Reprint ArticleSecondary Fracture Prevention Consensus Clinical Recommendations from a Multistakeholder CoalitionConley, Robert B1; Adib, Gemma2; Adler, Robert A3; Åkesson, Kristina E4; Alexander, Ivy M5; Amenta, Kelly C6; Blank, Robert D7,8; Brox, William Timothy9; Carmody, Emily E10; Chapman-Novakofski, Karen11; Clarke, Bart L12; Cody, Kathleen M13; Cooper, Cyrus14; Crandall, Carolyn J15; Dirschl, Douglas R16; Eagen, Thomas J17; Elderkin, Ann L18; Fujita, Masaki19; Greenspan, Susan L20; Halbout, Philippe21; Hochberg, Marc C22; Javaid, Muhammad23; Jeray, Kyle J24; Kearns, Ann E12; King, Toby25; Koinis, Thomas F26; Koontz, Jennifer Scott27,28; Kužma, Martin29; Lindsey, Carleen30; Lorentzon, Mattias31,32,33; Lyritis, George P34; Michaud, Laura Boehnke35; Miciano, Armando36; Morin, Suzanne N37; Mujahid, Nadia38; Napoli, Nicola39,40; Olenginski, Thomas P41; Puzas, J Edward10; Rizou, Stavroula34; Rosen, Clifford J42,43; Saag, Kenneth44; Thompson, Elizabeth45; Tosi, Laura L46; Tracer, Howard47; Khosla, Sundeep12; Kiel, Douglas P48Author Information 1Center for Medical Technology Policy, Baltimore, MD, USA 2Osteoporosis Centre, Damascus, Syria 3McGuire VA Medical Center, Richmond, VA, USA 4Lund University and Skåne University Hospital, Lund, Scania, Sweden 5UConn School of Nursing, University of Connecticut, Storrs, CT, USA 6Department of Physician Assistant Studies, Mercyhurst University, Erie, PA, USA 7Department of Endocrinology, Metabolism and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA 8Garvan Institute of Medical Research, Darlinghurst, NSW, Australia 9UCSF Fresno, Fresno, CA, USA 10Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA 11Division of Nutritional Sciences, University of Illinois, Urbana, IL, USA 12Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA 13American Bone Health, Raleigh, NC, USA 14University of Southampton, Southampton, UK 15Department of Medicine, University of California, Los Angeles, CA, USA 16Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL, USA 17National Council on Aging, New York, NY, USA 18American Society for Bone and Mineral Research, Washington, DC, USA 19Science Department, International Osteoporosis Foundation, Nyon, Switzerland 20Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA 21International Osteoporosis Foundation, Nyon, Switzerland 22Division of Rheumatology, University of Maryland School of Medicine and VA Maryland Health Care System, Baltimore, MD, USA 23Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, USA 24Prisma Health - Upstate (formerly Greenville Health System), Greenville, SC, USA 25US Bone and Joint Initiative, Rosemont, IL, USA 26Duke Primary Care Oxford, Oxford, NC, USA 27Orthopedics & Sports Medicine, Newton Medical Center, Newton, KS, USA 28Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, KS, USA 295th Department of Internal Medicine, University Hospital, Comenius University, Bratislava, Slovakia 30Bones, Backs and Balance, LLC, Bristol Physical Therapy, LLC, Bristol, CT, USA 31Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia 32Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden 33Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 34Hellenic Osteoporosis Foundation, Athens, Greece 35The University of Texas MD Anderson Cancer Center, Houston, TX, USA 36Nevada Rehabilitation Institute, Las Vegas, NV, USA 37Department of Medicine, McGill University, Montreal, Canada 38Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA 39Department of Nutrition and Metabolic Disorders, Campus Bio-Medico University of Rome, Rome, Italy 40Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA 41HiROC Program/Rheumatology, Geisinger Health System, Danville, PA, USA 42Tufts University School of Medicine, Boston, MA, USA 43Maine Medical Center Research Institute, Portland, ME, USA 44Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA 45National Osteoporosis Foundation, Arlington, VA, USA 46Department of Orthopaedic Surgery and Sports Medicine, Children’s National Hospital, Washington, DC, USA 47Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD, USA 48Harvard Medical School, Musculoskeletal Research Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA Address correspondence to: Douglas P Kiel, MD, Harvard Medical School, Musculoskeletal Research Center, Marcus Institute for Aging Research, Hebrew Senior- Life, 1200 Centre Street, Boston, MA 02131, USA. E-mail: email@example.com Received in original form August 14, 2019; revised form September 8, 2019; accepted September 11, 2019. Accepted manuscript online September 20, 2019. Journal of Bone and Mineral Research, Vol. 00, No. 00, Month 2019, pp 1–17. Received January 14, 2020 Accepted January 14, 2020 Journal of Orthopaedic Trauma: April 2020 - Volume 34 - Issue 4 - p e125-e141 doi: 10.1097/BOT.0000000000001743 Buy Metrics Abstract Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).©2019American Society for Bone andMineral Research. 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