Excerpts From NOGG 2017: Clinical guideline for the prevention and treatment of osteoporosis

The following are excerpts from Resource (2) below, NOGG 2017: Clinical guideline for the prevention and treatment of osteoporosis [PDF] from The National Osteoporosis Guideline Group, a British group.

Summary Of Main Recommendations

Assessment of fracture risk

1. Fracture probability should be assessed in postmenopausal women, and men age 50 years or more, who have
risk factors for fracture, using FRAX. In individuals at intermediate risk, bone mineral density (BMD) measurement
should be performed using dual-energy X-ray absorptiometry and fracture probability re-estimated using FRAX.
2. Vertebral fracture assessment should be considered in postmenopausal women and men age >50 years if there is
a history of ≥4cm height loss, kyphosis, recent or current long-term oral glucocorticoid therapy, or a BMD T-score
≤ -2.5.

Lifestyle and dietary measures

1. A daily calcium intake of between 700 and 1200mg should be advised, if possible achieved through dietary
intake, with use of supplements if necessary.
2. In postmenopausal women and older men (≥50 years) at increased risk of fracture a daily dose of 800IU
cholecalciferol should be advised.
3. In postmenopausal women and older men receiving bone protective therapy for osteoporosis, calcium
supplementation should be given if the dietary intake is below 700 mg/day, and vitamin D supplementation
considered in those at risk of, or with evidence of, vitamin D insufficiency.
4. Regular weight-bearing exercise should be advised, tailored according to the needs and abilities of the individual
patient.
5. Falls history should be obtained in individuals at increased risk of fracture and further assessment and appropriate
measures undertaken in those at risk.

Pharmacological intervention in postmenopausal women

1. Alendronate or risedronate are first line treatments in the majority of cases. In women who are intolerant of oral
bisphosphonates or in whom they are contraindicated, intravenous bisphosphonates or denosumab provide the
most appropriate alternatives, with raloxifene or hormone replacement therapy as additional options. The high cost
of teriparatide restricts its use to those at very high risk, particularly for vertebral fractures.
2. Treatment review should be performed after 3 years of zoledronic acid therapy and 5 years of oral bisphosphonate
treatment. Continuation of bisphosphonate treatment beyond 3-5 years can generally be recommended in individuals age ≥75 years, those with a history of hip or vertebral fracture, those who sustain a fracture while on treatment, and those taking oral glucocorticoids.
3. If treatment is discontinued, fracture risk should be reassessed after a new fracture, regardless of when this occurs.
If no new fracture occurs, assessment of fracture risk should be performed again after 18 months to 3 years.
4. There is no evidence to guide decisions beyond 10 years of treatment and management options in such patients
should be considered on an individual basis.

Glucocorticoid-induced osteoporosis

1. Women and men age ≥70 years with a previous fragility fracture, or taking high doses of glucocorticoids
(≥7.5 mg/day prednisolone), should be considered for bone protective therapy.
2. In other individuals fracture probability should be estimated using FRAX with adjustment for glucocorticoid dose.
3. Bone-protective treatment should be started at the onset of glucocorticoid therapy in individuals at high risk of
fracture.
4. Alendronate and risedronate are first line treatment options. Where these are contraindicated or not tolerated,
zoledronic acid or teriparatide are alternative options.
5. Bone protective therapy may be appropriate in some premenopausal women and younger men, particularly in
individuals with a previous history of fracture or receiving high doses of glucocorticoids.

Osteoporosis in men

1. Alendronate and risedronate are first line treatments in men. Where these are contraindicated or not tolerated,
zoledronic acid or denosumab provide the most appropriate alternatives, with teriparatide as an additional option.
2. For estimation of fracture probability, femoral neck BMD T-scores in men should be based on the NHANES female
reference database. When using the online version of FRAX for the estimation of fracture probability, femoral neck BMD values (g/cm2) should be entered and the manufacturer of the densitometer specified.

Systems of care

1. Coordinator-based Fracture Liaison Services (FLS) should be used to systematically identify men and women with
fragility fracture.

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Section 2: Background

1. Osteoporosis is described by the World Health Organization (WHO) as a “progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture” [Kanis et al 1994].

3. Common sites of fragility fracture include the vertebral bodies, distal radius, proximal humerus, pelvis and proximal
femur. Hip fractures account for occupation of over 4,000 beds at any one time across England, Wales and
Northern Ireland and an average hospital length of stay of around 20 days (http://www.nhfd.co.uk/2016report).
Hip fractures account for around 50% of the total cost of fractures to the UK annually [Svedbom et al 2013].
Approximately 53% of patients suffering a hip fracture can no longer live independently and 28.7% die within 12
months of the fracture. Only 54% of individuals admitted from home with a hip fracture return there within 30
days [http://www.nhfd.co.uk/2016report; Neuburger et al 2015]. Furthermore, most major osteoporotic fractures
are associated with reduced relative survival, with an impact persisting more than five years after the index event
[Bliuc et al 2009; Harvey et al 2010].

5. In Europe, osteoporosis accounts for more disability-adjusted life years than many non-communicable diseases
including rheumatoid arthritis, Parkinson’s disease, breast cancer and prostate cancer [Johnell & Kanis 2006].

6. Fall-related risk factors add significantly to the risk of fracture and often overlap with risk factors for osteoporosis.
Identification of older people at risk of fracture should therefore involve an integrated approach [Blain et al 2016].

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Section 3: Definition and diagnosis of osteoporosis

1. Prospective studies have shown that the risk of fracture increases progressively with decreasing bone mineral density (BMD). Systematic review and meta-analysis of observational population-based studies using absorptiometric techniques indicate that the risk of fracture increases approximately twofold for each standard deviation (SD) decrease in BMD [Marshall et al 1996, Johnell et al 2005]; (Evidence level Ia). The predictive value of BMD for hip fracture is at least as good as that of blood pressure for stroke.

2. Osteoporosis is defined operationally on the level of bone mass, measured as BMD. Two thresholds of BMD
have been defined by the World Health Organization, on the basis of the relationship of fracture risk to BMD.
‘Osteoporosis’ denotes a value for BMD that is 2.5 SDs or more below the young adult mean value for women (T-score equal to or less than –2.5). ‘Severe’ or ‘established’ osteoporosis denotes osteoporosis as defined above
in the presence of one or more documented fragility fractures [Kanis et al 1994].

3. The World Health Organization and the International Osteoporosis Foundation recommend that the reference
technology for the diagnosis of osteoporosis is dual-energy X-ray absorptiometry (DXA) applied to the femoral neck.
The femoral neck is the preferred site because of its higher predictive value for fracture risk [Kanis & Gluer 2000,
Kanis et al 2008]; (Evidence level 1a). The spine is not a suitable site for diagnosis in older people because of the
high prevalence of degenerative changes, which artefactually increase the BMD value; however, it is the preferred
site for assessing response to treatment [ISCD 2015]. The normal reference range in men and women is that
derived from the NHANES survey for Caucasian women age 20-29 years [Kanis et al 2008]. The writing group
endorses these recommendations (Grade C recommendation). Other sites and validated technologies may be used
in clinical practice but it should be recognised that the significance of a given T-score differs between sites and
technologies [Faulkner et al 1999]; (Grade B recommendation).

6. Some guidelines favour the concurrent use of BMD at the proximal femur and at the lumbar spine for patient
assessment. Patients are defined as having osteoporosis on the basis of the lower of the two T-scores. The prediction of fracture is, however, not improved by the use of multiple sites [Kanis et al 2006, Leslie et al 2007];
(Evidence level II) and the use of multiple sites for diagnosis is not recommended (Grade B recommendation).
However, where hip measurement is not possible for technical reasons or in younger postmenopausal women and
men in whom the spine is differentially affected, spine BMD measurements may be used. If neither hip nor spine
measurements are possible, BMD measurements at the distal radius may be considered.

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Section 4: Fracture risk assessment

1. In addition to its diagnostic use, the assessment of BMD provides information on the likelihood of future fractures.
The risk of fracture increases approximately twofold for each SD decrease in BMD, but the gradient of risk
(relative risk/standard deviation; RR/SD) varies according to the site and technique used, the patient’s age and
the fracture outcome [Johnell et al 2005]; (Evidence level Ia).

2. The use of BMD alone to assess fracture risk has a high specificity but low sensitivity, meaning that most fragility
fractures will occur in women who do not have osteoporosis as defined by a T-score ≤-2.5 [Siris et al 2001];
(Evidence level Ia). The working group does not recommend the use of BMD testing alone for population screening [NICE 2012]; (Grade B recommendation).

5. Several additional clinical risk factors have been identified that provide information on fracture risk independently
of both age and BMD (Evidence level Ia).
(a) Low body mass index (BMI). Low BMI is a significant risk factor for hip fracture, but the value of BMI
in predicting other fractures is very much diminished when adjusted for BMD [De Laet et al 2005]; (Evidence level 1a).
(b) A history of a prior fracture at a site characteristic for osteoporosis is an important risk factor for further
fracture. Fracture risk is approximately doubled in the presence of a prior fracture, including morphometric vertebral fractures. The increase in risk is even more marked for more than one vertebral fracture. The risks are in part independent of BMD [Kanis et al 2004a]; (Evidence level 1a).
(c) A parental history of hip fracture is a significant risk factor that is largely independent of BMD [Kanis et al
2004b]; (Evidence level 1a).
(d) Smoking is a risk factor that is in part dependent on BMD [Kanis et al 2005a]; (Evidence level 1a).
(e) Glucocorticoids increase fracture risk in a dose-dependent manner. The fracture risk conferred by the use
of glucocorticoids is, however, not solely dependent upon bone loss and BMD-independent risks have been
identified [van Staa et al 2000, Kanis et al 2004c]; (Evidence level 1a).
(f) Alcohol. The relationship between alcohol intake and fracture risk is dose-dependent. Where alcohol intake is
on average two units or less daily, no increase in risk has been identified. Intakes of 3 or more units daily are
associated with a dose-dependent increase in fracture risk [Kanis et al 2005b]; (Evidence level 1a).
(g) Rheumatoid arthritis. There are many secondary causes of osteoporosis (e.g. inflammatory bowel disease,
endocrine disorders), but in most instances it is uncertain to what extent this is dependent on low BMD
or other factors such as the use of glucocorticoids. By contrast, rheumatoid arthritis increases fracture risk
independently of BMD and the use of glucocorticoids [Kanis et al 2004c]; (Evidence level 1a). Recent information suggests that diabetes (particularly type 2) may also exert BMD-independent effects on fracture risk [Leslie et al 2012, Giangregorio et al 2012].

6. The consideration of these risk factors improves the sensitivity of testing without sacrificing specificity, and the
writing group recommend their inclusion in case finding algorithms (Grade B recommendation). Indeed, the use of
combined clinical risk factors alone performs very similarly to that of BMD alone [Johansson et al 2009]; the use
of clinical risk factors with the addition of BMD is optimal, but the latter can be included in targeted groups
(see below).

9. The International Osteoporosis Foundation and the World Health Organization (WHO) recommend that risk of
fracture should be expressed as an absolute risk, i.e. probability over a ten-year interval. The absolute risk of fracture depends upon age and life expectancy as well as the current relative risk. The period of 10 years covers the likely initial duration of treatment and the benefits that may continue if treatment is stopped. The writing group endorses these recommendations (Grade C recommendation).

12. Diagnostic assessment of individuals with osteoporosis should include not only the assessment of BMD where
indicated but also the exclusion of diseases that mimic osteoporosis, elucidation of the cause of the osteoporosis
and the management of any associated morbidity. Recommendations for the routine investigation of patients with
osteoporosis are shown in Table 1.

13. The majority of vertebral fractures do not come to medical attention and thus remain undiagnosed [Fink et al 2005]. Moderate or severe vertebral fractures, even when asymptomatic, are strong risk factors for subsequent fracture at the spine and other skeletal sites [Melton et al 1999, Lindsay et al 2001, Johansson et al 2014b]. Vertebral fracture assessment should therefore be considered in high risk individuals, using either lateral lumbar and thoracic spine radiographs or lateral spine DXA imaging. The latter delivers a significantly lower radiation dose but performs comparably to traditional radiographs [Lewiecki et al 2010].
14. Vertebral fracture assessment should be considered in postmenopausal women and older men if there is a
history of ≥4cm height loss, kyphosis, recent or current long-term oral glucocorticoid therapy, or a BMD T-score
≤-2.5 (Grade C recommendation). It should also be considered in individuals with a history of non-vertebral fracture
after the age of 50 years [Gallacher et al, 2007].

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Section 5: Lifestyle measures in the management
of osteoporosis

6. The majority of fractures are preceded by a fall. Multi-component group and home-based exercise programmes, Tai
Chi and home safety interventions have been shown to reduce the risk of falls in people living in the community
[Gillespie et al 2012]; (Evidence level 1a). Falls prevention exercise programmes in community dwelling adults age
>60 years may reduce falls resulting in fracture [El-Khoury et al 2013]; (Evidence level 1a) although in individuals
at higher risk of falling this benefit has not been shown. Falls history should be obtained in patients with
osteoporosis and further assessment and appropriate measures undertaken in those at risk (Grade B
recommendation).
7. Hip protectors may reduce the risk of hip fractures in older people in nursing care or residential care settings.
[Santesso et al 2014]; (Evidence level 1a). However, poor acceptance and adherence by older people offered hip
protectors are barriers to their use.

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Section 6: Pharmacological interventions

2. Bisphosphonates are analogues of inorganic pyrophosphate that inhibit bone resorption.
a) Alendronate is approved for the treatment of postmenopausal osteoporosis (10 mg daily or 70 mg once weekly
by mouth) and osteoporosis in men (10 mg daily). It is also approved for the prevention of postmenopausal
osteoporosis (5 mg daily) and for prevention and treatment of glucocorticoid-induced osteoporosis (5 mg daily
or, in postmenopausal women not receiving hormone replacement therapy 10 mg daily).
In postmenopausal women with osteoporosis, alendronate 10 mg daily has been shown to reduce vertebral,
non-vertebral and hip fractures [Black et al 1996]. Approval for the use of alendronate in men with
osteoporosis and in men and women taking glucocorticoids was granted on the basis of BMD bridging studies
[Orwoll et al 2000, Saag et al 1998].
Side-effects include upper gastrointestinal symptoms, bowel disturbance, headaches and musculoskeletal pain.
Alendronate should be taken after an overnight fast and at least 30 minutes before the first food or drink (other
than water) of the day or any other oral medicinal products or supplementation (including calcium). Tablets
should be swallowed whole with a glass of plain water (~ 200 ml) while the patient is sitting or standing in
an upright position. Patients should not lie down for 30 minutes after taking the tablet. Alendronic acid is also
available as 70 mg effervescent or soluble tablets, to be dissolved in half a glass of plain water (≥120 ml).

e). Contraindications and special precautions for the use of bisphosphonates

Oral and intravenous bisphosphonates are contraindicated in patients with hypocalcaemia, hypersensitivity to bisphosphonates, and severe renal impairment (GFR ≤ 35 ml/min for alendronate and zoledronic acid and ≤30
ml/min for other bisphosphonates). Pregnancy and lactation are also contraindications. Oral bisphosphonates
are contraindicated in people with abnormalities of the oesophagus that delay oesophageal emptying such as
stricture or achalasia, and inability to stand or sit upright for at least 30-60 minutes. They should be used with
caution in patients with other upper gastrointestinal disorders. Pre-existing hypocalcaemia must be investigated
and, where due to vitamin D deficiency, treated with vitamin D (e.g. 50,000 to 100,000 IU orally as a loading
dose) before treatment is initiated.
Rare adverse effects, in particular osteonecrosis of the jaw and atypical femoral fractures, have led to additional precautions. In patients with dental disease or other risk factors (e.g. glucocorticoids, tobacco use), dental examination with preventive dentistry is recommended prior to treatment with oral or intravenous bisphosphonates. While on treatment, patients should avoid invasive dental procedures if possible. For patients requiring dental procedures, there are no data available to indicate whether discontinuation of treatment
reduces the risk of osteonecrosis of the jaw. Clinical judgment of the treating physician should guide the
management plan of each patient based on individual benefit/risk assessment. During treatment, all patients
should be encouraged to maintain good oral hygiene, receive routine dental check-ups, and report any oral
symptoms such as dental mobility, pain, or swelling.

The possibility of osteonecrosis of the external auditory canal should be considered in patients who present with
ear symptoms including chronic ear infections. Possible risk factors for osteonecrosis of the external auditory
canal include steroid use and chemotherapy and/or local risk factors such as infection or trauma.

During treatment patients should be advised to report any thigh, hip or groin pain and any patient presenting
with such symptoms should be evaluated for possible atypical femur fracture.

3. Denosumab is a fully humanised monoclonal antibody against Receptor Activator of Nuclear factor Kappa B Ligand
(RANKL), a major regulator of osteoclast development and activity. It is approved for the treatment of osteoporosis
in postmenopausal women and men at increased risk of fractures, and for the treatment of bone loss associated
with hormone ablation in men with prostate cancer at increased risk of fractures. It is given as a subcutaneousinjection of 60 mg once every 6 months. Denosumab has been shown to reduce the incidence of vertebral, non-vertebral and hip fractures in postmenopausal women with osteoporosis [Cummings et al 2009]. Approval for its use in men with osteoporosis was granted on the basis of a BMD bridging study [Langdahl et al 2015].

4. Raloxifene is a selective oestrogen receptor modulator and inhibits bone resorption. It is approved for the treatment
and prevention of osteoporosis in postmenopausal women.
Raloxifene has been shown to reduce vertebral fracture risk [Ettinger et al 1999] but reduction in non-vertebral and
hip fractures has not been demonstrated.
Raloxifene is contraindicated in women with child-bearing potential, a history of venous thromboembolism or
unexplained uterine bleeding. Hepatic impairment and severe renal impairment are also contraindications. It should
be used with caution in women with a history of stroke or with risk factors for stroke. Side-effects include leg
cramps, oedema and vasomotor symptoms. There is a small increase in the risk of venous thromboembolism,
mostly within the first few months of treatment and a small increase in the risk of fatal stroke has been reported. In
the phase III trials, women treated with raloxifene had a significantly decreased risk of developing breast cancer.
Raloxifene is taken orally as a single daily dose (60 mg) and may be taken at any time without regard to meals.

5. Teriparatide (recombinant human parathyroid hormone [PTH] 1-34), when administered intermittently, has
anabolic skeletal effects which are most marked in cancellous bone. Teriparatide is approved for treatment of
osteoporosis in postmenopausal women and in men at high risk of fracture. Teriparatide is also approved for the
treatment of osteoporosis associated with systemic glucocorticoid therapy in women and men at increased risk
of fracture.

Teriparatide has been shown to reduce vertebral and non-vertebral fractures in postmenopausal women with
osteoporosis [Neer et al 2001]. No data are available for hip fractures. Approval for its use in men with
osteoporosis and in glucocorticoid-induced osteoporosis was granted on the basis of BMD bridging studies [Orwoll
et al 2003, Saag et al 2009].

6. Calcitriol (1,25-dihydroxyvitamin D) is the active form of vitamin D and is approved for the treatment of
established postmenopausal osteoporosis in an oral dose of 0.25 µg twice daily. It acts mainly by inhibiting
bone resorption. It has been shown to reduce vertebral fracture risk in postmenopausal women with osteoporosis
but effects on non-vertebral and hip fractures have not been demonstrated [Gallagher & Goldgar 1990]. It
is contraindicated in patients with hypercalcaemia or with metastatic calcification. Because it may cause
hypercalcaemia and/or hypercalciuria, serum calcium and creatinine levels should be monitored at 1, 3 and 6
months after starting treatment and at 6 monthly intervals thereafter.

8. No trials have been designed and powered to detect differences in the magnitude of fracture reduction between
different treatments. Direct comparison across trials is not possible because of differences in study design, but in
general reductions of 30-70% have been reported for vertebral fracture, up to 20% for non-vertebral fracture and
up to 40% for hip fracture.

9. The choice of agent is determined by the spectrum of anti-fracture effects across skeletal sites, side effects and
cost. The low cost of generic formulations of alendronate and risedronate, which have a broad spectrum of
anti-fracture efficacy, make these first line treatments in the majority of cases. In women who are intolerant of
oral bisphosphonates or in whom they are contraindicated, intravenous bisphosphonates or denosumab provide
appropriate and cost-effective treatment options with hormone replacement therapy or raloxifene as additional
options (Grade A recommendation). The high cost of teriparatide restricts its use to those at very high risk,
particularly for vertebral fractures.

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Section 7: Duration and monitoring of bisphosphonate therapy

1. Concerns over rare adverse effects of long-term bisphosphonate therapy, particularly osteonecrosis of the jaw and atypical femoral fractures, have raised questions about the optimal duration of therapy.

2. Withdrawal of treatment is associated with decreases in BMD and increased bone turnover after 2-3 years for alendronate [Ensrud et al 2004, Black et al 2006] and 1-2 years for ibandronate and risedronate [Ravn et al 1998, Watts et al 2008]. In the case of zoledronic acid, withdrawal after 3 years’ treatment was associated with only a very small decrease in BMD after a further 3 years without treatment [Black et al 2012a].

3. In the Fracture Intervention Trial Long-term extension study of alendronate (FLEX), there were significantly fewer clinical vertebral fractures in women previously treated with alendronate for 5 years who continued with
alendronate for five more years than in those assigned to placebo after 5 years of alendronate [Black et al 2006].
In the Health Outcomes and Reduced Incidence with Zoledronic acid Once Yearly (HORIZON) study extension,
the risk of morphometric vertebral fractures was significantly lower in women continuing on zoledronic acid for 3
years after three years therapy when compared to those switched to placebo, but the risk of non-vertebral fractures
was similar in the treatment and placebo groups [Black et al 2012a]. Post-hoc analyses from the alendronate and
zoledronic acid extension studies suggest that women most likely to benefit from long-term bisphosphonate therapy
are those with low hip BMD (T-score <-2.0 in FLEX and ≤-2.5 in HORIZON), those with a prevalent vertebral
fracture and those who sustained one or more incident fractures during the initial 3 or 5 years of treatment [Black
et al 2012b, Cosman et al 2014]; (Evidence level IIb). Older age was also associated with increased fracture risk
after discontinuation of alendronate therapy [Bauer et al 2014].

4. Based on the evidence above, continuation of bisphosphonate treatment beyond 3-5 years (3 years for zoledronic
acid and 5 years for alendronate, ibandronate and risedronate) can generally be recommended in the following
situations: (Evidence level IIb, Grade of recommendation B)
• age 75 years or more
• previous history of a hip or vertebral fracture
• occurrence of one or more low trauma fractures during treatment, after exclusion of poor adherence to
treatment (for example less than 80% of treatment has been taken) and after causes of secondary osteoporosis
have been excluded
• current treatment with oral glucocorticoids ≥7.5 mg prednisolone/day or equivalent

5. If treatment is discontinued, fracture risk should be reassessed:
• after a new fracture regardless of when this occurs
• if no new fracture occurs, after 18 months to 3 years (Grade C recommendation)

6. Treatment review should be performed after 5 years of treatment with alendronate, risedronate or ibandronate and
after 3 years of treatment with zoledronic acid (Grade C recommendation)
• Reassessment of fracture risk in treated individuals can be performed using FRAX with femoral neck BMD
[Leslie et al 2012]; (Grade B recommendation). The NOGG intervention thresholds can then be used to guide
the decision as to whether treatment can be stopped for a period of time (Figure 1). If the hip BMD T-score is
≤-2.5, resumption of treatment should be considered regardless of FRAX-derived fracture probability.
• If biochemical markers of bone turnover indicate relapse from suppressed bone turnover and BMD has
decreased following withdrawal, resumption of treatment should be considered (Grade C recommendation)
• There is no evidence base to guide decisions about treatment beyond 10 years and management of such
patients should be considered on an individual basis.

Resources:

(1) Final Recommendation Statement Osteoporosis: Screening from The U.S. Preventive Services Task Force Current as of: January 2011.

(2) NOGG 2017: Clinical guideline for the prevention and treatment of osteoporosis [PDF] from The National Osteoporosis Guideline Group.

(3) FRAX ®Fracture Risk Assessment Tool

(4) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS — 2016 [PubMed Abstract] [Full Text PDF]. Endocr Pract. 2016 Sep 2;22(Suppl 4):1-42. doi: 10.4158/EP161435.GL.

(5) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS – 2016–EXECUTIVE SUMMARY [PubMed Abstract]. Endocr Pract. 2016 Sep 2;22(Suppl 4):1-42. doi: 10.4158/EP161435.GL

(6) Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians [Pubmed Abstract] [Full Text HTML] [Link To Download Full Text PDF]. Ann Intern Med. 2017 Jun 6;166(11):818-839. doi: 10.7326/M15-1361. Epub 2017 May 9.

(7) Evidence-based recommendations on the bisphosphonates alendronic acid, ibandronic acid, risedronate sodium and zoledronic acid for treating osteoporosis. Technology appraisal guidance [TA464] Published date: 09 August 2017 Last updated: 07 February 2018:

The purpose of this technology appraisal was to establish at what level of absolute fracture risk bisphosphonates are cost effective. Please note that because of the reduction in prices for oral bisphosphonates over the last few years, the absolute risk level at which these drugs are cost effective is now very low. The absolute risk level at which oral bisphosphonates are recommended as treatment options in this guidance are therefore not clinical intervention thresholds. This technology appraisal guidance should be applied clinically in conjunction with:

  • NICE guideline on assessing the risk of fragility fractures (CG146) that defines who is eligible for osteoporotic fracture risk assessment.
  • NICE quality standard on osteoporosis (QS149) that defines the clinical intervention thresholds for the 10-year fracture probability of a major osteoporotic fracture, in those patients who have undergone fracture risk assessment. These thresholds are based on the NICE-accredited National Osteoporosis Guideline Group guideline.
  • The individual person’s circumstances, goals and informed preferences.

Further information is in the implementation section.

This guidance partially updates NICE technology appraisal guidance on raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women (TA160) and on raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (TA161).

(8) Osteoporosis – Quality standard [QS149] Published date: April 2017 from NICE

NICE has developed guidance and a quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside these quality statements.

Other quality standards that should be considered when commissioning or providing osteoporosis services include:

A full list of NICE quality standards is available from the quality standards topic library.

(9) Osteoporosis: assessing the risk of fragility fracture Clinical guideline [CG146] Published date: August 2012 Last updated: February 2017  from NICE

(10) UpToDate Pathways Management Of Osteoporosis In Women – podcast posted on June 17, 2017

(11) Osteoporosis Decision Aid from Mayo Clinic Shared Decision Making National Resource Center. You need to register (free) to use the site.

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