I am increasingly confused with the optimal management of osteoporosis for our patients. Although I have read and re-read the NICE guidelines for primary and secondary fractures, I still find them difficult to follow and understand. For primary prevention the criteria to be eligible for a DEXA scan vary enormously depending on the age of the woman. In addition, if NICE alone is used then it is impossible to estimate a fracture risk of our individual patients.
All women over 65 years (and even those over 60 years with a higher risk of osteoporosis) in the USA are currently offered a DEXA scan to screen for osteoporosis. Wouldn’t that be easy if that was the option here?
Alternatively, FRAX is a fantastic computer programme that calculates the age- and gender-specific 10 year absolute risk of a major osteoporotic fracture and the 10-year risk of a hip fracture. From this risk, it is then possible to recommend reassurance, a DEXA scan or even treatment. Another advantage of FRAX is one that it can be used for men and also those patients taking long-term steroids (both groups currently not covered by NICE).
Finally, NICE currently recommend that in those people who cannot tolerate alendronate, an alternative should only be considered if their T-score is even lower which hardly makes sense. The NOGG (National Osteoporosis Guidelines Group) recommends using FRAX and sensibly suggests using the alternative treatments without needing any further lowering in BMD.
I am sure you can guess that I am a “fan” of using FRAX but feel rebellious as it is going against NICE guidelines!