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Practice Guideline
. 2025 Sep 8;20(1):119.
doi: 10.1007/s11657-025-01588-3.

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

Celia L Gregson  1   2 , David J Armstrong  3 , Christina Avgerinou  4   5 , Jean Bowden  6 , Cyrus Cooper  7   8   9 , Lucy Douglas  10   11 , John Edwards  12   13 , Neil J L Gittoes  14 , Nicholas C Harvey  7   8 , John A Kanis  15 , Sarah Leyland  16 , Rebecca Low  17   18 , Eugene McCloskey  19 , Katie Moss  20 , Jane Parker  21 , Zoe Paskins  22 , Kenneth Poole  23 , David M Reid  24 , Mike Stone  25 , Julia Tomson  16 , Nic Vine  26 , Juliet Compston  27 ; National Osteoporosis Guideline Group (NOGG)
Affiliations
Practice Guideline

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

Celia L Gregson et al. Arch Osteoporos. .

Abstract

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).

Keywords: Fracture; Guideline; NOGG; Osteoporosis.

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Conflict of interest statement

Declarations. Conflict of interest: The National Osteoporosis Guideline Group (NOGG) Guideline Writing Group is divided into two groups, a Guideline Development Group (GDG) and an Expert Advisory Group (EAG). The GDG consists of eight voting members (CLG, JC, JE, JK, RL, SL, ZP, JT), and three lay members (JB, JP, NV). One member has a financial disclosure, unrelated to drug development (JC received honoraria for speaking at a CME approved bone academy meeting and for consultancy relating to the characterisation of people at very high fracture risk), and the remaining ten have no financial disclosures. ZP is funded by the National Institute for Health Research (NIHR) (Clinician Scientist Award (CS-2018–18-ST2-010)/NIHR Academy). ZP has undertaken consultancy for non-promotional activities for UCB. One member (JK) is also a member of the FRAX group; hence, all FRAX-based recommendations had to be agreed by consensus of all the GDG. The Chair (CLG) has no disclosures; she is funded by the National Institute for Health and Care Research (NIHR302394). The EAG is composed of nine members; all of whom have relevant conflicts of interest. DA has received advisory/speaking fees from UCB and Internis Pharma. CC has received advisory/speaking fees from Amgen, Danone, Eli Lilly, GSK, Kyowa Kirin, Medtronic, Merck, Nestle, Novartis, Pfizer, Roche, Servier, Shire, Takeda and UCB. NG is on the advisory board of UCB, Novo Nordisk, and Shire/Takeda and has received fees from UCB and Takeda. NCH has received advisory board/consultancy fees/honoraria from Alliance for Better Bone Health, A mgen, MSD, Eli Lilly, UCB, Radius, Servier, Shire, Consilient Healthcare and Internis Pharma. EMC has received advisory/honoraria from A mgen, Consilient Healthcare, Kyowa Kirin, Eli Lilly, Fresenius Kabi, Internis, ObsEva, Radius Inc and Redx Pharma and received research funding from A mgen, Internis, and Radius Inc. KM has received conference sponsorship from Abbvie, Alexion, UCB, Novartis, Kyowa Kirin, Lilly, Pfizer and Internis and advisory/honoraria from Alexion and UCB. KP received advisory/speaker fees from UCB, which were then donated to charities. DR has received advisory fees from UCB, Theramex and Osteolabs. MS has received advisory/speaker fees from UCB, and speaker fees from A mgen and Gedeon Richter. All members of the GDG and EAG have read NICE’s ‘Policy on declaring and managing interests for NICE advisory boards’ (version 1.1, July 2019). Disclosures of all members of both groups are available on the NOGG website. Both the GDG and the EAG attend online meetings and take part in email discussions. However, voting on the recommendations is restricted to the GDG. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Figures

Fig. 1
Fig. 1
NOGG assessment, interventions, and risk thresholds for major osteoporotic fracture probability (MOF) in the UK with the use of FRAX. Individuals with probabilities below the lower assessment threshold (LAT) are considered for lifestyle advice. Those at intermediate risk (probabilities between the upper assessment threshold (UAT) and lower assessment threshold (LAT) are further assessed with BMD measurement. Where probabilities calculated using BMD lie above or below the intervention threshold (IT), treatment or lifestyle advice, respectively, is recommended [3, 90]. Patients with probabilities above the upper assessment threshold (UAT) are considered for treatment. Those with probabilities above the very high-risk threshold (VHRT) should be considered for specialist referral. Where BMD measurement is not practical (e.g., when individuals are frail and unable to get onto a DXA table, or lie flat on a DXA table), patients with probabilities above the IT are considered for treatment
Fig. 2
Fig. 2
NOGG thresholds for intervention and/or referral using major osteoporotic fracture (MOF) and hip fracture (HF) probabilities in the UK. The panels show the thresholds following the recalculation of FRAX after the input of BMD; the same thresholds are used when BMD is unavailable. The intervention threshold (IT) and very high-risk threshold (VHRT) denote the thresholds for high and very high risk, respectively
Fig. 3
Fig. 3
Management algorithm for the assessment of individuals at risk of fracture [137]. Those at very high risk should be treated and considered for referral to an osteoporosis specialist in secondary care; some may benefit from parenteral treatment (including first-line anabolic drug treatment, especially if multiple vertebral fractures). All individuals should be offered lifestyle advice. CRF, clinical risk factor
Fig. 4
Fig. 4
Oral bisphosphonates: clinical flowchart for long-term treatment and monitoring. GC, glucocorticoids (oral ≥ 7.5 mg prednisolone/day or equivalent); BP, bisphosphonate
Fig. 5
Fig. 5
Intravenous bisphosphonates: clinical flowchart for long-term treatment and monitoring. GC, glucocorticoids (oral ≥ 7.5 mg prednisolone/day or equivalent); BP, bisphosphonate
See this image and copyright information in PMC

References

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    1. Harvey NC, McCloskey E, Kanis JA, Compston J, Cooper C (2018) Cost-effective but clinically inappropriate: new NICE intervention thresholds in osteoporosis (technology appraisal 464). Osteoporos Int 29:1511–1513 - PMC - PubMed

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