Compare Treatment initiation thresholds (FRAX / risk-based) for Osteoporosis across NICE, SIGN, and NOGG. Built for Adults. Setting: Primary & Secondary. Urgency: Routine.
Clear thresholds help clinicians answer "when do I act?" for osteoporosis, aligning expectations between NICE, SIGN, and NOGG. Use this side-by-side view to decide when to refer, escalate, monitor, or initiate treatment.
Osteoporosis affects approximately 3.5 million people in the UK, with around 500,000 fragility fractures occurring annually. The condition represents a significant public health burden, costing the NHS an estimated £4.4 billion per year. The key clinical challenge lies in balancing early intervention to prevent first fractures against the risks of overtreatment in lower-risk populations.
Getting treatment thresholds right is critical because delayed intervention leads to preventable fragility fractures, particularly hip fractures which carry 30% one-year mortality. Conversely, unnecessary treatment exposes patients to medication side effects and represents inefficient resource allocation. NICE adopts a health economic perspective focusing on cost-effectiveness, SIGN emphasizes Scottish population nuances and practical primary care implementation, while NOGG provides specialist-led, fracture risk-based guidance that integrates FRAX assessment directly into clinical pathways.
Approximately 1 in 2 women and 1 in 5 men over 50 will experience an osteoporosis-related fracture in their remaining lifetime. This high prevalence makes standardized threshold application essential for consistent care delivery across the NHS.
| Guideline body | Primary focus | Typical setting | Publication/update |
|---|---|---|---|
| NICE | Health economic assessment and cost-effective treatment allocation across England and Wales | Primary care with secondary care integration | 2022 (CG146 update) |
| SIGN | Scottish population considerations and practical primary care implementation | Community and hospital settings across Scotland | 2021 (SIGN 142) |
| NOGG | Fracture risk-based intervention using FRAX assessment and specialist pathways | Secondary care fracture liaison services and specialist clinics | 2024 (NOGG 2024 guidelines) |
Primary care clinicians should default to NICE guidance for routine decision-making, while SIGN provides essential Scottish-specific adaptations. NOGG offers valuable specialist perspectives particularly for complex cases or fracture liaison service settings. Cross-referencing between guidelines becomes important when managing patients with unusual risk profiles or when local policies reference multiple guidance sources.
| Guideline body | Position | Population & urgency |
|---|---|---|
| NICE | Position on Treatment initiation thresholds (FRAX / risk-based) for Osteoporosis | Adults | Urgency: Routine | Setting: Primary & Secondary |
| SIGN | Position on Treatment initiation thresholds (FRAX / risk-based) for Osteoporosis | Adults | Urgency: Routine | Setting: Primary & Secondary |
| NOGG | Position on Treatment initiation thresholds (FRAX / risk-based) for Osteoporosis | Adults | Urgency: Routine | Setting: Primary & Secondary |
| Threshold Type | NICE | SIGN | NOGG | Notes |
|---|---|---|---|---|
| Primary prevention FRAX 10-year major fracture risk | ≥10% | ≥10% | ≥10% (age-dependent thresholds) | Without prior fracture |
| Secondary prevention FRAX 10-year major fracture risk | Consider treatment regardless of FRAX score | Consider treatment regardless of FRAX score | ≥7% for hip fracture | With prior fragility fracture |
| T-score threshold for treatment | T-score ≤ -2.5 | T-score ≤ -2.5 | T-score ≤ -2.5 or clinical risk factors | DXA measurement |
| Age-specific intervention threshold | ≥75 years automatic consideration | ≥70 years with risk factors | FRAX-based without upper age limit | Age adjustments vary |
NICE recommends DXA scanning every 2 years for patients with osteopenia (T-score -1.0 to -2.5) and high clinical risk factors. For established osteoporosis patients on treatment, repeat DXA after 3-5 years of therapy. Monitor treatment adherence quarterly in first year, then 6-monthly. NICE emphasizes annual fracture risk reassessment using FRAX, particularly after new risk factors emerge.
SIGN recommends similar monitoring intervals but places stronger emphasis on primary care coordination. DXA follow-up at 2-year intervals for monitoring, with treatment efficacy assessment at 2 years. SIGN specifically addresses frail elderly patients, suggesting more frequent clinical review (6-monthly) even if DXA intervals remain standard. The guideline integrates falls risk assessment into routine osteoporosis monitoring.
NOGG provides the most detailed monitoring schedule, tailored to individual fracture risk. High-risk patients (FRAX >20%) require annual review, moderate risk (10-20%) biennial, and low risk (<10%) every 3-5 years. NOGG emphasizes treatment duration limits—5 years for bisphosphonates with drug holidays considered—and recommends bone turnover marker monitoring at 3 months to assess treatment response.
| Trigger Scenario | NICE | SIGN | NOGG |
|---|---|---|---|
| Treatment failure (fracture on therapy) | Refer to specialist metabolic bone service | Refer to secondary care for reassessment | Immediate specialist fracture liaison service review |
| Unclear diagnosis or unusual presentation | Secondary care investigation for secondary causes | Refer for specialist DXA and assessment | Specialist metabolic bone clinic referral |
| Severe osteoporosis (T-score ≤ -3.0) | Consider specialist input for complex cases | Routine secondary care management | Automatic fracture liaison service enrollment |
| Multiple fragility fractures | Urgent specialist assessment | Expedited secondary care referral | Immediate fracture liaison service activation |
| Young patients (<50 years) with osteoporosis | Always refer for secondary causes exclusion | Specialist assessment mandatory | Comprehensive metabolic workup required |
| Contraindications to first-line treatments | Specialist alternative therapy consideration | Secondary care for treatment options | Specialist clinic for individualised regimen |
Patient: 65-year-old woman, no prior fractures, maternal hip fracture history, BMI 22, current smoker. FRAX 10-year major fracture risk 9.5% (just below 10% threshold).
Analysis: NICE would not recommend treatment based strictly on the 10% threshold. SIGN might consider treatment given smoking status and family history. NOGG would use age-specific thresholds and likely recommend intervention given proximity to threshold and risk factors. Most appropriate action: Repeat FRAX with additional risk factors, consider DXA scan, and discuss shared decision-making about borderline risk.
Patient: 82-year-old man with recent wrist fracture after minimal trauma, no prior DXA, multiple comorbidities.
Analysis: NICE recommends treatment consideration after any fragility fracture regardless of FRAX. SIGN similarly recommends intervention. NOGG would calculate FRAX but treatment likely indicated regardless. Action: Initiate treatment without awaiting DXA in secondary prevention setting, arrange DXA for baseline, address falls risk.
Patient: 70-year-old woman on alendronate for 3 years presents with new vertebral fracture, adherent to therapy.
Analysis: All guidelines recommend immediate specialist referral. NICE suggests metabolic bone service. SIGN recommends secondary care reassessment. NOGG specifies fracture liaison service review. Action: Urgent specialist referral, consider switching to anabolic agent, assess for secondary causes of treatment failure.
FRAX Tool: The Fracture Risk Assessment Tool calculates 10-year probability of major osteoporotic fracture and hip fracture. All three guideline bodies incorporate FRAX, but with different applications. NICE uses FRAX for primary prevention thresholds, SIGN integrates Scottish population data, and NOGG uses FRAX as the central decision tool with intervention thresholds varying by age.
QFracture: While primarily a research tool, QFracture provides an alternative risk assessment that includes additional variables not in FRAX. NICE acknowledges QFracture but prefers FRAX for consistency with international standards.
Practical Application: Calculate FRAX for all patients being assessed for osteoporosis treatment. Remember to adjust for secondary causes when present. For patients already on treatment, use clinical judgment alongside tool outputs, as most tools are validated for treatment-naïve populations.
Refer to the full guidelines for exact wording and local adaptations. This summary is for rapid orientation and multidisciplinary alignment.
Disclaimer: This comparison is intended for clinical decision support and education. Always refer to the full published guidelines for definitive recommendations and the most up-to-date evidence. Clinical decisions should be individualized based on patient context and preferences.