Osteoporosis: diagnosis and management

Published on 15 August 2025 (updated, see below for version history)

This ACE Clinical Guidance (ACG) provides evidence-based recommendations on risk assessment, timely diagnosis, optimal treatment, and indications for specialist referral in adults with osteoporosis. It covers pharmacological management options, with a focus on antiresorptive and anabolic therapies, and is complemented by a supplementary guide on additional treatment options. Non-pharmacological interventions, including adequate calcium and vitamin D supplementation, regular physical activity and smoking cessation, are also addressed.

First published in 2018, the ACG on osteoporosis has been updated in 2025 to incorporate the latest evidence where relevant. Notably, the 2025 ACG introduces locally derived intervention thresholds for patients with osteopenia, based on an in-house Markov model contextualised to the Singapore healthcare setting. A supplementary guide detailing the methodology for the economic evaluation underpinning these thresholds is also available.

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Osteoporosis: diagnosis and management (Aug 2025) [PDF]

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ACG recommendations

1.Determine the need for bone mineral density testing in people with risk factors for osteoporosis or fragility fractures, particularly all post menopausal women, and men ≥65 years of age.

2.Optimise lifestyle management for all patients at risk of osteoporosis or fragility fractures, including calcium and vitamin D intake through diet and supplementation as appropriate.

3a.Diagnose osteoporosis and initiate treatment for patients with current or past fragility fracture, or a BMD (measured by central DXA) T-score ≤-2.5.

3b.Consider initiating treatment for people with a BMD (measured by central DXA) T-score between -1.0 and -2.5 and who are at high risk of fractures.

4.For patients in whom pharmacological treatment is indicated:

• Use oral alendronate or risedronate (or IV zoledronate if available and preferred)

• Consider using denosumab, if preferred and suitable for the patient.

5.Consider anabolic agents as first-line treatment for patients at very high risk of fractures, with specialist input as needed.

6.Consider referring patients with clinically complex or unusual presentations to specialists for further assessment and management.

Refer to the Evidence-to-Recommendation (EtR) framework below for a summary of the factors underpinning the ACG’s recommendations

ACG references and supplementary guides

Click below to see the list of references and supplementary guides for the osteoporosis ACG.

Osteoporosis: diagnosis and management references (Aug 2025) [PDF]

Supplementary guide on osteoporosis treatment options, in addition to antiresorptive and anabolic agents (Aug 2025) [PDF]

Supplementary guide on the methodology used for economic evaluation of intervention thresholds for patients with osteopenia (Aug 2025) [PDF]

ACG EtR framework

The Evidence-to-Recommendation (EtR) framework is a document that outlines the underpinning evidence and rationale for the recommendations in our ACGs. Download the osteoporosis EtR framework below to learn more about factors that have informed the strength of the ACG recommendations, including certainty of evidence, clinical benefit/risk balance, local resource implications, feasibility considerations, patient preferences and values.

Osteoporosis: diagnosis and management EtR framework (Aug 2025) [PDF]

Version history