SIGN142

1 Management of osteoporosis and the prevention of fragility fracturesA national clinical guidelineFirst published March 2015 Revised edition published June 2020 SIGN142 Key to evidence statements and recommendationsLevels of evidence1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias1 Meta-analyses, systematic reviews, or RCTs with a high risk of bias2++ High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal2+ Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal2 Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal3 Non-analytic studies, eg case reports, case series4 Expert opinionRecommendationsSome recommendations can be made with more certainty than others.

2 The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).The strength of a recommendation takes into account the quality (level) of the evidence. Although higher-quality evidence is more likely to be associated with strong recommendations than lower-quality evidence, a particular level of quality does not automatically lead to a particular strength of factors that are taken into account when forming recommendations include: relevance to the NHS in Scotland; applicability of published evidence to the target population; consistency of the body of evidence, and the balance of benefits and harms of the For strong recommendations on interventions that should be used, the guideline development group is confident that, for the vast majority of people, the intervention (or interventions) will do more good than harm.

3 For strong recommendations on interventions that should not be used, the guideline development group is confident that, for the vast majority of people, the intervention (or interventions) will do more harm than For conditional recommendations on interventions that should be considered , the guideline development group is confident that the intervention will do more good than harm for most patients. The choice of intervention is therefore more likely to vary depending on a person s values and preferences, and so the healthcare professional should spend more time discussing the options with the points Recommended best practice based on the clinical experience of the guideline development Improvement Scotland (HIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline.

4 This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at The EQIA assessment of the manual can be seen at The full report in paper form and/or alternative format is available on request from the Healthcare Improvement Scotland Equality and Diversity care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site has accredited the process used by Scottish Intercollegiate Guidelines Network to produce clinical guidelines. The accreditation term is valid until 30 June 2020 and is applicable to guidance produced using the processes described in SIGN 50: a guideline developer s handbook, 2019 edition ( ).

5 More information on accreditation can be viewed at Intercollegiate Guidelines NetworkManagement of osteoporosis and the prevention of fragility fracturesA national clinical guidelineFirst published March 2015 Revised edition published June 2020 Scottish Intercollegiate Guidelines Network Gyle Square, 1 South Gyle Crescent Edinburgh EH12 published March 2015 Revised edition published June 2020978-1-909103-75-7 Citation textScottish Intercollegiate Guidelines Network (SIGN). Management of osteoporosis and the prevention of fragility fractures. Edinburgh: SIGN; 2020. (SIGN publication no. 142). [June 2020]. Available from URL: document is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives International Licence. This allows for the copy and redistribution of this document as long as SIGN is fully acknowledged and given credit.

6 The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit The need for a guideline Remit of the guideline Statement of intent 32 Key recommendations Risk factors Quantifying the risk of fracture Management of osteoporosis in postmenopausal women Systems of care 53 Risk factors Risk in the context of osteoporosis Non-modifiable risk factors Modifiable risk factors Coexisting diseases Pharmacological risk factors Summary of risk factors 304 Quantifying the risk of fracture Introduction Risk-assessment tools Bone mineral density measurement Peripheral BMD measurement Ultrasound densitometry Biochemical bone turnover markers 365 Targeting treatment Introduction Targeting treatment on the basis of fracture risk Targeting treatment on the basis of vertebral fractures Targeting

7 Treatment on the basis of hip fracture Targeting treatment on the basis of screening for height loss Targeting treatment by population-based screening Algorithm for the detection and management of osteoporosis 406 Management of osteoporosis in postmenopausal women Introduction Exercise interventions Diet Pharmacological management Duration of treatment Monitoring of pharmacological effect Adherence, compliance and concordance 837 Management of osteoporosis in other groups Introduction Non-pharmacological management of osteoporosis in men Pharmacological management of osteoporosis in men Exercise interventions in premenopausal women Patients with glucocorticoid-induced osteoporosis Patients with painful vertebral fractures 938 Systems of care Introduction Reminders and educational strategies Multifaceted interventions 999 Provision of information Sources of further information Checklist for provision of information to patients at risk of fracture 10210 Implementing the guideline Implementation strategy Resource implications of key recommendations Auditing current practice Additional advice to NHSS cotland from Healthcare Improvement

8 Scotland and the Scottish Medicines Consortium 10411 The evidence base Systematic literature review Recommendations for research 10712 Development of the guideline Introduction The guideline development group Acknowledgements Consultation and peer review 110 Abbreviations 112 Annexes116 References12211 | Introduction1 The need for a guidelineOsteoporosis is a common bone disease characterised by reduced bone mass which is associated with an increased risk of low-trauma fractures. Data collected by NHS Scotland Information and Statistics Division showed the prevalence of osteoporosis in Scotland was in 2018 Rates of fractures in men and women over the age of 50 are higher in Scotland than other parts of the United Kingdom (UK).2 Fractures are an important cause of morbidity, and patients who have hip fractures and vertebral fractures have a decreased life expectancy compared with population-based controls.

9 A wide range of treatments that can reduce the risk of fractures occurring in patients with osteoporosis is now available. These have the potential to improve clinical outcomes for patients with osteoporosis and to reduce societal costs of medical care associated with Remit of the Overall objectivesThis guideline provides recommendations based on current evidence for best practice in the management of osteoporosis and prevention of fractures. It addresses risk factors for fracture, commonly-used tools for assessment of fracture risk, approaches to targeting therapy, pharmacological, and non-pharmacological treatments to reduce fracture risk, treatment of painful vertebral fractures and systems of care. The assessment and prevention of falls is excluded as it was covered by a national resource published by NHS Quality Improvement Scotland in 2010, which aimed to prevent fractures in older people by raising the profile of falls,3 and also in a clinical guideline published by the National Institute for Health and Care Excellence (NICE) in The guideline also excludes issues surrounding the surgical management of fractures and postoperative care of patients with Summary of updates to the guideline, by sectionThis guideline was published in 2015.

10 The following sections were updated in 2020 immunodeficiency virusCompletely revised treatment: introductionMinor treatment on the basis of fracture risk treatment on the basis of screening for height treatment by population-based for the detection and management of harms associated with and vitamin D treatmentCompletely revised2 Management of osteoporosis and the prevention of fragility between different recommendation acidNew recommendation of informationMinor Target users of the guidelineThis guideline will be of interest to rheumatologists, endocrinologists, general practitioners (GPs), physicians involved in care of the elderly, orthopaedic surgeons, gynaecologists, specialist nurses involved in the care of patients with osteoporosis and pharmacists. It will also be of interest to physiotherapists, occupational therapists and those involved in exercise sciences and nutritional management of people with osteoporosis .