Fig. 1

Figure 1 provides an algorithm summarising the group’s consensus recommendations for the management of patients categorised according to their fracture risk. Case finding and treatment pathways according to the categorisation of fracture risk: updated algorithm for management of postmenopausal osteoporosis. The determination of fracture risk was carried out based on fracture risk score calculation (e.g. FRAX) and the measurement of lumbar spine and hip BMD. *Stratification of osteoporotic fracture risk can be based on (I) NOGG (UK) as shown in the figures. The intervention threshold is set at a risk equivalent to that associated with a prior fracture. Two intervention thresholds are identified based on FRAX calculation based on BMD assessment. The treatment modality is suggested based on whether the individual either exceed the intervention threshold or lie below it. Alternatively, (II) using FRAX score alone, the fracture risks can be defined as follows: (1) low risk includes no prior hip or spine fractures, a BMD T score at the hip and spine both above − 1.0, a 10-year hip fracture risk < 1%, and 10-year risk of major osteoporotic fractures < 10%; (2) moderate risk includes no prior hip or spine fractures, a BMD T score at the hip and spine both above − 2.5, and 10-year hip fracture risk < 3% or risk of major osteoporotic fractures < 20%; (3) high risk includes a prior spine or hip fracture, or a BMD T score at the hip or spine of − 2.5 or below, or 10-year hip fracture risk ≥ 3%, or risk of major osteoporotic fracture risk ≥ 20%; and (4) very high risk includes multiple spine fractures and a BMD T score at the hip or spine of − 2.5 or below. **Continue treatment up to 3 years (IV zoledronate) or 5 years (oral bisphosphonate/denosumab), reassess fracture risk: (1) if low or low-moderate risk: consider drug holiday. Reassess fracture risk every 1–3 years; if bone loss, fracture occurs, or the patient becomes high risk consider restarting therapy. (2) If high risk continues therapy after checking for adherence or switch to another therapy. ***After completion of the anabolic therapy course, consider giving bisphosphonate, then stopping for a drug holiday. ^◊Patient who remains at high fracture risk or develop a fragility fracture after 2 years of being on the same treatment, in spite of good adherence to therapy and after exclusion of secondary causes, then consider switching to another therapy. ^#Drug holiday: patients should be assessed at 3 years (zoledronate) and 5 years (oral bisphosphonate/denosumab). Patients who achieve the expected treatment target can be offered a drug holiday. Reassess fracture risk every 1–3 years. If bone loss, fracture occurs, or patients become at high risk, consider restarting therapy