Osteoporosis: assessing the risk of fragility fracture – NICE guideline

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This National Institute for Health and Care Excellence (NICE) guideline covers assessing the risk of fragility fracture in people aged 18 and over with osteoporosis. It aims to provide guidance on the selection and use of risk assessment tools in the care of adults at risk of fragility fractures in all NHS settings.

Key recommendations

Targeting risk assessment

  • Consider assessment of fracture risk in:
    • all women aged 65 years and over and all men aged 75 years and over
    • women aged under 65 years and men aged under 75 years in the presence of risk factors, for example:
      • previous fragility fracture
      • current use or frequent recent use of oral or systemic glucocorticoids
      • history of falls
      • family history of hip fracture
      • other causes of secondary osteoporosis
      • low body mass index (BMI) (less than 18.5 kg/m2)
      • smoking
      • alcohol intake of more than 14 units per week for women and more than 21 units per week for men.
  • Do not routinely assess fracture risk in people aged under 50 years unless they have major risk factors (for example, current or frequent recent use of oral or systemic glucocorticoids, untreated premature menopause or previous fragility fracture), because they are unlikely to be at high risk.

Methods of risk assessment

  • Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage).
  • Use either FRAX (without a bone mineral density [BMD] value if a dual-energy X-ray absorptiometry [DXA] scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture. Above the upper age limits defined by the tools, consider people to be at high risk.
  • Interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk.
  • Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture.
  • Following risk assessment with FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and recalculate absolute risk using FRAX with the BMD value.
  • Consider measuring BMD with DXA before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
  • Measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).
  • Consider recalculating fracture risk in the future:
    • if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or
    • when there has been a change in the person's risk factors.
  • Take into account that risk assessment tools may underestimate fracture risk in certain circumstances, for example if a person:
    • has a history of multiple fractures
    • has had previous vertebral fracture(s)
    • has a high alcohol intake
    • is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer)
    • has other causes of secondary osteoporosis.
  • Take into account that fracture risk can be affected by factors that may not be included in the risk tool, for example living in a care home or taking drugs that may impair bone metabolism (such as anti-convulsants, selective serotonin reuptake inhibitors, thiazolidinediones, proton pump inhibitors and anti-retroviral drugs).

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or 'low energy') trauma. The World Health Organization (WHO) has quantified this as forces equivalent to a fall from a standing height or less.

Reduced bone density is a major risk factor for fragility fracture. Other factors that may affect the risk of fragility fracture include:

  • use of oral or systemic glucocorticoids
  • age
  • sex
  • previous fractures
  • family history of osteoporosis.

Because of increased bone loss after the menopause in women, and age-related bone loss in both women and men, the prevalence of osteoporosis increases markedly with age, from 2% at 50 years to more than 25% at 80 years in women. As the longevity of the population increases, so will the incidence of osteoporosis and fragility fracture.

Reasons for the guideline

There are a number of therapies and treatments available for the prevention of fragility fractures in people who are thought to be at risk, or to prevent further fractures in those who have already had one or more fragility fractures. However, identifying who will benefit from preventative treatment is imprecise.

A number of risk assessment tools are available to predict fracture incidence over a period of time, and these may be used to aid decision-making. These tools are limited in that they may not include all risk factors, or may lack details of some risk factors. Tools are dependent on the accuracy of the epidemiological data used to derive them and tools validated in other populations may not apply to the UK.

Two tools, FRAX and QFracture, are available for use in the UK. It is not clear whether these tools are equally accurate and whether choice of tool should depend on circumstances. This short clinical guideline aims to provide guidance on the selection and use of risk assessment tools in the care of people who may be at risk of fragility fractures in all settings in which NHS care is received.

You can read the guideline on NICE's website.