Intended for healthcare professionals

Rapid response to:

Analysis Too Much Medicine

Overdiagnosis of bone fragility in the quest to prevent hip fracture

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2088 (Published 26 May 2015) Cite this as: BMJ 2015;350:h2088

Rapid Response:

Perhaps a clinical trial is needed?

A clinical trial testing the utility of applying the WHO FRAX tool (and DXA, if subsequently indicated) in a real-world community setting of at-risk individuals might bring clarity here, alongside a carefully selected intervention threshold for offering treatment. Whether such an approach will lead to reductions in hip and other fractures, improvement in quality of life or indeed psychological or therapeutic harms are pertinent questions to ask, and it is hoped that SCOOP, the large multi-centre trial evaluating precisely those outcomes will provide answers. That carefully planned study involving almost 12000 women is now in its 6th year [1,2] supported by the Medical Research Council and Arthritis Research UK- and one hopes is close to finding some answers. A similarly powered trial evaluating the efficacy, plausibility and harms of the lifestyle/exercise measures lauded by Jarvinnen and colleagues would also be most welcome.

Until then, those of us looking after people suffering from, and at risk of vertebral fragility fractures might find it safest to make clinical decisions by following peer-reviewed, published RCT's and meta-analyses, rather than 'opinion piece' journalism. The old Welsh proverb that 'bad news goes around in clogs, good news in stockinged feet', seems apt here, and clinicians who do value an unbiased clinical effectiveness systematic review of osteoporosis therapy might wish to read the summary of the new draft NICE report, which covers both a primary and secondary indication for bisphosphonate therapy [3]. The authors of that report seem to be without major conflicts of interest. (https://www.nice.org.uk/guidance/GID-TAG462/documents/osteoporosis-preve...)

[1] http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=2490

[2] Shepstone L, Fordham R, Lenaghan E, Harvey I, Cooper C, Gittoes N, Heawood A, Peters T, O'Neill T, Torgerson D, Holland, R, Howe A, Marshall T, Kanis J, McCloskey E. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of screening older women for the prevention of fractures: rationale, design and methods for the SCOOP study. Osteoporos Int. 2012 Oct;23(10):2507-15.

[3] Davis S, Martyn-St James M, Sanderson J, Stevens J, Goka E, Rawdin A, Sadler S, Wong R, Campbell, F, Stevenson M, Strong M, Selby P, Gittoes N. Bisphosphonates for preventing osteoporotic fragility fractures (including a partial update of NICE technology appraisal guidance 160 and 161). Technology Assessment Report: Final report to the National Institute for Health and Care Excellence, 2015. https://www.nice.org.uk/guidance/GID-TAG462/documents/osteoporosis-preve...

Competing interests: Pharmaceutical advisory and lecturing roles for Amgen, Lilly and UCB Celltech via Cambridge Enterprise, the commercial arm of the University of Cambridge on a charity fee-donation basis (http://www.enterprise.cam.ac.uk/our-services/industry-government-and-non-profits/find-a-consultant/). I am not involved in the SCOOP study, or the NICE clinical effectiveness systematic review.

02 September 2015
Kenneth Poole
Consultant Rheumatologist and University Lecturer
University of Cambridge and Addenbrooke's Hospital
Box 157, Department of Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom, CB2 0QQ