Quality statement 2: Starting drug treatment

Quality statement

Adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.

Rationale

Fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life and sometimes to decreased life expectancy. Taking drug treatment to improve bone density reduces the chance of future fractures and related problems.

Quality measures

Structure

Evidence of local arrangements to ensure that adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.

Data source: Local data collection, for example, local protocols.

Process

Proportion of adults at high risk of fragility fracture receiving drug treatment to reduce fracture risk.

Numerator – the number in the denominator who receive drug treatment to reduce fracture risk.

Denominator – the number of adults at high risk of fragility fracture.

Data source: Local data collection, for example, local audit of patient records. The Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis, who are currently treated with an appropriate bone-sparing agent.

Outcomes

a) Incidence of fragility fractures.

Data source: Local data collection, for example, local audit of patient records.

b) Hospital admission rates for fragility fractures.

Data source: Local data collection, for example, Hospital episode statistics from NHS Digital.

What the quality statement means for different audiences

Service providers (general practices and secondary care services) ensure that systems are in place for adults at high risk of fragility fracture to be offered drug treatment to reduce fracture risk.

Healthcare professionals (GPs, specialists and specialist nurses) are aware of when to prescribe drug treatments to reduce fracture risk, and offer them to adults at high risk of fragility fracture.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.

Adults with a high chance of fragility fracture are offered medicine to help strengthen their bones and prevent fractures.

Source guidance

Definitions of terms used in this quality statement

At high risk of fragility fracture

Women with a prior fragility fracture (particularly hip or vertebral fracture) and men and women with a 10-year probability of a major osteoporotic fracture derived from FRAX, above the upper assessment threshold, should be considered for treatment (see table 1). Men and women with a 10-year probability between the upper and lower assessment threshold should be referred for bone mineral density measurement and their fracture probability reassessed. If their 10-year fracture probability is above the intervention threshold after reassessment (see table 1), treatment should be offered.

Table 1. Lower and upper assessment thresholds and intervention thresholds for major osteoporotic fracture probability based on fracture probabilities derived from FRAX (BMI set to 25 kg/m2)

10-year probability of a major osteoporotic fracture (%)

Age (years)

Lower assessment threshold

Upper assessment threshold

Intervention threshold

40

2.6

7.1

5.9

45

2.7

7.2

6.0

50

3.4

8.6

7.2

55

4.5

11

9.4

60

5.9

14

12

65

8.4

19

16

≥70

11

24

20

Reproduced with permission from McCloskey et al. (2015) FRAX-based assessment and intervention thresholds – an exploration of thresholds in women aged 50 years and older in the UK. Osteoporosis International 26 (8), 2091–9

[Adapted from National Osteoporosis Guideline Group's Clinical guideline for the prevention and treatment of osteoporosis, section 11, recommendation 7]

Drug treatment to reduce fracture risk

Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy).

[Adapted from National Osteoporosis Guideline Group's Clinical guideline for the prevention and treatment of osteoporosis, section 6]

Full details of the licensed indications for these drugs can be found in the summary of product characteristics. At the time of publication (April 2017), not all bisphosphonate and non-bisphosphonate drugs have UK marketing authorisation for preventing osteoporosis. The prescriber should follow relevant professional guidance, taking full responsibility for the decision to prescribe an unlicensed medicine. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

Equality and diversity considerations

Guidance on treatment to prevent fragility fractures has been focused on treating post-menopausal women, because of their increased risk. Clinicians should ensure that other populations who might benefit from recommended treatments are also considered.