Osteoporosis experts launch guidance to fill gaps left by NICEBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2204 (Published 21 October 2008) Cite this as: BMJ 2008;337:a2204
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The association of glucosorticoid induced osteoporosis (GIOP) is well
known since 1932 .This is the most common cause of secondary oetoporosis
.There is a bone loss of more than 30 percent in the first few months of
starting steroids. Antiresorptive agents like bisphosphonate have a clear
prognostic role. Health provider should recognise the recommendation for
treatment with bone risk estimation scale – FRAX. There is no doubt that
this reduces the incidence of fracture .However there still remains a
considerable variation in individual practises and an underutilisation of
DEXA scanning .The other novel treatment are –
pamidronate,treiparatide.There is a proven role of receptor activated
nuclear factor kappa B ligand osteoprotogenin system (1) which will lead
to better therapies .
1.Reid LR et al .Prevention of glucocorticoid-induced oetoporosis .Journal
of bone and mineral research.June 1990 vol./is.5/6 (619-23).
Competing interests: No competing interests
All women ≥ 75 years with a low-energy distal radius fracture should be referred to bone densitometry
The guideline of the National Institute for Health and Clinical
Excellence (NICE) suggests treatment for all women aged ≥ 75 years
presenting with a low-energy fracture without the need for bone
densitometry. The intention behind this guideline is sound, as it aims to
make treatment more cost-effective and to offer more applicable
guidelines, easy to use both for clinicians and patients. However, the
NICE guideline has given rise to much controversy.1 In a recently
published study, we investigated the prevalence of osteoporosis at femoral
neck (T-score ≤ –2.5 SD) and estimated the 10-year risk of hip
fracture and any major osteoporotic fracture by FRAX® in 1525 female and
212 male distal radius fracture patients aged 50-90 years.2 Among the
women, 428 were aged ≥ 75 years. If we had followed the NICE
guideline, 46% of the women would have received treatment without having
osteoporosis. This is similar to results reported by Ralston et al.3
The National Osteoporosis Guideline Group has updated previous
guidelines from the Royal College of Physicians and their new guideline
incorporates, inter alia, the use of FRAX® to estimate the 10-year risk of
hip fracture and any major osteoporotic fracture, in order to fill the
gaps left by the NICE guideline. Different intervention thresholds have
been tested for cost-effectiveness both in UK and US.4 5 We investigated
the prevalence of osteoporosis in patients aged ≥ 75 years with
distal radius fractures with various FRAX® thresholds. Only 53% of the
women with > 7% risk of a hip fracture and any major osteoporotic
fracture had osteoporosis. Even when the FRAX® score was above 15%, as
many as 45-47% did not have osteoporosis.
Because many women even at age ≥ 75 years do not have
osteoporosis, as we also found in our study of distal radius fracture
patients, all patients should be referred to bone densitometry if
osteoporosis treatment is being considered.
1. Mayor S. Osteoporosis experts publish new guidelines to fill gaps
left by NICE. BMJ 2008;337:a2204.
2. Oyen J, Gjesdal CG, Brudvik C, Hove LM, Apalset EM, Gulseth HC, et
al. Low-energy distal radius fractures in middle-aged and elderly men and
women - the burden of osteoporosis and fracture risk: A study of 1794
consecutive patients. Osteoporos Int 2009.
3. Ralston SH, de'Lara G, Farquhar DJ, Gallacher SJ, Hannan J,
McLellan AR. NICE on osteoporosis. Women over 75 with fragility fractures
should have DEXA. BMJ 2009;338:b2340.
4. Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A.
Case finding for the management of osteoporosis with FRAX--assessment and
intervention thresholds for the UK. Osteoporos Int 2008;19(10):1395-408.
5. Tosteson AN, Melton LJ, 3rd, Dawson-Hughes B, Baim S, Favus MJ,
Khosla S, et al. Cost-effective osteoporosis treatment thresholds: the
United States perspective. Osteoporos Int 2008;19(4):437-47.
Competing interests: No competing interests
The UK National Institute for Health and Clinical Excellence (NICE)
guidance on the management of osteoporosis has generated much controversy
and the publication of “alternative” guidelines by the National
Osteoporosis Guideline Group (NOGG) 1
An aspect of the NICE guidance which has not been debated is the
suggestion that DEXA scanning is not required in women over the age of 75
who have suffered a fragility fracture. This advice has been incorporated
into the Osteoporosis Direct Enhanced Service (DES) agreement for GP’s who
are being advised that such patients “should be offered preventative
treatment with bone sparing drugs” without recourse to further
The above guidance is presumably based on the assumption that women
over the age of 75 who have a fragility fracture almost always have
osteoporosis, but so far as we are aware, there is no evidence to show
that this is the case.
In order to determine the frequency of osteoporosis in this patient
group, we studied bone mineral density values as assessed by dual energy X
-ray absorptiometry (DEXA) in female patients age >75 with fragility
fractures who were dealt with by the Lothian and Glasgow fracture liaison
services (FLS) between January and December 2007. During this time, the
Lothian FLS dealt with 367 women over the age of 75 who had suffered
fragility fractures and the Glasgow FLS dealt with 677 women. The
prevalence of osteoporosis (BMD T-score <_-2.5 at="at" either="either" spine="spine" or="or" hip="hip" osteopenia="osteopenia" t-score="t-score" between="between" _-1.0="_-1.0" and="and" _-2.5="_-2.5" normal="normal" bmd="bmd"/>-
1.0) are summarised in the table.
Service Osteoporosis Osteopenia Normal Lothian (n=367) 145 (39.5%) 138 (37.6%) 84 (22%) Glasgow (n=677) 376 (51.2%) 252 (40.4%) 49 (8.5%) Combined (n=1044) 525 (50.1%) 390 (37.2%) 133 (12.7%)
These data show that only than half of women over the age of 75 years
with fragility fractures actually have osteoporosis; a large proportion
have osteopenia and 12% have normal BMD. To suggest that all of these
women should be given osteoporosis treatments is not supported by clinical
evidence since virtually all of the randomised controlled trials of drug
treatments for osteoporosis have evaluated patients with BMD values in the
osteoporotic range as evaluated by DEXA of the spine or hip 2-6 .
Furthermore, there is no evidence that osteoporosis treatments prevent
fractures in patients with osteopenia or normal BMD. For example, in the
fracture intervention trial, alendronate did not reduce the incidence of
fracture significantly in osteopenic women 7. Similarly, in a study with
risedronate, there was no significant reduction in the risk of hip
fracture in elderly women who were selected on the basis of clinical risk
factors alone 8. Calcium and vitamin D supplements which are used widely
as an adjunct to other osteoporosis treatments but similarly ineffective
in the secondary prevention of clinical fractures in elderly patients who
have had a fragility fracture 9.
Our observations demonstrate that adherence to the NICE guidelines
and DES would result in about 50% of elderly patients receiving
osteoporosis treatments for which evidence for benefit is lacking and
which in some cases may cause harm 10-12.
A basic principle of medical care is to administer treatment only
when the benefit outweighs the risk. We suggest that DEXA should be used
to evaluate the likely benefit of osteoporosis therapy in elderly patients
to ensure that treatment is being targeted appropriately.
(1) Mayor S. Osteoporosis experts publish new guidelines to fill
gaps left by NICE. Br Med J 2008; 337:a2204.
(2) Liberman UA, Weiss SR, Broll J, Minne HW, Quan H, Bell NH et al.
Effect of oral alendronate on bone mineral density and the incidence of
fractures in postmenopausal osteoporosis. The Alendronate Phase III
Osteoporosis Treatment Study Group. N Engl J Med 1995; 333:1437-1443.
(3) Reginster J, Minne HW, Sorensen OH, Hooper M, Roux C, Brandi ML
et al. Randomized trial of the effects of risedronate on vertebral
fractures in women with established postmenopausal osteoporosis. Vertebral
Efficacy with Risedronate Therapy (VERT) Study Group. Osteoporosis Int
(4) Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster
JY et al. Effect of parathyroid hormone (1-34) on fractures and bone
mineral density in postmenopausal women with osteoporosis. N Engl J Med
(5) Reginster JY, Seeman E, de Vernejoul MC, Adami S, Compston J,
Phenekos C et al. Strontium Ranelate reduces the risk of nonvertebral
fractures in postmenopausal women with osteoporosis: TROPOS study. J Clin
Endocrinol Metab 2005; 90:2816-2822.
(6) Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA et
al. Once-yearly zoledronic acid for treatment of postmenopausal
osteoporosis. N Engl J Med 2007; 356(18):1809-1822.
(7) Black DM, Thompson DE, Bauer DC, Ensrud K, Musliner T, Hochberg
MC et al. Fracture risk reduction with alendronate in women with
osteoporosis: the Fracture Intervention Trial. FIT Research Group. J Clin
Endocrinol Metab 2000; 85(11):4118-4124.
(8) McClung MR, Guesens P, Miller PD, Zippel H, Roux C, Roux C et
al. Effect of Risedronate on the Risk of Hip Fracture in Elderly Women. N
Engl J Med 2001; 344(5):333-340.
(9) Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS,
McPherson GC et al. Oral vitamin D3 and calcium for secondary prevention
of low-trauma fractures in elderly people (Randomised Evaluation of
Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial.
Lancet 2005; 365(9471):1621-1628.
(10) Bilezikian JP. Osteonecrosis of the jaw--do bisphosphonates
pose a risk? N Engl J Med 2006; 355(22):2278-2281.
(11) Twiss IM, van den Berk AH, de Kam ML, Bosch JJ, Cohen AF,
Vermeij P et al. A comparison of the gastrointestinal effects of the
nitrogen-containing bisphosphonates pamidronate, alendronate, and
olpadronate in humans. J Clin Pharmacol 2006; 46(4):483-487.
(12) Schneider JP. Bisphosphonates and low-impact femoral fractures:
current evidence on alendronate-fracture risk. Geriatrics 2009; 64(1):18-
SHR acts as a consultant for Proctor & Gamble, Merck and Novartis; Steven J Gallacher has received lecture fees for Eli Lilly, Alastair Mclellan has received lecture fees for Proctor & Gamble.
Competing interests: Service Osteoporosis Osteopenia NormalLothian (n=367) 145 (39.5%) 138 (37.6%) 84 (22%)Glasgow (n=677) 376 (51.2%) 252 (40.4%) 49 (8.5%)Combined (n=1044) 525 (50.1%) 390 (37.2%) 133 (12.7%)