Dr Celia Gregson is a Consultant Geriatrician in Bath and Consultant Senior Lecturer in Bristol. She is also a member of the National Osteoporosis Guideline Development Group. She tweets @celiagregson
The National Osteoporosis Guideline Group (NOGG) is pleased to announce that the UK NOGG 2017 Update was released via their website today. This new Guideline, accredited by the National Institute for Health and Care Excellence (NICE) in March 2017, includes a number of updates relating to fracture risk assessment, management of osteoporosis and treatment recommendations, all highly relevant for older people.
It is currently recommended that fracture risk should be assessed using the freely available online FRAX tool in all postmenopausal women, and men age 50 years or more, who have risk factors for sustaining a fracture. FRAX calculates a person’s probability (presented as percentage) of sustaining a hip fracture, and a major osteoporotic fracture, that is a fracture of the hip, humerus, forearm or clinical spine, over the next 10 years. NOGG then makes a recommendation for treatment based upon these FRAX probabilities, by applying different thresholds for intervention.
An obvious and important change in the new NOGG guidelines is the change to the age-related assessment and intervention thresholds; these now remain constant from the age of 70 years onwards. This change aims to provide clinically appropriate and equitable access to treatment for all people.
As before, women with a prior fragility fracture can be considered for treatment without the need for further bone mineral density (BMD) assessment, although BMD measurement may be appropriate, particularly at younger ages or where a baseline measurement is needed for future reference. Up until the age of 70 years the intervention threshold is set at a risk equivalent to that associated with a prior fracture, in line with current clinical practice, and therefore rises with age. Now, at age 70 years and then beyond, new fixed thresholds are applied. Though dramatic in appearance, the change in the threshold at these ages only increases the proportion of women treated in this age group from 45% to 52%, assuming that all women with a fracture are targeted for treatment. The main effect of the change is to ensure that older patients without fracture can access treatment at a similar level of risk to those with fracture. Overall, the proportion of women potentially eligible for treatment to reduce their fracture risk, rises from approximately 30% to 50% with age, largely driven by the increasing prevalence of a prior fracture in older women (see Osteoporosis International. 2015 Aug;26(8):2091-9. doi: 10.1007/s00198-015-3176-0. Epub 2015 Jun 16). These thresholds can also be applied to men. The thresholds remain automatically accessible from the FRAX UK risk assessment tool.
The newly updated NOGG Guideline includes further recommendations particularly relevant to older people. It re-enforces the importance of an integrated multi-component falls-risk assessment in all people at increased risk of sustaining a fracture, highlights the role muscle strengthening and balance training exercise has in reducing falls risk, and includes recommendation of adequate protein intake to maintain optimal musculoskeletal function.
A further, and very welcome addition to the guideline relates to its recommendation for Fracture Liaison Services, which currently are provided far too heterogeneously across the UK. Fracture Liaison Services should be provided for all patients sustaining a fragility fracture. Fracture Liaison Services (FLS) are cost-effective. The ideal approach is a service in which fracture identification, patient assessment and osteoporosis treatment are all conducted within an integrated electronic health care network, overseen by a dedicated FLS coordinator and utilising a dedicated database measuring performance (for example as provided by the Royal College of Physicians FLS-database (FLS-DB).
Despite the range of evidence-based therapies, for which recommendations are outlined in this NOGG Guideline, it has been estimated that fewer than one in five patients in England who have sustained a fragility fracture and hence have a requirement for therapy, actually receive therapy to reduce fracture risk within the first year of fracture. It is very much hoped these revised guidelines go some way towards narrowing this gap in care.
The British Geriatrics Society, amongst many other stake holders, has endorsed these new NOGG guidelines. The full NOGG Guideline, and an updated Patient Information Leaflet, are available in PDF formats from the website. The Guideline has also recently been published in Archives in Osteoporosis (doi 10.1007/s11657-017-0324-5).
Written on behalf of the NOGG Guideline Development and Expert Advisory Group