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The 2024 UK clinical guideline for the prevention and treatment of osteoporosis

NOGG · 2025 · United Kingdom

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Authors
Celia L Gregson, David J Armstrong, Christina Avgerinou et al.
Title
The 2024 UK clinical guideline for the prevention and treatment of osteoporosis
Journal
Archives of Osteoporosis, 2025
DOI
10.1007/s11657-025-01588-3
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12417299

Licence statement of the original publication

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Recommendations

  • A FRAX assessment should be performed in any postmenopausal woman or man age ≥ 50 years, with a clinical risk factor for fragility fracture to guide BMD measurement and prompt timely referral and/or drug treatment where indicatedStrong recommendation
  • When using FRAX to calculate the probability of fracture, clinical judgement is needed when clinical risk exceeds those factors able to be entered into FRAXStrong recommendation
  • Arithmetic adjustments to FRAX probabilities of major osteoporotic fracture (MOF: clinical spine, hip, forearm or humerus) and hip fracture (see Table 1) can be used in clinical practice to take account of additional clinical risk factors, such as high dose glucocorticoid use, discordantly low lumbar spine BMD, type 2 diabetes, and a history of fallsConditional recommendation
  • Vertebral fracture assessment (VFA) is indicated in postmenopausal women and men age ≥ 50 years if there is a history of ≥ 4 cm height loss, kyphosis, recent or current long-term oral glucocorticoid therapy, a BMD T-score ≤ − 2.5 at either the spine or hip, or in cases of acute onset back pain with risk factors for osteoporosisStrong recommendation
  • T-scores in men and women derived from femoral neck BMD should use normative values for BMD derived from young healthy women from NHANES IIIStrong recommendation
  • DXA scan results should be reported within 3 weeks of the scan, by healthcare professionals with specific training in DXA interpretation, and in accordance with national and international reporting standardsStrong recommendation
  • Patients with osteoporosis and/or a fragility fracture should be investigated for underlying causes, including the need for routine blood testsStrong recommendation
  • The use of quantitative ultrasound, IBEX bone health, and Radiofrequency Echographic Multi-Spectrometry are not recommended for the diagnosis of osteoporosisStrong recommendation
  • QCT-measured femoral neck areal BMD in postmenopausal women and men aged ≥ 50 years can be used for opportunistic diagnosis of osteoporosis and to inform individual treatment decisions using FRAXConditional recommendation
  • Computer Aided Diagnostics (CAD) may be considered to improve standard reporting of CTs performed on postmenopausal women and men aged ≥ 50 years to improve opportunistic identification of vertebral fracturesConditional recommendation
  • An initial FRAX assessment, which provides the ten-year probability of a major osteoporotic fracture (MOF; clinical spine, hip, forearm or humerus) and/or hip fracture, can be used to identify patients at low, intermediate, high or very high risk of fractureStrong recommendation
  • Consider, particularly in older people, drug treatment in those with a prior and/or recent fragility fracture, with fracture risk assessment informing the choice of drug treatmentStrong recommendation
  • Men and women with high and very high fracture risk (see Fig. 1) should have a DXA if a baseline measurement is needed against which to compare future BMD measurementsStrong recommendation
  • Men and women with intermediate fracture risk (i.e., between the upper and lower assessment thresholds) should be referred for BMD measurement, if practical. Thereafter, fracture probability should be reassessed using FRAXStrong recommendation
  • When BMD is included in a FRAX assessment, the patient’s risk (high, very high or low) is determined by the higher of the two (MOF and hip fracture) risk assessmentsStrong recommendation
  • In men and women with intermediate fracture risk, if BMD measurement is unavailable, contraindicated, or impractical (e.g., in frail individuals), drug treatment should be offered if there is a history of fragility fracture and/or if fracture risk exceeds the intervention thresholdStrong recommendation
  • Men and women with low fracture risk, without a prior fragility fracture, can be reassured that their fracture risk is low and offered lifestyle advice as appropriateStrong recommendation
  • Consider referral of very high-risk patients to an osteoporosis specialist in secondary care for assessment and consideration of parenteral treatment (some may need first-line anabolic drug treatment, especially those with multiple vertebral fractures). Indications of very high risk, where specialist referral should be considered, include (Conditional recommendation): The presence of single but important clinical risk factors, such as A recent vertebral fracture (within the last 2 years) ≥ 2 vertebral fractures (whenever they have occurred) BMD T-score ≤ − 3.5 Treatment with high-dose glucocorticoids (≥ 7.5 mg/day of prednisolone or equivalent over 3 months) (refer urgently given rapid loss in bone post initiation of glucocorticoids; if any delay is anticipated, start an oral bisphosphonate in the meantime) The presence of multiple clinical risk factors, particularly with a recent fragility fracture indicating high imminent risk of re-fracture, Or other indicators of very high fracture risk, including as defined by FRAX.
  • The presence of single but important clinical risk factors, such as A recent vertebral fracture (within the last 2 years) ≥ 2 vertebral fractures (whenever they have occurred) BMD T-score ≤ − 3.5 Treatment with high-dose glucocorticoids (≥ 7.5 mg/day of prednisolone or equivalent over 3 months) (refer urgently given rapid loss in bone post initiation of glucocorticoids; if any delay is anticipated, start an oral bisphosphonate in the meantime)
  • A recent vertebral fracture (within the last 2 years)
  • ≥ 2 vertebral fractures (whenever they have occurred)
  • Treatment with high-dose glucocorticoids (≥ 7.5 mg/day of prednisolone or equivalent over 3 months) (refer urgently given rapid loss in bone post initiation of glucocorticoids; if any delay is anticipated, start an oral bisphosphonate in the meantime)
  • Or other indicators of very high fracture risk, including as defined by FRAX.
  • The choice of drug treatment should be informed by the level of fracture risk, additional clinical risk factors, cost-effectiveness of treatment, and patient preferencesStrong recommendation
  • FRAX and the link to the NOGG website should be incorporated into electronic patient health record systemsStrong recommendation

Postmenopausal women and men, age ≥ 50 years, with osteoporosis or who are at risk of fragility fracture are recommended:

  • A healthy, nutrient-rich balanced dietStrong recommendation
  • An adequate intake of calcium (minimum 700 mg daily) preferably achieved through dietary intake or otherwise by supplementationStrong recommendation
  • To consume vitamin D from foods or be prescribed vitamin D supplements of at least 800 IU/day if they have identified vitamin D insufficiency or risk factors for vitamin D insufficiency. Those who are either housebound or living in residential or nursing care are more likely to require calcium and vitamin D supplementation to achieve recommended levels of intakeStrong recommendation
  • A combination of regular weight-bearing and muscle strengthening exercise, tailored according to the individual patient’s needs and abilityStrong recommendation
  • Advice about smoking cessation if an individual is a smokerStrong recommendation
  • Advice to restrict alcohol intake to ≤ 2 units/dayStrong recommendation
  • A falls assessment should be undertaken in all patients with osteoporosis and fragility fractures; those at risk should be offered exercise programmes to improve balance and/or that contain a combined exercise protocolStrong recommendation

Recommendations

  • Fracture risk assessment, patient suitability and preference should inform the choice of drug treatment. In most people at risk of fragility fracture, anti-resorptive therapy is the first-line optionStrong recommendation

Antiresorptive drug treatment

  • Offer oral bisphosphonates (alendronate or risedronate) or intravenous zoledronate as the most cost-effective interventions. Alternative options include denosumab, ibandronate, hormone replacement therapy, raloxifene, and strontium ranelateStrong Recommendation
  • Offer intravenous zoledronate as a first-line treatment option following a hip fractureStrong Recommendation
  • Consider offering younger postmenopausal women (age ≤ 60 years) with high fracture risk and low baseline risk for adverse malignant and thromboembolic events HRT as a first-line treatment optionConditional recommendation
  • Discuss continued use of HRT after the age of 60 years with the patient, with treatment based on an individual risk–benefit analysisConditional recommendation
  • When HRT is discontinued, reassess fracture risk and consider an alternative treatment if indicatedConditional recommendation
  • Before starting denosumab, ensure that a long-term personalised osteoporosis management plan is in place and that both the patient and the primary care practitioner are made aware that denosumab treatment should not be stopped or delayed without discussion with a healthcare professionalStrong recommendation
  • Avoid unplanned cessation of denosumab because it can lead to increased vertebral fracture risk; hence, it must not be stopped without considering an alternative therapyStrong recommendation
  • If denosumab therapy is stopped, intravenous infusion of zoledronate is recommended 6 months after the last injection of denosumab, with subsequent monitoring of serum CTX guiding the timing of further treatment (Strong Recommendation). Where monitoring of serum CTX is not possible, consider a further intravenous infusion of zoledronate 6 months after the first dose of zoledronateConditional Recommendation

Anabolic drug treatment

  • Consider teriparatide, abaloparatide or romosozumab as first-line treatment options in postmenopausal women at very high fracture risk, particularly in those with vertebral fracturesConditional Recommendation
  • Consider teriparatide as a first-line treatment option in men aged 50 years and older who are at very high fracture risk, particularly in those with vertebral fracturesConditional Recommendation
  • Consider as second-line treatment options, teriparatide in postmenopausal women and men age 50 years and older, and abaloparatide or romosozumab in postmenopausal women who are intolerant of bisphosphonate treatment, particularly in those with vertebral fracturesConditional recommendation
  • Following the approved duration of treatment with teriparatide, abaloparatide, or romosozumab (24, 18 or 12 months respectively), initiate treatment with alendronate, zoledronate, or denosumab without delayStrong Recommendation
  • Consider raloxifene as an option for follow-on treatment after an anabolic drug in womenConditional recommendation

Other treatments

  • When other antiresorptive and anabolic treatments are contraindicated or not tolerated, strontium ranelate can be used to treat postmenopausal osteoporosis and men with severe osteoporosis, provided the risk–benefit in relation to cardiovascular and thromboembolic events is considered. Initiation by a specialist who is an expert in osteoporosis management is advisedStrong recommendation
  • Offer calcium and/or vitamin D supplementation as an adjunct to anti-osteoporosis drug treatment, if dietary calcium is low and/or vitamin D insufficiency is a risk, respectivelyStrong recommendation
  • Treat vitamin D deficiency and insufficiency prior to initiation of parenteral anti-osteoporosis drug treatment, and alongside initiation of oral anti-osteoporosis drug treatmentStrong recommendation

Recommendations

  • Plan to prescribe oral bisphosphonates (alendronate, ibandronate and risedronate) for at least 5 years and then re-assess fracture risk. Longer durations of treatment, for at least 10 years, are recommended in the following men and women (Strong recommendation) (see Fig. 4): o Age ≥ 70 years at the time that the bisphosphonate is started o Who has a previous history of a hip or vertebral fracture(s) o Treated with oral glucocorticoids ≥ 7.5 mg prednisolone/day or equivalent o Who experiences one or more fragility fractures during the first 5 years of treatment (if treatment is not changed).
  • Age ≥ 70 years at the time that the bisphosphonate is started
  • Who has a previous history of a hip or vertebral fracture(s)
  • Treated with oral glucocorticoids ≥ 7.5 mg prednisolone/day or equivalent
  • Who experiences one or more fragility fractures during the first 5 years of treatment (if treatment is not changed).
  • Plan to prescribe an annual intravenous bisphosphonate (i.e., zoledronate) for at least 3 years and then re-assess fracture risk. Longer durations of treatment, for at least 6 years, are recommended in the following men and women (Strong recommendation) (see Fig. 5): o Age ≥ 70 years at the time that the bisphosphonate is started o Who has a previous history of a hip or vertebral fracture(s) o Treated with oral glucocorticoids ≥ 7.5 mg prednisolone/day or equivalent o Who experiences one or more fragility fractures during the first 3 years of treatment (if treatment is not changed).
  • Who experiences one or more fragility fractures during the first 3 years of treatment (if treatment is not changed).
  • If a new fracture occurs after bisphosphonate treatment is discontinued, reassess using FRAX and restart treatmentStrong recommendation
  • If bisphosphonate treatment is discontinued and no new fracture occurs, reassess using FRAX after 18 months for risedronate and ibandronate, 2 years for alendronate, and 3 years for zoledronate to inform whether treatment should be restartedStrong recommendation
  • Review treatment adherence in men and women who sustain a fragility fracture whilst on drug treatment, (poor adherence is when less than 80% of treatment has been taken correctly) and investigate for secondary causes of osteoporosisStrong recommendation
  • Fracture risk assessment in patients receiving drug treatment should be performed using FRAX with BMD, with arithmetic adjustments to FRAX probabilities to take account of additional clinical risk factors. If the FRAX-derived fracture probability exceeds the intervention threshold, drug treatment should be continuedStrong recommendation
  • If biochemical markers of bone turnover indicate relapse from suppressed bone turnover and/or BMD has decreased following bisphosphonate withdrawal, consider resumption of drug treatmentConditional recommendation
  • After 10 years of bisphosphonate treatment, patient management should be considered on an individual basisConditional recommendation
  • During bisphosphonate or denosumab therapy, encourage all patients to maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms such as dental mobility, pain, or swellingStrong recommendation
  • In those with severe dental disease who require bisphosphonate or denosumab treatment, timely dental review and dental treatment by an appropriately experienced dental surgeon should be pursued before drug administration, bearing in mind drug treatment should be initiated as soon as possible after a fragility fracture; a multi-disciplinary team (MDT) approach to discuss individual needs is encouragedConditional recommendation
  • During bisphosphonate or denosumab treatment, although ideally patients should minimise invasive dental procedures where possible, if indicated they can be carried out safely and successfully in most patients. When dental procedures are required, there are no data available to show whether treatment discontinuation reduces the risk of ONJ. Clinical judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment, ensuring patients continue to access routine dental careConditional recommendation
  • During bisphosphonate or denosumab therapy, advise patients to report any unexplained thigh, groin, or hip pain, and if such symptoms develop, the femur should be imaged (by full length femur X-ray, isotope scanning or MRI)Strong recommendation
  • If an AFF is identified, image the contralateral femurStrong recommendation
  • All patients who develop an AFF should be referred to an osteoporosis specialist to guide management of future bone healthStrong recommendation
  • In patients who develop an AFF, discontinue bisphosphonate or denosumab treatmentConditional recommendation
  • Because bone loss and increased fracture risk occur early after initiation of oral glucocorticoids, bone-protective treatment should be started in the following people, at the same time as glucocorticoid therapy without waiting for bone density assessment, which should follow later (Strong recommendations): anyone with a prior fragility fracture, women age ≥ 70 years, postmenopausal women, and men age ≥ 50 years, prescribed high doses of glucocorticoids, i.e., ≥ 7.5 mg/day of prednisolone or equivalent over 3 months (N.B., this is equivalent to ≥ 30 mg/day of prednisone for 4 weeks over 3 months). postmenopausal women, and men age ≥ 50 years, with a FRAX probability of major osteoporotic fracture or of hip fracture exceeding the intervention threshold.
  • Oral bisphosphonates (alendronate or risedronate) or intravenous zoledronate are the most cost-effective first-line drug options for bone protection. Denosumab is an alternative option. Teriparatide can be a first-line drug option in those at very high fracture riskStrong Recommendation
  • Adequate calcium intake should be achieved through dietary intake if possible, with the use of supplements if necessary. An adequate vitamin D status should be maintained, using supplements if requiredStrong Recommendation
  • If glucocorticoid therapy is stopped, withdrawal of bone-protective therapy may be considered at the same time, provided on re-assessment of fracture risk using FRAX, the probabilities of both major osteoporotic fracture and of hip fracture lie below the intervention thresholdStrong Recommendation
  • If glucocorticoids are continued long term, bone protection should be maintained in the majority of casesStrong Recommendation
  • Patients starting medium or low dose oral glucocorticoid therapy who have a FRAX probability near to, but below the intervention threshold, should have FRAX with BMD reassessed 12–18 months after starting glucocorticoid therapyConditional recommendation
  • All men starting androgen deprivation therapy (ADT) should have their fracture risk assessed using FRAX, considering ADT use as a secondary cause of osteoporosis, with BMD measured where availableStrong recommendation
  • Consider referring men, with high fracture risk requiring drug treatment, to secondary care for assessment and initiation of treatment with bisphosphonates or denosumabConditional recommendation
  • Men with FRAX probability near to, but below the intervention threshold, and patients going on to additional systemic therapies (particularly those requiring glucocorticoids), should have FRAX with BMD reassessed 12–18 months after starting ADTConditional recommendation
  • All women starting aromatase inhibitor (AI) therapy should have their fracture risk assessed using FRAX, considering AI use as a secondary cause of osteoporosis, including BMD measurement where practicalStrong recommendation
  • Women with high fracture risk should be commenced on drug treatment to prevent osteoporosis and fracture, with bisphosphonates or denosumabStrong recommendation
  • Women with a FRAX probability near to, but below the intervention threshold, and patients going on to additional systemic therapies (particularly those requiring glucocorticoids), should have FRAX with BMD reassessed 12–24 months after starting AI therapyConditional recommendation
  • If adjuvant high-dose bisphosphonate therapy is used as part of breast cancer management, consider assessing fracture risk at the end of this bisphosphonate therapy, particularly if AI therapy continuesConditional Recommendation
  • Administer analgesia orally rather than parenterally whenever possible. Pain should be regularly reviewed, and analgesia titrated up or down according to pain intensity and side effects, with use of the weakest effective agent for the shortest possible timeStrong recommendation
  • Avoid use of non-steroidal anti-inflammatory drugs (NSAIDs) in older people, but, if used, co-prescribe a proton-pump inhibitor, and monitor for gastrointestinal, renal and cardiovascular side-effectsStrong recommendation
  • Prescribe appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, whenever opioid therapy is used in older peopleStrong recommendation
  • It is recommended that exercise programmes following vertebral fracture include progressive muscle strengthening activity, including back extensor muscle strengthening and/or endurance exerciseStrong recommendation
  • When a patient is in pain, it may be advisable to initially perform exercise for back extensors in an unloaded positionConditional recommendation
  • Provide clear and prompt guidance on how to adapt movements involved in day-to-day living, including how exercises can help with posture and pain, to patients with painful vertebral fracturesStrong recommendation
  • Ensure prompt secondary fracture prevention is started following a fracture, with follow-up through fracture liaison services for all postmenopausal women, and men aged 50 years and older, with a newly diagnosed vertebral fractureStrong recommendation
  • Multidisciplinary, coordinator-based FLS are recommended to systematically identify men and women with fragility fractures, facilitating timely assessment of fracture and falls risk, and where appropriate, tests to exclude secondary causes of osteoporosis, radiological investigation including BMD testing, and initiation of pharmacological and non-pharmacological interventions to reduce risk of falls and fracturesStrong recommendation
  • FLSs should include embedded local audit systems supported by a clinical fracture database to enable monitoring of care provided to fracture patients [e.g., Royal College of Physicians FLS-Database];Strong recommendation
  • FLSs should employ a range of case-finding strategies to identify all inpatients and outpatients with fragility fracturesStrong recommendation
  • Diagnostic imaging services should routinely evaluate the spine in all imaging of postmenopausal women, and men aged ≥ 50 years, in which the spine is visualised, and report vertebral fractures using standardised methodsStrong recommendation
  • Patients recommended drug treatment for osteoporosis should be offered tailored information about osteoporosis and its treatments, and further medication reviews to support adherence and to discuss alternative treatments if unacceptable adverse events arise or adherence is difficultStrong recommendation
  • Primary care clinicians should always have in mind the possibility of vertebral fracture in postmenopausal women and men aged ≥ 50 years who present with acute onset back pain, especially thoracic pain, if they have risk factors for osteoporosisStrong recommendation

Examples of appropriate training

  • Training in Personalised Care. Training in enhanced consultation skills including risk communication, shared decision making, applying principles of health literacy and how to communicate about osteoporosis is available at http://www.ifraptraining.co.uk. The Personalised Care Institute is a virtual organisation, accountable for setting the standards for evidence-based training in personalised care in England. The Personalised Care Institute Curriculum sets out the standards for training programmes to become accredited with the Personalised Care Institute. The Personalised Care Institute provides eLearning modules, for example, on Shared Decision Making. The curriculum is designed for health care personnel within primary and secondary care and community teams https://www.personalisedcareinstitute.org.uk.
  • Training in Osteoporosis Management. The Royal Osteoporosis Society Fracture Prevention Practitioner Training is accredited for CPD by RCGP, RCP and RCN. The online training includes five foundation modules and then three advanced modules https://theros.org.uk/healthcare-professionals/courses-and-cpd/fracture-prevention-practitioner-training/. The Royal College of General Practice also provides a short e-Learning module on the diagnosis and management of osteoporosis https://elearning.rcgp.org.uk/course/info.php?id=233. Evidenced-based resources to support osteoporosis care are available at www.erohub.co.uk.
  • Training in Musculoskeletal Pain Management. The Health Education England e-Learning for Healthcare Pain Management programme includes training on musculoskeletal pain which encompasses the assessment and management of osteoporotic vertebral fractures https://www.e-lfh.org.uk/programmes/pain-management/.
  • Training in DXA conduct. The Royal Osteoporosis Society runs a National Training Scheme for Bone Densitometry. This online course provides a foundation in osteoporosis and DXA. All ROS course information is available here https://theros.org.uk/healthcare-professionals/courses-and-cpd/.

Concerning assessment of fracture risk in postmenopausal women, and men age ≥ 50 years:

  • Conduct a FRAX assessment in people with a clinical risk factor for fragility fracture.
  • Measure BMD in people with intermediate fracture risk by FRAX (amber) to refine the estimate of 10-year risk.
  • Measure BMD in people with high and very high fracture risk by FRAX (red) to guide drug choice and provide a baseline for BMD monitoring.
  • Consider imaging to look for a vertebral fracture in people with acute onset back pain who have risk factors for osteoporosis, and/or in people with a history of ≥ 4 cm height loss, kyphosis, recent or current long-term oral glucocorticoid therapy, or a BMD T-score ≤ − 2.5.
  • Assess falls risk in patients with osteoporosis and/or fragility fractures and offer those at risk an exercise programme to improve balance and muscle strength.

Regarding drug treatment to prevent fractures in postmenopausal women, and men age ≥ 50 years:

  • Offer drug treatment to people at high and very high risk of fracture.
  • If BMD measurement is not practical (e.g. due to frailty), use the online NOGG intervention thresholds based on FRAX, to guide treatment decisions.
  • Consider, particularly in older people, drug treatment in those with a prior and/or recent fragility fracture.

When selecting drug treatments to prevent fractures in postmenopausal women, and men age ≥ 50 years:

  • Consider the level of fracture risk, any additional clinical risk factors, patient choice, and the cost-effectiveness of treatment when deciding on a particular drug treatment.
  • Start treatment promptly following a fragility fracture, because the risk of re-fracture is highest immediately after a fracture and the risk remains elevated.
  • Consider referral of very high-risk patients to an osteoporosis specialist in secondary care for assessment and consideration of parenteral treatment (some may need first-line anabolic drug treatment, especially if multiple vertebral fractures). Indications of very high risk include the presence of important risk factors, including a recent vertebral fracture (within the last 2 years), ≥ 2 vertebral fractures (whenever they have occurred), BMD T-score ≤ − 3.5, treatment with high-dose glucocorticoids (≥ 7.5 mg/day of prednisolone or equivalent over 3 months); the presence of multiple clinical risk factors, particularly with a recent fragility fracture indicating high imminent risk of re-fracture; or other indicators of very high fracture risk, including as defined by FRAX.
  • In other patients for whom treatment is indicated, offer antiresorptive therapy with oral bisphosphonates (alendronate or risedronate) or intravenous zoledronate, or in postmenopausal women age ≤ 60 years, hormone replacement therapy.
  • Consider alternative treatment options if first-line bisphosphonates are unsuitable or not tolerated; denosumab, ibandronate, raloxifene, strontium ranelate, teriparatide, abaloparatide, or romosozumab.
  • Following treatment with an anabolic agent (teriparatide, abaloparatide or romosozumab), start alendronate, zoledronate, or denosumab without delay.

When postmenopausal women, and men age ≥ 50 years, have started drug treatment:

  • Regularly review patients‘ tolerance of, and adherence to, oral drug treatments.
  • Remember long-term treatment is often required because osteoporosis is a long-term condition for which there is currently no cure.
  • Plans to prescribe oral bisphosphonates for at least 5 years, or intravenous bisphosphonates for at least 3 years and then re-assess fracture risk. Longer durations of treatment will be needed in those who are older (age ≥ 70 years), have had a hip or vertebral fracture, are on high-dose oral glucocorticoids (≥ 7.5 mg/day of prednisolone or equivalent over 3 months), or have a further fragility fracture during osteoporosis treatment. In lower risk patients, a temporary treatment pause of 18 to 36 months can be considered after 5 years’ oral bisphosphonate or 3 years’ intravenous bisphosphonate (see clinical flowcharts on p.50 and p.51).
  • Before starting denosumab, ensure the long-term treatment plan considers the potential need to stop denosumab and how this would be managed.
  • Do not stop denosumab treatment without a plan for subsequent anti-resorptive therapy, where renal function permits.
  • Repeat fracture risk assessment after any new fracture, regardless of when this occurs.
  • Reassess fracture risk 18 months to 3 years after pausing drug treatment.

When postmenopausal women, and men age ≥ 50 years, are treated with oral glucocorticoids:

  • If starting ≥ 7.5 mg/day prednisolone or equivalent for the next 3 months, start bone protective treatment at the same time (without waiting for a DXA scan, which can follow later).
  • Offer antiresorptive therapy with oral bisphosphonates (alendronate or risedronate) or intravenous zoledronate, and in those at very high risk of vertebral fracture, refer for consideration of anabolic therapy.
  • Consider denosumab as an alternative treatment option.

When advising on lifestyle and dietary measures:

  • Recommend a healthy, balanced diet, moderation of alcohol consumption and avoidance of smoking.
  • Ensure a sufficient dietary calcium and vitamin D intake and supplement these as necessary.
  • Encourage a combination of regular weight-bearing and muscle strengthening exercise.

Regarding fracture prevention services:

  • Patients who sustain a fragility fracture should have access to a multidisciplinary, coordinator-based Fracture Liaison Service (FLS) which enables timely fracture and falls risk assessment, investigation, treatment, and monitoring.
  • Ensure that diagnostic imaging services routinely evaluate the spine in all imaging of postmenopausal women and men aged ≥ 50 years in which the spine is visualised and report vertebral fractures using standardised methods.

When a postmenopausal woman, or a man age ≥ 50 years has a symptomatic osteoporotic vertebral fracture:

  • Consider referral to an exercise programme which provides progressive muscle strengthening activity, including back extensor muscle strengthening and/or endurance exercise.
  • Investigate for underlying causes of fragility fracture.
  • Start treatment promptly to reduce the risk of further fractures.

Abstract

Summary: The National Osteoporosis Guideline Group (NOGG) has updated the revised UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. This guideline is relevant for all healthcare professionals involved in osteoporosis management.

Introduction: The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013, 2017 and 2021. This paper presents a minor update of the 2021 guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men aged 50 years and older.

Methods: Where available, systematic reviews, meta-analyses and randomised controlled trials have been used to provide the evidence base. Conclusions and recommendations have been systematically graded according to the strength of the available evidence.

Results: Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, as well as models of care for fracture prevention. Recommendations are made for training, service leads and commissioners of healthcare, and for review criteria for audit and quality improvement. Specific 2024 updates include guidance on fracture risk assessment by ethnicity, Parkinson’s disease, Down’s syndrome and lower-limb amputation; furthermore, the definition of very high fracture risk has been clarified. Hormone replacement therapy (HRT) is now recommended as a first-line treatment option in younger postmenopausal women with high fracture risk and low baseline risk for adverse events; recommendations regarding abaloparatide are included; additional training resources have been added.

Conclusion: The guideline provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).

Contents of the original publication

The section headings of the original.

  • Introduction
  • Summary of the 2024 update to the 2021 guideline
  • Background
  • Fracture risk assessment and case finding
  • Recommendations
  • Measurement of bone mineral density
  • Assessment of clinical risk factors
  • Fracture risk assessment tools
  • Investigation of osteoporosis and fragility fractures
  • Vertebral fracture assessment
  • Screening and case finding
  • Intervention thresholds and strategy
  • Recommendations
  • FRAX assessment thresholds for 10-year probability of fracture
  • Indications for specialist referral in those at very high fracture risk
  • FRAX—practical considerations
  • Non-pharmacological management of osteoporosis
  • Recommendations
  • Pharmacological treatment options
  • Recommendations
  • Overview of treatment options
  • Treatment sequence
  • Specific drug options
  • Anti-resorptive drugs: bisphosphonates
  • Contraindications and special precautions for the use of bisphosphonates
  • Anti-resorptive drugs: denosumab
  • Anti-resorptive drugs: hormone replacement therapy (HRT)
  • Anti-resorptive drugs: calcitriol
  • Anti-resorptive drugs: raloxifene
  • Other drugs: strontium ranelate
  • Anabolic drugs: teriparatide (recombinant human parathyroid hormone (PTH) 1–34)
  • Anabolic drugs: abaloparatide
  • Anabolic drugs with additional antiresorptive effect: romosozumab
  • Drug treatment for patients with very high fracture risk
  • Duration and monitoring of bisphosphonate treatment
  • Recommendations
  • Reassessment of fracture risk in individuals on osteoporosis drug treatment
  • Recommendations
  • Rare adverse effects of long-term bisphosphonate and denosumab treatment
  • Recommendations
  • Osteonecrosis of the jaw (ONJ)
  • Atypical femoral fractures (AFF)
  • Glucocorticoid-induced osteoporosis
  • Recommendations
  • Men receiving androgen-deprivation therapy
  • Recommendations
  • Women receiving aromatase inhibitor therapy
  • Recommendations
  • Management of symptomatic osteoporotic vertebral fractures
  • Recommendations
  • Models of care for fracture prevention
  • Recommendations
  • FLS models of care
  • FLS patient identification
  • Providing patient information and adherence support
  • Recommendations for training
  • Recommendations
  • Examples of appropriate training
  • Recommendations for commissioners of healthcare
  • Recommendations
  • Review criteria for audit and quality improvement
  • Quality standards for osteoporosis
  • Primary care
  • Fracture liaison services
  • DXA reporting
  • Summary of main recommendations
  • Concerning assessment of fracture risk in postmenopausal women, and men age ≥ 50 years:
  • Regarding drug treatment to prevent fractures in postmenopausal women, and men age ≥ 50 years:
  • When selecting drug treatments to prevent fractures in postmenopausal women, and men age ≥ 50 years:
  • When postmenopausal women, and men age ≥ 50 years, have started drug treatment:
  • When postmenopausal women, and men age ≥ 50 years, are treated with oral glucocorticoids:
  • When advising on lifestyle and dietary measures:
  • Regarding fracture prevention services:
  • When a postmenopausal woman, or a man age ≥ 50 years has a symptomatic osteoporotic vertebral fracture:
  • Appendix 1
  • Appendix 2 Grading of evidence
  • Appendix 3

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