Table 2.

Risk assessment

	France	Germany	Italy		Spain	UK		Europe
	Briot et al. (2018)	DVO (2023)	Corrao et al. (2023)	Nuti et al. (2019)	Riancho et al. (2022)	CG146 (2017)	NOGG (2021)	ESCEO-IOF
Fracture risk tool	FRAX® based on national validation and calibration	DVO risk model	De-FRA/De-FRAcalc79, or FRA-HS	DeFRA, FRAX®, or Fra-HS	Combination of clinical data and DXA	FRAX® or QFracture	FRAX®	Country-specific FRAX®
BMD DXA measurement	Indicated in all patients with clinical risk factors	Indicated in all patients with clinical risk factors	Measure risk with De-FRA first. DXA indicated in patients with intermediate risk	Measure risk with De-FRA first. DXA indicated in patients with intermediate risk	Indicated in all patients with clinical risk factors	Measure risk with FRAX® first. DXA indicated in patients with intermediate risk	Measure risk with FRAX® first. DXA indicated in patients with intermediate risk/to guide treatment	Measure risk with FRAX® first. DXA Indicated in patients with intermediate risk
Intervention threshold (IT)	Severe fracture: BMD T-score ≤  − 1.0 Non-severe fracture: BMD T-score ≤  − 2.0 Patients without fractures: BMD T-score ≤  − 3.0 (lumbar spine and/or hip)	DVO calc 3-year fracture risk of ≥ 3%	-	IT based on FRAX® or DeFRA	≥ 1 fragility fractures; or BMD T-score <  − 2.5; or BMD T-score <  − 2.0 together with factors strongly associated with fracture risk	IT based on FRAX- 10-year probability of MOF	IT based on FRAX- 10-year probability of MOF	FRAX®-based 10-year probability (%) of MOF
Definition of very high-risk	• ≥ 2 vertebral fractures • BMD ≤  − 3 T + severe fracture	• ≥ 10% 3-year absolute fracture risk calculated by DVO risk calculator	• ≥ 3 vertebral or hip fractures • ≥ 1 vertebral or hip fractures + BMD ≤  − 4	-	• ≥ 2 vertebral fractures or equivalenta • 1 spine or hip fracture + BMD <  − 3.0 T or • BMD <  − 3.5 T	-	• FRAX-based fracture probability exceeds IF by 60% • Recent vertebral fracture [≤ 2 years] • ≥ 2 vertebral fractures • BMD ≤  − 3.5 T • Treatment with high dose glucocorticoids
Definition of high-risk	• ≥ 1 severe fragility fracture and BMD ≤  − 1 T) • ≥ 1 non-severe fracture and BMD ≤  − 2 T) • BMD ≤  − 3 T)	• ≥ 5% 3-year absolute fracture risk calculated by DVO risk calculator	• Fragility fracture	• Femoral BMD <  − 2.5 T • Prior vertebral fractures and femoral BMD <  − 2.0 T	• Fragility fracture • BMD <  − 2.5 T • Low BMD + high risk factorsb	• Above upper age limit for 10-year absolute fracture risk, defined by FRAX® or QFracture	• Above upper age limit for 10-year absolute fracture risk, defined by FRAX®	• An age-specific fracture probability equivalent to same-age women with a prior fragility fracture

BMD bone mineral density, DXA dual energy X-ray absorptiometry, IT intervention threshold, MOF major osteoporotic fracture, TBS Trabecular bone score

^aFor example, vertebral and hip fracture

^bEspecially if T ≤  − 2 and factors strongly associated with fracture risks, such as hypogonadism, early menopause or treatment with glucocorticoids or sex hormone antagonists

^cIndicated in postmenopausal women if they have a history of ≥ 4-cm height loss, kyphosis, recent/current long-term oral glucocorticoid therapy, T-score ≤  − 2.5 or in cases of acute-onset back pain with risk factors for osteoporosis