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New osteoporosis guidance contradicts NICE

By Nigel Praities

GPs are caught in a dramatic showdown over the treatment of osteoporosis, with the launch of a major new national guideline that directly contradicts NICE.

Clinical bodies from across musculoskeletal medicine have joined forces on the document, which aims to throw open drug choice for osteoporosis and widen access to treatment for younger women.

Its launch is a direct challenge to the authority of NICE and has prompted a row reminiscent of the long-running dispute with the Joint British Societies over hypertension advice.

NICE is yet to release its final technology appraisals on primary and secondary prevention of fractures, but drafts have generated intense opposition and multiple appeal hearings.

Now, in a move designed to ratchet up the pressure on the institute, 10 medical organisations and societies, including the National Osteoporosis Society and the Primary Care Rheumatology Society, have produced rival guidance.

The new National Osteoporosis Guideline removes the stipulation made by NICE that patients under 70 who are intolerant of alendronate or have a contraindication to it should show deterioration in T-scores before being moved to an alternative drug.

Instead, it recommends GPs consider a range of bisphosphonates and other therapies such as strontium ranelate and raloxifene second line if alendronate is not well tolerated.

It also differs from NICE guidance in recommending all postmeno-pausal women be considered for secondary prevention after a fracture and in specifically endorsing the use of the FRAX risk score to identify patients for primary prevention.

Dr Alun Cooper, a GPSI in osteoporosis in Crawley, West Sussex, and chair of the National Osteoporosis Society's primary care forum, said: ‘We want to work with NICE but it has not come up with the goods. It hasn't managed to agree appraisals and a clinical guideline is at least a year off. GPs need simple guidance they can use.'

Dr Sally Hope, a GP in Woodstock, Oxfordshire, and RCGP representative working with NICE on the forthcoming osteoporosis clinical guideline, called the new guidance ‘excellent', and said some of those who worked on it were now working with NICE.

NICE said it would be ‘reconsidering' its clinical guideline on osteoporosis once its technology appraisals were finished.

Dr Jonathan Bayly, a former GP and scientific adviser to the National Osteoporosis Society, welcomed the new guidance but had reservations about its approach. ‘I would not recommend any clinician follows NICE guidance as it is flawed and unduly restrictive. But this guideline is a bit too liberal for my taste.'

New guidance in a nutshell

- No deterioration in T-scores required in order for patients to be put on an alternative treatment to alendronate
- All postmenopausal women are considered for secondary prevention after a fracture, regardless of bone mineral density
- World Health Organization's FRAX risk scoring tool recommended to assess patients for primary prevention
- Treatment options advised for patients on steroids and for secondary prevention in men

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