SIGN recommends DXA scanning in osteoporosis which will create pressure for better services, says Dr Gillian Hosie
The SIGN guidelines have an excellent reputation for being practical, accessible and evidence-based. The recently published SIGN guideline on the management of osteoporosis certainly lives up to our expectations.
It is difficult for those working in primary care to assess an individual’s risk factors for osteoporosis and to decide which patients to refer for open access DXA, if available, or to a local bone clinic. The guideline leads us through modifiable and non-modifiable risk factors and sets out a table of those groups considered at highest risk, with the main emphasis on individuals who have had a previous fragility fracture.
The guideline also pinpoints the importance of linking the risk of falling with the risk of osteoporosis, as osteoporosis by itself is only one risk factor for fracture.
DXA scanners are costly and not easily portable, so other methods of measuring bone mineral density have been investigated, such as quantitative ultrasound, quantitative computed tomography and biochemical markers. The guideline finds that forearm and heel scanning have no role in the diagnosis of osteoporosis in targeting therapy to reduce fracture risk, and that quantitative computed tomo-graphy is inappropriate in osteoporosis because of its limited availability, relatively high radiation dose and high cost.
Although at present biochemical markers have no place in the diagnosis of osteoporosis or the identification of patients at risk, there may be a limited role for them in monitoring therapy. DXA scanning is therefore the best investigation we have at present and should be more widely available to diagnose osteoporosis and to target therapy appropriately.
The guideline includes an excellent discussion of non-pharmacological interventions, such as diet and exercise. It also has a very useful update on the place of HRT in the management of osteoporosis, with good information on the risks and benefits – ideal for use when discussing potential therapy with a patient.
The section on pharmacological management is arranged according to clinical situation, for example post-menopausal women with multiple vertebral fractures, and shows the evidence-based options for therapy for each situation. This is a clear and logical layout and helps the reader to choose the best treatment.
Most guidelines and discussion documents on the subject of osteoporosis concentrate on the end point of fracture and its prevention but rarely give any advice on practical management. The distressing pain of vertebral fracture can be very difficult to manage and the advice on treating acute and chronic pain will be particularly helpful in primary care. Other very useful reference sections cover combination therapies, duration of treatment and monitoring treatment effect.
The guideline considers the cost-effectiveness of DXA scanning and treatment options, and suggests that local implementation should follow the recommendations of the National Osteoporosis Society’s osteoporosis framework. This now puts pressure on health authorities and health boards to improve services and provide not only DXA scanners but also medical and radiological staff to manage the service.
The guideline also includes a one-page quick reference guide with a summary of recommendations. While this is very valuable as an aide memoire, I strongly recommend the full guideline as an excellent resource for all those treating patients with osteoporosis.
SIGN 71. Management of Osteoporosis – A national clinical guideline can be downloaded free of charge from the SIGN website: www.sign.ac.uk