Guidance for Bone Health in Parkinson's Step 1 Optimise Vitamin D and Calcium intake Step 2 Assess for falls, prior fracture, back pain (consider imaging for vertebral fracture) Step 3 Apply FRAX to determine 10 year fracture probabilities (consider Parkinson’s as a cause of secondary osteoporosis) and link to NOGG guidance MOF probability ≥20% Treat NOGG: Measure BMD NOGG: Lifestyle ≥75 years, or expected treatment duration ≤5 years <75 years, or expected treatment duration >5 years Measure (if feasible) and recalculate FRAX and link to NOGG, including manual data entry for the hip. (NB. If DXA not feasible and FRAX probability ≥5% for Hip, treat) If close to threshold for measuring BMD, and ≥2 falls/year, follow ‘NOGG: Measure BMD’ pathway Treat, but consider baseline DXA and recalculate FRAX, including manual data entry for the hip Treat (no DXA) Treat Lifestyle Treat Lifestyle Lifestyle Review bone health annually, including medicines adherence. After 5 years of treatment, review continued therapy (link to NOGG ). Qfracture may be used to estimate hip fracture risk in (i) patients with multiple comorbidities that are not captured by FRAX and (ii) over shorter time periods than FRAX which estimates fracture probability over 10 years. Consider treatment when hip fracture risk is ≥5%. © Veronica Lyell and Celia Gregson 2017