Presenter: Dr.
Mukund
Moderator: Dr. Sivakumar S.P
What is ‘NOGG’
• The National Osteoporosis Guideline Group (NOGG)
• Established – 2007
• Multidisciplinary group - includes patients and
professionals involved in the care of people with
osteoporosis.
A. Postmenopausal
women
Provides a 1. Assessment and diagnosis of osteoporosis
2. Therapeutic interventions available
clinical 3. Approaches for the prevention of fragility
IN
guideline for: fractures
B. Men aged 50
years or older.
Latest Guidelines
• October 2021
• NICE* reaccredited the process
used by ‘NOGG’ to produce this
clinical guideline for the
prevention and treatment of
osteoporosis
*NICE- NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE
- Provides accreditation for guidance, advice and recommendations for clinical
practice
I. Scope of This Guideline
Reduce fragility Assessment & Dx
fracture risk of Osteoporosis
Advantages of NOGG
• Earlier- Not to Rx women without initial BMD except in hip/vertebral
fractures. (1998 an analysis- suggested reduced efficacy of alendronate -
BMD T-scores above -2.5 )
• Now outdated- studies show little or no interaction of BMD on the
effectiveness of several agents, including bisphosphonates (e.g.,
zoledronate, denosumab, raloxifene, and teriparatide)
• Targeted use of DXA scans- Resource limited settings
II. Osteoporosis & Fragility #
“Progressive systemic skeletal disease characterised by low BMD and
microarchitectural deterioration of bone tissue, with a consequent
increase in bone fragility and susceptibility to fracture”
• Microarchitecture cannot be measured clinically,
• So BMD- T score ≤ -2.5 roughly = osteoporosis.
Limitation of BMD
• Prevalence of NOF BMD T score ≤ -2.5 in those aged 50 yrs and above
(UK) :-
Males- 6.8%
Female- 21.8%
• But Majority who sustain a fragility fracture will have a femoral neck
BMD T score > -2.5. Therefore there are many other factors besides
BMD to assess fracture risk.
Fragility Fracture
Common Sites
“Low trauma # sustained
from fall from standing
height or less”
• vertebral bodies
• hip
• distal radius
• proximal humerus
• pelvis
III. Fracture Risk Assessment
• Using tools like FRAX score or Qfracture
• Risk of fracture is expressed as an absolute risk, i.e., probability over
a ten-year interval.
• FRAX probability of fracture accounting for mortality risk
• Qfracture cumulative risk of fracture (does not take BMD into
account)
FRAX Fracture Risk Assessment Tool
• Computes the 10-year probability of hip fracture and/or of major
osteoporotic fracture.
• A major osteoporotic fracture is a clinical spine, hip, forearm or
humerus fracture.
• FRAX score assessment-
in any post menopausal
women and men above 50
y/o with a clinical risk factor
for fragility fracture
FRAX does not account for:
1. Prior osteoporosis drug treatment
2. 2 prior fractures have more risk than single prior #
3. Prior clinical vertebral # x 2 times risk
4. Dose response to glucocorticoid use
‘Therefore clinical judgement needed to interpret the FRAX outputs’
Approximate adjustments and considerations to probabilities of hip fracture and
major osteoporotic
fracture to aid the interpretation of FRAX
Case history & Investigations
Clinical risk factors for osteoporosis/fractures, not accommodated
in FRAX, which should trigger fracture risk assessment.
IV. Intervention Thresholds &
Strategy
1. Low risk -> Lifestyle modifications
2. Intermediate risk -> BMD :- -
Below IT =>lifestyle
modification
-Above IT=> Treat
3. High risk-> treatment +/- BMD
4. Very high risk-> refer to specialist
NOTE: BMD NOT COMPULSORY
Managem
ent
Guideline
s
NOGG Intervention Thresholds
• MOF – Multiple
Osteoporotic # NOTE: BMD INCORPORATED
• HF- Hip #
• If discrepancy, prefer
one with highest risk
assessment
Indications for Referral to
Specialist
The presence of single but important clinical risk factors, such as:-
i. A recent vertebral fracture [within the last 2 years]
ii. ≥2 vertebral fractures [whenever they have occurred]
iii. BMD T-Score ≤-3.5
iv. Treatment with high dose glucocorticoids [≥7.5 mg/day of prednisolone or
equivalent over 3 months] (refer urgently given rapid loss in bone post
initiation of glucocorticoids; if any delay is anticipated, start an oral
bisphosphonate in the meantime)
The presence of multiple clinical risk factors, particularly with a recent
fragility fracture indicating high imminent risk of re-fracture
Other indicators of very high fracture risk
V. Non Pharmacological
Management
1. Balanced diet
2. Adequate calcium (min 700mg daily) via dietary intake
(preferred)/supplementation
3. Vitamin D from foods/ vitamin D supplements of at least 800IU/day (if
identified vitamin D insufficiency or risk factors +) ; Housebound or living in
residential or nursing care more likely to require calcium and vit D to achieve
RDA
4. Regular weight-bearing and muscle strengthening exercise as tolerated by
patient.
5. Smoking cessation
6. Restrict alcohol intake to ≤ 2 units/day.
7. Falls assessment in all patients with osteoporosis and fragility fractures; those
at risk- Exercise programmes to improve balance
Calcium & Vitamin D
• In combination, proven to reduce risk of hip & nonvertebral fractures
• Individually vit D, not proven to cause significant reduction in fracture risk
• Daily dose Vit D 400IU (800-2000IU if proven osteoporotic) preferred
• Intermittent high dose vit D (60k IU) not advised due to increased risk of
falls & fractures
• Beneficial in :-
• Combination with anabolic steroids
• House bound patients
• Malabsorption syndromes (Chronic IBD, Bariatric surgery)
• Complication- Risk of renal calculi
VI. Pharmacological Management
Anti- resorptives (1st line)
• Bisphosphonates- Oral(Alendronate (A), Risedronate)
• Bisph. IV (Zolendronate (Z))
• Denosumab (D)- Do not stop abruptly! (Inc vertebral # risk)
• HRT- (Early postmenopausal osteoporotic women)- malignancy/ thromboembolic events
Anabolic- 1st line with vertebral #, 2nd line when intolerant to bisph. & with vertebral #
• Teriparatide
• Romosuzumab- Dual action
Others
• Strontium Ranelate
• CA, vit D
NOTE: post 24m Teripartide/ 12m Romosuzumab, bridge with A/ Z/ D
Antifracture Efficacy
Long Term Oral
Bisphosphonate
Long Term IV
Bisphosphon
ate
Dose
DRUG DOSAGE
T. ALENDRONATE 70mg Once weekly P.O
T. RESIDRONATE 35mg Once weekly P.O
T./Inj IBANDRONATE 150mg Once Monthly/ 3ml slow IV push once 3 m
Inj. ZOLENDRONATE 5mg Once a year
Inj. DENOZUMAB 60mg Once in 6 months
Alendronate
• 70mg weekly (earlier 10mg daily) • Special instructions- To take on
• Indications:- an empty stomach, as a whole
• PMO with plenty of water and to sit or
• Men with osteoporosis stand for 30 mins after taking
• Glucocorticoids induced the tablet.
osteoporosis (GIO)
• Prevention of PMO & GIO
• Side Effect:-
• U GI symptoms
• Headache
• Muskuloskeletal pains
Risedronate
• 35mg Weekly once (earlier- 5mg
OD)
• Indications & Side effects- same
as A
Ibandronate
• 150mg Monthly/ 3mg prefilled IV • Special instructions- To take on
(as 15- 30sec push) every 3 monthly an empty stomach, as a whole
• Indications:- with plenty of water and to sit or
• PMO stand for 60 mins after taking
• Men with osteoporosis the tablet.
• (Note- no data on effect on hip
fractures)
• Side Effect:-
• U GI symptoms
• Bowel & bladder disturbance
• IV Acute phase rxn (transient)
Zolendronate
• 5mg IV yearly • Check eGFR
• Indications:-
• PMO
• Men with osteoporosis
• Glucocorticoids induced
osteoporosis (GIO)
• Prevention of PMO & GIO
• Side Effect:-
• Acute phase rxn
C.I & complications of
Bisphosphonates
• Hypocalcemia
• Hypersensitivity
• Pregnant or lactating women
• Oral – C.I in oesophageal disorders
• Renal impairment
• Long term bisphosphonate Rx -> Osteonecrosis jaw, Atypical femur
fractures
Denosumab
• RANKL inhibitor
• 60mg S/C 6 monthly
• Indication:-
• PMO
• Men at increased risk of fracture
• Bone loss a/w
• C.I
• Hypocalcemia
• Hypersensitivity
Thank You