Clinical Features

Osteoporosis Clinical Practice Guidelines: An Update

Written by: Professor John J. Carey, Consultant Physician in Rheumatology and Medicine, Clinical Lead in Osteoporosis, DXA and Fracture Liaison Services – Catherine Armstrong, Clinical Nurse Specialist in Osteoporosis and Fiona Heaney, Clinical Nurse Specialist in Osteoporosis

All at: Centre for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, Merlin Park Campus, Galway University Hospitals, Ireland.

School of Medicine and Health Sciences, University of Galway, Ireland.

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What are Clinical Practice Guidelines?

Clinical Practice guidelines (CPGs) form an essential part of modern medicine.1 In essence they provide a set of recommendations for health professionals derived by expert committees reflecting a summary of the evidence, opinions on the strength and relevance of the evidence, the benefits and harms, and consensus.1-3 CPGs can improve and standardise the assessment and management of important clinical disorders1,3 While the concept of evidencebased medicine is a good one, agreement between experts is not universal, particularly with respect to what constitutes good evidence, what to include, how much and for whom.1,4-12 An overly rigorous process compiling excessive output may prove redundant, and cause confusion.1,3,6 Practitioners confidence in, use of, and preference for CPGs varies.3,13,14

In osteoporosis huge gaps remain between best evidence and CPGs and what transpires in clinical practice.14-18 Key remaining challenges include clearly defining what constitutes quality, and harmonizing guidelines.13,14,16-20

What is Osteoporosis?

Osteoporosis is one of the commonest non-communicable diseases in the world today.2,13,14,16,19-24 This disease results in skeletal failure manifest as clinical events known as fragility fractures.13,14,16,19,20 Bone mineral density measurement is the test of choice for diagnosis of osteoporosis in older men and women without a prior fracture, which can also be incorporated into various algorithms to assess the risk of fracture and monitor the effectiveness of interventions over time.2,14,20,21,24 Osteoporosis and the associated fractures can be very detrimental to patients quality and quantity of life, and are associated with large healthcare costs.2,13,14,16,22-24 Although hundreds of CPGs have been formulated to address both primary and secondary prevention, considerable heterogeneity exists, but as outlined in table 1 the general principles are broadly similar.2,13,14,16,18-20,22-24 In this article we will focus on key principles captured in more recent American, Asian and European guidelines which we believe have relevance for managing our patients in Ireland.2,13,14,16,18-20,22-24

General Principles of Osteoporosis Clinical Practice Guidelines

The basic principles for the identification, evaluation and management of postmenopausal women and men aged 50 years and older are shared among osteoporosis experts, outlined in Table 1. However explicit terminology, level of detail and homogeneity of structure and content can vary.14,22-25 These contrast with recommendations from others whose expertise focuses on evidence rather than illness.2,26 Yet many of the core principles align with a universal goal – fracture preventionthough they differ in strength of recommendations, detail or philosophy of evidence.2,14,22-26

The first principle involves identification of those at risk for primary prevention, or with a prior fragility fracture for secondary prevention. A number of different strategies are suggested including case-finding, fracture liaison services, and screening those without prior fractures using either a multifactorial assessment tool, bone mineral density (BMD) measurement and vertebral fracture assessment or some combination of these.2,14,22-26

Measurement of BMD and fracture risk assessments are explored in great detail in some CPGs,22-25 while others are less specific or less enthusiastic,2,14,26 particularly when it comes to monitoring the effect of any intervention. There is general agreement screening (testing those without signs or symptoms of a disease) for postmenopausal women is clinically and cost effective, usually women aged 65 years and older. Although there is agreement screening older men is important, when, how and what to do requires further clarification and consensus.2,13,14,20-26 Importantly what is not explicitly stated is also important and needs more emphasis: not to screen healthy younger people who are not at risk. This is because all testing is imperfect, and overdiagnosis can occur, with important consequences for the patient including further unnecessary testing and concern, and unproven treatment. Unfortunately in Ireland multiple proposals for a national osteoporosis programme, and more recently an osteoporosis screening programme have been rejected. Contemporaneously a daft plan to provide free DXA scans for everyone who wants one is being funded by the tax payer which will do nothing to address quality, standards or appropriate osteoporosis care for our population. This will cost far more in the long run than one where scientific evidence and expert consensus is the foundation, and is already wreaking havoc with our patients.

Those identified at risk should undergo further evaluation to identify risk factors, in particular those which are amenable to modification such as smoking, excessive alcohol and glucocorticoid use. Assessment and management of fall risk is unanimous, though details on performance and management varies considerably. All agree addressing adequate nutrition, in particular an appropriate amount of intake of calcium and vitamin D. Exercise, physiotherapy and rehabilitation are widely acknowledged.14,22-25 The largest study ever performed which randomised postmenopausal women to calcium and vitamin D or placebo showed this practice does not reduce the risk of fracture, and actually more than doubles the risk in younger postmenopausal women.27

Treatment of low BMD with osteoporosis medication is the single most effective proven intervention for those with this disease or at high risk for fracture.2,13,14,16-20,22-26, and this principle has universal appeal to all CPGs . However this is where the greatest discordance exists in principles of who to treat, with what, for how long and how to monitor adherence, compliance and success.2,13,14,16,23-26 In general osteoporosis medications’ are very safe and very effective once prescribed and taken correctly. While side-effects can occur, they are usually mild and benign.

Unfortunately exaggerations of harm despite a lack of robust evidence to support this, in contrast to the huge evidence to support their use has limited their effectiveness in practice and undermined the whole principle of evidence-based medicine.2,13,16,17,19,22-26 Resolving this to ensure all women with postmenopausal osteoporosis and men aged 50 years and older with osteoporosis, in particular those with prior fragility fractures are prescribed them would have the greatest individual and population health benefit.15 Effective communication and discussion with patients to educate and empower them, and address their preferences and concerns is crucial for effective engagement.14,22

Some guidelines also address other areas critical to patient care, such as surgery, local bone enhancement procedures like kyphoplasty, pain management and rehabilitation of the patient post fracture.22-24 These important areas should not be overlooked as adequate pain control and a multidisciplinary assessment and management are essential to hasten patient recovery and independence following such events. Ireland lacks such programmes, but services are gaining momentum nationally with the appointment for the first time of several advanced nurse practitioners in Ireland in 2022 to support fracture liaison services.

Monitoring of patients to address their ongoing needs, and treatment compliance and effectiveness is needed.2,13,14,20-26 This includes history and physical examinations, discussions around their lifestyle choices, other medical problems as well as their osteoporosis management and medications, and biochemical and DXA testing. Standards for monitoring BMD have been established for more than 20 years, which include sending patients back to the same centre where the least significant change is known (a combination of measurement error and random error with a 95% confidence interval) in order to know whether the BMD or other DXA features have actually changed or not. H.S.E. funded and insurance companies in Ireland are undermining this whole principle of appropriate care by sending unsuspecting patients to different centres for repeat DXA scans which provides no clinically useful information. This is one more reason why a national programme is more essential than ever.

CPGs represent a roadmap to improve and standardise the care of patients. These are evidence-based consensus recommendations in so far as is possible. Today the principles for osteoporosis assessment and management are universally agreed across North America, Europe and the Asia-Pacific region.2,13,14,20-26 Experts agree a “one-size fits all approach” is not appropriate and tailored recommendations are needed for individual patients.1-6,10,13,14,20-26 However it is time a national programme for osteoporosis care in Ireland is put in place to provide basic standards of quality care for all patients with osteoporosis. Solutions to bring best practice into everyday use would be hugely rewarding, and far more clinically and cost effective for our patients and the taxpayer.15

References available on request

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