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      UK clinical guideline for the prevention and treatment of osteoporosis

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          Abstract

          Introduction

          In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over.

          Methods

          Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.

          Results

          Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds.

          Conclusion

          The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management.

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          Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis.

          R M Neer, C Arnaud, J. Zanchetta … (2001)
          Once-daily injections of parathyroid hormone or its amino-terminal fragments increase bone formation and bone mass without causing hypercalcemia, but their effects on fractures are unknown. We randomly assigned 1637 postmenopausal women with prior vertebral fractures to receive 20 or 40 microg of parathyroid hormone (1-34) or placebo, administered subcutaneously by the women daily. We obtained vertebral radiographs at base line and at the end of the study (median duration of observation, 21 months) and performed serial measurements of bone mass by dual-energy x-ray absorptiometry. New vertebral fractures occurred in 14 percent of the women in the placebo group and in 5 percent and 4 percent, respectively, of the women in the 20-microg and 40-microg parathyroid hormone groups; the respective relative risks of fracture in the 20-microg and 40-microg groups, as compared with the placebo group, were 0.35 and 0.31 (95 percent confidence intervals, 0.22 to 0.55 and 0.19 to 0.50). New nonvertebral fragility fractures occurred in 6 percent of the women in the placebo group and in 3 percent of those in each parathyroid hormone group (relative risk, 0.47 and 0.46, respectively [95 percent confidence intervals, 0.25 to 0.88 and 0.25 to 0.861). As compared with placebo, the 20-microg and 40-microg doses of parathyroid hormone increased bone mineral density by 9 and 13 more percentage points in the lumbar spine and by 3 and 6 more percentage points in the femoral neck; the 40-microg dose decreased bone mineral density at the shaft of the radius by 2 more percentage points. Both doses increased total-body bone mineral by 2 to 4 more percentage points than did placebo. Parathyroid hormone had only minor side effects (occasional nausea and headache). Treatment of postmenopausal osteoporosis with parathyroid hormone (1-34) decreases the risk of vertebral and nonvertebral fractures; increases vertebral, femoral, and total-body bone mineral density; and is well tolerated. The 40-microg dose increased bone mineral density more than the 20-microg dose but had similar effects on the risk of fracture and was more likely to have side effects.
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            Interventions for preventing falls in older people living in the community

            Lesley Gillespie, M. Clare Robertson, William J Gillespie … (2012)
            Cochrane Database of Systematic Reviews
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              Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research.

              Elizabeth Shane, David Burr, Bo Abrahamsen … (2014)
              Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis of the femur have been reported in patients taking BPs and in patients on denosumab, but they also occur in patients with no exposure to these drugs. In this report, we review studies on the epidemiology, pathogenesis, and medical management of AFFs, published since 2010. This newer evidence suggests that AFFs are stress or insufficiency fractures. The original case definition was revised to highlight radiographic features that distinguish AFFs from ordinary osteoporotic femoral diaphyseal fractures and to provide guidance on the importance of their transverse orientation. The requirement that fractures be noncomminuted was relaxed to include minimal comminution. The periosteal stress reaction at the fracture site was changed from a minor to a major feature. The association with specific diseases and drug exposures was removed from the minor features, because it was considered that these associations should be sought rather than be included in the case definition. Studies with radiographic review consistently report significant associations between AFFs and BP use, although the strength of associations and magnitude of effect vary. Although the relative risk of patients with AFFs taking BPs is high, the absolute risk of AFFs in patients on BPs is low, ranging from 3.2 to 50 cases per 100,000 person-years. However, long-term use may be associated with higher risk (∼100 per 100,000 person-years). BPs localize in areas that are developing stress fractures; suppression of targeted intracortical remodeling at the site of an AFF could impair the processes by which stress fractures normally heal. When BPs are stopped, risk of an AFF may decline. Lower limb geometry and Asian ethnicity may contribute to the risk of AFFs. There is inconsistent evidence that teriparatide may advance healing of AFFs.
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                Author and article information

                Contributors
                J. Compston: jec1001@cam.ac.uk
                A. Cooper: alun.cooper@outlook.com
                C. Cooper: cc@mrc.soton.ac.uk
                N. Gittoes: Neil.Gittoes@uhb.nhs.uk
                C. Gregson: celia.gregson@bristol.ac.uk
                N. Harvey: nch@mrc.soton.ac.uk
                S. Hope: sallyhope@doctors.org.uk
                J. A. Kanis: w.j.pontefract@sheffield.ac.uk
                E. V. McCloskey: e.v.mccloskey@sheffield.ac.uk
                K. E. S. Poole: kenneth.poole@nhs.net
                D. M. Reid: d.m.reid@abdn.ac.uk
                P. Selby: Peter.Selby@cmft.nhs.uk
                F. Thompson: F.Thompson@nos.org.uk
                A. Thurston: A.Thurston@nos.org.uk
                N. Vine: nic@nicvine.com
                Journal
                Journal ID (nlm-ta): Arch Osteoporos
                Journal ID (iso-abbrev): Arch Osteoporos
                Title: Archives of Osteoporosis
                Publisher: Springer London (London )
                ISSN (Print): 1862-3522
                ISSN (Electronic): 1862-3514
                Publication date (Electronic): 19 April 2017
                Publication date PMC-release: 19 April 2017
                Publication date (Print): 2017
                Volume: 12
                Issue: 1
                Electronic Location Identifier: 43
                Affiliations
                [1 ]Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
                [2 ]Crawley Fracture Liaison Service, Crawley, Sussex, UK
                [3 ]ISNI 0000 0004 1936 9297, GRID grid.5491.9, MRC Lifecourse Epidemiology Unit, , University of Southampton, ; Southampton, UK
                [4 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, , University of Birmingham & Birmingham Health Partners, ; Birmingham, UK
                [5 ]Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
                [6 ]Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
                [7 ]ISNI 0000 0004 1936 9262, GRID grid.11835.3e, Centre for Metabolic Diseases, , University of Sheffield Medical School, ; Sheffield, UK
                [8 ]ISNI 0000 0004 1936 9262, GRID grid.11835.3e, Metabolic Bone, , University of Sheffield, ; Sheffield, UK
                [9 ]ISNI 0000 0004 1936 7291, GRID grid.7107.1, Emeritus Professor of Rheumatology, , University of Aberdeen, ; Aberdeen, UK
                [10 ]ISNI 0000000121662407, GRID grid.5379.8, Metabolic Bone Disease, , University of Manchester, ; Manchester, UK
                [11 ]ISNI 0000 0001 2189 1621, GRID grid.470689.4, , National Osteoporosis Society, ; Camerton, UK
                Article
                Publisher ID: 324
                DOI: 10.1007/s11657-017-0324-5
                PMC ID: 5397452
                PubMed ID: 28425085
                SO-VID: 23347a8e-8443-45f5-93d7-26ee74092941
                Copyright © © The Author(s) 2017
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 7 March 2017
                Date accepted : 7 March 2017
                Funding
                Funded by: University of Cambridge
                Categories
                Subject: Position Paper
                Custom metadata
                issue-copyright-statement © International Osteoporosis Foundation and National Osteoporosis Foundation 2017

                ScienceOpen disciplines: Orthopedics
                Keywords: osteoporosis,fracture,nogg,guideline
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: osteoporosis, fracture, nogg, guideline

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