Clinician’s Guide to Prevention and Treatment of Osteoporosis

Recommendations apply to postmenopausal women and men age 50 and older.

Osteoporosis is the most common bone disease in humans, representing a major public health problem as outlined in Bone Health and Osteoporosis: A Report of the Surgeon General (2004) [1]. It is characterized by low bone mass, deterioration of bone tissue and disruption of bone architecture, compromised bone strength, and an increase in the risk of fracture. According to the WHO diagnostic classification, osteoporosis is defined by BMD at the hip or lumbar spine that is less than or equal to 2.5 standard deviations below the mean BMD of a young-adult reference population. Osteoporosis is a risk factor for fracture just as hypertension is for stroke. The risk of fractures is highest in those with the lowest BMD; however, the majority of fractures occur in patients with low bone mass rather than osteoporosis, because of the large number of individuals with bone mass in this range.

Osteoporosis affects an enormous number of people, of both sexes and all races, and its prevalence will increase as the population ages. Based on data from the National Health and Nutrition Examination Survey III (NHANES III), NOF has estimated that more than 9.9 million Americans have osteoporosis and an additional 43.1 million have low bone density [2]. About one out of every two Caucasian women will experience an osteoporosis-related fracture at some point in her lifetime, as will approximately one in five men [1]. Although osteoporosis is less frequent in African Americans, those with osteoporosis have the same elevated fracture risk as Caucasians.

Fractures and their complications are the relevant clinical sequelae of osteoporosis. The most common fractures are those of the vertebrae (spine), proximal femur (hip), and distal forearm (wrist). However, most fractures in older adults are due at least in part to low bone mass, even when they result from considerable trauma. A recent fracture at any major skeletal site in an adult older than 50 years of age should be considered a significant event for the diagnosis of osteoporosis and provides a sense of urgency for further assessment and treatment. The most notable exceptions are those of the fingers, toes, face, and skull, which are primarily related to trauma rather than underlying bone strength. Fractures may be followed by full recovery or by chronic pain, disability, and death [3].

Hip fractures are associated with an 8 to 36 % excess mortality within 1 year, with a higher mortality in men than in women [4]; additionally, hip fractures are followed by a 2.5-fold increased risk of future fractures [5]. Approximately 20 % of hip fracture patients require long-term nursing home care, and only 40 % fully regain their pre-fracture level of independence [1]. Although the majority of vertebral fractures are initially clinically silent, these fractures are often associated with symptoms of pain, disability, deformity, and mortality [3]. Postural changes associated with kyphosis may limit activity, including bending and reaching.

Multiple thoracic fractures may result in restrictive lung disease, and lumbar fractures may alter abdominal anatomy, leading to constipation, abdominal pain, distention, reduced appetite, and premature satiety. Vertebral fractures, whether clinically apparent or silent, are major predictors of future fracture risk, up to 5-fold for subsequent vertebral fracture and 2- to 3-fold for fractures at other sites. Wrist fractures are less disabling but can interfere with some activities of daily living as much as hip or vertebral fractures.

Pelvic fractures and humerus fractures are also common and contribute to increased morbidity and mortality. Fractures can also cause psychosocial symptoms, most notably depression and loss of self-esteem, as patients grapple with pain, physical limitations, and lifestyle and cosmetic changes.

Annually, two million fractures are attributed to osteoporosis, causing more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions in the USA [1]. Medicare currently pays for approximately 80 % of these fractures, with hip fractures accounting for 72 % of fracture costs. Due in part to an aging population, the cost of care is expected to rise to $25.3 billion by 2025 [6].

Despite the availability of cost-effective and well-tolerated treatments to reduce fracture risk, only 23 % of women age 67 or older who have an osteoporosis-related fracture receive either a BMD test or a prescription for a drug to treat osteoporosis in the 6 months after the fracture [7].

All postmenopausal women and men age 50 and older should be evaluated for osteoporosis risk in order to determine the need for BMD testing and/or vertebral imaging. In general, the more risk factors that are present, the greater is the risk of fracture. Osteoporosis is preventable and treatable, but because there are no warning signs prior to a fracture, many people are not being diagnosed in time to receive effective therapy during the early phase of the disease. Many factors have been associated with an increased risk of osteoporosis-related fracture (Table 1).

Since the majority of osteoporosis-related fractures result from falls, it is also important to evaluate risk factors for falling (Table 2). The most important of these are personal history of falling, muscle weakness and gait, selected medications, balance, and visual deficits [15]. Dehydration is also a risk factor for falls.

Several of these risk factors have been included in the WHO 10-year fracture risk model (Table 3). As suggested by the WHO [11], this set of risk factors increases fracture risk independently of BMD and can be combined with BMD measurements to assess an individual patient’s risk of future fracture.

Consider the possibility of osteoporosis and fracture risk based on the presence of the risk factors and conditions outlined in Tables 1 and 3. Metabolic bone diseases other than osteoporosis, such as hyperparathyroidism or osteomalacia, may be associated with low BMD. Many of these diseases have very specific therapies, and it is appropriate to complete a history and physical examination before making a diagnosis of osteoporosis on the basis of a low BMD alone. In patients in whom a specific secondary, treatable cause of osteoporosis is being considered (Table 1), relevant blood and urine studies (see below) should be obtained prior to initiating therapy. Any adulthood fracture may be an indication of osteoporosis and should be evaluated accordingly. Consider hip and vertebral fractures as indications of osteoporosis unless excluded by the clinical evaluation and imaging. Fractures present a sense of urgency as they signify increased fracture risk over the subsequent 5 years [16]. Patients with recent fractures, multiple fractures, or very low BMD should be evaluated for secondary etiologies.

Osteoporosis affects a significant number of men, yet the condition often goes undetected and untreated. The evaluation of osteoporosis in men requires special consideration as some of the laboratory testing to assess underlying causes in men differs from those in women. Screening BMD and vertebral imaging recommendations for men are outlined in Table 8. The 2012 Endocrine Society’s Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline provides a detailed approach to the evaluation and treatment of osteoporosis in men [17].

The diagnosis of osteoporosis is established by measurement of BMD or by the occurrence of adulthood hip or vertebral fracture in the absence of major trauma (such as a motor vehicle accident or multiple story fall). Laboratory testing is indicated to exclude secondary causes of osteoporosis [1, 14, 17] (Table 4).

DXA measurement of the hip and spine is the technology used to establish or confirm a diagnosis of osteoporosis, predict future fracture risk, and monitor patients. Areal BMD is expressed in absolute terms of grams of mineral per square centimeter scanned (g/cm²) and as a relationship to two norms: compared to the BMD of an age-, sex-, and ethnicity-matched reference population (Z-score) or compared to a young-adult reference population of the same sex (T-score). The difference between the patient’s BMD and the mean BMD of the reference population, divided by the standard deviation (SD) of the reference population, is used to calculate T-scores and Z-scores. Peak bone mass is achieved in early adulthood, followed by a decline in BMD. The rate of bone loss accelerates in women at menopause and continues to progress at a slower pace in older postmenopausal women (see Fig. 3) and in older men. An individual’s BMD is presented as the standard deviation above or below the mean BMD of the reference population, as outlined in Table 5. The BMD diagnosis of normal, low bone mass (osteopenia), osteoporosis, and severe or established osteoporosis is based on the WHO diagnostic classification (Table 5) [18].

BMD testing is a vital component in the diagnosis and management of osteoporosis. BMD has been shown to correlate with bone strength and is an excellent predictor of future fracture risk. Instead of a specific threshold, fracture risk increases exponentially as BMD decreases. Although available technologies measuring central (lumbar spine and hip) and peripheral skeletal sites (forearm, heel, fingers) provide site-specific and global (overall risk at any skeletal site) assessment of future fracture risk, DXA measurement at the hip is the best predictor of future hip fracture risk. DXA measurements of the lumbar spine and hip must be performed by appropriately trained technologists on properly maintained instruments. DXA scans are associated with exposure to trivial amounts of radiation.

In postmenopausal women and men age 50 and older, the WHO diagnostic T-score criteria (normal, low bone mass, and osteoporosis) are applied to BMD measurement by central DXA at the lumbar spine and femoral neck [18]. BMD measured by DXA at the one-third (33 %) radius site can be used for diagnosing osteoporosis when the hip and lumbar spine cannot be measured or are unusable or uninterpretable [19]. In premenopausal women, men less than 50 years of age, and children, the WHO BMD diagnostic classification should not be applied. In these groups, the diagnosis of osteoporosis should not be made on the basis of densitometric criteria alone. The International Society for Clinical Densitometry (ISCD) recommends that instead of T-scores, ethnic or race-adjusted Z-scores should be used, with Z-scores of −2.0 or lower defined as either “low bone mineral density for chronological age” or “below the expected range for age” and those above −2.0 being “within the expected range for age” [19].

The decision to perform bone density assessment should be based on an individual’s fracture risk profile and skeletal health assessment. Utilizing any procedure to measure bone density is not indicated unless the results will influence the patient’s treatment decision. The US Preventive Services Task Force recommends testing of all women age 65 and older and younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors [20].

Table 6 outlines the indications for BMD testing. BMD measurement is not recommended in children or adolescents and is not routinely indicated in healthy young men or premenopausal women unless there is a significant fracture history or there are specific risk factors for bone loss.

A vertebral fracture is consistent with a diagnosis of osteoporosis, even in the absence of a bone density diagnosis, and is an indication for pharmacologic treatment with osteoporosis medication to reduce subsequent fracture risk [18, 21]. Most vertebral fractures are asymptomatic when they first occur and often are undiagnosed for many years. Proactive vertebral imaging is the only way to diagnose these fractures. The finding of a previously unrecognized vertebral fracture may change the diagnostic classification, alter future fracture risk calculations, and affect treatment decisions [22].

Independent of BMD, age, and other clinical risk factors, radiographically confirmed vertebral fractures (even if completely asymptomatic) are a sign of impaired bone quality and strength and a strong predictor of new vertebral and other fractures. The presence of a single vertebral fracture increases the risk of subsequent fractures 5-fold and the risk of hip and other fractures 2- to 3- fold [23]. Vertebral imaging can be performed using a lateral thoracic and lumbar spine X-ray or lateral vertebral fracture assessment (VFA), available on most modern DXA machines. VFA can be conveniently performed at the time of BMD assessment, while conventional X-ray may require referral to a standard X-ray facility.

Because vertebral fractures are so prevalent in older individuals and most produce no acute symptoms, vertebral imaging tests are recommended for the individuals defined in Table 7. Once a first vertebral imaging test is done, it only needs to be repeated if prospective height loss is documented or new back pain or postural change occurs [3, 24]. A follow-up vertebral imaging test is also recommended in patients who are being considered for a medication holiday, since stopping medication would not be recommended in patients who have recent vertebral fractures.

Bone remodeling (or turnover) occurs throughout life to repair fatigue damage and microfractures in bone and to maintain mineral homeostasis. Biochemical markers of bone remodeling [e.g., resorption markers—serum C-telopeptide (CTX) and urinary N-telopeptide (NTX)—and formation markers—serum bone-specific alkaline phosphatase (BSAP), osteocalcin (OC), and aminoterminal propeptide of type I procollagen (PINP)] are best collected in the morning while patients are fasting.

Biochemical markers of bone turnover may [25]:

FRAX® was developed to calculate the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (defined as clinical vertebral, hip, forearm, or proximal humerus fracture), taking into account femoral neck BMD and the clinical risk factors shown in Table 3 [11]. The FRAX® algorithm is available at www.​nof.​org as well as at www.​shef.​ac.​uk/​FRAX. It is also available on newer DXA machines or with software upgrades that provide the FRAX® scores on the bone density report.

The WHO algorithm used in this Guide was calibrated to US fracture and mortality rates; therefore, the fracture risk figures herein are specific for the US population. Economic modeling was performed to identify the 10-year hip fracture risk above which it is cost-effective, from the societal perspective, to treat with pharmacologic agents. The US-based economic modeling is described in one report [12], and the US-adapted WHO algorithm and its clinical application are illustrated in a companion report [13].

The latter analyses generally confirm the previous NOF conclusion that it is cost-effective to treat individuals with a prior hip or vertebral fracture and those with a DXA femoral neck T-score ≤−2.5. Previous analyses have established that a lumbar spine T-score ≤−2.5 also warrants treatment [26].

FRAX underestimates fracture risk in patients with recent fractures, multiple osteoporosis-related fractures, and those at increased risk for falling. FRAX® is most useful in patients with low femoral neck BMD. Utilizing FRAX® in patients with low BMD at the lumbar spine but a relatively normal BMD at the femoral neck underestimates fracture risk in these individuals. Specifically, the WHO algorithm has not been validated for the use of lumbar spine BMD. NOF recommends treatment of individuals with osteoporosis of the lumbar spine as well as the hip.

The therapeutic thresholds proposed in this Guide are for clinical guidance only and are not rules. All treatment decisions require clinical judgment and consideration of individual patient factors, including patient preferences, comorbidities, risk factors not captured in the FRAX® model (e.g., frailty, falls), recent decline in bone density, and other sources of possible under- or overestimation of fracture risk by FRAX®.

The therapeutic thresholds do not preclude clinicians or patients from considering intervention strategies for those who do not have osteoporosis by BMD (WHO diagnostic criterion of T-score ≤−2.5), do not meet the cut points after FRAX®, or are not at high enough risk of fracture despite low BMD. Conversely, these recommendations should not mandate treatment, particularly in patients with low bone mass above the osteoporosis range. Decisions to treat must still be made on a case-by-case basis.

The following bone mass measurement technologies included in Table 8 are capable of predicting both site-specific and overall fracture risk. When performed according to accepted standards, these densitometric techniques are accurate and highly reproducible [19]. However, T-scores from these technologies cannot be used according to the WHO diagnostic classification because they are not equivalent to T-scores derived from DXA.

Advise all individuals to obtain an adequate intake of dietary calcium. Providing adequate daily calcium and vitamin D is a safe and inexpensive way to help reduce fracture risk. Controlled clinical trials have demonstrated that the combination of supplemental calcium and vitamin D can reduce the risk of fracture [29]. A balanced diet rich in low-fat dairy products, fruits, and vegetables provides calcium as well as numerous nutrients needed for good health. If adequate dietary calcium cannot be obtained, dietary supplementation is indicated up to the recommended daily intake.

Lifelong adequate calcium intake is necessary for the acquisition of peak bone mass and subsequent maintenance of bone health. The skeleton contains 99 % of the body’s calcium stores; when the exogenous supply is inadequate, bone tissue is resorbed from the skeleton to maintain serum calcium at a constant level.

NOF supports Institute of Medicine (IOM) recommendations that men age 50–70 consume 1000 mg/day of calcium and that women age 51 and older and men age 71 and older consume 1200 mg/day of calcium [30]. There is no evidence that calcium intake in excess of these amounts confers additional bone strength. Intakes in excess of 1200 to 1500 mg/day may increase the risk of developing kidney stones, cardiovascular disease, and stroke. The scientific literature is highly controversial in this area [31‐34].

Table 9 illustrates a simple method for estimating the calcium content of a patient’s diet. The average daily dietary calcium intake in adults age 50 and older is 600 to 700 mg/day. Increasing dietary calcium is the first-line approach, but calcium supplements should be used when an adequate dietary intake cannot be achieved.

Vitamin D plays a major role in calcium absorption, bone health, muscle performance, balance, and risk of falling. NOF recommends an intake of 800 to 1000 international units (IU) of vitamin D per day for adults age 50 and older. Institute of Medicine Dietary Reference Intakes for vitamin D are 600 IU/day until age 70 and 800 IU/day for adults age 71 years and older [30].

Chief dietary sources of vitamin D include vitamin D-fortified milk (400 IU/quart, although certain products such as soy milk are not always supplemented with vitamin D), some fortified juices and cereals (40 to 50 IU/serving or more), salt water fish, and liver. Some calcium supplements and most multivitamin tablets also contain vitamin D. Supplementation with vitamin D₂ (ergocalciferol) or vitamin D₃ (cholecalciferol) may be used. Vitamin D₂ is derived from plant sources and may be used by individuals on a strict vegetarian diet.

Many older patients are at high risk for vitamin D deficiency, including patients with malabsorption (e.g., celiac disease) or other intestinal diseases (e.g., inflammatory bowel disease, gastric bypass surgery), chronic renal insufficiency, patients on medications that increase the breakdown of vitamin D (e.g., some antiseizure drugs), housebound patients, chronically ill patients and others with limited sun exposure, individuals with very dark skin, and obese individuals. There is also a high prevalence of vitamin D deficiency in patients with osteoporosis, especially those with hip fractures, even in patients taking osteoporosis medications [35, 36].

Since vitamin D intakes required to correct vitamin D deficiency are so variable among individuals, serum 25(OH)D levels should be measured in patients at risk of deficiency. Vitamin D supplements should be recommended in amounts sufficient to bring the serum 25(OH)D level to approximately 30 ng/ml (75 nmol/L) and a maintenance dose recommended to maintain this level, particularly for individuals with osteoporosis. Many patients with osteoporosis will need more than the general recommendation of 800–1000 IU/day. The safe upper limit for vitamin D intake for the general adult population was increased to 4000 IU/day in 2010 [30].

Adults who are vitamin D deficient may be treated with 50,000 IU of vitamin D₂ or vitamin D₃ once a week or the equivalent daily dose (7000 IU vitamin D₂ or vitamin D₃) for 8–12 weeks to achieve a 25(OH)D blood level of approximately 30 ng/ml. This regimen should be followed by maintenance therapy of 1500–2000 IU/day or whatever dose is needed to maintain the target blood level [37, 38].

Recommend regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures [39‐42]. Among the many health benefits, weight-bearing and muscle-strengthening exercise can improve agility, strength, posture, and balance, which may reduce the risk of falls. In addition, exercise may modestly increase bone density. NOF strongly endorses lifelong physical activity at all ages, both for osteoporosis prevention and overall health, as the benefits of exercise are lost when people stop exercising.

Weight-bearing exercise (in which bones and muscles work against gravity as the feet and legs bear the body’s weight) includes walking, jogging, Tai Chi, stair climbing, dancing, and tennis. Muscle-strengthening exercise includes weight training and other resistive exercises, such as yoga, Pilates, and boot camp programs. Before an individual with osteoporosis initiates a new vigorous exercise program, such as running or heavy weight-lifting, a clinician’s evaluation is appropriate.

Major risk factors for falling are shown in Table 2. In addition to maintaining adequate vitamin D levels and physical activity, as described above, several strategies have been demonstrated to reduce falls. These include, but are not limited to, multifactorial interventions such as individual risk assessment, Tai Chi and other exercise programs, home safety assessment, and modification especially when done by an occupational therapist, and gradual withdrawal of psychotropic medication if possible. Appropriate correction of visual impairment may improve mobility and reduce risk of falls.

There is a lack of evidence that the use of hip protectors by community-dwelling adults provides statistically significant reduction in the risk of hip or pelvis fractures. Also, there is no evidence that the use of hip protectors reduces the rate of falls. In long-term care or residential care settings, some studies have shown a marginally significant reduction in hip fracture risk. There are no serious adverse effects of hip protectors; however, adherence to long-term use is poor [43]. There is additional uncertainty as to which hip protector to use, as most of the marketed products have not been tested in randomized clinical trials.

Advise patients to stop tobacco smoking. The use of tobacco products is detrimental to the skeleton as well as to overall health [44‐47]. NOF strongly encourages a smoking cessation program as an osteoporosis intervention.

Recognize and treat patients with excessive alcohol intake. Moderate alcohol intake has no known negative effect on bone and may even be associated with slightly higher bone density and lower risk of fracture in postmenopausal women. However, alcohol intake of more than two drinks per day for women or three drinks a day for men may be detrimental to bone health, increases the risk of falling, and requires further evaluation for possible alcoholism [48].

Postmenopausal women and men age 50 and older presenting with the following should be considered for treatment:

Although FRAX calculated fracture risk prediction has been confirmed in multiple studies, there are relatively few data confirming fracture risk reductions with pharmacotherapy in this group of patients.

Current FDA-approved pharmacologic options for the prevention and/or treatment of postmenopausal osteoporosis include, in alphabetical order: bisphosphonates (alendronate, alendronate plus D, ibandronate, risedronate and zoledronic acid), calcitonin, estrogens (estrogen and/or hormone therapy), estrogen agonist/antagonist (raloxifene), tissue-selective estrogen complex (conjugated estrogens/bazedoxifene), parathyroid hormone (PTH [1‐34], teriparatide), and the receptor activator of nuclear factor kappa-B (RANK) ligand (RANKL) inhibitor denosumab. Please see prescribing information for specific details of their use.

The antifracture benefits of FDA-approved drugs have mostly been studied in women with postmenopausal osteoporosis. There are limited fracture data in glucocorticoid-induced osteoporosis and in men. FDA-approved osteoporosis treatments have been shown to decrease fracture risk in patients who have had fragility fractures and/or osteoporosis by DXA. Pharmacotherapy may also reduce vertebral fractures in patients with low bone mass (osteopenia) without fractures, but the evidence supporting overall antifracture benefit is not as strong. Thus, the clinician should assess the potential benefits and risks of therapy in each patient and the effectiveness of a given osteoporosis treatment on reduction of vertebral and nonvertebral fractures.

Note that the intervention thresholds do not take into account the nonskeletal benefits or risks associated with specific drug use. NOF does not advocate the use of drugs not approved by the FDA for prevention and treatment of osteoporosis. Examples of these drugs are listed in Table 11 for information only.

When osteoporosis is diagnosed in young individuals, choices of osteoporosis medication may change over time to take advantage of the best benefit to risk ratio at each stage of life (sequential monotherapy). For more severe osteoporosis, sequential treatment with anabolic therapy followed by an antiresorptive agent is generally preferred to concomitant combination therapy. However, combination therapy with teriparatide and an antiresorptive can be considered in a few clinical settings in patients with very severe osteoporosis such as spine and hip fractures. There are few indications for combining two antiresorptive treatments, but such options could be considered in the short term in women who are experiencing active bone loss while on low dose HT for menopausal symptoms or raloxifene for breast cancer prevention.

No pharmacologic therapy should be considered indefinite in duration. All nonbisphosphonate medications produce temporary effects that wane upon discontinuation. If these treatments are stopped, benefits rapidly disappear. In contrast, bisphosphonates may allow residual effects even after treatment discontinuation. Therefore, it may be possible to discontinue bisphosphonates and retain residual benefits against fracture at least for several years.

Evidence of efficacy beyond 5 years is limited, whereas rare safety concerns such as ONJ and atypical femur fractures become more common beyond 5 years [67, 92]. Since there is no extensive evidence base to guide treatment duration decisions, duration decisions need to be individualized [93]. After the initial 3- to 5-year treatment period, a comprehensive risk assessment should be performed. This should include interval clinical history, particularly with respect to intercurrent fracture history and new chronic diseases or medications, as well as height measurement, BMD testing, and vertebral imaging if there has been any documented height loss during the treatment period. It is reasonable to discontinue bisphosphonates after 3 to 5 years in people who appear to be at modest risk of fracture after the initial treatment period. In contrast, for those who appear to be at high risk for fracture, continued treatment with a bisphosphonate or an alternative therapy should be considered [94].

It is important to ask patients whether they are taking their medications and to encourage continued and appropriate compliance with their osteoporosis therapies to reduce fracture risk. It is also important to review their risk factors and encourage appropriate calcium and vitamin D intakes, exercise, fall prevention, and other lifestyle measures. Furthermore, the need for continued medication to treat osteoporosis should be reviewed annually. Duration of treatment must be individualized. Some patients may be able to discontinue treatment temporarily after several years of therapy, particularly after bisphosphonate administration [95, 96]. Other patients will need to continue treatment. If treatment is discontinued, serial monitoring should include clinical assessment for fractures, falling, any interval chronic disease occurrence and consideration of serial BMD testing, use of biochemical markers, and vertebral imaging in some patients.

Accurate yearly height measurement is a critical determination of osteoporosis treatment efficacy. Patients who lose 2 cm (or 0.8 in.) or more in height either acutely or cumulatively should have a repeat vertebral imaging test to determine if new or additional vertebral fractures have occurred since the prior vertebral imaging test.

Serial central DXA testing is an important component of osteoporosis management. Measurements for monitoring patients should be performed in accordance with medical necessity, expected response, and in consideration of local regulatory requirements. NOF recommends that repeat BMD assessments generally agree with Medicare guidelines of every 2 years but recognizes that testing more frequently may be warranted in certain clinical situations.

The following techniques may be used to monitor the effectiveness of treatment:

FLS programs have been implemented successfully in a number of closed and open settings over the last 15 years, both in the USA (including the American Orthopedic Association Own the Bone program) as well as abroad. These programs have accomplished a reduction in secondary fracture rates as well as health care cost savings [98, 99]. In the USA, Kaiser Permanente’s Healthy Bones program has reduced the expected hip fracture rate by 38 % since 1998 [100]; Geisinger Health System achieved $7.8 million in cost savings over 5 years [101].

A Fracture Liaison Service is a coordinated care system headed by an FLS coordinator (a nurse practitioner, physician’s assistant, nurse, or other health professional) who ensures that individuals who suffer a fracture receive appropriate diagnosis, treatment, and support [102]. The FLS uses established protocols to find and assess fracture patients. The program creates a population database of fracture patients and establishes a process and timeline for patient assessment and follow-up care. An FLS coordinator is frequently based in a hospital and requires support from a qualified physician or physician team.