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This summary outlines risk factors and recommendations associated with fragility fractures, and includes 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
Abbreviations: BMI=body mass index; DMPA=depot medroxyprogesterone acetate; GnRH=gonadotropin-releasing hormone; PPI=proton pump inhibitor; RA=rheumatoid arthritis; SLE=systemic lupus erythematosus; TZD=thiazolidinedione
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 (RA or SLE)
  • 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 DMPA
  • GnRH (in men with prostate cancer)
  • PPIs
  • Oral glucocorticoids
  • TZDs

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

Risk categoryAffected groupRecommendation
Abbreviation: BMI=body mass index 
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 (<20 kg/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 over the age of 50

Pathway from risk factors to pharmacological treatment selection in postmenopausal women v4


Want to learn more about this guideline?

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Read the related Guidelines in Practice article, Osteoporosis: target treatment on the basis of fracture risk

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: March 2015.

Last updated: January 2021.


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