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

Celia L Gregson; David J Armstrong; Christina Avgerinou; Jean Bowden; Cyrus Cooper; Lucy Douglas; John Edwards; Neil J L Gittoes; Nicholas C Harvey; John A Kanis; Sarah Leyland; Rebecca Low; Eugene McCloskey; Katie Moss; Jane Parker; Zoe Paskins; Kenneth Poole; David M Reid; Mike Stone; Julia Tomson; Nic Vine; Juliet Compston; National Osteoporosis Guideline Group (NOGG)

doi:10.1007/s11657-025-01588-3

Clinical Guidelines and Standards Guidelines by Clinical Area

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

Gregson CL, Armstrong DJ, Avgerinou C, Bowden J, Cooper C, Douglas L, Edwards J, Gittoes NJL, Harvey NC, Kanis JA, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Tomson J, Vine N, Compston J, National Osteoporosis Guideline Group (NOGG)

Published September 8, 2025 Archives of osteoporosis, 20(1), 119

DOI 10.1007/s11657-025-01588-3 PMID 40921943 PMC PMC12417299

RRM Academy Synopsis

UK osteoporosis guideline names HRT a first-line option for some women

The guideline conditionally names HRT first-line for younger postmenopausal women at high fracture risk and low baseline risk of cancer or blood clots. The 2024 update comes from the UK National Osteoporosis Guideline Group. It applies to postmenopausal women and men aged 50 and older. Younger means 60 or under.

Key Findings

A conditional recommendation names HRT a first-line option for postmenopausal women aged 60 or younger with high fracture risk and a low baseline risk of adverse malignant and thromboembolic events.
The guideline reports that oral estrogen-containing HRT increases venous thromboembolism risk above baseline population risk, with no such increase for transdermal HRT at standard doses.
Some HRT preparations, especially those that contain synthetic progestins, show an association with a small excess in breast cancer incidence.
The guideline names anti-resorptive therapy the first-line option for most people at risk of fragility fracture, and oral alendronate or risedronate or intravenous zoledronate the most cost-effective choices (strong recommendations).
A meta-analysis of three screening trials found a 20% reduction in hip fracture risk, and the guideline calls case finding appropriate while no population screening policy is universally accepted.

Interpretation

The paper is a UK clinical guideline. A writing group graded each recommendation as strong or conditional. The group used systematic reviews, meta-analyses and randomized trials where available. The group identified its reviews and meta-analyses in PubMed from July 2016 to September 2020 and added evidence from its own expertise. The 2024 version makes minor updates to the 2021 guideline. The scope is women after menopause and men aged 50 and older. Fragility fractures are breaks from a fall at standing height or less. They are uncommon in women before menopause and in men younger than 50. The authors state that the guideline does not replace clinical judgment.

RRM Context

RRM treats the ovulatory cycle as a vital sign. Before menopause, the cycle supplies the body's own estrogen and progesterone in balance. A root-cause search for bone loss includes the cycle. The guideline begins at menopause, after the years in which peak bone mass is built.

Our editorial summary of this paper, not the article's abstract.

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).

Topics

Clinical Guidelines and Standards › Guidelines by Clinical Area › Bone and Endocrine Guidelines · Bone Health › Osteoporosis › Diagnosis and Treatment

Celia L Gregson, David J Armstrong, Christina Avgerinou, Jean Bowden, Cyrus Cooper, Lucy Douglas, John Edwards, Neil J L Gittoes, Nicholas C Harvey, John A Kanis, Sarah Leyland, Rebecca Low, Eugene McCloskey, Katie Moss, Jane Parker, Zoe Paskins, Kenneth Poole, David M Reid, Mike Stone, Julia Tomson, Nic Vine, Juliet Compston

C Gregson, Dave Armstrong, D Armstrong, C Avgerinou, J Bowden, C Cooper, L Douglas, Jack Edwards, J Edwards, N Gittoes, Nick Harvey, N Harvey, Jack Kanis, J Kanis, S Leyland, Becky Low, R Low, E McCloskey, Katherine Moss, K Moss, J Parker, Z Paskins, Ken Poole, K Poole, Dave Reid, D Reid, Michael Stone, M Stone, J Tomson, N Vine, J Compston

PMID 40921943 40921943 DOI 10.1007/s11657-025-01588-3 10.1007/s11657-025-01588-3 Gregson et al. 2025, Gregson 2025

Keywords

Fracture, Guideline, NOGG, Osteoporosis

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

UK osteoporosis guideline names HRT a first-line option for some women

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

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Keywords