NICE guidance for osteoporosis: women aged over 75 with fragility fractures should have DEXA
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.
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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%)