Guideline | Inclusion/exclusion | Investigation | Treatment* |
---|---|---|---|
BSG | All patients with cirrhosis or severe cholestasis (bilirubin >3 times upper limit of normal for 6 months) | DXA (unless previous fracture) Thyroid function Bone profile Oestradiol/FSH/LH Testosterone ±spine x-rays | Treat if osteoporosis, or empirical treatment if previous fracture First line: treatment of hypogonadism if present Second line: bisphosphonates Reassess with DXA after 2 years |
NICE TAG 160/204 (primary prevention) | Postmenopausal women not on steroids without previous fracture Men excluded | Empirical treatment if age >75 years and indicator of low BMD or ≥2 CRFs for fracture DXA if: 70–75 years and ≥1 CRF or indicator of low BMD 65–69 years and ≥1 CRF <65 years and ≥1 CRF and indicator of low BMD | Bisphosphonates First line: alendronate Second line: risedronate and etidronate (different age, CRF combinations apply) Third line: Denosumab (TAG 204) or Strontium (different age, CRF combinations apply) |
NICE TAG 161/204 (secondary prevention) | Postmenopausal women not on steroids with previous fracture Men excluded | Empirical treatment if age >75 years DXA if: <75 years | Treat if osteoporosis or empirically if >75 years Bisphosphonates First line: alendronate Second line: risedronate and etidronate (different age, CRF combinations apply) Third line: Denosumab (TAG 204) or Strontium (different age, CRF combinations apply) |
FRAX/NOGG | Applies to postmenopausal women and men aged >50 years | Treat if previous fracture in postmenopausal women Calculate FRAX score and treat if high risk, lifestyle advice if low risk DXA if intermediate risk and recalculate risk | Bisphosphonates |
*All recommend adequate intake of calcium and vitamin D.
BMD, bone mineral density; BSG, British Society of Gastroenterology; CRF, clinical risk factor; DXA, dual-emission x-ray absorptiometry; FRAX, fracture risk assessment tool; FSH, follicle-stimulating hormone; LH, luteinising hormone; NICE, National Institute for Health and Clinical Excellence; NOGG, National Osteoporosis Guidelines Group.