NOF Guidelines

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In 1998, the NOF issued new guidelines for bone densitometry that were limited to the detection and management of postmenopausal osteoporosis (2,3). The guidelines initially appeared in an extensive document on osteoporosis that was published in Osteoporosis International (2). With some modification, they subsequently appeared in a document titled "Physician's Guide to Prevention and Treatment of Osteoporosis" (3).

In the original 1998 document, extensive cost-benefit analyses were undertaken to determine the feasibility and benefits not only of measuring bone density but of treating women who were found to have a low bone mass. The authors of the paper insightfully noted that the conclusions were only as good as the evidence on which they were based and such evidence might change as new therapies became available or as more was learned about the pathophysiology of osteoporosis. In essence, however, the original 1998 NOF recommendations stated that it was cost-effective to assess bone density in all Caucasian women over the age of 60 regardless of other risk factors and in all Caucasian women between age 50 and 60 who had a strong risk factor for fracture. BMD testing was recommended for all women who had a vertebral fracture unless calcitonin was the only acceptable treatment option. In women with a nonvertebral fracture, testing was recommended for women age 60 even without other risk factors and women age 50 to 59 with other risk factors. The risk factors for fracture that were emphasized in this report included a history of fracture after age 40, a history of hip, spine, or wrist fracture in a first-degree relative, weight equal to or less than 127 lb, and current cigarette smoking. These risk factors were chosen because they were easy to determine in clinical practice and they were demonstrated as being independent predictors of hip fracture in the Study of Osteoporotic Fractures (4). In order to help the clinician determine when it would be cost-effective to measure the bone density, nomograms were developed that were specific for the presence or absence of a prior spine fracture and the therapy being considered. The clinician would use the number of remaining risk factors from the list given above to determine if the patient should be tested. An example of such a nomogram is shown in Fig. 7-1. Another nomogram was provided for women with spine fractures in whom alendronate therapy was being considered. Nomograms for women with and without spine fractures and each of the remaining therapies that were approved for clinical use in 1998 were also provided.

The complexity of these guidelines made them unsuitable for widespread clinical use. In response, the NOF published guidelines tailored for the clinician (3). In the introduction to the these guidelines, the NOF noted that the guidelines were primarily intended to be applied to postmenopausal Caucasian women because the data used to create the guidelines came from studies of that group. They also noted that their recommendations were based on measurements of bone density at the hip although they noted that BMD measurements at any site had value in predicting fracture risk. The NOF did not characterize any particular technique as being preferred, although measurements at the hip would, of necessity, require the use of DXA.

These clinical guidelines from the NOF in 1998 formed the cornerstone of subsequently released guidelines from other major organizations. The circumstances in which

Fig. 7-1. Testing decision nomogram. If 5 years of alendronate therapy are being considered, a woman should undergo BMD testing if she falls into the shaded area based on her age and number of risk factors. ♦-no risk factors; A-1 risk factor; D-2 risk factors.

Reproduced with permission of the publisher from National Osteoporosis Foundation. Osteoporosis: review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis. Osteoporos Int 1998;S4:S7-S80. ©Springer-Verlag

Fig. 7-1. Testing decision nomogram. If 5 years of alendronate therapy are being considered, a woman should undergo BMD testing if she falls into the shaded area based on her age and number of risk factors. ♦-no risk factors; A-1 risk factor; D-2 risk factors.

Reproduced with permission of the publisher from National Osteoporosis Foundation. Osteoporosis: review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis. Osteoporos Int 1998;S4:S7-S80. ©Springer-Verlag the NOF recommended bone density testing in postmenopausal Caucasian women in 1998 were:

• All women under age 65 who have one or more additional risk factors for osteoporotic fracture.

• All women age 65 and older regardless of additional risk factors.

Postmenopausal women who present with fractures.

• Women who are considering therapy if BMD testing would facilitate the decision.

• Women who have been on HRT for prolonged periods.

In all cases, the NOF emphasized that testing should never be done if the results would not influence treatment decisions.

The risk factors listed by the NOF in the clinical guidelines were numerous, but the same four risk factors used in the cost-benefit analyses were emphasized again as contributing to the risk of hip fracture: personal history of fracture as an adult, history of fracture in a first-degree relative, current cigarette smoking, and body weight less than 127 lb. The diseases and drugs noted by the NOF as being associated with an increased risk of osteoporosis are listed in Tables 7-1 and 7-2.

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