Education Resource from the Society for Endocrinology
J R M Francis
Reader in Medicine (Geriatrics), University of Newcastle upon Tyne, and Consultant Physician, Bone Clinic, Freeman Hospital, Newcastle upon Tyne, NE7 7DN
Summer School 5-8 July 2005
St Aidan’s College, Durham University, Durham, UK
NICE published their Technology Appraisal of the Secondary Prevention of Osteoporotic Fragility Fractures in Postmenopausal Women in January 2005. This recommends that women aged 75 years and above presenting with an osteoporotic fracture should be offered bisphosphonate treatment, without the need for dual energy x-ray absorptiometry (DXA) measurement of bone mineral density density (BMD). In women under the age of 75 years, BMD measurements are advocated, to identify those who should be offered bisphosphonates. Treatment is considered to be cost effective in women between the ages of 65 and 74 years with evidence of osteoporosis (T Score <-2.5) and in women below the age of 65 years with a very low BMD (T Score <-3.0) or documented osteoporosis (T Score <-2.5) and an additional risk factor, such as low body mass index, family history of hip fracture and conditions associated with bone loss.
Raloxifene is recommended as an alternative treatment option in women who are unable to comply with the instructions on the administration of bisphosphonates, where bisphosphonates are contraindicated or not tolerated and in women who have had an unsatisfactory response to bisphosphonates. Unsatisfactory response to treatment is defined as the development of a further low trauma fracture and a declining BMD, despite full adherence for one year. Teriparatide is only recommended in women aged 65 years and older who have had an unsatisfactory response to bisphosphonates or intolerance to bisphosphonates and an extremely low BMD (T Score <-4.0) or a very low BMD (T Score <-3.0) and multiple fractures and one or more additional risk factors.
NICE guidance is welcome, as it emphasises the importance of secondary prevention of osteoporotic fractures and encourages the wider use of DXA measurements in the management of younger postmenopausal women with low trauma fractures. Disadvantages include the possibility that older women could be offered treatment unnecessarily and women below the age of 65 years with a low trauma fracture and a T Score between –2.5 and –3.0 may be denied effective treatment. Teriparatide will also effectively be restricted to women between the ages of 65 and 74 years with marked osteoporosis and a failure to respond to bisphosphonate treatment. It is important to appreciate that guidance arising from the NICE Technology Appraisal is based on cost effectiveness rather than clinical effectiveness alone and that the resulting recommendations do not override the clinician’s responsibility to make appropriate decisions in the circumstances of the individual patient.
The opinions expressed in this paper are those of the speaker and do not necessarily reflect the views of the Society
Revised:
28-Jul-2005