The importance of regular reviews in patients prescribed with medication to reduce fracture risk has been highlighted in a recent NICE guideline.¹ This is part of a quality statement aimed at improving risk assessment and preventative treatment in people at risk of a fragility fracture.

It is recognised that adherence to treatment can be poor in patients taking drugs to prevent fractures. This often occurs because of adverse effects. The report recommends: “Checking how well a person is managing their treatment at each medication review means that any problems can be discussed and their treatment adjusted if needed, which will improve adherence and quality of life”.

A review should focus on asking about adverse effects, particularly upper gastrointestinal effects such as dyspepsia or reflux. The patient should be also be asked about any atypical fractures that may present, such as new onset hip, groin or thigh pain. Any dental issues should be investigated.

Patients should be asked if they are following their prescribed treatment and taking their medication in the manner recommended.

Reviewing treatment

If there are adverse effects that are proving unacceptable or where the patient is not taking the prescribed treatment, alternative treatments should be explored.

Prescribed drugs for preventing fragility fractures include a range of bisphosphonates and other treatments. The aim is to improve bone density to reduce the chance of future fractures and other problems. 

Regarding long-term follow-up, adults who have been on long-term bisphosphonate therapy should be reviewed to assess the need for continuing treatment. This provides the opportunity to look at the various options including continuing treatment, changing therapy or stopping it altogether. The report says: “The optimal duration of bisphosphonate therapy is unclear and there are possible adverse effects of long-term treatment.”

Patients who have been taking zoledronic acid for three years or alendronate, ibandronate, or risedronate for five years should have a review of their treatment. Continuation of treatment is recommended for patients with any of the following risk factors:

• Over 75 years old

• Previous hip or vertebral fracture

• One or more low-trauma fractures during treatment (having excluded adherence problems and secondary causes of osteoporosis)

• Those taking oral glucocorticoids of 7.5mg or more prednisolone a day or equivalent.

Fracture risk and BMD assessment

DXA scans are recommended for patients without risk factors. In those cases patients with a T-score of less than -2.5 should have their treatment continued. In addition, fracture risk and BMD should be assessed every 3-5 years.

If the T-score is greater than -2.5 treatment can be stopped and fracture risk and BMD should be reassessed after two years.

The report recommends that general practices, fracture liaison services and secondary care services have systems in place to ensure that people who have already had a fragility fracture, have a history of falls or who are using systemic glucocorticoids have their fracture risk assessed and are offered treatment.

Fragility fractures can cause severe pain and disability. This leads to a reduced quality of life and can reduce life expectancy. 

The report recommends use of the FRAX system to assess patients who are at high risk of a fragility fracture and should be considered for treatment. 

“An assessment of fracture risk should include estimating absolute fracture risk (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage). Either FRAX (without a bone mineral density [BMD] value if a DXA scan has not previously been undertaken) or QFracture should be used within their allowed age ranges. Above the upper age limits defined by the tools, consider people to be at high risk. Measure BMD to assess fracture risk in people aged under 40 years.” 

Reference

1. Osteoporosis. Quality Standard 149. April 2017. https://www.nice.org.uk/guidance/qs149/chapter/Quality-statement-2-Starting-drug-treatment