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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Prevention of Fractures

The National Institute of health and Clinical Excellence (NICE) published a technology appraisal on the secondary prevention of osteoporotic fractures in postmenopausal women in January 2005.

NICE are also working on a similar appraisal aimed at primary prevention but until this is published it will be difficult to assess who to treat as primary prevention should be based upon a risk assessment.

The Secondary Prevention appraisal recommends that unless patients have an adequate dietary calcium intake and are vitamin D replete that they be provided with supplementation. Continual monitoring and assessment of diet would be required in order to assure adequate levels of calcium and vitamin D are maintained and therefore provision of supplementation may be sensible in most cases. Suitable supplements (which should be prescribed by brand to avoid confusion) are as follows:

  • Adcal-D3® tablets
  • Calcichew-D3® Forte tablets
  • Calceos® tablets
  • Calfovit D3® granules

The NICE appraisal recommends that Bisphosphonates should be prescribed to women who have already had an osteoporotic fragility (low impact) fracture providing they are:

  • Aged over 75 years old
  • Aged 65 to 74 years old and T-Score from a DEXA scan is at least -2.5 SD
  • Aged below 65 years old and T Score from a DEXA scan is at least -3 SD or -2.5 SD and the patient has at least one additional risk factor

The appraisal also recommends that choice of bisphosphonate is based upon an assessment of efficacy against tolerability and adverse effects in individual patients.

There are currently four bisphosphonates available on the NHS in the UK that are licensed for use in osteoporosis, these are:

  • Alendronate
  • Etidronate
  • Ibandronate
  • Risedronate

The main aim of treatment is to prevent hip fractures due the impact these have on morbidity, mortality and quality of life. Studies of the bisphosphonates have looked the drugs beneficial effects on the rate of vertebral and non-vertebral fractures.

All of these drugs reduce the rate of vertebral fractures, but hip fractures are included in the non-vertebral data. Currently, only alendronate and risedronate have shown reductions in the rates of non-vertebral fractures. Clinical evidence ranks both of these drugs as beneficial. Choosing between alendronate and risedronate as a first line treatment option therefore must involve an assessment of acquisition cost. Alendronate is now off patent and therefore has a lower acquisition cost making it the first line choice where a bisphosphonate is indicated.

Action: Clinicians who encounter postmenopausal women with fragility fractures should be aware of the NICE Technology Appraisal. Adequate calcium and vitamin D supplementation should be provided where appropriate and alendronate is the first-line evidence-based bisphosphonate.

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