fatty fish, fortified foods; supplements if 25(OH)D <30ng/mL.
    
3. Fall Prevention:
   • Home modifications: Remove rugs, install handrails, improve lighting.
   • Gait/balance training; avoid sedatives/hypnotics; review medications for dizziness.
    

V. Special Populations (Key Adjustments)

VI. Clinical Takeaways

1. Use FRAX + BMD to stratify fracture risk; offer pharmacotherapy to high-risk women (FRAX major ≥20% or hip ≥3%; T-score ≤-2.5).
2. Bisphosphonates (alendronate/risedronate) are first-line; denosumab is an alternative; teriparatide for severe cases.
3. Combine pharmacotherapy with lifestyle optimization, calcium/vitamin D supplementation, and fall prevention.
4. Monitor BMD every 2 years; switch therapy if BMD declines >4% or new fractures occur.
5. Advocate for policy support to improve access to pharmacotherapy for high-risk women.