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Osteoporosis

About

What is covered

This interactive flowchart covers NICE guidance on osteoporosis in adults (18 years and older), including assessing the risk of fragility fracture and drug treatment for the primary and secondary prevention of osteoporotic fragility fractures.
Identifying who will benefit from preventative treatment is imprecise. A number of risk assessment tools are available to predict fracture incidence over a period of time, and these may be used to aid decision-making. This interactive flowchart provides guidance on the selection and use of risk assessment tools in the care of people who may be at risk of fragility fractures in all settings in which NHS care is received.

Updates

Updates to this interactive flowchart

28 February 2017 Structure revised, and summarised recommendations replaced with full recommendations and one recommendation updated to correct reference to the WHO in relation to the FRAX tool.
20 September 2016 Recommendation on bisphosphonate treatment from NICE guideline NG56 on multimorbidity added to primary prevention of osteoporotic fragility fractures in postmenopausal women and secondary prevention of osteoporotic fragility fractures in postmenopausal women.
2 September 2013 Information about independent clinical risk factors removed from the section on denosumab in secondary prevention of osteoporotic fragility fractures in postmenopausal women. The use of denosumab for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (recommendation 1.2 of NICE technology appraisal guidance 204) does not depend on independent clinical risk factors.
24 April 2013 Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures (NICE technology appraisal guidance 279) added to treatment of vertebral compression fractures.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on assessing the risk of, preventing and treating osteoporotic fragility fractures in adults in an interactive flowchart

What is covered

This interactive flowchart covers NICE guidance on osteoporosis in adults (18 years and older), including assessing the risk of fragility fracture and drug treatment for the primary and secondary prevention of osteoporotic fragility fractures.
Identifying who will benefit from preventative treatment is imprecise. A number of risk assessment tools are available to predict fracture incidence over a period of time, and these may be used to aid decision-making. This interactive flowchart provides guidance on the selection and use of risk assessment tools in the care of people who may be at risk of fragility fractures in all settings in which NHS care is received.

Updates

Updates to this interactive flowchart

28 February 2017 Structure revised, and summarised recommendations replaced with full recommendations and one recommendation updated to correct reference to the WHO in relation to the FRAX tool.
20 September 2016 Recommendation on bisphosphonate treatment from NICE guideline NG56 on multimorbidity added to primary prevention of osteoporotic fragility fractures in postmenopausal women and secondary prevention of osteoporotic fragility fractures in postmenopausal women.
2 September 2013 Information about independent clinical risk factors removed from the section on denosumab in secondary prevention of osteoporotic fragility fractures in postmenopausal women. The use of denosumab for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (recommendation 1.2 of NICE technology appraisal guidance 204) does not depend on independent clinical risk factors.
24 April 2013 Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures (NICE technology appraisal guidance 279) added to treatment of vertebral compression fractures.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Causes of secondary osteoporosis include:
  • endocrine
    • hypogonadism in either sex including
      • untreated premature menopause and
      • treatment with aromatase inhibitors or androgen deprivation therapy
    • hyperthyroidism
    • hyperparathyroidism
    • hyperprolactinaemia
    • Cushing's disease
    • diabetes
  • gastrointestinal
    • coeliac disease
    • inflammatory bowel disease
    • chronic liver disease
    • chronic pancreatitis
    • other causes of malabsorption
  • rheumatological
    • rheumatoid arthritis
    • other inflammatory arthropathies
  • haematological
    • multiple myeloma
    • haemoglobinopathies
    • systemic mastocytosis
  • respiratory
    • cystic fibrosis
    • chronic obstructive pulmonary disease
  • metabolic (homocystinuria)
  • chronic renal disease and immobility (due for example to neurological injury or disease).

Glossary

bone mineral density
dual-energy X-ray absorptiometry
the level of risk at which an intervention is recommended; people whose risk is in the region from just below to just above the threshold may be reclassified if BMD is added to assessment (it was out of the scope of the osteoporosis: fragility fracture risk clinical guideline to recommend intervention thresholds; healthcare professionals should follow local protocols or other national guidelines for advice on intervention thresholds)
standard deviations

Paths in this pathway

Pathway created: August 2012 Last updated: March 2017

© NICE 2017

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