UK clinical guideline for the prevention and treatment of osteoporosis

Archives of Osteoporosis (2022) 17:58 https://doi.org/10.1007/s11657-022-01061-5 POSITION PAPER UK clinical guideline for the prevention and treatment of osteoporosis Celia L. Gregson1,2 · David J. Armstrong3 · Jean Bowden1 · Cyrus Cooper4,5,6 · John Edwards7 · Neil J. L. Gittoes8 · Nicholas Harvey4,5 · John Kanis9 · Sarah Leyland10 · Rebecca Low11 · Eugene McCloskey12 · Katie Moss13 · Jane Parker1 · Zoe Paskins14 · Kenneth Poole15 · David M. Reid16 · Mike Stone17 · Julia Thomson10 · Nic Vine1 · Juliet Compston18 Received: 20 December 2021 / Accepted: 3 January 2022 © The Author(s) 2022 Abstract Summary The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management. Introduction The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Methods Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement. Conclusion The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases. Keywords Osteoporosis · Fracture · NOGG · Guideline Introduction This updated guideline has been prepared, with the support of the societies listed (Appendix 1), to provide guidance on the prevention and treatment of osteoporosis with the overarching aim of reducing fragility fracture risk. This guideline updates previous National Osteoporosis Guideline Group (NOGG) guidance [1–3]. The scope of the guideline Jean Bowden, Jane Parker, and Nic Vine are public and patient representatives. * Celia L. Gregson Extended author information available on the last page of the article is to review the assessment and diagnosis of osteoporosis, the therapeutic interventions available and the approaches for the prevention of fragility fractures, in postmenopausal women, and in men aged 50 years or older. This focus is chosen as fragility fractures and osteoporosis are uncommon in premenopausal women, and men younger than 50 years and therefore when these occur patients need thorough investigation for secondary causes of osteoporosis, and careful consideration of treatment options. Specialist referral is usually required. This NOGG guidance has appraised the current evidencebased to inform these updated recommendations. The aim of the guideline is to provide clinically appropriate recommendations which integrate available evidence on clinical 13 Vol.:(0123456789) 58 Page 2 of 46 efficacy, effectiveness and safety. This contrasts with, but complements, the remit of the National Institute for Health and Care Excellence (NICE), which focuses principally on establishing criteria for cost-effectiveness. Cost-effectiveness analyses are generally supportive for treatment guided by clinical effectiveness thresholds, rather than defining intervention thresholds per se [4]. The NOGG recommendations have been previously demonstrated to be costeffective and at the time of writing, NICE’s appraisal of romosozumab is awaited, with preliminary evidence of its cost-effectiveness established [5]. The guideline has been prepared by a writing group and has been approved after consultation with stakeholders (Appendix 1). The guideline is intended for all healthcare professionals involved in the prevention and treatment of osteoporosis and fragility fractures. This includes primary care practitioners, allied health professionals, and relevant specialists in secondary care including rheumatologists, gerontologists, gynaecologists, endocrinologists, clinical biochemists, and orthopaedic surgeons. The guideline includes recommendations for training in osteoporosis care. The conclusions and recommendations in the document are systematically graded, according to the quality of information available, to indicate the level of evidence on which recommendations are based. The grading methodology is summarised in Appendix 2. Where available, systematic reviews, meta-analyses, and randomized controlled trials have been used to provide the evidence base. The evidence base has been updated using PubMed to identify systematic reviews and meta-analyses from July 2016 to September 2020. The quality of systematic reviews and meta-analyses used in the formulation of recommendations was assessed using AMSTAR2 [6] (Appendix 3). The recommendations in this guideline were agreed upon by the National Osteoporosis Guideline Development Group. This guideline provides a framework from which local management protocols should be developed to provide advice for healthcare professionals. Implementation of this guideline should be audited at a local and national level. The recommendations in the guideline should be used to aid management decisions but do not replace the need for clinical judgment in the care of individual patients in clinical practice. Background The conceptual definition of osteoporosis was made by the World Health Organization (WHO) in 1994 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” [7]. Since microarchitectural deterioration 13 Archives of Osteoporosis (2022) 17:58 could not be measured clinically, the operational description was based on a bone mineral density (BMD) T-Score of ≤  − 2.5. Over the years, this was adopted as a clinical definition; however, the limitations of (...truncated)