Risk assessment of fragility fractures: summary of NICE guidanceBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e3698 (Published 08 August 2012) Cite this as: BMJ 2012;345:e3698
- Silvia Rabar, senior project manager and research fellow1,
- Rosa Lau, research fellow1,
- Norma O’Flynn, clinical director1,
- Lilian Li, health economist1,
- Peter Barry, consultant paediatric intensivist and honorary senior lecturer 2
- on behalf of the Guideline Development Group
- 1National Clinical Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
- 2Department of Child Health, Leicester Royal Infirmary, Leicester LE2 7LX, UK
- Correspondence to: S Rabar
Osteoporosis is characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture, particularly fractures that result from mechanical forces that would not ordinarily result in fracture, known as fragility fractures. The prevalence of osteoporosis rises markedly with age, and in women this rises from 2% at 50 years to more than 25% at 80 years. Risk of fracture is also increased by factors such as lifestyle, drug treatments, family history, and other conditions that cause secondary osteoporosis. Several validated risk assessment tools are available to predict fracture risk. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on risk assessment of fragility fractures.1
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Who needs risk assessment?
Consider assessing fracture risk in:
-All women aged ≥65 years and men aged ≥75. [Based on moderate/low quality observational studies in a large number of patients]
-Women between 50 and 65 years and men between 50 and 75 years if they have risk factors—for example, previous fragility fracture; history of falls; current or frequent recent use of oral or systemic glucocorticoids; other causes of secondary osteoporosis (box 1); smoking; alcohol intake >14 units a week for women and >21 units a week for men; family history of hip fracture; low body mass index (kg/m2) (<18.5). [Based on moderate or low quality observational studies in a large number of patients and on the experience and opinion of the Guideline Development Group (GDG)]
People aged <50 years are unlikely to be at high risk of fracture, so do not routinely assess their fracture risk with a risk assessment tool unless they have major risk factors (for example, current or frequent recent use of oral or systemic glucocorticoids, untreated premature menopause, or previous fragility fracture). [Based on the experience and opinion of the GDG]
In people aged <40 years, consider measuring bone mineral density to assess their fracture risk only if they have a major risk factor such as history of multiple fragility fractures, major osteoporotic fracture, or current or recent use of high dose oral or high dose systemic glucocorticoids (>7.5 mg prednisolone or equivalent daily for three months or longer). [Based on the experience and opinion of the GDG]
Consider to be at high risk people over the age limit of the risk assessment tools (90 years for FRAX and 85 years for QFracture; box 2). [Based on the experience and opinion of the GDG]
Box 1 Main causes of secondary osteoporosis
Endocrine—Hypogonadism in either sex including untreated premature menopause and treatment with aromatase inhibitors or androgen deprivation therapy; hyperthyroidism; hyperparathyroidism; hyperprolactinaemia; Cushing’s disease; diabetes
Gastrointestinal—Coeliac disease; inflammatory bowel disease; chronic liver disease; chronic pancreatitis; other causes of malabsorption
Rheumatological—Rheumatoid arthritis; other inflammatory arthropathies
Haematological—Multiple myeloma; haemoglobinopathies; systemic mastocytosis
Respiratory—Cystic fibrosis; chronic obstructive pulmonary disease
Renal—Chronic renal disease
Immobility—Resulting, for example, from neurological injury or disease
Box 2 Risk assessment tools
FRAX (www.shef.ac.uk/FRAX), the World Health Organization’s fracture risk assessment tool can be used for people aged 40-90 years, with or without values for bone mineral density
QFracture (www.qfracture.org/index.php) can be used for people aged 30-85 years of age. Values for bone mineral density cannot be incorporated into the risk algorithm
How to carry out risk assessment
Estimate the absolute risk of fragility fracture—for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as percentage. [Based on the experience and opinion of the GDG]
Use FRAX (without a value for bone mineral density) or QFracture, within these tools’ allowed age range, to estimate absolute risk of fracture. [Based on moderate/low quality observational studies in a large number of patients]
If, after such risk assessment, the fracture risk is in the region of an intervention threshold for a proposed treatment, consider measuring bone mineral density with dual energy x ray absorptiometry (DXA), and recalculate the absolute risk by using FRAX again but this time incorporating the value for bone mineral density. (The guideline does not provide advice on what level of risk merits consideration of intervention. NICE will not be able to recommend drug interventions until its current technology appraisals dealing with drug interventions for reduced bone mineral density are updated.)
Consider measuring bone density with DXA before starting treatments that may rapidly adversely affect bone mineral density—for example, sex hormone deprivation for breast or prostate cancer. [Based on the experience and opinion of the GDG]
Risk assessment tools may underestimate fracture risk in certain circumstances—for example, when a patient has a history of multiple fractures; has had previous vertebral fracture(s); has a high alcohol intake; has had high dose oral or high dose systemic glucocorticoids (>7.5 mg prednisolone or equivalent) daily for three months or longer; or has other causes of secondary osteoporosis. [Based on the experience and opinion of the GDG]
Fracture risk may be affected by factors that might not be included in the risk tool—for example, living in a care home or taking drugs that may impair bone metabolism (such as anticonvulsants, selective serotonin reuptake inhibitors, thiazolidinediones, proton pump inhibitors, and antiretroviral drugs). [Based on the experience and opinion of the GDG]
When to repeat risk assessment
Consider recalculating fracture risk if (a) the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of two years; or (b) the person’s risk factors have changed. [Based on the experience and opinion of the GDG]
Implementation of the guideline will require a change in approach to use absolute risk rather than measures of bone mineral density when considering risk assessment. Healthcare professionals do not routinely consider risk of fragility fracture when they see people opportunistically, and the recommendations are likely to result in a larger number of people being assessed by general practitioners (or other healthcare professionals in different settings), potentially either increasing the duration of a consultation or resulting in an additional consultation. There should, however, be a reduction in inappropriate referrals for measurement of bone mineral density.
Further information on the guidance
Identifying people at risk of fragility fracture can be difficult. The availability of measurement of bone mineral density varies widely, and in any case, such measurement is not the best approach for detecting people at risk. Most fragility fractures occur in people who do not have osteoporosis and who would not be given treatment without a risk assessment that includes clinical factors.2 This guideline provides recommendations on risk assessment and identifies areas needing further research.
The guideline was developed according to NICE guideline methodology (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). This involved systematic searching, selection of relevant papers, and critically appraising and summarising the clinical and cost effectiveness evidence. A multidisciplinary Guideline Development Group (GDG) also did a new economic analysis to assess costs for risk assessment tools and conducted a further threshold analysis for comparative purposes, specifically to identify the proportion of patient referrals at which one risk assessment tool would be cost neutral compared with the other tool. Estimates of resource use were based on the GDG’s assumptions, and cost data were derived from national sources. The multidisciplinary GDG discussed the evidence and formulated clinical recommendations. The guideline went through an external consultation with stakeholders. The GDG assessed the comments, reanalysed the data where necessary, and modified the guideline.
NICE has produced four different versions of the guideline: a full version; a version known as the “NICE guideline” (which summarises the recommendations); a version for patients and the public; and a NICE pathway (an interactive tool that brings together all related NICE guidance on a topic in one interface). All these versions are available from the NICE website. Updates of the guideline will be published according to the NICE guideline development programme.
What is the clinical and cost effectiveness of using general practice lists to identify people at high risk of fracture, leading to formal risk assessment and possible treatment?
What is the utility of FRAX and QFracture in adults receiving bone protective treatment?
What is the utility of FRAX and QFracture in detecting risk of fragility fracture in adults with causes of secondary osteoporosis?
What is the added prognostic value of measurement of bone mineral density in the assessment of fracture risk with FRAX?
What is the utility of FRAX and QFracture in detecting risk of fragility fracture in adults living in long term care?
Cite this as: BMJ 2012;345:e3698
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group were Terry Aspray, Peter Barry (chair), Kathleen Briers, Gary Collins, Juliet Compston, Frances Dockery, Lina Gulhane, Rosa Lau, Lilian Li, Norma O’Flynn, Silvia Rabar, Sheila Ruddick, Peter Selby, David Stephens, Angela Thornhill, Jonathan Tobias.
Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved this version. SR is the guarantor.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: all authors were members of the Guideline Development Group for the NICE guideline; no authors have relationships with any companies that might have an interest in the submitted work in the previous three years; and no authors have non-financial interests that may be relevant to the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.