Table 3:

Fracture risk assessment and treatment initiation in postmenopausal females and males aged 50 years and older^*

Recommendations	Strength of recommendation and certainty of evidence^†
3. Fracture risk assessment and treatment initiation
3.1. A clinical assessment for osteoporosis and fracture includes identifying risk factors and assessing for signs of undiagnosed vertebral fracture(s).^‡	Good practice statement
3.2. We suggest that the Canada-specific FRAX tool is the preferred tool for fracture risk estimation. Remark: CAROC is an alternative fracture risk assessment tool. FRAX and CAROC may underestimate fracture risk in the presence of specific risk factors such as recency of fractures, recurrent falls, other comorbidities or very low BMD at the lumbar spine and total hip sites.^§	Conditional recommendation; moderate-certainty evidence
3.3. We suggest BMD testing in postmenopausal females and males who are aged 50–64 yr with a previous osteoporosis-related fracture or ≥ 2 clinical risk factors OR are aged ≥ 65 yr with 1 clinical risk factor for fracture OR are aged ≥ 70 yr	Conditional recommendation; low-certainty evidence (females), very low-certainty evidence (males)
3.4. We suggest vertebral imaging with lateral spine radiograph or vertebral fracture assessment in postmenopausal females and males without known vertebral fractures who are aged ≥ 65 yr with a T-score ≤ −2.5 (femoral neck, total hip or lumbar spine) OR have a 10-yr major osteoporotic fracture risk between 15% and 19.9%. Remark: Lateral spine imaging can also be considered when there are clinical signs of undiagnosed vertebral fractures. The presence of vertebral fractures can guide appropriate choice and duration of therapy.^¶	Conditional recommendation; moderate-certainty evidence (females), low-certainty evidence (males)
3.5. We recommend initiating pharmacotherapy in postmenopausal females and males aged ≥ 50 yr who have had previous hip, vertebra or ≥ 2 osteoporosis-related fractures OR have a 10-yr major osteoporotic fracture risk ≥ 20% OR are aged ≥ 70 yr and have a T-score ≤ −2.5 (femoral neck, total hip or lumbar spine).	Strong recommendation; high-certainty evidence (females: a and c), moderate-certainty evidence (females: b; males: a, b and c)
3.6. We suggest initiating pharmacotherapy in postmenopausal females and males aged ≥ 50 yr who have a 10-yr major osteoporotic fracture risk between 15% and 19.9% OR are aged < 70 yr and have a T-score ≤ −2.5 (femoral neck, total hip or lumbar spine). Remark: The risk of subsequent fracture is greatest shortly after a fracture, and greater consideration should be given to a fracture in the last 2 years.	Conditional recommendation; moderate-certainty evidence (females), very low-certainty evidence (males)
3.7. We suggest that for individuals who do not meet the threshold for initiating pharmacotherapy or choose not to initiate therapy, BMD testing can be repeated at: 5–10 yr if the risk of major osteoporotic fracture is < 10% 5 yr if the risk of major osteoporotic fracture is 10%–15% 3 yr if the risk of major osteoporotic fracture is > 15%. Remark: A shorter retesting interval may be appropriate for those with secondary osteoporosis or new clinical risk factors, such as a fracture.	Conditional recommendation; low-certainty evidence (females), very low-certainty evidence (males)
3.8. We recommend that postmenopausal females and males aged ≥ 50 yr presenting with a recent fracture have access to a Fracture Liaison Service to improve identification and treatment initiation for osteoporosis.^**	Strong recommendation; high-certainty evidence

Note: BMD = bone mineral density, CAROC = Canadian Association of Radiologists and Osteoporosis Canada, FRAX = Fracture Risk Assessment Tool.
↵* Integrated approach is shown in Figure 1.
↵† See Table 1 for definitions.
↵‡ For list of risk factors, see Figure 1 and Appendix 1, Supplementary Table 5 (causes of secondary osteoporosis) and Supplementary Table 6 (Clinical Assessment of Vertebral Fractures), available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221647/tab-related-content
↵§ For information on fracture risk assessment tools, see www.osteoporosis.ca
↵¶ See Appendix 1, Supplementary Table 6 (clinical assessment of vertebral fractures).
↵** See https://fls.osteoporosis.ca/for list of Fracture Liaison Services in Canada.