Tools to predict fracture risk are useful for selecting patients for pharmacological therapy in order to reduce fracture risk and redirect limited healthcare resources to those who are most likely to benefit. FRAX (R) is a World Health Organization fracture risk assessment algorithm for estimating the 10-year probability of hip fracture and major osteoporotic fracture. Effective application of FRAX (R) in clinical practice requires a thorough understanding of its limitations as well as its utility. For some patients, FRAX (R) may underestimate or overestimate fracture risk. In order to address some of the common issues encountered with the use of FRAX (R) for individual patients, the International Society for Clinical Densitometry (ISCD) and International Osteoporosis Foundation (IOF) assigned task forces to review the medical evidence and make recommendations for optimal use of FRAX (R) in clinical practice. Among the issues addressed were the use of bone mineral density (BMD) measurements at skeletal sites other than the femoral neck, the use of technologies other than dual-energy X-ray absorptiometry, the use of FRAX (R) without BMD input, the use of FRAX (R) to monitor treatment, and the addition of the rate of bone loss as a clinical risk factor for FRAX (R). The evidence and recommendations were presented to a panel of experts at the Joint ISCD-IOF FRAX (R) Position Development Conference, resulting in the development of Joint ISCD-IOF Official Positions addressing FRAX (R)-related issues.