Accurate diagnosis and evidence-based treatment will reduce suffering from osteoporosis, says Dr Tricia Donald, chair of the guideline development group

Osteoporosis is a common disease in which a deterioration in bone mineral density (BMD) results in bones that are fragile and liable to break easily, most commonly at the wrist, spine or hip. It is estimated that one in three women and one in 12 men over the age of 50 years will suffer an osteoporotic fracture, and more than 20 000 such fractures are reported in Scotland each year.1

Sufferers of osteoporotic fractures experience considerable pain, deformity and disability. Half of hip fracture patients are no longer able to live independently and 20% die within 6 months. In addition, osteoporotic fractures cost the NHS £1.7 billion annually – almost £5 million each day.2

In recent years, efforts to improve osteoporosis management have been hampered by several factors. There is widespread variation in the availability of diagnostic equipment and a shortage of physicians with an interest in osteoporosis.There is also variation in referral and treatment rates.

A wide range of diagnostic and monitoring tools has recently emerged, however the clinical efficacy of these new tools has yet to be established. This factor and the lack of good quality information for patients on prevention and management of osteoporosis have compounded the problems of access to appropriate care.

It is against this background that SIGN has developed its new clinical guideline on the management of osteoporosis.3

Risk assessment and referral

Attempts have been made to develop risk scores for osteoporosis, but so far they have not been of a satisfactory quality nor have they been validated. Until a validated tool is available, it will be down to the GP to assess which patients are most at risk of developing osteoporosis.

Priority should be given to identifying and managing patients with the highest risk of fracture. Evidence shows that individuals who have suffered one fragility fracture are at increased risk of another, so patients in this group should be referred for investigation and treatment.

The next group to target is individuals with risk factors for osteoporosis who have not yet sustained a fracture.The factors that have the best evidence for increasing risk are listed in Box 1 (below).

Box 1: Risk factors for osteoporosis when no history of fracture
Strongest risk factors
Female sex
Age >60 years
Family history of osteoporosis
Other significant risk factors
Caucasian or Asian origin
Early menopause
Low body mass index
Smoking
Sedentary lifestyle
Long term (>=3 months) corticosteroid use

There is a lack of evidence for particular combinations of risk factors that justify further investigation, but there seems to be an additive effect – the more risk factors present, the greater the risk.4 A systematic approach should be developed to offer osteoporosis assessment to all patients with multiple risk factors; scarce resources should be targeted at those whose risk is greatest.

Diagnosis

BMD is the major criterion used for the diagnosis and monitoring of osteoporosis. There is evidence of only a moderate correlation between BMD at different sites, so BMD at a specific site is the best predictor of fracture.

Our review of the evidence of current techniques for measuring BMD has produced a number of significant recommendations:

  • Conventional radiographs should not be used to diagnose or exclude osteoporosis.There is marked variation in assessment of BMD from plain radiographs and apparently normal density does not exclude osteoporosis.5 Basing treatment decisions on radiographs could mean that some patients are treated unnecessarily while many with osteoporosis go untreated.
  • Dual-energy X-ray absorptiometry (DXA) scanning, which can measure BMD of the spine, hip, forearm, heel and whole body, is now the recognised standard for assessing BMD and diagnosing osteoporosis. There is strong evidence to recommend that BMD should be measured by DXA scanning at two sites, preferably the anteroposterior spine and hip.
  • Following DXA scanning, a management report should be provided to the referring GP along with the results of the scan, to aid treatment. In the case of hip fracture, this report should include the estimated annual hip fracture risk.

The guideline also recommends that it would be good practice to provide DXA scanners in all health board areas.

This recommendation, based upon the clinical experience of the guideline development group, may have significant resource implications, but it would help to ensure equity of access to treatment.

Treatment

Osteoporosis treatment falls into three main categories:

  • non-pharmacological management
  • pharmacological management
  • hormone replacement therapy (HRT).

The quick reference guide reproduced below summarises the decision-making process.

Figure 1: First page of the quick reference guide
Figure 2: Second page of the quick reference guide
© Scottish Intercollegiate Guidelines Network, 2003. The quick reference guide can be downloaded from the SIGN website at www.sign.ac.uk

Non-pharmacological management

A number of non-pharmacological factors are recognised as preventing fractures in patients with osteoporosis; some also have positive effects on bone density.

In particular there is mounting evidence to suggest that physical exercise reduces the risk of falling in older people. Gait training, appropriate use of assistive devices, and balance training are key components of exercise programmes for older people living in the community.6

A number of systematic reviews and meta-analyses 7-9 have suggested that an exercise programme combining low impact weight-bearing exercise and high-intensity strength training maintains bone density in men and postmenopausal women. The guideline therefore makes strong recommendations that both of these should form part of a management strategy for osteoporosis. It is also good practice for all healthcare professionals to encourage regular exercise, such as walking, to promote good bone and general health.

Two systematic reviews 10,11 suggest that calcium derived from the diet is as effective as that from pharmacological sources at maintaining adequate calcium balance in postmenopausal Caucasian women.The guideline recommends that postmenopausal women should aim for a dietary intake of 1000 mg of calcium per day. Sources of dietary calcium are listed in an annex to the guideline.

Pharmacological management

The guideline contains a comprehensive section on pharmacological treatment for osteoporosis which makes recommendations for patients in the following five groups:

  • Postmenopausal women with multiple vertebral fractures
  • Postmenopausal women with osteoporosis determined by axial DXA and with a history of at least one vertebral fracture
  • Postmenopausal women with osteoporosis determined by axial DXA with or without a previous non-vertebral fracture
  • Frail elderly women with a diagnosis of osteoporosis, with or without previous osteoporotic fracture
  • Men with a diagnosis of osteoporosis determined by axial DXA with or without previous osteoporotic fracture.

Hormone replacement therapy

Most women in the UK use HRT for the relief of unpleasant menopausal symptoms. It tends to be used for relatively short durations in the perimenopausal period 12 and is generally prescribed at an age when fracture risk is low.

There is evidence of the efficacy of HRT in the primary prevention of osteoporosis (an area outside the remit of the new SIGN guideline). However, there is less evidence for its use in osteoporosis management, so it is not yet possible to determine how effective HRT is at preventing fractures.

It is imperative to weigh up the complex risks and benefits of HRT and each patient considering treatment should be individually assessed. Therefore, we were unable to develop an evidence-based recommendation for HRT. The guideline does, however, contain a good practice point which recommends that HRT can be considered as a treatment option for osteoporosis, but that the risks and benefits should be discussed with each individual before starting treatment.

Duration, monitoring and combination of treatment

It is disappointing that there is very little evidence on the long-term effects of pharmacological treatment for osteoporosis, particularly as treatment is likely to be lifelong. Data on the combined use of different osteoporotic treatments are also scarce.

Although the guideline provides some guidance in these important areas it is clear that further research is required.

Patient information

SIGN worked very closely with the National Osteoporosis Society (NOS) during the development of the guideline. The NOS was represented on the guideline development group and it played a fundamental role in ensuring that patients’ concerns were highlighted and addressed.

Specific concerns were identified by reviewing calls received by the NOS helpline (managed by osteoporosis nurse advisers), contacting osteoporosis patients direct, and conducting literature reviews. In addition to responding to patients’ concerns in this manner, the guideline includes a useful information section for patients and their carers.

Further information for patients can be found on the websites of the NOS, at www.nos.org.uk, and NHS Health Scotland, at www.hebs.com/library.

Methodology

The guideline was developed using the SIGN guideline development methodology.13 A systematic literature review was carried out using a search strategy devised by members of the guideline development group. Searches were restricted to systematic literature reviews, meta-analyses, randomised controlled trials and longitudinal studies.

Internet searches were carried out on the websites of the Canadian practice guidelines Infobase, the UK Health Technology Assessment Programme, the US National Guideline Clearinghouse, and the US Agency for Healthcare Research and Quality. The search engines Google and OMNI were used, and all suitable links followed up. Database searches were carried out on the Cochrane Library, Embase 1993-2000 and Medline 1990-2000. Searches were later updated to June 2001.

The main searches were supplemented by material identified by individual members of the development group. All selected papers were evaluated using standard methodological checklists before being used as evidence.

Conclusion

We believe the new SIGN guideline will be an invaluable resource for GPs and other healthcare professionals. We are confident that if its recommendations are implemented it will help to ensure that those at risk of osteoporosis are identified and referred for scanning, and those with the condition are offered appropriate advice and treatment. It will also enable policymakers to allocate resources in a more effective, evidence-based way, to the benefit of all patients.

References

  1. Scottish Needs Assessment Programme: osteoporosis. Glasgow: Scottish Forum for Public Health Medicine, 1997.
  2. Torgerson D, Bell-Syer S. Hormone replacement therapy and prevention of non-vertebral fractures; a meta-analysis of randomised trials. JAMA 2001; 285(22): 2891-7.
  3. Scottish Intercollegiate Guidelines Network. SIGN 71. Management of osteoporosis. Edinburgh: SIGN, 2003.
  4. Lydick E,Cook K,Turpin J et al.Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care 1998; 4(1): 37-48.
  5. Garton M, Robertson E, Gilbert F et al. Can radiologists detect osteopenia on plain radiographs? Clin Radiol 1994; 49(2): 118-22.
  6. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001; 49: 664-72.
  7. Ernst E. Exercise for female osteoporosis. A systematic review of randomised clinical trials. Sports Med 1998; 25: 359-68.
  8. Kelley G. Aerobic exercise and lumbar spine bone mineral density in postmenopausal women: a meta-analysis. J Am Geriatr Soc 1998; 46: 143-52.
  9. Kelley GA,Kelley KS,Tran ZV. Resistance training and bone mineral density in women: a metaanalysis of controlled trials. Am J Phys Med Rehabil 2001; 80: 65-77.
  10. Heaney RP. Calcium, dairy products and osteoporosis. J Am Coll Nutr 2000; 19: 83S-99S.
  11. Weinsier RL, Krumdieck CL. Dairy foods and bone health: examination of the evidence. Am J Clin Nutr 2000; 72: 681-9.
  12. Hope S, Rees M. Why British women start and stop hormone replacement therapy. J Br Meno Soc 1995; 1: 26-8.
  13. Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline Developer’s Handbook. Edinburgh: SIGN, 2001.

Guidelines in Practice, October 2003, Volume 6(10)
© 2003 MGP Ltd
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