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Xrays may show osteopenia but not severity of osteoporosis accurately 
Calcium and phosphate levels are normal in osteoporosis
assess due to risk of fragility fractures

NICE guidelines 2012
assess all women >65 and men >75 and younger if ....
    previous fragility fracture
    current use or frequent recent use of oral or systemic glucocorticoid
    history of falls
    family history of hip fracture
    other causes of secondary osteoporosis
    low body mass index (BMI) (less than 18.5 kg/m²)
    smoking
    alcohol intake of more than 14 units per week for women and more than 21 units per week for men.

''Methods of risk assessment''
use clinical prediction tool eg FRAX or QFracture to assess patients 10 year risk of fracture

''FRAX''
    estimates the 10-year risk of fragility fracture
    valid for patients aged 40-90 years
    based on international data so use not limited to UK patients
    assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake
    bone mineral density (BMD) is optional, but improves accuracy of results - do if FRAX result is intermediate

''QFracture''
    estimates the 10-year risk of fragility fracture
    developed in 2009 based on UK primary care dataset
    can be used for patients aged 30-99 years (?-85?)
    includes a larger group of risk factors e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants

Do DEXA rather than clinical prediction tool if ...
    before starting treatments that may have rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
    in people <40y who have major risk factor eg Hx multiple fragility fracture, major osteoporotic fracture, current or recent high-dose oral or systemic glucocorticoids (>7.5 mg prednisolone/day for >3/12)