What are the NOGG recommendations for the diagnosis and management of osteoporosis?

Updated: Sep 26, 2019
  • Author: Monique Bethel, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

In June 2013, the National Osteoporosis Guideline Group (NOGG) updated its guidelines on the diagnosis and management of osteoporosis in men and postmenopausal women, aged 50 years or older, in the United Kingdom. Recommendations include the following [228] :

  • Pharmacotherapies shown to lower the risk for vertebral fracture (and for hip fracture in some cases) include bisphosphonates, denosumab, parathyroid hormone peptides, raloxifene, and strontium ranelate

  • Generic alendronate is usually first-line treatment because of its broad spectrum of anti-fracture efficacy and low cost

  • Ibandronate, risedronate, zoledronic acid, denosumab, raloxifene, or strontium ranelate may be appropriate therapy if alendronate is contraindicated or poorly tolerated

  • Because of their high cost, parathyroid hormone peptides should be used only for patients at very high risk, especially for vertebral fractures

  • Postmenopausal women may benefit from calcitriol, etidronate, and hormone replacement therapy

  • Treatments for men at increased fracture risk include alendronate, risedronate, zoledronic acid, and teriparatide

  • Patients at increased risk for fracture should start alendronate or other bone-protective treatment when beginning glucocorticoid therapy

  • For postmenopausal women, pharmacotherapy for prevention and treatment of glucocorticoid-induced osteoporosis includes alendronate, etidronate, and risedronate; treatment options for both sexes are teriparatide and zoledronic acid

  • Calcium and vitamin D supplementation is widely recommended for older persons who are housebound or live in residential or nursing homes and is often recommended as an adjunct to other treatments for osteoporosis

  • Potential adverse cardiovascular effects of calcium supplementation are controversial, but it may be prudent to increase dietary calcium intake and use vitamin D alone rather than using both calcium and vitamin D supplementation

  • Withdrawal of bisphosphonate treatment is associated with decreases in BMD and bone turnover after 2-3 years for alendronate and 1-2 years for ibandronate and risedronate

  • Continuation of bisphosphonates without the need for further evaluation is recommended for high-risk individuals; when bisphosphonates are continued, treatment review, including renal function evaluation, is needed every 5 years

  • If bisphosphonates are discontinued, fracture risk should be reevaluated after every new fracture, or after 2 years if no new fracture occurs

  • After 3 years of zoledronic acid treatment, the benefits on BMD density persist for at least another 3 years after discontinuation; most patients should stop treatment after 3 years, and their physician should review the need for continuation of therapy 3 years later

  • Treatment review is recommended after 5 years for alendronate, risedronate, or ibandronate and after 3 years for zoledronic acid

  • Persons with a previous vertebral fracture or a pretreatment hip BMD T-score of -2.5 SD or less may be at increased risk for vertebral fracture if zoledronic acid is discontinued

A 2019 guideline from the Endocrine Society on pharmacological management of osteoporosis in postmenopausal women includes the following recommendations [229] :

  • Treat patients who are at high risk—particularly those with previous fracture.
  • Consider bisphosphonates as the first-line therapeutic choice for postmenopausal women at high risk of fracture.
  • Reassess fracture risk after patient has been on bisphosphonates for 3-5 years.
  • Following reassessment, prescribe a “bisphosphonate holiday” for women who are on bisphosphonates and are low-to-moderate risk of fracture.
  • Consider anabolic therapy (teriparatide or abaloparatide) for women at very high risk of fractures, including those with multiple fractures.
  • All women undergoing treatment with osteoporosis therapies other than anabolic therapy should consume calcium and vitamin D in their diet or via supplements.
  • Monitor the BMD of high-risk individuals with a low BMD every 1 to 3 years.

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