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This summary outlines risk factors and recommendations associated with fragility fractures and a treatment pathway for postmenopausal women from risk factors to pharmacological treatment. For further information, refer to the full guideline.

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Risk factors

Table 1: Risk factors associated with fragility fracture which should prompt consideration of fracture-risk assessment

Risk categoryCausative factor
risk factors
  • Previous fracture
  • Parental history of osteoporosis
  • History of early menopause (below age of 45)
Modifiable risk factors
  • Low BMI (<20 kg/m2)
  • Smoking
  • Low bone mineral density
  • Alcohol intake
Coexisting diseases
  • Diabetes
  • Inflammatory rheumatic diseases (rheumatoid arthritis or systemic lupus erythematosus)
  • Inflammatory bowel disease and malabsorption
  • Institutionalised patients with epilepsy
  • Human immunodeficiency virus
  • Primary hyperparathyroidism and endocrine diseases
  • Chronic liver disease
  • Neurological diseases (including Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, stroke)
  • Moderate to severe chronic kidney disease
  • Asthma
Drug therapy
  • Long-term antidepressants
  • Antiepileptics
  • Aromatase inhibitors
  • Long-term depot medroxyprogesterone acetate
  • Gonadotropin-releasing hormone agonists (in men with prostate cancer)
  • Proton pump inhibitors
  • Oral glucocorticoids
  • Thiazolidinedione

Table 2: Recommendations associated with modifiable risk factors for fragility fractures

Risk categoryAffected groupRecommendation
Alcohol People who consume more than 3.5 units per day of alcohol Reduce alcohol intake to nationally recommended levels (<14 units per week)
Smoking All smokers Stop smoking
Weight People with low BMI (<20kg/m2) Achieve and maintain a BMI level of 20–25 kg/m2
Coexisting diseases People with conditions that predispose to osteoporosis (see Table 1) Where possible treat coexisting disease
Drug treatments People taking drugs that predispose to osteoporosis (see Table 1) Where possible reduce or stop drug therapy

Algorithm 1: Pathway from risk factors to pharmacological treatment selection in postmenopausal women

Pathway from risk factors to pharmacological treatment selection in postmenopausal women


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Read the related Guidelines in Practice article

Full guideline:

Scottish Intercollegiate Guideline Network. Management of osteoporosis and the prevention of fragility fractures. Edinburgh: SIGN; 2015. (SIGN Guideline No. 142). Available at: www.sign.ac.uk/our-guidelines/management-of-osteoporosis-and-the-prevention-of-fragility-fractures

Published date: August 2015.

Last updated: June 2020.