The full reasoning pathway — case-find those at risk, quantify with FRAX, map onto NOGG to decide DXA vs treat, give bone protection, modify falls & bone-health factors, and safety-net. Follows NICE/NOGG.StartDecisionInvestigateActionReferStop / Admit
Presentation · NICE CG146 / NOGGIdentify who is at risk (case-finding)
Assess fracture risk in: women ≥65 and men ≥75; younger with risk factors — previous fragility fracture, oral glucocorticoids (prednisolone ≥7.5 mg/day ≥3 months), parental hip fracture, smoking, alcohol ≥3 units/day, low BMI, RA, premature menopause (<45y), falls. (No population screening.)
Step 1 · Safety — the fracture not to missStraight to DXA / urgent action?
Some high-risk groups proceed straight to DXA: NICE — anyone <40 with a major risk factor (fragility fracture, glucocorticoids, untreated premature menopause). Acute presentation: a vertebral fracture (sudden back pain/height loss) or any low-trauma fracture needs assessment + imaging.
Straight to DXA
InvestigateDXA first
<40 with a major risk factor, or after a fragility fracture (per local pathway) → arrange DXA, then re-enter FRAX with the BMD/T-score.
Most people
Investigate · FRAXCalculate 10-year fracture risk
Use FRAX (or QFracture) without BMD first. (In T2DM, tick the RA box.) Gives 10-year risk of major osteoporotic and hip fracture.
map FRAX onto NOGG
Green — low risk
Lifestyle alone
Reassure; address modifiable risk; reassess if circumstances change.
Amber — intermediate
Arrange DXA
Do a DXA, re-enter the T-score into FRAX, and review NOGG guidance again.
Red / deep red — high
Treat
Above the NOGG intervention threshold → treat (deep red: treat + consider specialist referral). NOGG: treatment may start immediately while awaiting DXA.
Before starting: check renal function, calcium and vitamin D; correct deficiency; arrange a dental check. Ensure dietary calcium ~700 mg/day (supplement only if intake inadequate — not within 2h of a bisphosphonate).
First-line: oral bisphosphonate (alendronate/risedronate). If not tolerated/absorbed → IV zoledronate or denosumab. Severe vertebral osteoporosis → consider referral for anabolic agents (teriparatide, romosozumab).
Review oral bisphosphonate at ~5 years (3 years for IV zoledronate) — consider a drug holiday vs continuation by ongoing risk.
Step 5 · ReferEscalation
Metabolic bone / endocrine deep-red risk, severe or recurrent vertebral fractures despite treatment, or for anabolic therapy. Investigate secondary causes in: any man, pre-/early-menopausal women, fractures at unusual sites, or vertebral fractures painful >6 weeks (FBC, U&E, LFT, bone profile, TFT, CRP/ESR, vitamin D, phosphate ± myeloma screen).
Step 8 · bone health & falls prevention
Step 8 · Lifestyle & falls preventionStrengthen bone, prevent the fall
Weight-bearing & resistance exercise, balance work (tai chi) · adequate dietary calcium (~700 mg/day) + vitamin D · stop smoking, alcohol <3 u/day · falls assessment (home hazards, footwear, vision, postural BP) · review culprit drugs (long-term steroids, sedatives, drugs causing postural drop). Bone protection works only alongside fall reduction.
Step 9 · monitoring & safety-net
Step 9 · Monitoring & safety-netReview & when to return
Review adherence/tolerance early; reassess oral bisphosphonate at ~5 years (IV zoledronate at 3) for a drug holiday vs continuation by risk; repeat DXA if a treatment decision depends on it. Seek help for sudden severe back pain/height loss (new vertebral fracture), any new low-trauma fracture (→ fracture liaison), or thigh/groin pain on a bisphosphonate (rare atypical femoral fracture) and jaw symptoms (ONJ — maintain dental care).
⚠️ Every fragility fracture is a treatment opportunity (a low-trauma fracture in an adult ≥50 is osteoporosis until proven otherwise). The three UK guidelines (NICE, NOGG, SIGN) differ — pick one and don't switch mid-assessment. This pathway follows NICE/NOGG (FRAX → NOGG thresholds).
1
Safety
Red Flags — The Fracture You Must Not Miss
A fragility fracture — a fracture from a fall at standing height or less, in an adult aged ≥50 — is osteoporosis until proven otherwise and is the strongest predictor of the next fracture.
Sudden back pain / height loss / kyphosis Vertebral fragility fracture — often unrecognised. Image (spine X-ray) and assess; a vertebral fracture markedly raises future risk and warrants treatment, often without waiting for DXA.
Hip fracture Highest-mortality fragility fracture. After a hip fracture, IV bisphosphonate reduces mortality and re-fracture — ensure bone protection is started (fracture liaison service).
Glucocorticoids — prednisolone ≥7.5 mg/day for ≥3 months High fracture risk; assess and usually start bone protection early (don't wait for DXA in high-risk steroid users).
Fractures at unusual sites, or vertebral fractures painful >6 weeks / worsening Investigate for a secondary cause (incl. myeloma, malignancy, metabolic bone disease).
Half of patients presenting with a hip fracture have had an earlier, often vertebral, fragility fracture that was not acted on. Each fracture roughly doubles the risk of the next, so the case-finding priority is to recognise the index fragility fracture and start assessment and treatment — the "fracture liaison" model exists precisely to close this secondary-prevention gap.
2
Diagnose
Case-finding — Who to Assess
There is no population screening — fracture-risk assessment is targeted (case-finding). Assess anyone in the groups below.
By age
Women ≥65 and men ≥75 — assess all.
Younger + a risk factor
Previous fragility fracture, oral glucocorticoids (prednisolone ≥7.5 mg/day for ≥3 months), parental hip fracture, current smoking, alcohol ≥3 units/day, low BMI (<18.5), rheumatoid/secondary osteoporosis, premature menopause <45y, recurrent falls.
Straight to DXA
NICE: anyone <40 with a major risk factor (fragility fracture, glucocorticoids, untreated premature menopause) — scan first rather than FRAX.
Don't forget men
Osteoporosis is under-diagnosed in men; a man with any fragility fracture warrants assessment and a secondary-cause screen.
Population screening for osteoporosis is not cost-effective, so the strategy is opportunistic case-finding around age and clinical risk factors. The under-40 "straight to DXA" group exists because FRAX is not validated below 40 and these patients have a clear high-risk trigger that warrants direct bone-density measurement.
3
Diagnose
Quantify Risk — FRAX & the DXA T-score
Tool (this pathway)
Use FRAX — gives 10-year risk of major osteoporotic and hip fracture and links directly to NOGG. (SIGN prefers QFracture.) In T2DM, tick the RA box to offset FRAX's underestimate.
Which score to act on
NICE: use the major-osteoporotic-fracture risk. NOGG: use the higher of the two scores.
FRAX without BMD first
Calculate FRAX without a DXA T-score initially; only scan if the result lands in the assessment (amber) zone.
DXA T-score
≤ −2.5 = osteoporosis; −1 to −2.5 = osteopenia; ≥−1 = normal. Re-enter the BMD into FRAX to refine the decision.
Fracture risk is driven by far more than bone density — age, prior fracture, steroids and parental hip fracture each add independent risk — which is why a validated tool (FRAX or QFracture) rather than DXA alone is the starting point. FRAX is favoured in the NICE/NOGG route because its output links straight to the NOGG intervention thresholds, telling you whether to reassure, scan, or treat.
Below threshold — lifestyle alone; reassess if circumstances change.
Amber / yellow
Arrange DXA, re-enter the T-score into FRAX, and review NOGG guidance again.
Red
Above the intervention threshold — treat. NOGG allows starting treatment immediately while awaiting DXA.
Deep red
Treat and consider specialist referral.
Secondary causes — screen if
Any man; pre-/early-menopausal woman; fractures at unusual sites; vertebral fractures painful >6 weeks. NOGG bloods: FBC, U&E/creatinine, LFT, bone profile, TFT, CRP/ESR, vitamin D, phosphate. Consider spine X-ray for silent vertebral fractures.
2WW Myeloma (NICE NG12)
In a patient ≥60 with persistent bone pain or an unexplained fragility fracture (esp. with raised ESR/plasma viscosity or anaemia), request very urgent serum protein electrophoresis + serum-free light chains / Bence-Jones (urine BJP) and FBC — myeloma can present as osteoporosis or a low-trauma vertebral fracture.
The NOGG colour-coded graph turns a percentage risk into an action: green = reassure, amber = measure bone density to refine, red = treat. Screening for secondary causes matters because treating "primary" osteoporosis when the real driver is myeloma, hyperparathyroidism or osteomalacia means treating the wrong target — the NG12 myeloma pathway exists precisely to catch the malignancy hiding behind an unexplained fracture.
5
Refer
Referral & Escalation
2WW Suspected myeloma
NICE NG12 — ≥60 with bone pain/unexplained fracture + abnormal protein electrophoresis or plasma viscosity/ESR → urgent haematology referral.
Metabolic bone / endocrine
Deep-red risk; treatment failure (fractures despite adherence); intolerance of multiple agents; consideration of anabolic therapy; complex secondary osteoporosis.
Fracture liaison service
Anyone presenting with a fragility fracture — for systematic assessment and secondary prevention.
Guideline note
NICE, NOGG and SIGN differ; this pathway follows NICE/NOGG (FRAX → NOGG thresholds). Avoid switching guidelines mid-assessment.
Most osteoporosis is managed entirely in primary care; referral is reserved for diagnostic complexity, treatment failure, or the need for parenteral/anabolic agents. The myeloma 2WW sits here because an unexplained fragility fracture in an older adult is one of NG12's recognised malignancy presentations and must not be absorbed silently into a "primary osteoporosis" label.
6
Treat
Bone Protection — Pre-checks & First-line Drug
Before starting
Check renal function, calcium and vitamin D; correct deficiency first. Arrange a dental check (osteonecrosis-of-jaw risk). Aim ~700 mg/day dietary calcium; supplement only if intake inadequate (not within 2h of a bisphosphonate).
First-line
Oral bisphosphonate
Alendronate 70 mg weekly or risedronate 35 mg weekly. Take on an empty stomach with a full glass of water, sit/stand upright ≥30 min, fast afterwards.
Oral not tolerated / absorbed
IV zoledronate or denosumab
IV zoledronate once yearly, or denosumab 60 mg SC every 6 months. Correct vitamin D/calcium first — hypocalcaemia risk with potent antiresorptives.
Severe vertebral / specialist
Anabolic therapy
Teriparatide or romosozumab via specialist for severe or progressive vertebral osteoporosis.
Oral bisphosphonates are first-line because they reduce vertebral, non-vertebral and hip fractures cheaply and safely for most people; the upfront checks (renal function, calcium/vitamin D, dental review) minimise the rare harms (hypocalcaemia, osteonecrosis of the jaw, atypical femoral fracture). Correcting vitamin D and calcium before a potent antiresorptive is essential to avoid precipitating symptomatic hypocalcaemia.
7
Treat
Review, Drug Holiday & Adherence
Adherence
Persistence with oral bisphosphonates is poor — confirm the patient understands the dosing ritual and the long-term, often symptom-free, nature of treatment. Poor adherence is the commonest cause of apparent "failure".
Oral bisphosphonate review
Reassess at ~5 years: consider a drug holiday if low ongoing risk (no new fracture, T-score > −2.5), or continue if high risk (prior vertebral/hip fracture, T-score ≤ −2.5, ongoing steroids).
IV zoledronate review
Reassess at ~3 years on the same risk basis.
Denosumab caution
Do not stop denosumab without follow-on therapy (e.g. a bisphosphonate) — abrupt cessation causes rapid rebound bone loss and multiple vertebral fractures.
The "drug holiday" concept reflects the long skeletal retention of bisphosphonates, which continue to protect for a period after stopping in lower-risk patients, reducing cumulative exposure to rare harms. Denosumab is the opposite — its effect reverses quickly, so stopping it without a follow-on agent is dangerous, a point examiners frequently test.
8
Lifestyle
Bone Health & Falls Prevention
Bone protection works only alongside fall reduction — most fractures need both a fragile bone and a fall.
Exercise Weight-bearing & muscle-strengthening exercise; balance training (e.g. tai chi) to cut falls.
Calcium & vitamin D Adequate dietary calcium (~700 mg/day) and vitamin D; supplement if intake/levels low.
Falls assessment Review home hazards, footwear, vision, and check a postural BP.
Culprit drugs Review long-term steroids, sedatives and drugs causing a postural drop.
Antiresorptive drugs reduce relative fracture risk, but the absolute number of fractures prevented depends just as much on whether the person falls. A combined approach — strengthen the bone, reduce the fall — is why structured falls assessment is part of every osteoporosis plan, not an optional extra.
9
Follow-up
Monitoring & Safety-net
Early review
Check adherence and tolerance soon after starting; address GI upset (commonest reason oral bisphosphonates are abandoned).
Reassess treatment
Oral bisphosphonate at ~5 years, IV zoledronate at ~3 years — drug holiday vs continuation by risk; repeat DXA if a decision depends on it.
Seek help urgently
Sudden severe back pain/height loss (new vertebral fracture) or any new low-trauma fracture → fracture liaison.
Drug-specific warnings
Thigh/groin pain on a bisphosphonate (rare atypical femoral fracture) or jaw pain/non-healing socket (osteonecrosis) — review the drug and maintain dental care.
Structured review keeps patients on therapy long enough to benefit and catches the rare but serious adverse events (atypical femoral fracture, osteonecrosis of the jaw) early. Naming the specific warning symptoms to the patient both protects them and documents your safety-netting.
Educational use only. Follows NICE CG146 (2017) and NOGG 2021 (FRAX → NOGG intervention thresholds) as summarised in the GEMS "Osteoporosis" guide, with NICE technology appraisals (TA160/161, TA464, TA204, TA791) for drug choice. The UK guidelines (NICE, NOGG, SIGN) differ — use one consistently. Verify thresholds and doses against the live tools and BNF.