NICE 2026 Osteoporosis Guideline: What Has Changed in Fracture Risk Assessment?

The NICE 2026 osteoporosis guideline introduces an updated approach to fracture-risk assessment, DXA scanning, vertebral fracture detection and patient follow-up. Published as NICE guideline NG259 on 29 July 2026, it replaces the previous CG146 guideline

The updated guideline provides a clearer approach to identifying adults at risk of fragility fractures. It explains who should receive a fracture-risk assessment, when a DXA scan should be considered, how vertebral fractures may be detected and how people should be followed up when treatment is not started.

The NICE 2026 osteoporosis guideline is relevant to primary care, orthogeriatrics, fracture liaison services and other professionals involved in fragility-fracture prevention. This article explains the most important recommendations and how they may affect clinical practice.

This practical guide summarises the most important points for healthcare professionals, patients and families.

Important points at a glance

• A previous fragility fracture should trigger assessment for future fracture risk.
• Women aged 65 and over and men aged 75 and over should be considered for fracture-risk assessment.
• FRAX or QFracture can be used to estimate ten-year major osteoporotic fracture risk in people aged 40 to 90.
• QFracture is recommended for people aged 30 to 39 when formal risk calculation is appropriate.
• A DXA scan should be offered directly in several important clinical situations, including a previous hip or vertebral fragility fracture.
• A DXA scan should be considered when the calculated ten-year risk of a major osteoporotic fracture is 10% or higher.
• Vertebral fracture assessment may identify previously unrecognised spinal fractures.
• Treatment decisions should not be based on a risk score alone.
• People who do not start treatment may still require planned reassessment.

Contents

1. What is osteoporosis?
2. What is a fragility fracture?
3. Who should receive a fracture-risk assessment?
4. Which risk factors are important?
5. How are FRAX and QFracture used?
6. When should a DXA scan be requested?
7. What does a DXA result mean?
8. When should vertebral fracture assessment be considered?
9. How are treatment decisions made?
10. What follow-up is required?
11. What can patients do to protect their bones?
12. Frequently asked questions

What Is Osteoporosis?

Osteoporosis is a condition in which bones become less strong and more likely to fracture.

Bone loss usually develops gradually and may not produce symptoms. For some people, the first sign of osteoporosis is a fracture after a minor fall or low-impact injury.

Osteoporosis is not an inevitable part of ageing. Age increases fracture risk, but other factors such as previous fractures, medicines, medical conditions, low body weight, smoking, alcohol consumption and falls can also contribute.

What Is a Fragility Fracture?

A fragility fracture is a fracture caused by an injury that would not normally be expected to break a healthy bone.

A common example is a fracture following a fall from standing height or lower.

Fragility fractures commonly affect the following areas:

• Hip
• Spine
• Wrist
• Upper arm
• Pelvis

A fragility fracture should not be viewed as an isolated accident. It may be an important warning sign of osteoporosis and an increased risk of another fracture.

The risk of a subsequent fracture is particularly important during the first two years after an initial fragility fracture. This makes prompt assessment and secondary fracture prevention essential.

Who Should Receive a Fragility-Fracture Risk Assessment?

NICE recommends assessing fragility-fracture risk in people aged 50 and over, and in women who have experienced menopause, if they have either of the following:

• A previous fragility fracture.
• Current or frequent use of systemic glucocorticoids.

An example of significant glucocorticoid exposure is prednisolone 5 mg or more daily, or an equivalent dose, for more than three months. Intermittent courses of higher doses may also increase risk.

Physiological glucocorticoid replacement for adrenal insufficiency is treated differently because it replaces hormones that the body is unable to produce adequately.

Who Should Be Considered for Assessment?

Fracture-risk assessment should be considered for:

• All women aged 65 and over.
• All men aged 75 and over.
• People aged 50 to 74 who have additional fracture-risk factors.
• Women under 65 who have experienced menopause and have additional risk factors.

Which Risk Factors Are Important?

Relevant risk factors include:

• Two or more falls during the previous year.
• A hip fracture in a first-degree relative.
• A first-degree relative who sustained a hip fracture before the age of 80.
• A body mass index below 18.5 kg/m².
• Current smoking.
• Alcohol consumption above 14 units per week.
• Previous fragility fracture.
• Long-term or frequent systemic glucocorticoid use.
• Premature ovarian insufficiency or untreated early menopause.
• Reduced mobility or prolonged immobility.
• Medical conditions associated with reduced bone strength.

Medical conditions that may increase fracture risk include:

• Rheumatoid arthritis and other inflammatory disorders.
• Coeliac disease.
• Crohn’s disease and other inflammatory bowel diseases.
• Chronic liver disease.
• Chronic pancreatitis or other causes of malabsorption.
• Hyperthyroidism.
• Hyperparathyroidism.
• Cushing’s disease.
• Diabetes.
• Chronic obstructive pulmonary disease.
• Parkinson’s disease.
• Stroke or multiple sclerosis associated with reduced mobility.
• Chronic kidney disease stages 4 and 5.
• Multiple myeloma.
• Eating disorders associated with low body weight.

Some medicines may also contribute to fracture risk. These can include systemic glucocorticoids, aromatase inhibitors, androgen-deprivation therapy, some anticonvulsants and certain other long-term medicines.

A person’s medicines should be reviewed clinically. Prescribed medication should not be stopped without advice from the responsible healthcare professional.

How Are FRAX and QFracture Used?

FRAX and QFracture estimate a person’s probability of sustaining a fracture over a defined period.

For people aged between 40 and 90, NICE recommends using either FRAX or QFracture alongside a full clinical assessment.

For people aged between 30 and 39 who need formal risk calculation, QFracture should be used.

For people older than 90, the result should be interpreted carefully. FRAX calculates risk as though the person were aged 90, while QFracture calculates risk for the number of years remaining until the age of 100.

The same risk tool should normally be used throughout the person’s care. This makes future comparisons more meaningful.

A fracture-risk score should not be interpreted in isolation. Clinical judgement remains essential because calculators may not fully capture factors such as:

• Multiple previous fractures.
• A very recent fracture.
• Recurrent falls.
• Frailty.
• The location and severity of previous fractures.
• Rapid bone loss.
• Certain medicines or medical conditions.
• A suspected rare bone disease.

When Should a DXA Scan Be Requested?

A DXA scan measures bone mineral density, usually at the hip and lower spine.

NICE recommends offering a DXA scan to people aged 30 and over who have had any of the following:

• A previous hip fragility fracture.
• A previous vertebral fragility fracture.
• A single major osteoporotic fragility fracture during the previous two years.
• Two or more fragility fractures.

In these situations, the person may proceed directly to DXA without requiring a risk-calculation tool first. A risk calculation may still be useful when discussing risk or making clinical decisions.

For other people, a formal risk assessment may be completed before deciding whether DXA is needed.

A DXA scan should be considered when the estimated ten-year risk of a major osteoporotic fracture is 10% or higher.

A baseline DXA scan should normally be obtained when treatment is started. Exceptions may apply when scanning is not tolerated, is not technically possible or would not change treatment or monitoring.

Treatment should not necessarily be delayed when a DXA scan cannot be obtained promptly. The appropriate approach depends on the person’s fracture history, clinical risk and the type of treatment being considered.

What Does a DXA Result Mean?

A DXA scan provides information about bone mineral density. Results are commonly expressed using a T-score.

A T-score compares the person’s bone density with that of a healthy young adult.

In postmenopausal women and men aged 50 and over, results are generally described as follows:

• A T-score of minus 1.0 or above is generally considered within the expected range.
• A T-score between minus 1.0 and minus 2.5 indicates low bone mass.
• A T-score of minus 2.5 or lower is consistent with osteoporosis.

The DXA result is only one part of the assessment. A person may remain at high fracture risk even when the T-score is not within the osteoporosis range.

Treatment decisions should consider bone density together with age, previous fractures, falls, medicines, medical conditions and estimated fracture risk.

When Should Vertebral Fracture Assessment Be Considered?

Vertebral fractures can occur without a major injury and may not always cause severe pain. Some remain undiagnosed.

Vertebral fracture assessment, often called VFA, is a low-radiation imaging assessment that can be performed during a DXA appointment.

VFA may be considered when a person undergoing DXA has clinical features suggesting a possible vertebral fracture or an increased likelihood of an unrecognised spinal fracture.

Important clues may include:

• Significant loss of height.
• New or unexplained kyphosis.
• Back pain suggestive of vertebral fracture.
• Long-term systemic glucocorticoid use.
• Very low bone mineral density.
• A previous fragility fracture.

Finding a previously unrecognised vertebral fracture can alter the person’s risk classification and treatment plan.

How Are Treatment Decisions Made?

The decision to start osteoporosis medication should be shared with the patient.

The discussion should consider:

• The estimated ten-year risk of a major osteoporotic fracture.
• Bone mineral density, when available.
• The number of previous fragility fractures.
• The sites of previous fractures.
• How recently the fractures occurred.
• A history of hip or vertebral fracture.
• Falls and frailty.
• Medical conditions and medicines affecting bone health.
• The person’s preferences and treatment priorities.
• Potential benefits, adverse effects and practical treatment requirements.

A FRAX or QFracture percentage should not be the sole basis for treatment.

People with multiple fractures, hip fractures, vertebral fractures or very recent fractures may require prompt assessment because their risk may be particularly high.

Some people may need specialist assessment, especially when there is a suspected rare bone disease, very high fracture risk, multiple vertebral fractures, treatment failure or uncertainty about the most appropriate medication.

What Follow-Up Is Required?

People who decline or delay treatment should be told:

• How to return to the service.
• When their decision should be reviewed.
• Who to contact if they change their mind.
• Why they should contact their GP if their clinical circumstances change.

For people whose estimated ten-year risk of a major osteoporotic fracture is below 10%, reassessment should be considered:

• When clinical circumstances change.
• After a new fragility fracture.
• When a new risk factor develops.
• At five years if there has been no clinical change.

For people with a ten-year risk of 10% or higher, or those who had a DXA scan but did not meet treatment criteria, repeat DXA may be considered:

• Within two to three years if the person was close to the treatment threshold.
• Within two to three years if accelerated bone loss is a concern.
• When clinical circumstances change, provided this is not too soon after the previous scan.
• At five years if there has been no relevant clinical change.

A DXA scan should not routinely be repeated within two years of the previous scan unless exceptional circumstances apply.

What Can Patients Do to Protect Their Bones?

Lifestyle measures form part of bone-health care, but they do not replace medication when osteoporosis treatment is clinically indicated.

Helpful measures may include:

• Eating a balanced diet containing adequate calcium.
• Addressing vitamin D deficiency when present.
• Performing appropriate weight-bearing exercise.
• Including strength and balance exercises.
• Remaining physically active.
• Stopping smoking.
• Keeping alcohol consumption within recommended limits.
• Reviewing medicines that may increase falls or fracture risk.
• Having vision and hearing problems assessed.
• Wearing suitable footwear.
• Reducing trip hazards at home.
• Seeking help after a fall.

Exercise should be appropriate to the person’s health, mobility and fracture risk. People with severe osteoporosis, recent fractures or significant balance problems may need professional guidance before beginning a new exercise programme.

Falls Prevention Is Part of Fracture Prevention

Bone strength is only one part of fracture prevention.

A person may have osteoporosis but never sustain a fracture if falls and other injuries are prevented. Conversely, recurrent falls may create a high fracture risk even when bone-density loss is moderate.

A comprehensive assessment may need to address:

• Balance and muscle strength.
• Walking ability.
• Dizziness or postural hypotension.
• Vision and hearing.
• Foot conditions and footwear.
• Sedative or blood-pressure-lowering medicines.
• Home hazards.
• Continence problems.
• Cognitive impairment.
• Fear of falling.
• Vitamin D deficiency.
• Access to walking aids or physiotherapy.

Frequently Asked Questions

Is a DXA scan the same as a DEXA scan?

Yes. DXA and DEXA are commonly used to describe the same type of bone-density scan. DXA is the preferred abbreviation.

Does a normal DXA scan mean that I cannot sustain a fragility fracture?

No. Bone density is important, but fracture risk is also affected by age, previous fractures, falls, frailty, medicines and medical conditions.

Does every older adult need a DXA scan?

No. Some people should be assessed first using their clinical risk factors and a recognised risk calculator. Others may proceed directly to DXA because of their fracture history.

Can osteoporosis exist without pain?

Yes. Osteoporosis itself commonly causes no pain until a fracture occurs. Vertebral fractures may also be silent or cause symptoms that are mistaken for ordinary back pain.

Should osteoporosis treatment wait until the DXA scan is completed?

Not always. If there is likely to be a significant delay, treatment may sometimes begin before DXA when the clinical need is clear. The decision depends on the person’s overall risk and the treatment being considered.

How often should a DXA scan be repeated?

A DXA scan should not routinely be repeated within two years. The appropriate interval depends on the clinical situation, treatment status and risk of accelerated bone loss.

What should happen after a fragility fracture?

The person should be assessed for future fracture risk, underlying osteoporosis, falls and other relevant factors. Referral to a Fracture Liaison Service may be appropriate where one is available.

Key Message

The main purpose of osteoporosis assessment is not simply to diagnose low bone density. It is to identify people at risk of a disabling or life-changing fracture and to intervene before another fracture occurs.

The NICE 2026 guideline provides a structured approach, but successful fracture prevention still depends on careful clinical assessment, shared decision-making, treatment when appropriate and attention to falls prevention.

Medical Disclaimer

This article is intended for general educational purposes. It does not provide an individual diagnosis or replace personalised advice from a qualified healthcare professional.

Clinical decisions should consider the person’s complete medical history, examination findings, current medicines, investigation results, preferences and local treatment pathways.

Do not start, stop or change prescribed medication without discussing it with the responsible healthcare professional.

References

1. National Institute for Health and Care Excellence. Osteoporosis: risk assessment. NICE guideline NG259. Published 29 July 2026.
2. National Institute for Health and Care Excellence. Osteoporosis: risk assessment. Recommendations on fragility-fracture risk assessment, risk-prediction tools, bone-density assessment, vertebral-fracture identification, treatment criteria and follow-up.