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Practice Guidelines

Cerebral palsy in adults: summary of NICE guidance

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l806 (Published 19 March 2019) Cite this as: BMJ 2019;364:l806

NICE guidance: fractures and quality of life in individuals with cerebral palsy

The National Institute for Health and Care Excellence (NICE) provided an important recommendation that we should assess osteoporotic fracture risk in adults with cerebral palsy and risk factors (1). Here I would like to point out that the risk factors mentioned by NICE (1) could need to be amended. In addition to skeletal fragility caused by physical disability (1), for example, joint contracture is another key risk factor that we need to know (2). In contrast to the NICE suggestion (1), however, current evidence is unlikely to support the concern that proton pump inhibitor use is a causal risk factor that adversely affects bone health (3-5).

Among individuals with cerebral palsy, fracture is one of the serious health problems that impair their quality of life, but no effective therapy has been established for the management of bone fragility resulting from physical disability (2). Although they cannot perform dynamic exercise that results in bone gain, inhibiting the activity of sclerostin secreted from bones would have the effect of such vigorous exercise (6-8). Consequently, treatment with romosozumab, a monoclonal antibody that inhibits the sclerostin activity, recently approved in Japan and under review in the USA and the EU, is highly expected to reduce fragility fractures in individuals with physical disability.

(1) Bromham N, Dworzynski K, Eunson P, Fairhurst C on behalf of the Guideline Committee. Cerebral palsy in adults: summary of NICE guidance. BMJ 2019;364:l806.
(2) Sugiyama T, Taguchi T, Kawai S. Spontaneous fractures and quality of life in cerebral palsy. Lancet 2004;364:28.
(3) Sugiyama T. Proton pump inhibitor use and fracture risk. Aliment Pharmacol Ther 2018;47:449-50.
(4) Sugiyama T. Association between proton pump inhibitor use and fracture risk - causality or confounding? Aliment Pharmacol Ther 2018;47:1569-70.
(5) Sugiyama T. Proton pump inhibitor use and fracture risk: an update of drug safety communication needed? Am J Gastroenterol 2019;114:360-1.
(6) Sugiyama T, Kim YT, Oda H. Osteoporosis therapy: a novel insight from natural homeostatic system in the skeleton. Osteoporos Int 2015;26:443-7.
(7) Sugiyama T, Torio T, Miyajima T, Kim YT, Oda H. Romosozumab and blosozumab: alternative drugs of mechanical strain-related stimulus toward a cure for osteoporosis. Front Endocrinol 2015;6:54.
(8) Sugiyama T, Oda H. Osteoporosis therapy: bone modeling during growth and aging. Front Endocrinol 2017;8:46.

Competing interests: No competing interests

20 March 2019
Toshihiro Sugiyama
Assistant Professor
Department of Orthopaedic Surgery, Saitama Medical University, Saitama 350-0495, Japan