National Osteoporosis Society Research Articles

Aromatase inhibitors and fracture prevention – do 2017 guidelines work in real world?

ObjectivesAromatase inhibitor induced bone loss (AIBL) is a recognised adverse event with resultant increase in fracture risk. We aimed to determine the real-world impact of the 2017 consensus guidelines on AIBL and see if it is effective in fracture prevention.MethodsOver a 7-year study period, 1001 women prescribed AI were split in two groups. First group were offered bone active treatment based on NOS 2008 guidelines whereas the second group followed the 2017 consensus guidelines.Results1001 women were included.First group: 361 women had a baseline DEXA with 143 (40%) women who had a normal DEXA, 174 (48%) had osteopenia and 44 (12%) had osteoporosis. Of the women with osteopenia, 44 (25%) women were offered treatment, and 22 (13%) women had a fracture. Second group: 640 women had a baseline DEXA with 216 (33%) women with a normal result, 322(50%) had osteopenia and 107 (17%) had osteoporosis. Of the women with osteopenia, 127 (39%) women were offered treatment, and 8 (2.5%) women had a fracture.ConclusionsOur study provides real world evidence of the success of 2017 consensus statement in lowering fracture risk. A significant reduction in fractures pre (13%) and post guidelines change (2.5%) was demonstrated (absolute risk reduction of 10.5%) which has implications for healthcare systems worldwide as we have demonstrated this approach can reduce morbidity.Lay summaryBreast cancer is the most common cancer in women with over two million women diagnosed with it annually. Early diagnosis and treatment with hormonal therapies have helped reduce mortality. Aromatase inhibitors (AIs) are the main drugs in this class and have demonstrated improved survival. However, whilst conveying major benefits, AIs reduce oestrogen levels leading to significant bone loss and increasing fracture risk. Several protocols have been recommended to address this concern. We compared the two guidelines published by National Osteoporosis Society UK in 2008 and consensus statement recommended by seven breast cancer and bone health groups in 2017 to see which work better in preventing fractures in women prescribed AIs for breast cancer. Our study shows that the 2017 guidelines are better at preventing fractures in the real world. Hence, we suggest that these should be adopted by specialists treating breast cancer which can help women avoid fractures and improve long term health.

Vitamin D monitoring and management in the inpatient services – reaudit

AimsTo survey the prevalence of monitoring of vitamin D on an inpatient ward.To audit the treatment if there is identified vitamin D deficiency or insufficiencyTo compare differences between findings in auditsMethodAll inpatients admitted to Milford centre between August 2019 and August 2020 were selected as part of the sample size.Data were collected by FY1 and FY2Patients’ laboratory results were accessed to determine vitamin D levels.E-notes were used to conclude who were vitamin D sufficient or deficient for treatmentThe standard for the audit were as per:Management of vitamin D deficiency or insufficiency in adults – CKS (2018)The above was based on National Osteoporosis Society (NOS) guideline Vitamin D and bone health: a practical clinical guideline for patient management [National Osteoporosis Society, 2013] and Scientific Advisory Committee on Nutrition (SACN) guidelineResult201748/188 patients had vitamin D levels measured36/48 patients had sufficient vitamin D levels12/48 patients were either deficient or insufficient12/12 patients were treated where found deficient or insufficient202090/115 patients had vitamin D levels measured47/90 patients had sufficient vitamin D Levels43/90 patients had either insufficient or deficient vitamin D levels22/43 patients had treatment documented in noted where found deficient or insufficientConclusionDifficult to make comparisons with previous audit due to difference in number of patients testedVitamin D is routinely tested on Milford ward on admission hence the large number compared to the last audit52% had noted to have sufficient levels of vitamin DConcerning were results that only 51% of those deemed to have insufficient or deficient were treated based on notesPotential reasons could be:Prescribed in medication card and not documented in notes.Vitamin D results checked in another ward, no supplementation given, and then transferred to Milford house.Patients refused treatment but not documented adequately.Patient discharged before results were received due to quick aroundResults were deemed insufficient in terms of the range but very close to normal hence decision made not to start supplementationResults to be disseminated with medical and nursing colleaguesRe-audit in September 2021

PMS54 FRACTURE LIAISON SERVICES

Osteoporosis and fractures are a significant burden on the NHS. Fracture liaison services (FLS) may help alleviate this burden through accelerated comprehensive, multidisciplinary care. This study aimed to assess compare the healthcare resource use and relevant clinical outcomes of patients treated at hospitals with an FLS with those without an FLS. The investigators utilized Hospital Episode Statistics, an administrative healthcare dataset covering all secondary care interactions in England. Patients with newly diagnosed fragility fractures and osteoporosis were identified with the relevant ICD-10 from April 2012 to March 2018 in the dataset. An audit performed by the National Osteoporosis Society was utilized to classify trusts into gold (fully configured FLS), grey (partially configured FLS), and black (no FLS) in 2016. Healthcare resource use and clinical outcomes were assessed. Comparisons were made between patients in treated among the 3 cohorts, where matching based on age, sex, fracture site, socioeconomic deprivation and Charlson Co-Morbidity Index was performed. There were 51,212, 72,149, and 106,689 patients included from gold, grey and black trusts, respectively. Refracture rates, rates of pneumonia, deep vein thrombosis, and inpatient mortality do not appear to have significantly decreased between gold and black, and grey and black trusts, with p > 0.05. However, trusts with an FLS have a significant reduction in non-elective admissions (p< 0.0001), mean length of stay (p<0.0001), and outpatient appointments (p<0.0001). There were significant inpatient and outpatient cost savings of £176.08 per patient (p< 0.0001) among those treated in trusts with an FLS compared to those without. This trend held for both 1 year and 2 years from fracture. FLS do not appear to reduce morbidity post-fracture, but result in significant cost savings to the healthcare system. Deeper investigation into the impact of FLS should be performed, along with an examination of proper implementation of such services.

Public priorities for osteoporosis and fracture research: results from a general population survey

SummaryThis is the first national study of public and patient research priorities in osteoporosis and fracture. We have identified new research areas of importance to members of the public, particularly ‘access to information from health professionals’. The findings are being incorporated into the research strategy of the National Osteoporosis Society.PurposeThis study aimed to prioritise, with patients and public members, research topics for the osteoporosis research agenda.MethodsAn e-survey to identify topics for research was co-designed with patient representatives. A link to the e-survey was disseminated to supporters of the UK National Osteoporosis Society (NOS) in a monthly e-newsletter. Responders were asked to indicate their top priority for research across four topics (understanding and preventing osteoporosis, living with osteoporosis, treating osteoporosis and treating fractures) and their top three items within each topic. Descriptive statistics were used to describe demographics and item ranking. A latent class analysis was applied to identify a substantive number of clusters with different combinations of binary responses.ResultsOne thousand one hundred eighty-eight (7.4%) respondents completed the e-survey. The top three items overall were ‘Having easy access to advice and information from health professionals’ (63.8%), ‘Understanding further the safety and benefit of osteoporosis drug treatments’ (49.9%) and ‘Identifying the condition early by screening’ (49.2%). Latent class analysis revealed distinct clusters of responses within each topic including primary care management and self-management. Those without a history of prior fracture or aged under 70 were more likely to rate items within the cluster of self-management as important (21.0 vs 12.9 and 19.8 vs 13.3%, respectively).ConclusionThis is the first study of public research priorities in osteoporosis and has identified new research areas of importance to members of the public including access to information. The findings are being incorporated into the research strategy of the National Osteoporosis Society.

Delivering a quality-assured fracture liaison service in a UK teaching hospital-is it achievable?

To determine whether new national guidance on the specifications of a fracture liaison service are realistically deliverable, 1year of data on the performance of such a service were audited. Audit targets were mostly met. This audit demonstrates that these standards are deliverable in a real world setting. UK service specifications for a fracture liaison service (FLS) have been produced (National Osteoporosis Society, NOS) to promote effective commissioning and delivery of the highest quality care to patients with fragility fractures. How deliverable these standards are has not as yet been methodically reported. Our FLS was modelled on the ten NOS standards; performance was audited after 1year to determine whether these standards could be delivered and to describe the lessons learnt. Performance was audited against the NOS FLS Service Standards, with management based on the Fracture Risk Assessment Tool (FRAX®), the four-item Falls Risk Assessment Tool (FRAT), National Institute for Health and Care Excellence (NICE) and the National Osteoporosis Guideline Groups (NOGG) guidance. Data were recorded prospectively on a database. The FLS commenced in May 2014, was fully operational in August 2014 and data were captured from 1 September 2014 to 1 September 2015. The FLS detected 1773 patients and standards were largely achieved. Most, 94%, patients were seen within 6weeks, 533 DXA requests were generated, 804 outpatient FRAT assessments were recorded (134 required falls intervention) and 773 patients had bone treatments started. On follow-up at 3months, between 78-79% were still taking medication. Preliminary evaluation of a FLS implemented according to UK NOS standards demonstrates that the model is practical to apply to a large teaching hospital population. Collection and review of outcome and cost effectiveness data is required to determine the performance of this model in comparison with existing models.

Assessment of bone mineral content and fracture risk: a UK prospective cohort study

BackgroundPoor early growth is associated with reduced adult bone mineral content (BMC), but not bone mineral density (BMD). Although low BMD is a well-established risk factor for future fracture, little is known about the performance characteristics of BMC in fracture prediction. We therefore investigated the predictive value of bone area, BMC, and BMD for incident fracture in a prospective cohort of UK women. MethodsWomen aged 20–80 years, recruited from four general practices in Southampton, underwent assessment by dual energy X-ray absorptiometry between 1991 and 1993. All women were then contacted in 1998–99 with a validated postal questionnaire to collect information on incident fractures and potential confounding factors including medication use. All fractures were confirmed by assessment of images and radiology reports by a research nurse. Cox proportional hazards models were used to explore the risk of incident fracture and results expressed as gradient of risk (GR) and 95% CI. Associations were adjusted for age, body-mass index, alcohol consumption, smoking, hormone replacement therapy, medications, and history of fracture. This study was approved by the Southampton Joint Ethics Committee. Findings674 women were recruited and 443 responded to the questionnaire. 55 women (12%) reported a fracture. In fully adjusted models, femoral neck BMC and BMD were similarly predictive of incident fracture (GR 1·64, 95% CI 1·19–2·26 [p=0·002] and 1·76, 1·19–2·60 [p=0·005], respectively). By contrast, femoral neck bone area was not associated with incident fracture (1·15, 0·88–1·50; p=0.32). Similar results were found with bone indices at the lumbar spine and whole body. InterpretationBMC and BMD seem to predict incident fracture with similar gradients of risk, even after adjustment for body size. These findings suggest that factors in early life that are associated with total skeletal mineralisation are likely to have implications for adult fracture risk. FundingMedical Research Council; British Heart Foundation; Arthritis Research UK; National Osteoporosis Society; International Osteoporosis Foundation; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford.

National Osteoporosis Society.

Established in 1986, the National Osteoporosis Society has 25,000 members and employs 50 staff. With an estimated three million people in the UK living with osteoporosis, this website performs a valuable information service.

Calcaneal quantitative ultrasound and phalangeal radiographic absorptiometry alone or in combination in a triage approach for assessment of osteoporosis: a study of older women with a high prevalence of falls.

BackgroundThe objective of this study was to investigate if application of United Kingdom National Osteoporosis Society (UK-NOS) triage approach, using calcaneal quantitative ultrasound (QUS), phalangeal radiographic absorptiometry (RA), or both methods in combination, for identification of women with osteoporosis, would reduce the percentage of women who need further assessment with Dual Energy X-ray Absorptiometry (DXA) among older women with a high prevalence of falls.MethodsWe assessed 286 women with DXA of hip and spine (Hologic Discovery) of whom 221 were assessed with calcaneal QUS (Achilles Lunar), 245 were assessed with phalangeal RA (Aleris Metriscan), and 202 were assessed with all three methods. Receiver operator characteristics (ROC) curve for QUS, RA, and both methods in combination predicting osteoporosis defined by central DXA were performed. We identified cutoffs at different sensitivity and specificity values and applied the triage approach recommended by UK-NOS. The percentage of women who would not need further examination with DXA was calculated.ResultsMedian age was 80 years (interquartile range [IQR]) [75–85], range 65–98. 66.8% reported at least one fall within the last 12 months. Prevalence of osteoporosis was 44.4%. Area under the ROC-curve (AUC) (95% confidence interval (CI)) was 0.808 (0.748-0.867) for QUS, 0.800 (0.738-0.863) for RA, and 0.848 (0.796-0.900) for RA and QUS in combination. At 90% certainty levels, UK-NOS triage approach would reduce the percentage of women who need further assessment with DXA by 60% for QUS, and 43% for RA. The false negative and false positive rates ranged from 4% to 5% for QUS and RA respectively. For the combined approach using 90% certainty level the proportion of DXAs saved was 22%, the false negative rate was 0% and false positive rate was 0.5%. Using 85% certainty level for the combined approach the proportion of DXAs saved increased to 41%, but false negative and false positive values remained low (0.5%, and 0.5% respectively).ConclusionsIn a two-step, triage approach calcaneal QUS and phalangeal RA perform well, reducing the number of women who would need assessment with central DXA. Combining RA and QUS reduces misclassifications whilst still reducing the need for DXAs.

National Osteoporosis Society vitamin D guideline summary.

The National Osteoporosis Society (NOS) published its document, Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management, in 2013 as a practical clinical guideline on the management of vitamin D deficiency in adult patients with, or at risk of developing, bone disease. There has been no clear consensus in the UK on vitamin D deficiency its assessment and treatment, and clinical practice is inconsistent. This guideline is aimed at clinicians, including doctors, nurses and dieticians. It recommends the measurement of serum 25 (OH) vitamin D (25OHD) to estimate vitamin D status in the following clinical scenarios: bone diseases that may be improved with vitamin D treatment; bone diseases, prior to specific treatment where correcting vitamin D deficiency is appropriate; musculoskeletal symptoms that could be attributed to vitamin D deficiency. The guideline also states that routine vitamin D testing is unnecessary where vitamin D supplementation with an oral antiresorptive treatment is already planned and sets the following serum 25OHD thresholds: <30 nmol/l is deficient; 30-50 nmol/l may be inadequate in some people; >50 nmol/l is sufficient for almost the whole population. For treatment, oral vitamin D3 is recommended with fixed loading doses of oral vitamin D3 followed by regular maintenance therapy when rapid correction of vitamin D deficiency is required, although loading doses are not necessary where correction of deficiency is less urgent or when co-prescribing with an oral antiresorptive agent. For monitoring, serum calcium (adjusted for albumin) should be checked 1 month after completing a loading regimen, or after starting vitamin D supplementation, in case primary hyperparathyroidism has been unmasked. However, routine monitoring of serum 25OHD is generally unnecessary but may be appropriate in patients with symptomatic vitamin D deficiency or malabsorption and where poor compliance with medication is suspected. The guideline focuses on bone health as, although there are numerous putative effects of vitamin D on immunity modulation, cancer prevention and the risks of cardiovascular disease and multiple sclerosis, there remains considerable debate about the evaluation of extraskeletal factors and optimal vitamin D status in these circumstances.

OP0015 Changing Patterns of Requests for Measurement of Vitamin D in Primary Care: an Observational Study

BackgroundThere is increasing awareness of the importance of vitamin D for maintaining musculoskeletal health by both the medical profession and the public. Vitamin D appears to have effects on both...

Association between body composition and subsequent childhood asthma and wheeze outcomes in the Southampton Women's Survey cohort study

BackgroundObesity is associated with adult asthma, notably non-atopic asthma. The association between obesity and childhood asthma is unclear and complicated by changes in body composition during growth. We aimed to determine whether and how body composition and change in body composition are associated with childhood asthma, wheeze, and atopic outcomes. MethodsParticipants were 940 children born between February, 2000, and June, 2003, to women recruited within the Southampton Women's Survey. Body composition was characterised with body-mass index (BMI) at 3 years and 6 years of age, standardised for age and sex; lean and fat mass measured at 4 years and 6 years of age with dual energy X-ray absorptiometry (DEXA) scanning; and serial measures of subscapular skinfold thickness. Relative risks were calculated with Poisson regression for questionnaire-determined asthma and wheeze at age 6 years. Wheeze was defined as atopic or non-atopic according to skin prick testing. Spirometry, bronchial hyper-responsiveness (BHR), and fractional exhaled nitric oxide (FeNO) were assessed at 6 years of age. Potential maternal and socioeconomic confounders were adjusted for and exposure variables combined in multivariable models. Written informed parental consent was obtained for each participant. The study was approved by the Southampton and South West Hampshire Local Research Ethics Committee. FindingsBMI at 6 years of age was not associated with asthma, atopy, any wheeze phenotype, or measure of lung function. Higher BMI at age 3 years was associated with greater BHR at age 6 (p=0·032) and with lower forced expiratory volume in the first second of expiration corrected for lung size by dividing by forced vital capacity (FEV1/FVC) (p=0·013). Although a conditional increase in subscapular skinfold thickness between 1 and 2 years was associated with asthma at age 6 years (relative risk 1·27, 95% CI 1·07–1·51), a decrease in subscapular skinfold thickness between 2 and 3 years was associated with increased risks of asthma (0·73, 0·55–0·96), wheeze, atopy, and atopic wheeze at age 6 years and with greater FeNO. InterpretationCurrent BMI at 6 years was not associated with asthma symptoms or impaired lung function in this cohort of children at age 6 years, although a higher BMI at age 3 years was associated with increased BHR and reduced FEV1/FVC at age 6 years. More rapid adiposity gain between ages 1 and 2 years was associated with increased asthma risk; although this finding might be an adverse effect of increased adiposity on respiratory development, rapid postnatal adiposity gain might be catch-up growth and might be a marker for adverse in-utero factors. By contrast, lower adiposity gain between 2 and 3 years was associated with asthma and markers of atopy and eosinophilic airway inflammation, suggesting that factors associated with poor weight gain in this period, such as recurrent respiratory infection, might predispose to atopic sensitisation. FundingMedical Research Council, British Heart Foundation, Food Standards Agency, Arthritis Research UK, National Osteoporosis Society, International Osteoporosis Foundation, Cohen Trust, NIHR Southampton Biomedical Research Centre, NIHR Oxford Biomedical Research Unit, British Lung Foundation.

National Osteoporosis Society's Position Statement on hormone replacement therapy in the prevention and treatment of osteoporosis

Hormone replacement therapy (HRT) has been shown to increase bone density, reduce the risk of fracture and can successfully relieve menopausal symptoms. From a time when HRT was the major therapeutic option for the management of osteoporosis, women and their clinicians now have a range of treatments available. Following the publication of the Women's Health Initiative (WHI) and the Million Women Study highlighting potential side-effects, such as breast cancer, heart disease and stroke, many doctors and women are now reluctant to use HRT. The National Osteoporosis Society felt that the role of HRT in the management of osteoporosis needed to be clarified. Using the Charity's expert clinical and scientific advisers, and through public consultation with members and key stakeholders, a Position Statement has been published. We conclude that HRT has a role to play in the management of osteoporosis in postmenopausal women below the age of 60 years. The key recommendations of the Position Statement are presented in this paper.

Parkinson's Disease and Bone Health

SIR—We were very interested in the paper by Abou-Raya et al. [1] regarding bone health and Parkinson’s disease. In our rural community of Ceredigion, West Wales, we carried out a similar study in 2007. We were prompted by a spate of hip fractures amongst our patients attending the movement disorder clinic. We looked at 50 patients (31 males) and enrolled their carers as controls for vitamin D levels. We excluded those with other causes for osteoporosis and whilst we did not perform spinal radiology to look for occult vertebral fracture, we did collect data on known fractures in the patient group. Our data were presented in poster form at the National Osteoporosis Society meeting in 2007. Five of our patient group had a prevalent fragility fracture (four females). Four of the group (three males) had osteoporosis at the femoral neck (T score <−2.5) and six (four males) had vertebral osteoporosis. Forty patients (29 males) had insufficient vitamin D as defined by a vitamin D level of <30 ng/ml. We found a weak correlation between bone health and Hoehn and Yahr score (r = −0.32, P = 0.06). We also found that 32 of 41 carers had vitamin D levels <30 ng/ml. As a consequence of our findings and published data relating to bone health in movement disorder patients, we now perform dual energy X-ray absorptiometry scan at diagnosis and at two yearly intervals thereafter. Experience tells us that patients with movement disorder fare poorly after major fragility fracture and we need to do all we can to reduce this risk whilst there is time to do so. Time will tell if we have been able to reduce the risk of fragility fracture in this vulnerable population, and we are gratified to find other centres recommending the same approach!

Webwise.

If you are a woman aged 45 to 70, the National Osteoporosis Society website will inform you and may even change your life. Osteoporosis is a condition in which the bones, particularly those of the wrist, hip and spine, become increasingly fragile and prone to fracture.

Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK

In 1999 and 2000 the Royal College of Physicians published guidelines for the prevention and treatment of osteoporosis [ Royal College of Physicians. Osteoporosis: clinical guidelines for the prevention and treatment. London: Royal College of Physicians; 1999; Royal College of Physicians and Bone and Tooth Society of Great Britain. Update on pharmacological interventions and an algorithm for management. London, UK: Royal College of Physicians; 2000.; Royal College of Physicians. Glucocorticoid-induced osteoporosis. Guidelines on prevention and treatment; Bone and Tooth Society of Great Britain, National Osteoporosis Society and Royal College of Physicians. London, UK: Royal College of Physicians; 2002]. Since then, there have been significant advances in the field of osteoporosis including the development of new techniques for measuring bone mineral density, improved methods of assessing fracture risk and new treatments that have been shown to significantly reduce the risk of fractures. Against this background, the National Osteoporosis Guideline Group (NOGG), in collaboration with many Societies in the UK, have updated the original guidelines [ Royal College of Physicians, National Osteoporosis Guideline Group on behalf of the Bone Research Society, British Geriatrics Society, British Orthopaedic Association, British Society of Rheumatology, National Osteoporosis Society, Osteoporosis 2000, Osteoporosis Dorset, Primary Care Rheumatology Society, Society for Endocrinology. Osteoporosis. Clinical guideline for prevention and treatment, Executive Summary. University of Sheffield Press; 2008], a practical summary of which is detailed below. The management algorithms are underpinned by a health economic analysis applied to the epidemiology of fracture in the UK.

The Alara Metriscan phalangeal densitometer: evaluation and triage thresholds

The Metriscan (Alara Inc, CA) is a compact digital radiographic absorptiometry device capable of determining phalangeal bone mineral density in arbitrary units (BMD(au)) from the second phalanges of the middle three digits. We have examined the utility and the in vitro and in vivo performances of the Metriscan, and established triage thresholds based on the UK's National Osteoporosis Society guidelines on peripheral densitometry. 170 white female participants (70 osteoporotic and 100 non-osteoporotic at the hip or spine) aged between 55 years and 70 years were recruited from patients attending for routine dual X-ray absorptiometry (DXA) examination. All participants underwent two scans of the non-dominant hand (with repositioning) and one of the dominant hand. An additional 10 participants were excluded owing to finger or hand deformities. Radiation exposure to the patient per scan was <0.1 microSv, and a controlled area of 1 m was established around the device. Phantom-based in vitro short-term precision (%CV) was 0.17% without, and 0.22% with, repositioning. Long-term in vitro precision was 0.31% over a 6-month period. In vivo short-term precision was 1.42% for the group as a whole, and 1.30% and 2.23% for the non-osteoporotic and osteoporotic groups, respectively. Triage thresholds for reassurance/referral or referral/treatment were 54.30 BMD(au) and 46.89 BMD(au), respectively, for the non-dominant hand, and 55.02 BMD(au) and 48.73 BMD(au) for the dominant hand. The dominant side proved superior for triage purposes, with a triage referral rate of 44%, compared with 48% for the non-dominant hand. The Metriscan is suitable for use on post-menopausal women in a community-based setting preferably in a triage role as an adjunct to axial BMD.

NICE continues to muddy the waters of osteoporosis

The storm generated by the National Institute for Health and Clinical Excellence (NICE) over the appraisal of osteoporosis treatments in the UK continues unabated. An editorial in Bone earlier this year outlined the history of the prolonged appraisal process, begun in 2002, that continues to evaluate the cost-effectiveness of interventions for the primary and secondary prevention of osteoporotic fractures [1]. At that time NICE had issued its Final Appraisal Determinations (FADs) for primary and secondary prevention that restricted the use of interventions to generic alendronate [2, 3]. The appraisal was successfully appealed for this and other reasons. As a result, further consultation documents have been issued [4, 5]. The new documents now include appraisals for other treatments, including risedronate, raloxifene, strontium ranelate and (for secondary prevention only) teriparatide. Other changes have been microscopic despite public and private concern. What are these concerns, and why should they trouble the international readership of Osteoporosis International? NICE is one of the premier agencies that assess health technology in the UK. Estimates of cost-effectiveness by an Appraisal Committee are generally followed by Clinical Guidelines issued by a Guideline Development Group (GDG). The guidance that is issued by the Appraisal Committee is mandatory in England and Wales. Despite some criticism [6], NICE has a good track record with a prodigious output of excellent appraisals supported by clinical guidelines. Indeed, the reputation of NICE is such that the many countries that have less capacity for health technology appraisals look to NICE for their own guidance. This is beneficial to the international community where the guidance is fair, but disastrous in other circumstances— which brings us back to osteoporosis. A major concern has been that, despite a six-fold reduction in the price of alendronate, the estimates of cost-effectiveness have barely changed. This has been achieved by alteration of some of the model assumptions, in the absence of new evidence, so that the costeffectiveness of alendronate has remained unchanged despite its fall in price. Furthermore, these changes to the model have had a negative impact on the cost-effectiveness of the other treatments under consideration. The manner in which this has been achieved has been explored in an independent analysis commissioned by the National Osteoporosis Society [7]. Contrary to the findings of NICE, this analysis showed cost-effectiveness of generic alendronate in treating all women with osteoporosis and established osteoporosis, and cost-effective scenarios were found for other treatments in a sensitivity analysis. A second concern relates to the model construct that is based on a 10-year time horizon, rather than considering the lifetime of the patient as is the norm for chronic diseases. As noted previously, “an individual who dies after 9 years is dead for life, and not for 1 year, as would be assumed with a 10-year horizon” [1]. Whereas deaths after 10 years were ‘bolted’ onto the NICE model, none of the other consequences of fracture were included. Sensitivity analyses in the independent report [7] and, ironically, previous Osteoporos Int (2008) 19:1105–1107 DOI 10.1007/s00198-008-0649-4

Use of bisphosphonates and dual-energy X-ray absorptiometry scans in the prevention and treatment of glucocorticoid-induced osteoporosis in rheumatology

Patients treated with steroids are at risk of glucocorticoid-induced osteoporosis. Appropriate investigations and therapeutic agents can decrease rate of bone loss and fracture. To review adherence to current UK guidelines for the prevention of glucocorticoid-induced osteoporosis in rheumatology outpatient clinics. Retrospective case note review. The management of patients taking glucocorticoids who attended outpatient rheumatology clinics at a Teaching Hospital NHS Trust over a 4-week period was reviewed against current UK recommendations for prevention and treatment of osteoporosis (Bone and Tooth Society, National Osteoporosis Society, Royal College of Physicians. Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment. London: Royal College Physicians, 2002). Over the study period, 519 patients attended rheumatology outpatient clinics, amongst whom 104 were current glucocorticoid users. Most patients had been taking oral steroids for over 12 months (n = 79, 76%). The majority had also received steroids by at least one other route (n = 67, 64.4%). According to the guidelines, 51 patients, at relatively low risk of osteoporosis (<65 years, no previous fragility fracture) should have been referred for bone density assessment; of these, 27 (53%) had received a DEXA scan. In total, 58 subjects fulfilled criteria for bisphosphonates (>65 years, fragility fracture, T-score <-1.5) and, of these, 51 (87.9%) were appropriately treated. In 21 cases, a DEXA scan had been performed when guidelines recommended that treatment could commence without further assessment. The findings indicate a high level of awareness of glucocorticoid-induced osteoporosis amongst UK rheumatologists. Most patients identified to be at high risk of bone loss were offered treatment. Although encouraging, current practice could potentially be improved, particularly through more targeted use of DEXA scanning.

Factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis: a cross-sectional survey

To determine the factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis. Cross-sectional survey. National survey in the UK. Participants were recruited through the National Osteoporosis Society and advertisements in the press and on the radio and included 533 women over age 50 with osteoporosis who were currently taking or had taken bisphosphonate therapy within the previous 12 months. Self-reported factors influencing adherence and persistence to bisphosphonate therapy in osteoporosis: fracture history, pain, practical difficulties taking medication (frequency of dosing, dealing with comedications, impact on daily routine), perceptions of therapy, and concerns about bisphosphonate therapy. Adherence to bisphosphonate therapy was 48% and was associated with previous fracture [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.14-3.02], concerns about medication (OR 1.49, 95% CI 1.01-2.20), and less dissatisfaction with medication (OR 0.65, 95% CI 0.44-0.97). Nonpersistence was associated with dissatisfaction with medication (hazard ratio (HR) 1.83, 95% CI 1.38-2.43), side effects (HR 3.69, 95% CI 2.74-4.97), and concerns about bisphosphonate therapy (HR 2.21, 95% CI 1.48-3.30). For both daily (HR 1.53, 95% CI 1.1-2.33) and weekly bisphosphonates (HR 1.90, 95% CI 1.17-3.07), practical difficulties taking bisphosphonate medication-in particular, too frequent dosing-were associated with nonpersistence. Self-reported nonadherence to daily and weekly bisphosphonates is independent of the decision to stop taking treatment (nonpersistence). Nonpersistence is associated with side effects and other factors that could be modified in clinical practice through education, information, and concordant partnerships.

Heel bone densitometry: device specific thresholds for the assessment of osteoporosis

A diagnosis of osteoporosis is facilitated by bone mineral density (BMD) measurement of the lumbar spine and hip using dual energy X-ray absorptiometry (DXA), interpreted in accordance with criteria published by the World Health Organization (WHO). The use of peripheral DXA is growing in primary care and guidance on its use has recently been published by the National Osteoporosis Society (NOS), recommending a triage approach using thresholds specific to each type of peripheral device. However, no data currently exist for the Norland Apollo heel densitometer (Cooper Surgical, Trumbull, USA). 215 women between 50 years and 75 years of age (mean age 64.6 years) referred for hip and spine BMD measurements also had a heel BMD measurement. Device specific upper and lower thresholds were calculated for the Norland Apollo heel densitometer to give a 90% sensitivity and 90% specificity for osteoporosis at the hip or spine. Patients with a heel T-score of above -1.2 are very likely to have normal bone density on axial densitometry, whilst patients with heel T-score of below -2.2 are very likely to have osteoporosis at the hip or spine. Patients whose measurements lie between the thresholds should be referred for axial DXA.