Following on from the study which suggested that calcium supplements may increase the risk of myocardial infarction in postmenopausal women, several articles, which discuss different approaches to the management of osteoporosis, have been published in the British Medical Journal.
One article argues that a change of approach is needed in managing osteoporosis, and suggests that efforts should be put into preventing falls rather than treating low bone mineral density (BMD) with medication. The authors point out that falling, not osteoporosis is the strongest single risk factor for fractures in elderly people and that BMD is a poor predictor of an individual’s fracture risk. Evidence shows that at least 15% of falls in older people can be prevented, with individual trials reporting relative reductions of up to 50%. Strength and balance training, reduction in the number and doses of psychotropic drugs, calcium and vitamin D supplementation, and assessment and modification of home hazards in high-risk populations, have all been shown to reduce the risk of falls. But the absolute rate of fracture is low and this may be the reason why the evidence that preventing falls among older adults also prevents fractures is less clear. Similarly, while bisphosphonates reduce the relative risk of fracture, there is comparatively little evidence that they prevent hip fractures in the general elderly population rather than being targeted at those at high risk of fracture. Also, administration requirements are complicated,and they can cause adverse effects making adherence with bisphosphonate regimens notoriously poor – around 50%. The authors conclude that general practitioners should shift the focus in fracture prevention by systematically assessing patients’ risk of falling and providing appropriate interventions to reduce the risk.
So, as discussed in an accompanying editorial, the problem is how best to prevent falls? A systematic review and meta-analysis of 19 trials has evaluated the efficacy of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary, community or emergency care settings. It found little evidence to support the effectiveness of multifactorial interventions to prevent falls and injuries. The authors conclude that interventions that actively provide treatments aimed at reducing risk factors may be more effective than those that only provide knowledge or referral. However, absolute reductions in the number of fallers may be smaller than previously thought.
Although drug treatment may be considered to be indicated in women with osteoporosis, the evidence is less clear in those with osteopenia. Another article examines data from four post-hoc analyses of trials used to support the treatment of women with slightly lowered BMD but at a low absolute risk of fracture. The authors argue that the benefits of such treatments (raloxifene, alendronate, risedronate, strontium ranelate▼) have been exaggerated and the harms have been played down. They state “when absolute baseline risk of fracture is low, as it is for women without existing fractures or other major risk factors, the absolute benefits of any treatment will similarly be low, and the numbers needed to treat will be high. Impressive sounding reductions in relative risk can mask much smaller reductions in absolute risk.”
Action: NICE Clinical Guideline 21 on the assessment and prevention of falls in older people is the current definitive guideline in this area. A NICE technology appraisal on primary and secondary prevention in osteoporosis is also in preparation, while NICE Technology Appraisal 87 on the secondary prevention of osteoporosis is still available and remains current national NHS policy.
In addition, a risk assessment tool for primary prevention would be most welcome, or at least definitive guidance on the approach to take. Assessment of fracture risk and the prevention of osteoporotic fractures in individuals at high risk is the subject of a NICE Clinical guideline in development.
There will be a suite of educational materials on osteoporosis available on NPC shortly.