Updated July 2019

The full guideline PDF is available from here

Assessment of fracture risk

Assessment of fracture risk

  • Fracture probability should be assessed in postmenopausal women, and men age 50 years or more, who have risk factors for fracture, using FRAX. In individuals at intermediate risk, bone mineral density (BMD) measurement should be performed using dual energy X-ray absorptiometry and fracture probability re-estimated using FRAX.
  • Vertebral fracture assessment should be considered in postmenopausal women and men age >50 years if there is a history of >=4cm height loss, kyphosis, recent or current long-term oral glucocorticoid therapy, or a BMD T-score <= -2.5.

Lifestyle and dietary measures

  • A daily calcium intake of between 700 and 1200mg should be advised, if possible achieved through dietary intake, with use of supplements if necessary.
  • In postmenopausal women and older men (>50 years) at increased risk of fracture a daily dose of 800IU cholecalciferol should be advised.
  • In postmenopausal women and older men receiving bone protective therapy for osteoporosis, calcium supplementation should be given if the dietary intake is below 700 mg/day, and vitamin D supplementation considered in those at risk of or with evidence of vitamin D insufficiency.
  • Regular weight-bearing exercise should be advised, tailored according to the needs and abilities of the individual patient.
  • Falls history should be obtained in individuals at increased risk of fracture and further assessment and appropriate measures undertaken in those at risk.

Pharmacological intervention in postmenopausal women

  • Alendronate or risedronate are first line treatments in the majority of cases. In women who are intolerant of oral bisphosphonates or in whom they are contraindicated, intravenous bisphosphonates or denosumab provide the most appropriate alternatives, with raloxifene or hormone replacement therapy as additional options. The high cost of teriparatide restricts its use to those at very high risk, particularly for vertebral fractures.
  • Treatment review should be performed after 3 years of zoledronic acid therapy and 5 years of oral bisphosphonate treatment. Continuation of bisphosphonate treatment beyond 3-5 years can generally be recommended in individuals age >75 years, those with a history of hip or vertebral fracture, those who sustain a fracture while on treatment, and those taking oral glucocorticoids.
  • If treatment is discontinued, fracture risk should be reassessed after a new fracture, regardless of when this occurs. If no new fracture occurs, assessment of fracture risk should be performed again after 18 months to 3 years.
  • There is no evidence to guide decisions beyond 10 years of treatment and management options in such patients should be considered on an individual basis.

Glucocorticoid-induced osteoporosis

  • Women and men age >70 years, with a previous fragility fracture, or taking high doses of glucocorticoids (>7.5 mg/day prednisolone) should be considered for bone protective therapy.
  • In other individuals fracture probability should be estimated using FRAX with adjustment for glucocorticoid dose.
  • Bone-protective treatment should be started at the onset of glucocorticoid therapy in individuals at high risk of fracture.
  • Alendronate and risedronate are first line treatment options. Where these are contraindicated or not tolerated, zoledronic acid or teriparatide are alternative options.
  • Bone protective therapy may be appropriate in some premenopausal women and younger men, particularly in individuals with a previous history of fracture or receiving high doses of glucocorticoids.

Osteoporosis in men

  • Alendronate and risedronate are first line treatments in men. Where these are contraindicated or not tolerated, zoledronic acid or denosumab provide the most appropriate alternatives, with teriparatide as an additional option.
  • For estimation of fracture probability, femoral neck BMD T-scores in men should be based on the NHANES female reference database. When using the online version of FRAX for the estimation of fracture probability, femoral neck BMD values (g/cm2) should be entered and the manufacturer of the densitometer specified.

Intervention thresholds for pharmacological intervention

  • The thresholds recommended for decision-making are based on probabilities of major osteoporotic and hip fracture derived from FRAX and can be similarly applied to men and women.
  • Women with a prior fragility fracture can be considered for treatment without the need for further assessment, although BMD measurement may be appropriate, particularly in younger postmenopausal women.
  • Age-dependent intervention thresholds up to 70 years and fixed thresholds thereafter provide clinically appropriate and equitable access to treatment.

Systems of care

  • Coordinator-based Fracture Liaison Services (FLS) should be used to systematically identify men and women with fragility fracture.
Risk assessment is based on an opportunistic case finding strategy in which physicians are alerted to the possibility of high fracture risk by the presence of clinical risk factors (CRFs) associated with fracture.
Thresholds based on FRAX output are used to:
  • Provide assessment thresholds for the use of BMD i.e. the fracture probabilities at which a BMD test might or might not be recommended.
  • Provide intervention thresholds i.e. the fracture probability at which intervention should be considered.
NB - Thresholds are provided for guidance only and the final decision to assess BMD or to initiate therapeutic intervention lies with the individual clinician.

Centre for Metabolic Bone Diseases, University of Sheffield, UK