FRAX Results – BMD not included
Welcome to the NOFSA 2025 Guideline. These new thresholds ensure equality of access to treatment for older patients with and without fracture, and identify a group who are at very high fracture risk who should be considered for specialist referral (for full details, see the Full Clinical Guideline).
Intervention Thresholds
Interpretation
Following the assessment of fracture risk using FRAX® in the absence of BMD, the patient may be classified to be at low, intermediate, high or very high risk, based on MOF fracture risk
- LOW RISK – give lifestyle advice, and reassess in 5 years or less depending on the clinical context.
- INTERMEDIATE RISK – measure BMD and recalculate fracture risk. If BMD measurement not practical (e.g. , frailty) or is unavailable, offer treatment if risk is at or above the Intervention Threshold shown.
- HIGH RISK – offer treatment to reduce fracture risk. Measure BMD to guide drug choice and provide a baseline for BMD monitoring.
- VERY HIGH RISK – Consider referral to osteoporosis specialist for assessment and consideration of parenteral treatment. If a delay anticipated, start oral treatment in meantime. If not for referral, treat as for high risk.
NB – These thresholds are for guidance only and the final decision to assess BMD or to initiate therapeutic intervention lies with the individual clinician.
Management
- For a more detailed description of investigations and treatments, please refer to the Full Guideline.
- Arithmetic adjustments can be applied to FRAX probabilities of hip fracture and major osteoporotic fracture to take into account some common clinical scenarios.
- 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.
- 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.
Treatment options in postmenopausal women, and men age ≥50
Very High Risk
- Consider anabolic (bone-forming) drug treatments as first-line treatment in those at very high fracture risk, particularly in those with vertebral fractures.
High Risk
- Offer oral bisphosphonates (alendronate or risedronate) or intravenous zoledronate. Alternative first line options include denosumab, ibandronate, hormone replacement therapy, and raloxifene.
- Offer intravenous zoledronate as a first-line treatment option following a hip fracture.
Low Risk
- Offer calcium and/or vitamin D supplementation if needed.
- Treat vitamin D deficiency and insufficiency prior to initiation of parenteral anti-osteoporosis drug treatment.
- Reassess fracture risk and start treatment promptly following a fragility fracture.