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NICE issues fracture prevention guidance

The National Institute for Health and Clinical Excellence (NICE) has issued guidance for the primary and secondary prevention of fractures due to osteoporosis in postmenopausal women. The full guidance documents are currently available with quick reference guides (QRGs) and patient information due for publication shortly.

The full guidance documents for primary (PDF) and secondary (PDF) prevention contain the recommendations with a full discussion of the evidence and interpretation. This guidance has taken several years to complete (the final scope was published in October 2004) and is perhaps the most complicated set if guidance to be issued by NICE.

Action: Clinicians who treat patients with osteoporosis with the aim of preventing primary or secondary fractures should assess the recommendations made in these two documents and implement necessary changes to practice (More details are provided below). It is hoped that the QRGs will be available soon and make the advice more accessible.

Primary Prevention

The Primary Prevention guidance makes treatment recommendations based upon age, clinical risk factors and indicators of low bone mineral density (BMD).

Clinical risk factors defined in the document are parental history of hip fracture, alcohol intake of 4 or more units per day and rheumatoid arthritis.

Indicators of low BMD are defined as BMI less than 22kg/m2, medical conditions such as ankylosing spondylitis, Crohn’s disease, conditions that result in prolonged immobility, and untreated premature menopause.

Women aged 65 years and older with a confirmed osteoporosis (BMD T-score of -2.5 SD or below) and an independent clinical risk factor for fracture and at least one additional indicator of low BMD are recommended for treatment with alendronate in addition to ensuring adequate calcium intake and vitamin D levels either through diet or supplementation.

As age increases the number of additional risk factors or indicators of low BMD required to be recommended for treatment are fewer until at age 75 a diagnosis of osteoporosis can be assumed if a DXA scan to be clinically inappropriate or unfeasible.

Alternative treatments are recommended (including etidronate, risedronate and strontium renelate) in place of alendronate if patients cannot comply with the treatment, have a contraindication to or are intolerant of alendronate however the recommendations vary based upon the combination of T-score, age and number of independent clinical risk factors.

Raloxifene is not recommended for primary prevention.

Secondary Prevention

The Secondary Prevention guidance makes treatment recommendations based upon age and the clinical risk factors defined above.

Alendronate is recommended first line.

Risedronate and etidronate are recommended as second line alternative treatment options where patients are unable to comply, are intolerant or are contraindicated to treatment with alendronate however the combination of T-score, age and number of independent clinical risk factors becomes more stringent.

Strontium ranelate and raloxifene are recommended as third line alternative treatment options where patients cannot comply with, tolerate or are contraindicated to alendronte or one of the second line drugs. Again the combination of factors becomes more stringent.

Teriparatide is recommended as a final option is patients who cannot comply with, tolerate or are contraindicated to alendronte and second and third line recommendations or who have who have had an unsatisfactory response defined as another fragility fracture despite adhering to 1 year of treatment with evidence of continued decline in BMD.