Dr Juliet Compston describes how the Bone and Tooth Society's update of the RCP guidelines on osteoporosis aims to improve the management of individual patients
In 1999, guidelines on the prevention and treatment of osteoporosis were prepared under the auspices of the Royal College of Physicians, sponsored by the Department of Health. These reviewed the assessment and diagnosis of osteoporosis, therapeutic agents available, and management strategies for the prevention and treatment of the disease.
The aim of these guidelines was not to produce a working document for clinical practice but to provide a framework from which local management protocols could subsequently be developed.
The guidelines were produced by an expert group after review by a range of relevant specialists and representatives of the Royal Colleges, professional societies and relevant patient organisations.
In July 2000, a supplement to the guidelines was produced with an updated account of therapeutic interventions and an algorithm for the management of individual patients.
This document was prepared by members of a working group of the Bone and Tooth Society (BATS) and the original Royal College of Physicians writing group.
Fractures due to osteoporosis are a major cause of morbidity and mortality in the elderly population. Individuals at risk present to a wide variety of specialists and also, increasingly, to primary care physicians.
The two main purposes of the supplement were:
- To provide up-to-date, evidence-based information on new therapeutic indications for existing and novel pharmacological interventions
- To distil an algorithm, from currently available evidence-based information, for the management of individual patients in clinical practice.
|Figure 1: Algorithm for the medical management of men and women over 45 years of age who have or are at risk of osteoporosis|
The grading of recommendations is shown in Table 1.
|Table 1: Grading of evidence base*|
Meta-analysis of randomised controlled trials (RCTs) or from at least one RCT
|Grade B||From at least one well-designed controlled study without randomisation|
|From at least one other type of well-designed quasi-experimental study|
|From well-designed non-experimental descriptive studies, e.g. comparative studies, correlation studies, case-control studies|
|Grade C||From expert committee reports/opinions and/or clinical experience of authorities|
These gradings were made solely on the basis of level of evidence for efficacy, irrespective of the size of the effect. It was also pointed out that for some agents there were inconsistencies between studies.
This grading of recommendations was used to construct tables summarising the effect of interventions on prevention/reduction of postmenopausal bone loss (Table 2) and on reduction of spine, non-vertebral and hip fracture (Table 3).
Table 2: Effect of interventions on the prevention/reduction of postmenopausal bone loss: grade of recommendations*
|Cessation of smoking||B|
|Hormone replacement therapy||A|
|Reduced alcohol consumption||C|
|Vitamin D + calcium||A|
Table 3. Anti-fracture efficacy of interventions in postmenopausal osteoporotic women: grade of recommendations*
|Calcium + vitamin D||nd||A||A|
|Hormone replacement therapy||A||A||B|
|nd = not demonstrated|
|* Tables 1,2 and 3 are reproduced from: Royal College of Physicians and Bone and Tooth Society of Great Britain. Osteoporosis: Clinical Guidelines for Prevention and Treatment. Update on pharmacological interventions and an algorithm for management. London: RCP, 2000, pp 3 & 4, by kind permission of the Royal College of Physicians|
At present, many individuals who are at risk of osteoporosis or who already have the disease do not receive appropriate management. This is largely because even strong risk factors such as a previous fragility fracture and glucocorticoid therapy are not sufficiently well recognised.
The update provides evidence-based information on risk assessment, diagnosis and pharmacological and non-pharmacological interventions which can be used by medical practitioners to improve both the detection and treatment of osteoporosis.
Some of the main points contained in the supplement, in addition to the grading of recommendations for different interventions and the management algorithm, are summarised below:
- The management of osteoporosis in clinical practice is based on a selective case-finding approach, in which individuals with risk factors for, or evidence of the disease are referred for investigation and, where indicated, treatment.
- A variety of bone mass measurement techniques is predictive of fracture. However, measurements made at different sites and/or using different technologies are not well correlated and a universal diagnostic criterion is therefore inappropriate.
- In order to avoid variations in disease classification, measurement of total hip bone mineral density by dual-energy X-ray absorptiometry is most appropriate for the diagnosis of osteoporosis.
- Fracture risk in an individual patient should ideally be expressed as absolute risk and related to a relevant time interval, e.g. 10 years. A variety of bone mass measurements, together with clinical risk factors and biochemical markers of bone turnover, can be used for fracture risk assessment. This approach is likely to be increasingly used in the future to determine thresholds for intervention as opposed to diagnosis.
- In recent years, there has been a move away from long-term preventive strategies towards shorter-term intervention in high-risk individuals. Significant reductions in vertebral and non-vertebral fracture have been demonstrated for some interventions after only one year's treatment in women with established osteoporosis.
- As yet there is no established treatment for men with osteoporosis although there is evidence that the response to bisphosphonates in men is similar to that in women. Referral to a specialist centre should be considered for men with osteoporosis, particularly those aged <65 years.
The update document will be widely disseminated to medical practitioners in primary and secondary care. It is also being distributed to health authorities and others involved in healthcare policy to encourage the provision of adequate resources at a national and local level for the management of patients with osteoporosis.
Implementation of these relatively simple and evidence-based recommendations in clinical practice will ensure that individuals at risk of fracture are identified and treated appropriately, with the ultimate aim of reducing the burden of osteoporotic fractures in the population.