European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Abstract

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk of fractures due to osteoporosis.

Introduction: The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2008. This manuscript updates these in a European setting.

Methods: Systematic literature reviews.

Results: The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk, general and pharmacological management of osteoporosis, monitoring of treatment, assessment of fracture risk, case finding strategies, investigation of patients and health economics of treatment.

Conclusions: A platform is provided on which specific guidelines can be developed for national use.

Fig. 1

Ten-year probability of hip fracture in women from Sweden according to age and T-score for femoral neck BMD [52] with kind permission from Springer Science and Business Media

Fig. 2

Screen page for input of data and format of results in the UK version of the FRAX^® tool (UK model, version 3.5. http://www.shef.ac.uk/FRAX) [With permission of the World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, UK]

Fig. 3

Ten year probability (in percent) of a hip fracture in women from different European countries. BMI set to 24 kg/m²

Fig. 4

Management algorithm for the assessment of individuals at risk of fracture [89] with kind permission from Springer Science and Business Media

Fig. 5

The 10-year probability of a major osteoporotic fracture by age in women with a prior fracture and no other clinical risk factors in the five major EU countries as determined with FRAX (version 3.5). Body mass index was set to 24 kg/m² without BMD

Fig. 6

The density of central DXA equipment (units per million of the general population in the EU countries in 2010 [Kanis JA, data on file])

Fig. 7

Assessment of fracture risk in countries with high access to DXA. DXA is undertaken in women with a clinical risk factor. Assessment with DXA and/or treatment is not recommended where the FRAX probability is lower than the lower assessment threshold (green area). BMD is recommended in other women and treatment recommended where the fracture probability exceeds the intervention threshold (dotted line). The intervention threshold used is that derived from Table 7

Fig. 8

Assessment guidelines based on the 10-year probability of a major fracture (in percent). The dotted line denotes the intervention threshold. Where assessment is made in the absence of BMD, a BMD test is recommended for individuals where the probability assessment lies in the orange region. The intervention threshold and BMD assessment thresholds used are those derived from Table 7

Fig. 9

The impact of a fixed treatment threshold in postmenopausal women in the UK according to threshold values for the probability of a major fracture. The left-hand panel shows the proportion of the postmenopausal population exceeding the threshold shown at each age. The right-hand panel shows the proportion of the total postmenopausal population that exceeds a given threshold

Fig. 10

The risk of hip fracture with age in a model that considers 10-year fracture risk alone (the Garvan tool) and FRAX which computes the probability of hip fracture from the fracture and death hazards (FRAX). The T-scores are set differently in the two models so that the risks are approximately equal at the age of 60 years. Data are computed from the respective websites [127]. With kind permission from Springer Science and Business Media

Fig. 11

Correlation between the 10-year probability of a major fracture (calculated with BMD) and cost-effectiveness of generic alendronate at the age of 50 years in women. Each point represents a particular combination of BMD and clinical risk factors (all possible combinations of CRFs at BMD T-scores between 0 and −3.5 SD in 0.5 SD steps—512 combinations) with a BMI set to 26 kg/m². The horizontal line denotes the threshold for cost-effectiveness (a willingness to pay of £20,000/QALY gained) ([122], with permission from Elsevier)