Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures

  • J. A. KanisEmail author
  • N. C. Harvey
  • E. McCloskey
  • O. Bruyère
  • N. Veronese
  • M. Lorentzon
  • C. Cooper
  • R. Rizzoli
  • G. Adib
  • N. Al-Daghri
  • C. Campusano
  • M. Chandran
  • B. Dawson-Hughes
  • K. Javaid
  • F. Jiwa
  • H. Johansson
  • J. K. Lee
  • E. Liu
  • D. Messina
  • O. Mkinsi
  • D. Pinto
  • D. Prieto-Alhambra
  • K. Saag
  • W. Xia
  • L. Zakraoui
  • J. -Y. Reginster
Position Paper



Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures.


The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach.


Clinical perspective and updated literature search.


The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis.


A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions.


Anabolic agents Fracture risk assessment FRAX Inhibitors of bone resorption Treatment of osteoporosis 



We are grateful to the Scientific Advisory Board of ESCEO and the Committee of Scientific Advisors and the Committee of National Societies of the IOF for their review and endorsement of the recommendations in this guidance.

Compliance with ethical standards

Conflicts of interest

NM Al-Daghri G Adib, C Campusano, M Chandran, F Jiwa, H Johansson, JK Lee, E Liu, D Pinto, N Veronese, W Xia, L Zakraoui have no conflicts of interest to declare.

O Bruyère received research grants from Biophytis, IBSA, MEDA, Servier and SMB and consulting or lecture fees from Amgen, Biophytis, IBSA, MEDA, Servier, SMB, TRB Chemedica and UCB.

C Cooper reports personal fees from Alliance for Better Bone Health, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda and UCB.

B. Dawson-Hughes has received grant support from Pfizer and DSM and consulting fees from TTY Biopharma Co, Ltd, Intrinsic Therapeutics and Agnovos.

NC Harvey has received consultancy/lecture fees/honoraria/grant funding from Alliance for Better Bone Health, Amgen, MSD, Eli Lilly, Radius Health, Servier, Shire, UCB, Consilient Healthcare and Internis Pharma.

MK Javaid has received honoraria, unrestricted research grants, travel and/or subsistence expenses from Amgen, Lilly UK, Internis, Consilient Health, Zebra Medical Vision, Kyowa Kirin Hakin and UCB.

JA Kanis reports grants from Amgen, Eli Lilly and Radius Health and consulting fees from Theramex. JAK is the architect of FRAX® but has no financial interest.

M Lorentzon has received lecture fees from Amgen, Lilly, Meda, Renapharma and UCB Pharma and consulting fees from Amgen, Radius Health, UCB Pharma, Renapharma and Consilient Health, all outside the presented work.

EV McCloskey has received consultancy/lecture fees/grant funding/honoraria from ActiveSignal, AgNovos, Amgen, AstraZeneca, Consilient Healthcare, Fresenius Kabi, Gilead, GSK, Hologic, Internis, Lilly, Medtronic, Merck, Novartis, Pfizer, Radius Health, Redx Oncology, Roche, SanofiAventis, Servier, Synexus, Tethys, UCB, Viiv, Warner Chilcott, I3 Innovus and Unilever.

OD Messina has received honoraria from Amgen, Lilly, Novartis and Pfizer

O Minski received honorary fees for lectures, from Abbvie, Roche, Pfizer, Pierre Fabre, Janssen, Novartis and MSD.

D Prieto-Alhambra’s research group has received research grants from Amgen, Servier and UCB; speaker fees from Amgen and UCB; educational grants from Johnson & Johnson and consultancy fees from Amgen and UCB.

J-Y Reginster has received advisory board or consulting fees from IBSA-Genévrier, Pierre Fabre, Radius Health, TEVA and Mylan; lecture fees from Agnovos, IBSA-Genévrier, Mylan, CNIEL, Dairy Research Council (DRC) and Theramex and institutional grant support from IBSA-Genévrier, Mylan, CNIEL and Radius Health.

R Rizzoli has received consulting fees or advisory board fees from Radius Health, Labatec, Danone, Nestlé, CNIEL and Sandoz.

K Saag reports grant support from Amgen and Radius and consulting fees from Amgen, Radius and Roche.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  • J. A. Kanis
    • 1
    • 2
    Email author
  • N. C. Harvey
    • 3
  • E. McCloskey
    • 1
    • 4
  • O. Bruyère
    • 5
  • N. Veronese
    • 6
  • M. Lorentzon
    • 2
    • 7
    • 8
  • C. Cooper
    • 3
    • 9
  • R. Rizzoli
    • 10
  • G. Adib
    • 11
  • N. Al-Daghri
    • 12
  • C. Campusano
    • 13
  • M. Chandran
    • 14
  • B. Dawson-Hughes
    • 15
  • K. Javaid
    • 9
  • F. Jiwa
    • 16
  • H. Johansson
    • 1
    • 2
  • J. K. Lee
    • 17
  • E. Liu
    • 2
  • D. Messina
    • 18
  • O. Mkinsi
    • 19
  • D. Pinto
    • 20
    • 21
  • D. Prieto-Alhambra
    • 9
    • 22
  • K. Saag
    • 23
  • W. Xia
    • 24
  • L. Zakraoui
    • 25
  • J. -Y. Reginster
    • 12
    • 26
  1. 1.Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffieldUK
  2. 2.Mary McKillop Health InstituteAustralian Catholic UniversityMelbourneAustralia
  3. 3.MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
  4. 4.MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing MellanbySheffieldUK
  5. 5.World Health Organization Collaborating Center for the Public Health Aspects of Musculoskeletal Health and Aging, Department of Public Health, Epidemiology and Health EconomicsUniversity of LiègeLiègeBelgium
  6. 6.National Research Council, Neuroscience InstituteAging BranchPadovaItaly
  7. 7.Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
  8. 8.Region Västra Götaland, Geriatric Medicine ClinicSahlgrenska University HospitalGothenburgSweden
  9. 9.NIHR Musculoskeletal Biomedical Research UnitUniversity of OxfordOxfordUK
  10. 10.Service of Bone DiseasesGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
  11. 11.Syrian National Osteoporosis SocietyDamascusSyria
  12. 12.Chair for Biomarkers of Chronic Diseases, Biochemistry Dept., College of ScienceKing Saud UniversityRiyadhKingdom of Saudi Arabia
  13. 13.Clinica Universidad de los Andes and Faculty of MedicineUniversidad de los AndesSantiagoChile
  14. 14.Osteoporosis and Bone Metabolism Unit, Department of EndocrinologySingapore General Hospital, ACADEMIASingaporeSingapore
  15. 15.Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts UniversityBostonUSA
  16. 16.Chair of the Committee of Patients Societies at the International Osteoporosis FoundationOsteoporosis CanadaTorontoCanada
  17. 17.Beacon International Specialist CentrePetaling JayaMalaysia
  18. 18.IRO Medical Research Center, Buenos Aires and Rheumatology sectionCosme ArgerichBuenos AiresArgentina
  19. 19.Department of RheumatologyIbn Rochd University HospitalCasablancaMorocco
  20. 20.Department of Physical TherapyMarquette UniversityMilwaukeeUSA
  21. 21.Department of Medical Social Sciences, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  22. 22.GREMPAL Research Group, CIBERFes and Idiap Jordi GolInstituto de Salud Carlos III and Universitat Autonoma de BarcelonaBarcelonaSpain
  23. 23.University of Alabama at BirminghamBirminghamUSA
  24. 24.Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
  25. 25.Service de RhumatologieUniversity Tunis Manar and Hôpital Mongi-Slimla MarsaTunisia
  26. 26.Department of Public Health, Epidemiology and Health EconomicsUniversity of LiègeLiègeBelgium

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