Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013
Introduction
In 2008 the National Osteoporosis Guideline Group (NOGG), in collaboration with many Societies in the UK, produced guidance for the diagnosis and management of osteoporosis in postmenopausal women and older men in the UK [1], [2]. Since that time there has been a number of advances in the field, particularly with respect to glucocorticoid-induced osteoporosis, the role of calcium and vitamin D therapy, and the benefits and risks of long-term bisphosphonate therapy. In addition new pharmacological interventions have been approved for the prevention of glucocorticoid-induced osteoporosis and the management of osteoporosis in postmenopausal women and men at increased risk of fracture. These advances have been incorporated into an updated version of the guideline, detailed below.
Section snippets
Diagnosis of osteoporosis
The diagnosis of osteoporosis relies on the quantitative assessment of bone mineral density (BMD), usually by central dual energy X-ray absorptiometry (DXA). BMD at the femoral neck provides the reference site. It is defined as a value for BMD 2.5 SD or more below the young female adult mean (T-score less than or equal to −2.5 SD). Severe osteoporosis (established osteoporosis) describes osteoporosis in the presence of one or more fragility fractures [3].
Diagnostic thresholds differ from
Investigation of osteoporosis
The range of tests will depend on the severity of the disease, age at presentation and the presence or absence of fractures. The aims of the clinical history, physical examination and clinical tests are to:
- •
exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma);
- •
identify the cause of osteoporosis and contributory factors;
- •
assess the risk of subsequent fractures;
- •
select the most appropriate form of treatment;
The procedures that may be relevant to the investigation of osteoporosis are
Clinical risk factors
At present there is no universally accepted policy for population screening in the UK to identify individuals with osteoporosis or those at high risk of fracture. Patients are identified opportunistically using a case finding strategy on the finding of a previous fragility fracture or the presence of significant CRFs [4], [5]. Some of these risk factors act independently of BMD to increase fracture risk whereas others increase fracture risk through their association with low BMD (e.g. some of
Postmenopausal women and men aged ≥50 years
Fracture probability should be assessed in postmenopausal women and in men aged 50 years or more using FRAX, where assessment would influence management.
- •
Women with a prior fragility fracture should be considered for treatment without the need for further risk assessment although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.
- •
In the presence of other CRFs, the 10-year probability of a major osteoporotic fracture (clinical spine, hip, forearm or
Intervention thresholds
The intervention threshold at each age is set at a risk equivalent to that associated with a prior fracture and, therefore rises with age. The proportion of women in the UK potentially eligible for treatment rises from 20% to 40% with age [5].
Probabilities of a major osteoporotic fracture (as well as hip fracture probabilities) can be plotted at the NOGG web site (www.shef.ac.uk/NOGG) available through FRAX (Fig. 1).
The chart is colour coded. Green denotes that an individual's risk lies below
Treatment of osteoporosis
General management includes assessment of the risk of falls and their prevention. Maintenance of mobility and correction of nutritional deficiencies, particularly of calcium, vitamin D and protein, should be advised.
Calcium and vitamin D supplementation
Calcium and vitamin D supplementation is widely recommended in older people who are housebound or living in residential or nursing homes, where vitamin D deficiency and low dietary calcium intake are common. Supplementation is also often advocated as an adjunct to other treatments for osteoporosis, as the clinical trials of these agents were performed in patients who were calcium and vitamin D replete. It has been suggested that calcium supplementation may potentially be associated with adverse
Duration and monitoring of therapy
In most patients at increased risk of fracture, treatment needs to be continued long-term. The beneficial effects of treatment with drugs other than bisphosphonates wear off soon after therapy is discontinued, but may be maintained for longer periods of time after cessation of bisphosphonate therapy. This, together with concerns over possible adverse effects of long-term bisphosphonate therapy, particularly osteonecrosis of the jaw and atypical femoral fractures [2], has raised questions over
Contributors
All authors contributed to the revision of the guideline. The paper was drafted by JEC and reviewed by all contributing authors.
Competing interest
All members of NOGG have provided details of potential conflicts of interest to the International Osteoporosis Foundation as follows: Roger Francis: Consultancy fees from Servier, Consilient Health and Amgen/GSK, and lecture fees from Servier, Amgen/GSK, Shire and Eli Lilly. David Reid: lecturer fees and/or consultancy fees for Amgen, Servier and Consilient Health. Alun Cooper: honoraria for Advisory Boards, Research Grants and/or Conference Invitations from Amgen, GSK, MSD, Novartis, Proctor &
Funding
The guideline development process was conducted without financial support from any commercial organisation and the members of the National Osteoporosis Guideline Group have maintained complete editorial independence.
References (17)
- et al.
Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK
Maturitas
(2009) - et al.
Changes in biochemical markers and bone mass after withdrawal of ibandronate treatment: prediction of bone mass changes during treatment
Bone
(1998) - Osteoporosis, Clinical guideline for prevention and treatment, www.shef.ac.uk/NOGG, Updated May...
Assessment of osteoporosis at the primary health-care level. Technical report
(2008)- et al.
FRAX® and the assessment of fracture probability in men and women from the UK
Osteoporosis International
(2008) - et al.
Case finding for the management of osteoporosis with FRAX® – assessment and intervention thresholds for the UK
Osteoporosis International
(2008) - et al.
Guidance for the adjustment of FRAX according to the dose of glucocorticoids
Osteoporosis International
(2011) - et al.
A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis
Osteoporosis International
(2012)
Cited by (247)
Intraoperative and post-procedural complications and disorders of musculoskeletal system hospitalization profile in England and Wales
2023, Clinical Epidemiology and Global HealthThe effect of drug holiday on preventing medication-related osteonecrosis of the jaw in osteoporotic rat model
2023, Journal of Orthopaedic TranslationBisphosphonate-based nanocomposite hydrogels for biomedical applications
2023, Functional Nanocomposite Hydrogels: Synthesis, Characterization, and Biomedical ApplicationsEffects of vitamin D, omega-3 fatty acids, and a simple home strength exercise program on fall prevention: the DO-HEALTH randomized clinical trial
2022, American Journal of Clinical NutritionTreatment of bisphosphonate induced osteonecrosis of jaw in rats using an angiogenesis factor (A-Heal) and ABMDO (Autologous Bone Marrow Derived Osteoblasts)
2022, Saudi Dental JournalCitation Excerpt :With bisphosphonates as first-line treatment for osteoporosis, the numbers of ONJ have increased and come into focus. ONJ affects the maxilla or the mandible and is associated with bisphosphonate therapy, and in 2003, the condition was defined as a pathological entity (Compston et al., 2013). Many theories have been proposed for the cause of ONJ, and it was suggested that ONJ occurs primarily due to disruption of vascular supply followed by impaired angiogenesis (Wan et al., 2020; Mücke et al., 2016; Pazianas, 2011; Reid, 2009).
- 1
On behalf of the National Osteoporosis Guideline Group (NOGG).