New national osteoporosis guidance-implications for geriatricians

Abstract

Fragility fractures are painful, debilitating, often life-changing and accounted for an estimated 2.4% of pre-pandemic health care spending in the UK. Those who are older, frail and multimorbid have the highest fracture risk and therefore the most to gain from anti-osteoporosis treatments to reduce this risk. Currently, an unacceptable treatment gap exists between those eligible for and those who receive treatment. This commentary discusses the major changes to the new, National Institute for Health and Care Excellence accredited, UK National Osteoporosis Guideline Group (NOGG) guidance (published March 2022) most relevant to the management of older people's bone health. Changes include intervention thresholds; using fracture probabilities from FRAX; for patients too frail to undergo DXA; greater emphasis on vertebral fracture detection and the use of intravenous zoledronate as a first-line anti-osteoporosis therapy; the new concept of 'very high fracture risk' which should prompt consideration of use of parenteral anti-osteoporosis therapy; new guidance regarding anabolic treatment options; concerns regarding denosumab cessation; and the urgent need to get patients with a fragility fracture onto treatment to reduce re-fracture risk with follow-up to check tolerance and ensure adherence.

Keywords: FRAX; NOGG; clinical guidelines; fracture risk; fragility fracture; older people; osteoporosis.

Figure 1

Flow diagram showing process of giving intravenous zoledronate to older people. APR: Acute Phase Reaction, iv: intravenous. ^a: If an orthopaedic operation has been performed, there is minimal post hoc evidence to support delaying zoledronate administration to ≥2 weeks [22], so it is important to balance the benefit of ensuring prompt treatment of imminent fracture risk against waiting the SmPC-advised 2 weeks. ^b: an example of a rapid cholecalciferol loading schedule: provided there is no hypercalcaemia, if serum 25OHD < 25 nmol/l, prescribe 300,000 iu of cholecalciferol, e.g. as 50,000 iu alternate daily; if 25–50 nmol/l, prescribe 150,000 iu of cholecalciferol, e.g. as 25,000 iu alternate daily; if cholecalciferol replacement is documented as given, there is no need to recheck the serum 25OHD level prior to administration if zoledronate. ^c: https://theros.org.uk/information-and-support/osteoporosis/treatment/zoledronic-acid/). ^d: Some advocate giving slowly over one hour to reduce risk of APR; evidence is needed to support this. ^e: To check no hyperparathyroidism unmasked by vitamin D replacement. Check renal function if there is pre-existing renal impairment.