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 from 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 2013. This manuscript updates these in a European setting.

Methods: Systematic reviews were updated.

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; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

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

Keywords: Bone mineral density; Diagnosis of osteoporosis; FRAX; Fracture risk assessment; Health economics; Treatment of osteoporosis.

Fig. 1

Ten-year probability of hip fracture in women from Sweden according to age and T-score for femoral neck BMD [49], 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 Centre for Metabolic Bone Diseases, University of Sheffield Medical School, UK]

Fig. 3

Ten-year probability (%) of a major osteoporotic fracture in women from different European countries. BMI set to 25 kg/m². Data from http://www.shef.ac.uk/FRAX

Fig. 4

Management algorithm for the assessment of individuals at risk of fracture [114], with kind permission from Springer Science and Business Media

Fig. 5

Ten-year probabilities (%) of a major osteoporotic fracture for women from Kuwait at a T-score of − 2.5 SD (open triangle), − 1.5 SD (open square) and prior fracture (open diamond). The shaded area represents fracture probabilities in women with no clinical risk factors and average BMD. From [120] with kind permission from Springer Science and Business Media

Fig. 6

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 set to 24 kg/m² without BMD. From [3], with kind permission from Springer Science and Business Media

Fig. 7

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

Fig. 8

Assessment of major osteoporotic 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 6. From [3], with kind permission from Springer Science and Business Media

Fig. 9

Assessment guidelines based on the 10-year probability of a major osteoporotic fracture (%). 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 6. From [3], with kind permission from Springer Science and Business Media

Fig. 10

The impact of a fixed treatment threshold in postmenopausal women in the UK according to threshold values for the probability of a major osteoporotic 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 exceed a given threshold. From [3], with kind permission from Springer Science and Business Media

Fig. 11

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 web sites [137]. With kind permission from Springer Science and Business Media

Fig. 12

Schematic diagram showing the effects of a bone-forming agent on the relative fracture risk reduction (RRR) compared with placebo. In scenario A, treatment with a bone-forming agent induces a marked effect on fracture risk over an 18 months exposure compared with placebo. On stopping the bone-forming agent, the effect on fracture wanes off over a similar time interval of 18 months. In scenario C, placebo group remains untreated, whereas the group treated with a bone-forming agent is transitioned to an inhibitor of bone turnover, which maintains the efficacy up to 4 years. In scenario B, both the treatment and the placebo groups are treated after the exposure with an inhibitor of bone turnover [270]. With kind permission from Springer Science and Business Media

Fig. 13

Schema of a Fracture Liaison Service (FLS) integrated with post-fracture falls risk assessment [after [307]]

Fig. 14

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 (BMI set to 26 kg/m²). 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). From [114], with kind permission from Springer Science and Business Media