Updated UK Clinical Guidelines for Osteoporosis Emphasize Risk Assessment and Prevention

The UK National Osteoporosis Guideline Group released a 2017 update1 to previous versions from 2009 and 2013 developed by the Royal College of Physicians2,3 and the National Osteoporosis Guideline Group4,5 for the prevention of fragility fracture in postmenopausal women and in men aged 50 years or older.

The new guidelines were recently published in the Archives of Osteoporosis, and are based on systematic reviews and meta-analyses of epidemiologic and clinical data from the United Kingdom gathered between January 2009 and June 2016. The researchers chose to focus on diagnosis and long-term management of osteoporosis in patients ages >50 years. Considering the increase in the rates of hip fracture in men during the last decade, the researchers paid particular attention to this group.6 Management strategies for women with osteoporosis were also expanded on, in alignment with increasing rates of vertebral fractures in women.

An epidemiologic compendium report of osteoporosis in the European Union estimated that in 2010, 536,000 fragility fractures occurred in the United Kingdom alone, most commonly at the distal radius, proximal humerus, pelvis, proximal femur, and vertebrae.7 Other studies indicated that morbidity from fractures was extremely high, showing that an estimated 53% of people who experienced a hip fracture were not able to return to independent living. In addition, 28.7% of those patients were likely to die within a year of the event, and relative survival was significantly reduced during the 5 years after a fracture.8-11

The committee found that femoral neck and hip T-scores were still most commonly used to diagnose osteoporosis. Low bone mineral density (BMD) measurements added to diagnosis, and were found to be highly predictive of future fractures, with fracture risk increasing by 2-fold for every decrease in standard deviation from normal.12 Despite the high specificity, however, BMD had low sensitivity, indicated by the fact that “most fragility fractures will occur in women who do not have osteoporosis as defined by a T-score ≤ −2.5,” the committee reported.13

Several other factors were identified as improving the sensitivity of BMD assessment of fracture risk in men and women (independent of age and BMD), and included low body mass index, prior history of fracture, parental history of fracture, smoking, alcohol, and the use of glucocorticoids. The UK National Osteoporosis Guideline Group recommended use of the Fracture Risk Assessment Tool algorithm to assess 10-year probability of a future major fracture, as this tool provides the basis for intervention thresholds for therapy, including lifestyle modifications and bisphosphonates.

The committee also addressed concerns over rare risks of osteonecrosis of the neck and jaw and promotion of atypical femoral fractures associated with longer duration of bisphosphonate therapy. Most clinical trials of bisphosphonates have been conducted in postmenopausal women, with extensions only out to 3 years, the UK National Osteoporosis Guideline Group found.14 The evidence to date suggests that alendronate, ibandronate, and risedronate could be continued beyond 5 years, and zoledronic acid for 3 years, in specific situations, with treatment reviews performed at the designated 3- to 5-year mark.

These new guidelines promote a general shift in management focus for osteoporosis to prevention, stating that, “In the context of strategies for treating individuals at high risk of fracture, no distinction is made between prevention and treatment.” The guidelines offer extensive recommendations on the effective implementation of systematic secondary fracture prevention models.

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