An estimated 1.2 million women in the UK have osteoporosis, and osteoporotic fractures have a considerable impact on healthcare resources as well as on the individual’s quality of life. The recent NICE guidance on secondary prevention of osteoporotic fractures in postmenopausal women is clear and straightforward, and most welcome.
The guidance recommends bisphosphonates as first-line therapy for most patients. It does not make recommendations about which bisphosphonate to use in particular situations, but advises clinicians to balance effectiveness against tolerability and adverse effects in individual patients. A further fracture within a few months of starting bisphosphonate therapy does not indicate treatment failure.
In the over-75 age group, the guidance recommends beginning bisphosphonate therapy without the need for a DEXA scan. Some women will be unwilling to subject themselves to a prolonged course of medication without some evidence of the fragility of their bones, and they will therefore require a DEXA scan. In women aged between 65 and 74 years, osteoporosis should be confirmed by DEXA scan.
For postmenopausal women under 65 years of age, the guidance recommends treatment only if bone mineral density is very low (a T score of approximately –3 SD or below), or if the patient has osteoporosis and one or more additional age-independent risk factors. These risk factors are well recognised, but time and skill will be needed to make a full assessment of women in this age group.
Raloxifene is the recommended alternative in patients who are intolerant of bisphosphonates. The raloxifene dose regimen is simpler than that of bisphosphonates, but the side-effect profile is well recognised.
For patients whose response to bisphosphonates has been unsatisfactory and who have an extremely low BMD or a very low BMD plus other factors, teriparatide is recommended. I suspect that most GPs will seek specialist help with this therapy.
Treatment failure will be a concern for GPs. The evidence suggests that even with the best dosage regimen, therapy reduces the chance of further fracture at best by 50%. In women who experience further fractures it may be difficult to tell whether BMD has declined below pre-treatment levels if a DEXA scan is not performed at baseline. And I suspect many of these women will not fulfil the criteria for teriparatide therapy.
Implementing this guidance will have a significant impact in general practice. We will need to identify women at risk, assess them, initiate and monitor treatment and then audit the effectiveness of our work.
Most information on fractures comes from the local A&E department or the orthopaedic clinic, and many practices will already have a system for transcribing A&E slips onto the computer. These practices will know how difficult this can be – there are several different clinical descriptions of fracture and a number of Read codes.
Once the information is recorded, the patient must be called and assessed and treatment options discussed. This can be a lengthy process, and explaining the dosage scheduling of bisphosphonates can also be time consuming. Monitoring treatment is important to improve compliance with bisphosphonate treatment, which is often poor.
Our area has a fracture liaison nurse who works with the local fracture clinic, and the service, based on the Glasgow model, works well in our practice.
Implementing the new guidance will significantly benefit our patients at risk of secondary osteoporotic fractures. However, as well as an increased demand for DEXA scans, greater pressure will be placed on practice time and organisation.
Technology Appraisal 87. Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women can be downloaded from the NICE website: www.nice.org.uk