UK clinical guideline for the prevention and treatment of osteoporosis

Arch Osteoporos (2017) 12:43 DOI 10.1007/s11657-017-0324-5 POSITION PAPER UK clinical guideline for the prevention and treatment of osteoporosis J. Compston 1 & A. Cooper 2 & C. Cooper 3 & N. Gittoes 4 & C. Gregson 5 & N. Harvey 3 & S. Hope 6 & J. A. Kanis 7 & E. V. McCloskey 8 & K. E. S. Poole 1 & D. M. Reid 9 & P. Selby 10 & F. Thompson 11 & A. Thurston 11 & N. Vine 1 & The National Osteoporosis Guideline Group (NOGG) Received: 7 March 2017 / Accepted: 7 March 2017 # The Author(s) 2017. This article is an open access publication Abstract Introduction In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. 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 or over. 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. Affiliations of the NOGG writing group are provided in Appendix 1 * J. Compston F. Thompson A. Cooper A. Thurston C. Cooper N. Vine N. Gittoes 1 Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK C. Gregson 2 Crawley Fracture Liaison Service, Crawley, Sussex, UK 3 MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK 4 University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK 5 Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK N. Harvey S. Hope J. A. Kanis 6 E. V. McCloskey Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK 7 Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK K. E. S. Poole 8 Metabolic Bone, University of Sheffield, Sheffield, UK 9 Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK D. M. Reid P. Selby 10 Metabolic Bone Disease, University of Manchester, Manchester, UK 11 National Osteoporosis Society, Camerton, UK 43 Page 2 of 24 Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds. 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 who are involved in its management. Keywords Osteoporosis . Fracture . NOGG . Guideline Introduction This updated guideline provides guidance on the prevention and treatment of osteoporosis in the UK. It updates guidelines previously developed by the Royal College of Physicians [1, 2] and the National Osteoporosis Guideline Group [3, 4]. The scope of the guideline is to review the assessment and diagnosis of osteoporosis, the therapeutic interventions available and the manner in which these can be used to develop management strategies for the prevention of fragility fracture in postmenopausal women and in men age 50 years or over. The guideline was prepared by a writing group (Appendix 1) and finalised after consultation with stakeholders (Appendix 2). The guideline is intended for all healthcare professionals involved in the management of osteoporosis. 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 3. Where available, systematic reviews, meta-analyses and randomised controlled trials have been used to provide the evidence base. The evidence base was updated using PubMed to identify systematic reviews and meta-analyses from January 2009 to June 2016. The recommendations in this guideline were agreed unanimously by the National Osteoporosis Guideline Development Group. The recommendations in the guideline should be used to aid management decisions but do not replace the need for clinical judgement in the care of individual patients in clinical practice. Background Osteoporosis is described by the World Health Organisation (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’ [5]. The clinical significance of Arch Osteoporos (2017) 12:43 osteoporosis lies in the fractures that arise. In the UK, approximately 536,000 new fragility fractures occur each year, comprising 79,000 hip fractures, 66,000 clinically diagnosed vertebral fractures, 69,000 forearm fractures and 322,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) [6]. Such fractures cause severe pain and disability to individual sufferers, at an annual cost to the National Health Service (NHS) of over £4.4 billion, estimated for 2010. First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to £3.2 billion, £1.1 billion and £84 million, respectively [6]. More than one third of adult women and one in five men will sustain one or more fragility fractures in their lifetime [7]. Common sites of fragility fracture include the vertebral bodies, distal radius, proximal humerus, pelvis and proximal femur. Hip fractures account for occupation of over 4000 beds at any one time across England, Wales and Northern Ireland and an average hospital length of stay of around 20 days [8]. Hip fractures account for around 50% of the total cost of fractures to the UK annually [6]. 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 [8, 9]. Furthermore, most major fractures are associated with reduced relative survival, with an impact persisting more than 5 years after the index event [10, 11]. In the UK, fracture rates vary by geographic location, socioeconomic status and ethnicity [12, 13] and changes in age- and sex-adjusted fracture rates have been observed in recent decades, with increases in hip fractures amongst men and vertebral fracture amongst women [14]. Furthermore, the ageing of the UK population will give rise to a doubling in the number of fragility fractures over the next (...truncated)