National Osteoporosis Guideline Group Research Articles

Access to fracture risk assessment by FRAX and linked National Osteoporosis Guideline Group (NOGG) guidance in the UK-an analysis of anonymous website activity.

In the UK, guidance on assessment of osteoporosis and fracture risk is provided by the National Osteoporosis Guideline Group ( www.shef.ac.uk/NOGG ). We wished to determine access to this guidance by exploring website activity. We undertook an analysis of FRAX and NOGG website usage for the year between 1st July 2013 and 30th June 2014 using Google Analytics software. During this period, there was a total of 1,774,812 sessions (a user interaction with the website) on the FRAX website with 348,964 of these from UK-based users; 253,530 sessions were recorded on the NOGG website. Of the latter, two-thirds were returning visitors, with the vast majority (208,766; 82%) arising from sites within the UK. The remainder of sessions were from other countries demonstrating that some users of FRAX in other countries make use of the NOGG guidance. Of the UK-sourced sessions, the majority was from England, but the session rate (adjusted for population) was the highest for Scotland. Almost all (95.7%) of the UK sessions arose from calculations being passed through from the FRAX tool ( www.shef.ac.uk/FRAX ) to the NOGG website, comprising FRAX calculations in patients without a bone mineral density (BMD) measurement (74.5%) or FRAX calculations with a BMD result (21.2%). National Health Service (NHS) sites were identified as the major source of visits to the NOGG website, comprising 79.9% of the identifiable visiting locations, but this is an underestimate as many sites from within the NHS are not classified as such. The study shows that the facilitated interaction between web-based fracture risk assessment and clinical guidelines is widely used in the UK. The approach could usefully be adopted in other countries for which a FRAX model is available.

Estudio comparativo de la aplicación de la calibración FRIDEX y de la guía NOGG en el manejo de la osteoporosis en la práctica clínica habitual

ObjectiveThe recent FRIDEX calibration proposed cost-effectiveness thresholds for the Spanish population. The aim of our study is to evaluate the impact of its application in routine clinical practice and to compare its thresholds with those of the National Osteoporosis Guideline Group (NOGG). Material and methodsCross-sectional study in women referred to a bone densitometry unit who were not receiving antiresorptive therapy. The absolute risk of major fracture or hip fracture was calculated with the Spanish and British formulas of the FRAX® tool using the intervention thresholds of the FRIDEX calibration and the NOGG guideline, respectively. ResultsThe study included 607 women with a median age of 59.4 (IQR=14) years. Treatment was initiated in 31.4% after bone mineral densitometry. With the application of the FRIDEX calibration, bone mineral density testing would have been indicated in 35.4% of the sample and treatment in 26.7%, reducing costs by 18.8% over a 5-year period. The NOGG guideline would have recommended testing in 32% and treatment in 21.3% of the participants, resulting in a reduction in costs of 35% over 5years, when compared with the standard approach. Agreement between the FRIDEX calibration and the NOGG guideline, as defined by Cohen's kappa coefficient, was low in terms of both diagnostic (0.16 [95%CI, 0.09-0.24]) and therapeutic indications (0.39 [95%CI, 0.31-0.47]). ConclusionsThe application of the FRIDEX calibration and the NOGG guideline improves efficiency in the management of osteoporosis, although the level of agreement between the two is low.

Predicting the 10-year risk of hip and major osteoporotic fracture in rheumatoid arthritis and in the general population: an independent validation and update of UK FRAX without bone mineral density

ObjectivesFRAX incorporates rheumatoid arthritis (RA) as a dichotomous predictor for predicting the 10-year risk of hip and major osteoporotic fracture (MOF). However, fracture risk may deviate with disease severity, duration...

Predicting fracture risk in osteoporosis: the use of fracture prediction tools in an osteoporosis clinic population

BackgroundIn the UK, the National Institute for Health and Care Excellence recommends either fracture risk assessment tool (FRAX) or QFracture to estimate the 10 year fracture risk of individuals. However,...

A multi-study cost-effectiveness comparison of the QFracture and FRAX fracture risk algorithms

BACKGROUND: The FRAX and QFracture risk calculators have previously been validated but their relative performance with respect to cost-effectiveness has yet to be evaluated. METHODS: The relative costs of implementing these two fracture risk calculators were assessed in two scenarios, firstly in a case-control group of 584 post-menopausal women using the National Osteoporosis Guideline Group (NOGG) guidelines, and then using the QResearch database, which contains over 8 million patient-years of prospective data. RESULTS: QFracture was more cost-effective in the first scenario while the underlying cost drivers were different for each algorithm; however, the cost per fracture prevented could not be estimated. The incremental cost-effectiveness ratio of FRAX was £516.22 per hip fracture saved compared with QFracture in the second scenario. LIMITATIONS: The comparison yielded virtually identical false negative rates for both calculators. In cases where these rates are significantly different, an all-encompassing cost comparison would be a challenge. CONCLUSIONS: FRAX was more cost-effective per fracture prevented when the same risk assessment cost was used for the two algorithms; a key factor in assessing the relative cost-effectiveness of these algorithms is the cost of the risk assessment process. QFracture considers more risk factors than FRAX and has been developed to incorporate additional risk factors in the future. This makes QFracture costly, however, this calculator may benefit from automated systems to reduce its cost of implementation.

Impact of the NOGG and NOF Guidelines on the Indication of Bone Mineral Density in Routine Clinical Practice

The universal screening for osteoporosis by bone mineral density (BMD) is not feasible because of its unfavorable cost-benefit due to its low sensitivity. The aim of the present study was to estimate the population and economic impact of the diagnostic criteria of the National Osteoporosis Guideline Group (NOGG) and the National Osteoporosis Foundation (NOF) and assess the appropriateness of the BMD tests performed in routine clinical practice. A cross-sectional study was conducted in individuals referred for BMD testing who were not receiving antiresorptive therapy. The absolute risk of major and hip fracture was calculated using the British formula of the Fracture Risk Assessment Tool. NOGG and NOF guidelines diagnostic thresholds interventions were used. A total of 640 individuals were included, of which 95% were women, with a median age of 59.4 years (interquartile range = 14). When applying the NOGG criteria, BMD testing was recommended in 32.3% of the individuals, whereas this percentage increased to 75.6% with the NOF guidelines (p < 0.05). Regarding the appropriateness of the BMD tests performed, 31.9% were deemed appropriate according to both the NOGG and NOF guidelines, whereas 23.9% were considered inappropriate. In conclusion, the application of the NOGG and NOF guidelines led to a decrease in BMD indications, reducing costs and improving efficiency in the diagnostic management of osteoporosis, although variability exists between the guidelines.

Incidence of hip fracture in Brazil and the development of a FRAX model.

The Brazilian FRAX model is described and used to determine intervention thresholds for the treatment of osteoporosis. A FRAX model for Brazil was released May 1, 2013. This paper describes the data used to develop the Brazilian FRAX(®) model, illustrates its features and develops intervention thresholds. Age- and sex-stratified hip fracture incidence rates were extracted from four regional estimates from the age of 40years. For other major fractures, Brazilian incidence rates were estimated using Swedish ratios for hip to other major osteoporotic fracture (humerus, forearm or clinical vertebral fractures). Assessment and intervention thresholds were determined using the approach recommended by the National Osteoporosis Guideline Group (UK) applied to the Brazilian FRAX model. Fracture incidence rates increased with increasing age: for hip fracture, incidence rates were higher amongst younger men than women but with a female preponderance from the age of 50years. Ten-year probability of hip or major fracture was increased in patients with a clinical risk factor, lower BMI, female gender, a higher age and a decreased BMD T-score. Of the clinical risk factors, prior fracture accounted for the greatest increase in 10-year fracture probability at younger ages while a parental hip fracture history was the strongest risk factor at ages 80-90years. Age-dependent probability-based intervention thresholds were developed equivalent to women with a prior fragility fracture. The FRAX tool is the first to provide a country-specific fracture prediction model for Brazil. It is based on the original FRAX methodology, which has been externally validated in several independent cohorts. Despite some limitations, the strengths make the Brazilian FRAX tool a good candidate for implementation into clinical practice.

Managing osteoporosis with FRAX® in Australia: Proposed new treatment thresholds from the 45&Up Study cohort

IntroductionMany people at high risk of fractures are not following traditional guidelines and not being recommended for intervention. This study aimed to propose and evaluate a new set of intervention thresholds. MethodsParticipants were 213,375 men and women aged ≥50years living in New South Wales, Australia. Fracture Risk Assessment Paper Charts (Australia) was used to estimate the 10-year fracture risk. The standardized rates (to Australia population distribution 2007) for intervention were calculated for different thresholds: our proposed new thresholds (i.e. 10-year probability of hip fracture: ≥3%, 5% or 7% for 50–69, 70–79 and ≥80years respectively), thresholds by the National Osteoporosis Guideline Group (NOGG) approach, UK thresholds and US thresholds. ResultsThe NOGG, UK and US thresholds did not work well in the Australian population. For example, the NOGG and UK thresholds respectively qualified only 1 in 12 (8.1%) and 1 in 9 (11.3%) Australian men aged ≥70years and the US thresholds qualified about 9 in 10 (90.6%) Australian women aged ≥70years. For men or women aged ≥70years, our proposed new thresholds gave more realistic treatment rates of 21.6% for men and 70.5% for women. Compared to the current Australian guidelines (i.e. T-score≤−2.5 and age≥70years or a fragility fracture), our thresholds identified an additional 4.9% of men and 18.2% of women aged≥70years for treatment. ConclusionThe proposed new thresholds could identify currently under-recognised high-risk individuals for treatment. It should be considered as a recommendation for osteoporosis management in Australia.

Assessment and management of fracture risk in patients with Parkinson's disease.

Parkinson's disease (PD) is associated with substantially increased fracture risk, particularly hip fracture, which can occur relatively early in the course of PD. Despite this, current national clinical guidelines for PD fail to adequately address fracture risk assessment or the management of bone health. We appraise the evidence supporting bone health management in PD and propose a PD-specific algorithm for the fracture risk assessment and the management of bone health in patients with PD and related movement disorders. The algorithm considers (i) calcium and vitamin D replacement and maintenance, (ii) quantification of prior falls and fractures, (iii) calculation of 10-year major osteoporotic and hip fracture risks using Qfracture, (iv) application of fracture risk thresholds, which if fracture risk is high (v) prompts anti-resorptive treatment, with or without dual X-ray absorptiometry, and if low (vi) prompts re-assessment with FRAX and application of National Osteoporosis Guidelines Group (NOGG) guidance. A range of anti-resorptive agents are now available to treat osteoporosis; we review their use from the specific perspective of a clinician managing a patient population with PD. In conclusion, our current evidence base supports updating of guidelines globally concerning the management of PD, which presently fail to adequately address bone health.

Magnitude of fragility fracture risk in the very old--are we meeting their needs? The Newcastle 85+ Study.

Fractures due to osteoporosis are common in older people. This study assessed the management of osteoporosis in a group of 85-year-olds and found both assessment and current treatment to be suboptimal. Fragility fractures are a major cause of excess mortality, substantial morbidity, and health and social service expenditure in older people. However, much less is known about fracture risk and its management in the very old, despite this being the fastest growing age group of our population. Cross-sectional analysis of people who reached the age of 85 during the year of 2006 was carried out. Data were gathered by general practice record review (GPRR) and a multidimensional health assessment (MDHA). Seven hundred thirty-nine individuals were recruited. Mean age was 85.55 years (SD 0.44), and 60.2% were female; 33.7% (n = 249) had experienced one or more fragility fractures (F 45.2% vs M 16.3% p < 0.001); in total, 332 fractures occurred in these 249 individuals. A formal documented diagnosis of osteoporosis occurred in 12.4%, and 38% of individuals had experienced a fall in the last 12 months. When the fracture risk assessment tool (FRAX) and National Osteoporosis Guideline Group (NOGG) guidelines were applied, osteoporosis treatment would be recommended in 35.0%, with a further 26.1% identified as needing bone mineral density (BMD) measurement and 38.9% not requiring treatment or BMD assessment. Women were more likely than men to need treatment (47.4 vs 16.3%, p < 0.001, odds ratio (OR) 4.62 (3.22-5.63)) and measurement of BMD (40.0 vs 5.1%, p < 0.001, OR 12.4 (7.13-21.6)). Of the 259 individuals identified as requiring treatment, only 74 (28.6%) were on adequate osteoporosis treatment. The prevalence of high fracture risk in the very old is much higher than the documented diagnosis of osteoporosis or the use of adequate treatments.

Impact of femoral neck and lumbar spine BMD discordances on FRAX probabilities in women: a meta-analysis of international cohorts.

There are occasional marked discordances in BMD T-scores at the lumbar spine (LS) and femoral neck (FN). We investigated whether such discordances could contribute independently to fracture prediction using FRAX. We studied 21,158 women, average age 63 years, from 10 prospective cohorts with baseline FRAX variables as well as FN and LS BMD. Incident fractures were collected by self-report and/or radiographic reports. Extended Poisson regression examined the relationship between differences in LS and FN T-scores (ΔLS-FN) and fracture risk, adjusted for age, time since baseline and other factors including FRAX 10-year probability for major osteoporotic fracture calculated using FN BMD. To examine the effect of an adjustment for ΔLS-FN on reclassification, women were separated into risk categories by their FRAX major fracture probability. High risk was classified using two approaches: being above the National Osteoporosis Guideline Group intervention threshold or, separately, being in the highest third of each cohort. The absolute ΔLS-FN was greater than 2 SD for 2.5% of women and between 1 and 2 SD for 21%. ΔLS-FN was associated with a significant risk of fracture adjusted for baseline FRAX (HR per SD change = 1.09; 95% CI = 1.04-1.15). In reclassification analyses, only 2.3-3.2% of the women moved to a higher or lower risk category when using FRAX with ΔLS-FN compared with FN-derived FRAX alone. Adjustment of estimated fracture risk for a large LS/FN discrepancy (>2SD) impacts to a large extent on only a relatively small number of individuals. More moderate (1-2SD) discordances in FN and LS T-scores have a small impact on FRAX probabilities. This might still improve clinical decision-making, particularly in women with probabilities close to an intervention threshold.

Failure in the application of fragility fracture prevention guidelines.

The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services. Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX(®) risk calculations were applied to patients prior to their admission with a new hip fracture. Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX(®) ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice. In conjunction with NICE and NOGG recommendations, FRAX(®) was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.

AB0821 'Keep Taking the Tablets? A Pilot Study of the Scale of the Potential Problem from Long-Term Bisphosphonate Prescribing in South Wales

BackgroundLong term anti-resorptive therapy (usually in the form of bisphosphonates (BP)) is recognised as an effective anti-fracture therapy in patients with osteoporosis, particularly in patients at high risk of fracture....

Impact on the Population of Different Bone Mineral Density Testing Criteria and Appropriateness of Densitometries in the ESOSVAL Cohort, Spain

There is little consensus regarding which individuals should be recommended for bone mineral density (BMD) testing, a situation that could eventually affect the appropriateness of routine clinical practice. The aim of this study was to estimate the impact on the population of the application of the BMD testing criteria provided by the National Osteoporosis Guideline Group (NOGG), National Osteoporosis Foundation (NOF), and Osteoporosis Canada and to assess the appropriateness of the BMD tests currently performed. A cross-sectional study was conducted using the baseline data of the ESOSVAL cohort. Participants included 11 035 men and women aged 50 years old and over attending primary health care centers in the Valencia region, Spain (2009-2010). BMD testing by dual-energy X-ray absorptiometry was recorded. Of the 10 710 people included in the study, 1617 (15.1%; 95% confidence interval [CI]: 14.4-15.8) received a BMD test. When applying the NOGG criteria, BMD testing would be recommended in 17.4% (95% CI: 16.7-18.1) of individuals, whereas this percentage would rise to 74.6% (95% CI: 73.7-75.4) and 80.1% (95% CI: 79.4-80.9) when using the Osteoporosis Canada and the NOF criteria, respectively. Regarding the appropriateness of the BMD tests performed in the ESOSVAL cohort, 40.7% (95% CI: 38.3-43.1), 86.0% (95% CI: 84.3-87.7), and 82.2% (95% CI: 80.3-84.1) of individuals having a BMD test met the NOGG, NOF, and the Canadian guidelines criteria, respectively. Of the tests performed, 40.7% would be deemed as appropriate, whereas 10.7% would be considered inappropriate. The impact on the population of the different recommendations is enormous, varying from 17% to 80% of the population over 50 who would be tested. Although in men it seems that a clinical rationale exists between the presence of risk factors and the rates of BMD testing, this pattern does not seem to exist in women. One in 10 of the densitometric tests performed were inappropriate according to all the guidelines.

Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening

We identified that use of VFA may be cost-effective in either selected women from primary care or women attending after a low trauma fracture. Lateral DXA scanning of the spine for vertebral fracture assessment (VFA) is used for research, but its wider role is unclear. We aimed to establish whether VFA is cost-effective in women based on two different scenarios: following a low-trauma fracture, and after screening of high-risk women identified in primary care. The fracture cohort (FC) consisted of 377 women and the primary care cohort (PCC) of 251. Vertebral fractures were identified on VFA images by quantitative morphometry (QM). Outcome was cost-effectiveness of VFA, based on predicted change in clinical management defined as the identification of a vertebral fracture in a patient who otherwise falls below the threshold for treatment. FRAX treatment thresholds assessed were (1) 20/3 % thresholds and (2) National Osteoporosis Guidelines Group (NOGG) thresholds. As a result, 9.8 % from FC and 13.9 % from PCC were identified with vertebral fractures. Management was changed in 21 to 22/377 (5.6-5.8 %) in FC and 12 to 26/251 (4.8-10.4 %) from PCC depending on which thresholds were used. Sensitivity analyses identified medication adherence as the assumption which most influenced the model. The best-estimate cost-per-QALY for use of VFA in FC was £3,243 for 20/3 threshold and £2,130 for NOGG; for PCC, this was £7,831 for 20/3 and was cost-saving for NOGG. Further analyses to adjust for potential false-positive vertebral fracture identification with QM showed VFA was no longer cost-effective. VFA appears to be cost-effective in routine clinical practise, particularly when relatively inaccurate methods of identification of vertebral fractures are used such as QM.

Outcomes of applying the NOF, NOGG and Taiwanese guidelines to a cohort of Chinese early postmenopausal women

We applied the NOF (National Osteoporosis Foundation, USA), NOGG (National Osteoporosis Guideline Group, UK) and Taiwanese guidelines to a cohort of postmenopausal women and compared the effectiveness in fracture prevention according to these guidelines. This study is part of the Hong Kong Osteoporosis Study in which postmenopausal women underwent regular assessment and followed up for fracture outcome. We studied 2266 treatment-naïve postmenopausal women with mean age of 62·1 years and mean follow-up of 4·5 years. The treatment recommendations based on different guidelines were compared. The women were followed up to determine the rate of fracture occurrence. A total of 106 new major osteoporotic fractures (MOF) were reported, of which 21 were hip fractures (HF). Application of the NOF, NOGG and Taiwanese guidelines resulted in bone mineral density (BMD) screening of 40·7%, 1·3% and 31·8% and treatment of 26·8%, 15·5% and 25·4% of the cohort, respectively. 85·7%, 52·4% and 85·7% of the subjects who sustained HFs would be offered treatment according to the NOF, NOGG and Taiwanese guidelines, respectively. Likewise, 58·5%, 34% and 59·4% of the subjects who sustained MOF would be offered treatment according to the 3 guidelines, respectively. The clinical utility indexes for the 3 guidelines based on the occurrence of MOF during follow-up were 0·0597, 0·0345 and 0·0651, respectively. The corresponding numbers for HFs were even lower. The clinical utility for these three guidelines is low for this postmenopausal cohort. Specific guidelines should be needed to guide BMD screening and treatment in our society.

Effect of additional sensory information on functional mobility and static balance of fallers elderly

risk based guidelines were used as compared to using the current Danish guidelines. Methods.– Female patients attending a falls clinic and evaluated by bone mineral density bone densitometry and referred for bone densitometry were studied. 10-year fracture risks were calculated using the Garvan Fracture Risk Calculator and FRAXrax (WHOFracture Risk Assessment Tool). tools. PercentagePercentages of patients eligible for treatment wereas determined using fourusing four guidelines: Danish Bone Society (DBS), the FRAX based age-dependent UK National Osteoporosis Guideline Group (NOGG), the US National Osteoporosis Foundation FRAX based 3% (hip)/20% (any) cut) cut-off guidelinesoff guidelines (US-FRAX) and the Australian Garvan derived 20% cut-off guidelines (Garvan). Results.– Median age [IQR] of patients (n=85) was 81 years ([IQR=75–85]). Mean 10-year % risk (SD) of major/any osteoporotic fractures wererisk (SD) ofmajor/any osteoporotic fractures was: DK-FRAX 29.8% (12.8), UK-FRAX 19.9% (9.5), US-FRAX 21.8% (10.3), Garvan 50.2% (23.8). Proportion of patients (95%CI) eligible for treatment were:wasere; DBS 55.3% (44.7–65.9), NOGG 51.2% (40.5–61.9), US-FRAX 87.1% (80.0–94.2), Garvan 90.6% (84.4–96.8). Conclusion.– These data show that the choice of guideline has a major impact on treatment decisions in this group of older Danish women with falls. Adherence to the US-FRAX and Garvan algorithms would result in extremely discrepant treatment rates compared to adherence with the DBS and UK-NOGG guidelines.

Ability of Fracture Risk Assessment Tool and National Osteoporosis Guideline Group Guidance to Stratify People Appropriately Before Fracture

Ability of Fracture Risk Assessment Tool and National Osteoporosis Guideline Group Guidance to Stratify People Appropriately Before Fracture

Sri Lankan FRAX model and country-specific intervention thresholds

There is a wide variation in fracture probabilities estimated by Asian FRAX models, although the outputs of South Asian models are concordant. Clinicians can choose either fixed or age-specific intervention thresholds when making treatment decisions in postmenopausal women. Cost-effectiveness of such approach, however, needs to be addressed. This study examined suitable fracture probability intervention thresholds (ITs) for Sri Lanka, based on the Sri Lankan FRAX model. Fracture probabilities were estimated using all Asian FRAX models for a postmenopausal woman of BMI 25 kg/m² and has no clinical risk factors apart from a fragility fracture, and they were compared. Age-specific ITs were estimated based on the Sri Lankan FRAX model using the method followed by the National Osteoporosis Guideline Group in the UK. Using the age-specific ITs as the reference standard, suitable fixed ITs were also estimated. Fracture probabilities estimated by different Asian FRAX models varied widely. Japanese and Taiwan models showed higher fracture probabilities while Chinese, Philippine, and Indonesian models gave lower fracture probabilities. Output of remaining FRAX models were generally similar. Age-specific ITs of major osteoporotic fracture probabilities (MOFP) based on the Sri Lankan FRAX model varied from 2.6 to 18% between 50 and 90 years. ITs of hip fracture probabilities (HFP) varied from 0.4 to 6.5% between 50 and 90 years. In finding fixed ITs, MOFP of 11% and HFP of 3.5% gave the lowest misclassification and highest agreement. Sri Lankan FRAX model behaves similar to other Asian FRAX models such as Indian, Singapore-Indian, Thai, and South Korean. Clinicians may use either the fixed or age-specific ITs in making therapeutic decisions in postmenopausal women. The economical aspects of such decisions, however, need to be considered.

Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013

Since the launch in 2008 by the National Osteoporosis Guideline Group (NOGG), of guidance for the diagnosis and management of osteoporosis in postmenopausal women and older men in the UK there have been significant advances in risk assessment and treatment. These have been incorporated into an updated version of the guideline, with an additional focus on the management of glucocorticoid-induced osteoporosis, the role of calcium and vitamin D therapy and the benefits and risks of long-term bisphosphonate therapy. The updated guideline is summarised below. The recommendations in the guideline are intended to aid management decisions but do not replace the need for clinical judgement in the care of individuals in clinical practice.