In the long-term management of osteoporosis, most countries recommend first assessing fracture risk factors in the population, including age, sex, genetic background, body weight and body mass index, nutritional status, and lifestyle. This helps identify individuals at high risk. The assessment is then used to determine whether bone mineral density testing and fracture-risk stratification are needed, followed by an individualized prevention and treatment plan. Countries still differ in the age at which screening begins, screening frequency, and screening strategies.
In Europe, the health burden of osteoporosis exceeds that of many other noncommunicable diseases, including rheumatoid arthritis, Parkinson disease, breast cancer, and prostate cancer. According to World Health Organization data, the United States, Europe, and Japan together have approximately 75 million people with osteoporosis. The clinical situation remains concerning: many patients do not receive standardized osteoporosis-prevention guidance, and many more do not receive targeted testing to establish a diagnosis or assess fracture risk. As a result, the overall proportion receiving standardized anti-osteoporosis treatment remains low.
1. International management of osteoporosis
The UK National Osteoporosis Guideline Group (NOCG) recommends fracture-risk-factor assessment for postmenopausal women and men aged 50 years or older. Belgian osteoporosis-management guidance for postmenopausal women likewise recommends regular assessment after menopause or from age 50, with screening every two years. If one or more fracture risk factors are present, fracture risk should be assessed. The UK recommends the Fracture Risk Assessment Tool (FRAX), while Belgium recommends the Garvan fracture risk calculator and FRAX.
After precise calibration, FRAX incorporates mortality as an important competing risk. It estimates the probability of osteoporotic fracture and hip fracture over the next 10 years in populations from different countries and ethnic groups. Because of its broad application and predictive accuracy, FRAX has become one of the most authoritative and widely used tools for global osteoporosis-risk assessment.
FRAX fracture-risk and intervention thresholds are not fixed. They vary with economic conditions, ethnicity, and other factors, so values differ between countries. NOCG provides age-specific thresholds and intervention thresholds to identify low-, medium-, high-, and very-high-risk patients. When the two calculated probabilities place a patient in different risk categories, the highest category should guide intervention. For people at moderate fracture risk, bone mineral density measurement may be considered, with medication determined according to the individual situation. Men and women at high or very high risk should have bone mineral density measured by DXA and have their fracture probability recalculated; these patients require drug treatment.
In the United States, the American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommend that postmenopausal women younger than 65 first undergo FRAX assessment. The Canadian Osteoporosis Society recommends further bone-density testing for patients with a fracture risk above 10%, or with diseases or medications associated with increased fracture risk. Canadian guidance also emphasizes risk-assessment tools such as FRAX or CAROC to identify patients with an absolute 10-year fracture risk of at least 20%; these patients should also undergo bone-density testing.
According to the latest ACOG clinical practice guidance, all postmenopausal women older than 65 should undergo fracture-risk assessment and bone-density measurement by dual-energy X-ray absorptiometry to prevent osteoporotic fractures. ACOG notes that postmenopausal patients whose initial bone-density result is close to the treatment threshold, or whose risk factors change substantially, should repeat osteoporosis screening after two years. Similar to NOCG, SOGC recommends medication for patients at moderate, high, or very high risk.
2. Domestic management of osteoporosis
In China, initial screening may use the International Osteoporosis Foundation (IOF) one-minute osteoporosis risk test or the Osteoporosis Self-assessment Tool for Asians (OSTA). Individuals with a positive screening result or an OSTAT value < -1.0 are recommended to undergo bone-density measurement and FRAX assessment. DXA bone-density measurement is recommended for women older than 65, men older than 70, and younger people who have at least one osteoporosis risk factor. Drug treatment is required for patients with a T-score ≤ -2.5 or high FRAX risk, patients with a T-score between -1.0 and -2.5 who have a fragility-fracture history, and patients with a history of hip fracture, fragility fracture, or vertebral compression fracture. Treatment may be considered for patients assessed as having moderate FRAX risk, according to their individual situation.
Osteoporosis requires long-term management. In addition to identifying patients at moderate or high risk, a complete care and information-management system should be established. Medical staff should receive regular professional training, and patient follow-up and adherence monitoring should be strengthened to prevent fractures and falls. Under Chinese guidance, bone-density testing is recommended annually after treatment begins to monitor response and disease changes. Once bone density is stable, testing may be adjusted to every two years. The United States recommends testing every one to three years, Belgium every five years, and the UK every three years.
For patient care, the International Osteoporosis Foundation recommends Fracture Liaison Services (FLS). This internationally recognized service has been shown to improve the diagnosis of osteoporotic fractures and reduce secondary fractures. For example, Guangdong Provincial Hospital of Chinese Medicine received FLS gold certification, demonstrating strong results in osteoporosis and fragility-fracture prevention and treatment. FLS identifies patients at risk of fragility fracture, promptly assesses fracture and fall risk, performs bone-density testing, and starts interventions to reduce falls and fractures.
For patients who experience a fracture, recovery after the fracture is critical. Clinicians commonly arrange follow-up at 16 and 52 weeks after the fracture to confirm that treatment is appropriate and effective. In one study of sartorius muscle-pedicle bone-flap transplantation for subcapital femoral-neck fractures in adolescents, the follow-up success rate was 100.00%, with a mean follow-up of 3.1 ± 0.4 years. During follow-up, clinicians review treatment response, assess fracture healing, and confirm adherence to rehabilitation and treatment instructions. They also ask about discomfort, check improvements in mobility, and watch for complications. Detailed follow-up allows timely adjustment of the plan and supports the best possible outcome.
The UK has also implemented integrated care systems (ICS) to ensure that patients can access fracture liaison services. This can relieve postoperative pain, improve quality of life, and reduce the economic burden of fragility fractures. Combining the two systems may help reduce refracture and mortality. For information management, NOGG proposes linking patient health-record systems with FRAX and the NOGG website, and enabling electronic health records to be shared between FLS and primary-care teams.
Based on these experiences and recommendations, China has increased its focus on osteoporosis prevention and treatment and introduced a series of improvements. In 2018, China established 54 community osteoporosis health-management bases and 30 national tiered-diagnosis and treatment centers for osteoporosis. In 2020, China launched the Bone Strength Initiative, drawing on the internationally recommended FLS model, building an intelligent data platform, and strengthening multidisciplinary collaboration to develop a standardized management model for patients at high risk of fragility fracture. In 2021, China issued the Expert Consensus on the Diagnosis and Treatment of Osteoporosis in Older Adults with Hip Fracture, which recommends using the FLS model to manage anti-osteoporosis treatment and fall-prevention interventions for older patients with hip fracture.