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