The National Institute for Health and Care Excellence (NICE) just released an update to its 2012 guideline, Osteoporosis: Assessing the Risk of Fragility Fracture. The new, 2026 guideline, Osteoporosis: Risk Assessment, includes guidance on fragility fracture risk assessment, identifying vertebral fragility fractures, deciding whether pharmacological treatment is appropriate, follow-up for patients not having treatment, and more. 

NICE notes that an anticipated 2027 update to Osteoporosis: Risk Assessment is in the works, and will feature recommendations for treatment options, treatment monitoring, risk assessment recommendations for people with learning disabilities, and more. That update is forecast to release in June 2027.

Today, we are looking at a selection of key recommendations from the Fragility Fracture Risk Assessment section. For the complete look at all the guidance provided in the 2026 NICE guideline, Osteoporosis: Risk Assessment, view the full-text version.

Key Highlights from the 2026 NICE Osteoporosis: Risk Management Guideline:

Risk Factors for Fragility Fractures

The following is directed to people older than 50 and women who experienced menopause:

  • Assess fragility fracture risk in all people aged 50 and over and women who have experienced menopause with either of the following risk factors: a previous fragility fracture; current or frequent use of systemic glucocorticoids (for example, 5 mg or more prednisolone daily or equivalent for over three months, or intermittent use of higher doses) unless this is a replacement dose for adrenal insufficiency.
  • Consider assessing fragility fracture risk in: all men aged 75 and over; all women aged 65 and over; all people aged 50 to 74 and women aged under 65 who have experienced menopause with any of the following risk factors:
    • History of two or more falls in the last year
    • History of hip fracture in a first-degree relative (particularly if the first-degree relative was aged under 80 at the time of hip fracture).
    • Low body mass index (BMI; less than 18.5 kg/m2)
    • Current smoker
    • Alcohol intake of more than 14 units per week
    • Any other factor associated with increased risk of fragility fracture

The following is directed to men younger than 50 and women younger than 50 who have not experienced menopause:

  • Assess fragility fracture risk in men aged under 50 and women aged under 50 who have not experienced menopause if they have either: a previous hip or vertebral fragility fracture or two or more major osteoprotic fractures.
  • Consider assessing fragility fracture risk in men aged under 50 and women aged under 50 who have not experienced menopause who do not meet the criteria in recommendation 1.1.3 if they have a different major risk factor, such as: a previous non-hip, non-vertebral fragility fracture; a current of frequent use of systemic glucocorticoids (for example, 5 mg or more prednisolone daily or equivalent for over three months, or intermittent use of higher doses) unless this is a replacement dose for adrenal insufficiency; untreated early menopause or premature ovarian insufficiency.

The following is directed to trans or non-binary people:

  • When assessing fracture risk in trans or non-binary people, carry out individualised risk assessment that also takes into account all of the following: sex registered at birth; hormonal history (for example, puberty suppression, gender-affirming hormone therapy or menopause); current hormone treatment, if clinically relevant.

Bone Density Assessment

Offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) (with or without completing a risk prediction tool) when assessing fragility fracture risk in people aged 30 and over who have had: a previous hip or vertebral fragility fracture; a single major osteoporotic fragility fracture in the last two years; two or more fragility fractures. If DXA scan is not tolerated, not technically feasible, or not needed for treatment or monitoring decisions, see recommendation 1.7.4.

Consider BMD measurement with a DXA scan to help guide treatment decisions for people with a 10-year risk of major osteoporotic fracture of 10% or more. Seek advice from a specialist for people with, or suspected of, primary hyperparathyroidism and follow recommendations 1.1.1, 1.3.1, and 1.6.1 in NICE’s guideline on primary hyperparathyroidism.

Do a baseline BMD measurement with a DXA scan when starting treatment, unless it is not tolerated, not technically feasible, or not needed for treatment or monitoring decisions. If there is likely to be significant delay in doing a DXA scan before treatment, consider either: fast-tracking people for a DXA scan within six weeks if they are likely to need anabolic (bone-forming) treatment; starting antiresorptive treatment (to slow the rate of bone breakdown) if the person is unlikely to need anabolic treatment.

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