UK and other osteoporosis guidelines uniformly recommend the use of either oral or intravenous bisphosphonates for reducing fracture risk in patients meeting their country-specific intervention threshold.56 Secondary care guidelines also recommend bisphosphonate use in patients taking chronic glucocorticoid therapies or with oncology-related conditions such as osteolytic metastases.78 Taken orally, bisphosphonate bioavailability is low (about 1%), and even lower if taken within 30-60 minutes of food intake.9 After administration, bisphosphonates are incorporated into the crystalline mineral structure of bone, particularly at sites of active resorption (fig 1). [...]osteoclast activity is inhibited, and bone resorption is reduced.10 Despite their low oral bioavailability, bisphosphonates have proved effective at reducing bone loss and thereby maintaining bone density. A 2019 network meta-analysis including 26 studies of bisphosphonates versus calcium, vitamin D, or placebo suggested that bisphosphonates reduce the relative risk of any non-vertebral osteoporotic fracture by approximately 20% (95% confidence interval 10% to 30%), and the relative risks of vertebral and hip fractures by about 40% and 30%, respectively.14 Table 1 shows the estimated fracture risk reductions for individual bisphosphonates based on clinical trial data and real-world data. IV = Intravenous. * Real world studies present hazard ratios and incidence rate ratios, not strictly relative risk Personalise the anticipated risk reduction to the patient’s absolute 10-year fracture risk, using positive and negative framing (that is, present both the likelihood of not having a fracture and the likelihood of having a fracture), and provide a visual depiction of risk (fig 2).19 For some patients, it may be helpful to discuss the role of non-prescription strategies such as calcium and vitamin D supplementation20 and exercise to reduce falls,21 though these strategies should not be viewed as equal alternatives to medications for fracture prevention.