osteoporosis (fragility fracture risk assessment + pragmatic treatment pathways)

• Assess fracture risk in: all women ≥65, all men ≥75, and younger adults with risk factors (prior fragility fracture, oral/systemic glucocorticoids, falls history, low BMI, smoking, alcohol >14 units/week, secondary osteoporosis).
• Do not routinely assess under-50s unless major risk factors (e.g., prior fragility fracture or prolonged high-dose glucocorticoids).
• Use FRAX or QFracture (within age ranges) to estimate 10-year absolute fracture risk. FRAX: 40–90 (with or without BMD). QFracture: 30–84 (BMD not incorporated).
• DXA: do not use DXA routinely without prior FRAX/QFracture. Consider DXA when risk is around the local intervention threshold and you want to re-classify by adding BMD (FRAX + BMD).

Note: CG146 covers risk assessment; medication choices are typically guided by local thresholds and NICE technology appraisals (e.g. TA464 for bisphosphonates). Use your local formulary/pathway for intervention thresholds.

• Usually treat without delay if there is a low-trauma (fragility) hip or vertebral fracture (plus falls prevention and secondary causes screen).
• Typical first-line for most: an oral bisphosphonate if suitable (e.g. alendronic acid 70 mg once weekly), with counselling on administration (full glass of water, upright 30 minutes, empty stomach).
• Alternatives if intolerance/contraindications: risedronate 35 mg weekly, ibandronate 150 mg monthly, or IV options / denosumab via specialist pathway (ensure a “stop plan” for denosumab to avoid rebound vertebral fractures).
• Calcium/vitamin D: ensure dietary calcium and correct vitamin D deficiency; supplement where indicated (particularly if prescribing antiresorptives and intake is low).

• Secondary causes: check calcium, vitamin D, renal function, LFTs, TFTs, coeliac screen when appropriate; review steroids and endocrine contributors.
• Renal function: oral bisphosphonates are usually avoided in significant renal impairment (follow product SPC/local formulary).
• Specialist referral if: very high fracture risk / multiple fractures, suspected vertebral fractures needing imaging and onward care, complex secondary osteoporosis, treatment failure, or if parenteral/anabolic therapy is being considered.
• Review horizon: reassess adherence and tolerability after initiation; many pathways consider a “drug holiday” after 5 years of oral bisphosphonate in lower-risk patients (per local protocol).