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## Complete Summary

#### GUIDELINE TITLE

Management of osteoporosis. A national clinical guideline.

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
osteoporosis. A national clinical guideline. Edinburgh (Scotland):
Scottish Intercollegiate Guidelines Network (SIGN); 2003 Jun. 45
p. (SIGN publication; no. 71). \[149 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Osteoporosis

**Note**: The guideline does not address corticosteroid induced
osteoporosis.

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Obstetrics and Gynecology\
Orthopedic Surgery\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Nurses\
Patients\
Physical Therapists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To ensure the timely identification of those individuals at highest
    risk of osteoporosis, as well as those who already have the disease

-   To explore the treatment options that can be used in these patients
    to reduce their increased risk of further fractures with the aim of
    achieving \"secondary prevention of fracture\"

#### TARGET POPULATION

Individuals at high risk for, or who currently have, osteoporosis,
including women and men over 50 who present with fractures (that occur
in the absence of major trauma, such as road traffic accidents)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Risk Assessment**

1.  Assessment of risk factors including history of falls/fracture, age,
    sex, ethnicity, reproductive factors, family history, weight,
    smoking history, alcohol use, exercise, diet, and risk scores

**Diagnosis**

1.  Techniques for measuring bone mineral density, including:

    -   Dual-energy X-ray absorptiometry (DEXA or DXA)

    -   Peripheral dual-energy X-ray absorptiometry (pDXA) (not
        recommended)

    -   Peripheral quantitative computed tomography (pQCT) (not
        recommended)

    -   Single photon absorptiometry (SPA)(not recommended)

    -   Single-energy X-ray absorptiometry (SEXA or SXA) (not
        recommended)

    -   Radiograph absorptiometry

2.  Techniques discussed but not specifically recommended:

    -   Quantitative ultrasound (QUS) to assess bone quality and
        structure

    -   Biochemical markers such as resorption markers to assess bone
        turnover

    -   Quantitative computed tomography (QCT)

**Treatment**

*Non-pharmacological*

1.  Exercise

2.  Calcium + vitamin D

3.  Interventions discussed but not specifically recommended:

    -   Fluoridation of water

    -   Use of ipriflavone

    -   Elimination of caffeine

*Pharmacological*

1.  Bisphosphonates (alendronate, etidronate, risedronate)

2.  Hormone replacement therapy (considered but not recommended)

3.  Raloxifene

4.  Calcitonin

#### MAJOR OUTCOMES CONSIDERED

-   Fracture rates and risk

-   Fracture related morbidity

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence base for this guideline was synthesised in accordance with
Scottish Intercollegiate Guidelines Network (SIGN) methodology. A
systematic review of the literature was carried out using an explicit
search strategy devised in collaboration with members of the guideline
development group. Searches were restricted to systematic reviews,
meta-analyses, randomised controlled trials, and longitudinal studies.
Internet searches were carried out on the websites of the Canadian
Practice Guidelines Infobase, the UK Health Technology Assessment
Programme, the US National Guidelines Clearinghouse, and the US Agency
for Healthcare Research and Quality. Searches were also carried out on
the search engines Google and OMNI, and all suitable links followed up.
Database searches were carried out on Cochrane Library, Embase 1993 to
2000, and Medline 1990 to 2000. Searches were later updated to June
2001.

The main searches were supplemented by material identified by individual
members of the development group. All selected papers were evaluated
using standard methodological checklists before conclusions were
considered as evidence.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort or
studies; high quality case control or cohort studies with a very low
risk of confounding or bias and a high probability that the relationship
is causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies, e.g. case reports, case series

**4**: Expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Scottish Intercollegiate Guidelines Network (SIGN) carries out
comprehensive systematic reviews of the literature using customized
search strategies applied to a number of electronic databases and the
Internet. This is often an iterative process whereby the guideline
development group will carry out a search for existing guidelines and
systematic reviews in the first instance and, after the results of this
search have been evaluated, the questions driving the search may be
redefined and focused before proceeding to identify lower levels of
evidence.

Once papers have been selected as potential sources of evidence, the
methodology used in each study is assessed to ensure its validity. SIGN
has developed checklists to aid guideline developers to critically
evaluate the methodology of different types of study design. The result
of this assessment will affect the level of evidence allocated to the
paper, which in turn will influence the grade of recommendation it
supports.

Additional details can be found in the companion document titled \"An
Introduction to the SIGN Methodology for the Development of
Evidence-based Clinical Guidelines\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\]).
Available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The process for synthesising the evidence base to form graded guideline
recommendations is illustrated in the companion document titled \"An
Introduction to the SIGN Methodology for the Development of
Evidence-based Clinical Guidelines.\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\],
available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

Evidence tables should be compiled, summarizing all the validated
studies identified from the systematic literature review relating to
each key question. These evidence tables form an important part of the
guideline development record and ensure that the basis of the guideline
development group\'s recommendations is transparent.

In order to address how the guideline developer was able to arrive at
their recommendations given the evidence they had to base them on, SIGN
has introduced the concept of considered judgement.

Under the heading of considered judgement, guideline development groups
are expected to summarise their view of the total body of evidence
covered by each evidence table. This summary view is expected to cover
the following aspects:

-   Quantity, quality, and consistency of evidence

-   Generalisability of study findings

-   Applicability to the target population of the guideline

-   Clinical impact (i.e., the extent of the impact on the target
    patient population, and the resources need to treat them.)

Guideline development groups are provided with a pro forma in which to
record the main points from their considered judgement. Once they have
considered these issues, the groups are asked to summarise their view of
the evidence and assign a level of evidence to it, before going on to
derive a graded recommendation.

The assignment of a level of evidence should involve all those on a
particular guideline development group or subgroup involved with
reviewing the evidence in relation to each specific question. The
allocation of the associated grade of recommendation should involve
participation of all members of the guideline development group. Where
the guideline development group is unable to agree on a unanimous
recommendation, the difference of opinion should be formally recorded
and the reason for dissent noted.

The recommendation grading system is intended to place greater weight on
the quality of the evidence supporting each recommendation, and to
emphasise that the body of evidence should be considered as a whole, and
not rely on a single study to support each recommendation. It is also
intended to allow more weight to be given to recommendations supported
by good quality observational studies where randomised controlled trials
(RCTs) are not available for practical or ethical reasons. Through the
considered judgement process guideline developers are also able to
downgrade a recommendation where they think the evidence is not
generalisable, not directly applicable to the target population, or for
other reasons is perceived as being weaker than a simple evaluation of
the methodology would suggest.

On occasion, there is an important practical point that the guideline
developer may wish to emphasise but for which there is not, nor is their
likely to be, any research evidence. This will typically be where some
aspect of treatment is regarded as such sound clinical practice that
nobody is likely to question it. These are marked in the guideline as
\"good practice points.\" It must be emphasized that these are
[not]{.underline} an alternative to evidence-based recommendations, and
should only be used where there is no alternative means of highlighting
the issue.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The grade of recommendation relates to the strength of the evidence on
which the recommendation is based. It does not reflect the clinical
importance of the recommendation.

**A**: At least one meta-analysis, systematic review of randomised
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

#### COST ANALYSIS

**Cost Effectiveness of Diagnostic Approaches**

Only three relevant economic papers on the use of dual-energy X-ray
absorptiometry (DXA) scanning were identified. These all involved
modelling, rather than incorporation of economic evaluation into
clinical trials.

There is some evidence that for relatively expensive medication, such as
bisphosphonates, treatment programmes with prior bone density screening
are likely to be more cost-effective than those without and, in some
circumstances, become cost saving.

One recent paper concluded that diagnosis and treatment of women at risk
of osteoporosis would be made more cost effective by targeting treatment
to those with the lowest bone measurement results. Inclusion of another
assessment, such as a risk profile, may improve the cost effectiveness
of diagnosis.

**Cost Effectiveness of Treatment**

A recent Health Technology Assessment (HTA) examined the cost utility
and cost effectiveness of different treatments for established
osteoporosis. This study compared treatments using the cost per
quality-adjusted life-year (QALY). It used a threshold of £30,000 or
less per quality-adjusted life-year to represent cost effectiveness.
Using an economic model developed by the authors, at age 50 years only
hormone replacement therapy (HRT) and calcium plus vitamin D were likely
to be considered cost-effective (assuming that the agent would decrease
the risk of non-vertebral fractures at this age). In older age groups a
wider range of treatments, including hormone replacement therapy,
calcium with or without vitamin D and bisphosphonates were considered
cost effective.

This Health Technology Assessment demonstrates that age is an important
determinant of cost effectiveness since the risk of fractures increases
with age. High costs of intervention are associated with poorer cost
effectiveness since, in general, the variation in cost is greater than
any proven variation in efficacy.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A national open meeting is the main consultative phase of Scottish
Intercollegiate Guidelines Network (SIGN) guideline development, at
which the guideline development group presents its draft recommendations
for the first time. The national open meeting for this guideline was
held in February 2002 and was attended by 328 representatives of all the
key specialties relevant to the guideline. The draft guideline was also
available on the SIGN website for a limited period at this stage to
allow those unable to attend the meeting to contribute to the
development of the guideline. The comments received from the national
open meeting were considered when the guideline was redrafted for peer
review.

The guideline was also reviewed in draft form by independent expert
referees, who were asked to comment primarily on the comprehensiveness
and accuracy of interpretation of the evidence base supporting the
recommendations in the guideline.

As a final quality control check, the guideline is reviewed by an
Editorial Group comprising the relevant specialty representatives on
SIGN Council to ensure that the peer reviewers\' comments have been
addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised.

Each member of the guideline development group then approved the final
guideline for publication.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Note from the Scottish Intercollegiate Guidelines Network (SIGN) and
National Guideline Clearinghouse (NGC): In addition to these
evidence-based recommendations, the guideline development group also
identifies points of best clinical practice in the original guideline
document.*

The strength of recommendation grading (A-D) and level of evidence (1++,
1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the \"Major
Recommendations\" field.

**Risk Factors for Osteoporosis**

**B** - Patients who have suffered one or more fragility fractures
should be priority targets for investigation and treatment of
osteoporosis.

**C** - Use of family history in assessing risk of osteoporosis should
include maternal, paternal, and sister history.

**C** - Family history should include not only a given diagnosis of
osteoporosis but also kyphosis and low trauma fracture after age 50.

**B** - Smokers should be considered at greater risk of osteoporosis
than non-smokers, and advised to stop, for this and other reasons.

**Measurement, Diagnosis and Monitoring**

**B** - Conventional radiographs should not be used for the diagnosis or
exclusion of osteoporosis.

**B** - When plain films are interpreted as \"severe osteopaenia\" it is
appropriate to suggest referral for dual-energy X-ray absorptiometry
(DXA).

**A** -- Bone mineral density (BMD) should normally be measured by DXA
scanning performed on two sites, preferably anteroposterior spine and
hip.

**B** - Repeat measurements should only be performed if they influence
treatment.

**C** - If DXA investigations are repeated, anteroposterior (AP) spine
and total hip measurements should be used to follow response to
treatment.

**C** - Following a DXA scan of the hip, the annual hip fracture risk
(or 10 year fracture risk) should be included in the DXA report.

**C** - Where lateral spine scans acquired with fan-beam DXA are
available, visual assessment should be used to assess prevalent
vertebral fractures.

**B** - Evidence of existing vertebral deformity should be used to
modify the hip fracture risk estimated from age, sex, and BMD.

**A** - Biochemical markers of bone turnover should have no role in the
diagnosis of osteoporosis or in the selection of patients for BMD
measurement.

**Non-pharmacological Interventions**

**B** - High intensity strength training is recommended as part of a
management strategy for osteoporosis.

**B** - Low impact weight bearing exercise is recommended as part of a
management strategy for osteoporosis.

**A** - Postmenopausal women should aim for a dietary intake of 1,000 mg
calcium per day.

**B** - Ipriflavone should not be used as a sole therapy for fracture
reduction in patients with osteoporosis.

**Pharmacological Management**

[For postmenopausal women with multiple vertebral fractures]{.underline}

**A** - To reduce fracture risk at all sites: treatment with oral
risedronate (5 mg daily or 35 mg once weekly + calcium [+]{.underline}
vitamin D).

**A** - To reduce vertebral fracture risk: treatment with intermittent
cyclical etidronate (400 mg daily for 14 days + 500 mg calcium daily for
76 days, repeating 3 monthly cyclical therapy).

[For postmenopausal women with osteoporosis determined by axial DXA and
with a history of at least one vertebral fracture]{.underline}

**A** - To reduce fracture risk at all sites: treatment with oral
alendronate (10 mg daily or 70 mg once weekly + calcium [+]{.underline}
vitamin D).

**A** - To reduce vertebral fracture risk: treatment with oral
raloxifene (60 mg daily + calcium [+]{.underline} vitamin D).

**B** - To reduce vertebral fracture risk: treatment with intranasal
calcitonin (200 IU daily + calcium [+]{.underline} vitamin D).

[For postmenopausal women with osteoporosis determined by axial DXA,
with or without previous non-vertebral fracture]{.underline}

**A** - To reduce fracture risk at all sites: treatment with either oral
alendronate (10 mg daily or 70 mg once weekly + calcium [+]{.underline}
vitamin D) or oral risedronate (5 mg daily or 35 mg once weekly +
calcium [+]{.underline} vitamin D).

**A** - To reduce vertebral fracture risk: treatment with oral
raloxifene (60 mg per day + calcium [+]{.underline} vitamin D).

[For frail, elderly (aged 80+ years) women with a diagnosis of
osteoporosis, with or without previous non-vertebral
fractures]{.underline}

**A** - To reduce fracture risk at all sites, elderly women who have
suffered multiple vertebral fractures or who have had osteoporosis
confirmed by DXA scanning should be considered for treatment with either
oral risedronate (5 mg daily or 35 mg once weekly+ calcium
[+]{.underline} vitamin D) or oral alendronate (10 mg daily or 70 mg
once weekly + calcium [+]{.underline} vitamin D).

**A** - To reduce hip fracture risk, frail elderly women who are
housebound should receive oral calcium 1,000 to 1,200 mg daily + 800 IU
vitamin D.

[For men with a diagnosis of osteoporosis determined by axial DXA with
or without previous osteoporotic fracture]{.underline}

**A** - To reduce fracture risk at all sites, men with low BMD and/or a
history of one or more vertebral fractures or one non-vertebral
osteoporotic fracture should be treated with oral alendronate (10 mg +
500mg calcium [+]{.underline} 400 IU vitamin D daily).

**[Definitions]{.underline}**:

**Grades of Recommendation**

**A**: At least one meta-analysis, systematic review of randomised
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies; high quality case control or cohort studies with a very low
risk of confounding or bias and a high probability that the relationship
is causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies, e.g. case reports, case series

**4**: Expert opinion

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
management of glucocorticoid-induced osteoporosis in men and women.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Reduction in the incidence of fractures

-   Alleviation of fracture related morbidity

-   Prevention of subsequent fractures

-   Identification of risk factors to provide targeted treatment

#### POTENTIAL HARMS

All bisphosphonates can potentially be associated with gastrointestinal
side effects. For aminobisphosphonates such as alendronate, this can on
rare occasions present as oesophageal ulceration. The risk of these
symptoms can be lessened by the avoidance of lying flat within 30
minutes of ingestion or by using the once weekly preparations.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Previous history of venous thromboembolism (VTE) contraindicates oral
hormone replacement therapy (HRT) or raloxifene.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This guideline is not intended to be construed or to serve as a
    standard of medical care. Standards of care are determined on the
    basis of all clinical data available for an individual case and are
    subject to change as scientific knowledge and technology advance and
    patterns of care evolve. These parameters of practice should be
    considered guidelines only. Adherence to them will not ensure a
    successful outcome in every case, nor should they be construed as
    including all proper methods of care or excluding other acceptable
    methods of care aimed at the same results.

-   The ultimate judgement regarding a particular clinical procedure or
    treatment plan must be made by the doctor in light of the clinical
    data presented by the patient and the diagnostic and treatment
    choices available. However, it is advised that significant
    departures from the national guideline or any local guidelines
    derived from it should be fully documented in the patient´s case
    notes at the time the relevant decision is taken.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of national clinical guidelines is the responsibility of
each National Health System (NHS) Trust and is an essential part of
clinical governance. It is acknowledged that every Trust cannot
implement every guideline immediately on publication, but mechanisms
should be in place to ensure that the care provided is reviewed against
the guideline recommendations and the reasons for any differences
assessed and, where appropriate, addressed. These discussions should
involve both clinical staff and management. Local arrangements may then
be made to implement the national guideline in individual hospitals,
units and practices, and to monitor compliance. This may be done by a
variety of means including patient-specific reminders, continuing
education and training, and clinical audit.

The National Osteoporosis Society (NOS) has produced an Osteoporosis
Framework setting out standards for osteoporosis services in Scotland.
This framework has been endorsed by the Chief Medical Officer.

The key recommendations from the National Osteoporosis Society framework
document are:

-   Include prevention of osteoporotic fractures in the local Health
    Improvement Plan (HIP)

-   Identify lead clinicians in primary and secondary care to develop a
    local osteoporosis programme based on this framework. Each Local
    Health Cooperative, Primary Care, and Acute Trust should have a lead
    clinician for osteoporosis.

-   Each Health Board should have a consultant in Public Health to
    assist in coordinating this osteoporosis strategy between primary
    and secondary care.

-   Establish a local osteoporosis advisory group to facilitate
    multidisciplinary implementation of this framework.

-   Use a selective case-finding approach to target treatment at
    individuals at high risk.

-   Provide access to adequate levels of diagnostic and specialist
    services - e.g. a Local Health Care Co-operative serving a
    population of 50,000 would require approximately 500 dual-energy
    X-ray absorptiometry (DXA) scans per year.

-   Promote the use of care pathways and audit to improve standards of
    care.

-   Monitor performance to assess health impact.

Key points for audit are identified in the original guideline document.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
osteoporosis. A national clinical guideline. Edinburgh (Scotland):
Scottish Intercollegiate Guidelines Network (SIGN); 2003 Jun. 45
p. (SIGN publication; no. 71). \[149 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jun

#### GUIDELINE DEVELOPER(S)

Scottish Intercollegiate Guidelines Network - National Government Agency
\[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Scottish Executive Health Department

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Guideline Development Group*: Dr Tricia Donald (*Chair*), General
Practitioner, Edinburgh; Dr John Ennis (*Secretary*), General
Practitioner, Edinburgh; Dr Lisa Mackenzie (Methodologist), SpR
Rheumatology, Glasgow Royal Infirmary; Dr Graham Beastall, Clinical
Biochemist, Glasgow Royal Infirmary; Dr Lucy Caird, Consultant
Gynaecologist, Raigmore Hospital, Inverness; Dr Clare Campbell, General
Practitioner, Broxburn; Dr Donald Farquhar, Consultant Geriatrician, St.
John´s Hospital, Livingston; Dr Ailsa Gebbie, Community Gynaecologist,
Edinburgh; Mr Alberto Gregori, Consultant Orthopaedic Surgeon, Hairmyres
Hospital, East Kilbride; Dr Jim Hannan, Physicist, Western General
Hospital, Edinburgh; Mr Robin Harbour, Quality & Information Director,
Scottish Intercollegiate Guidelines Network; Ms Janice Harris, Senior
Pharmacist, Royal Victoria Hospital, Edinburgh; Dr Andrew Jamieson,
Consultant Physician, Queen Margaret Hospital, Dunfermline; Dr Justus
Krabshuis, Highland Data Ltd; Ms Ann Lees, Health Planning Manager
(Health Economist), Argyll and Clyde Acute Hospitals National Health
System Trust; Dr Alastair McLellan, Consultant Endocrinologist, Western
Infirmary, Glasgow; Ms Alice Mitchell, Health Visitor, Glasgow; Dr Sarah
Mitchell, Physiotherapist, Glasgow Royal Infirmary; Dr Caroline
Morrison, Public Health Consultant, Greater Glasgow Health Board, Dr
Anne Payne, Lecturer in Clinical Nutrition and Dietetics, Glasgow
Caledonian University; Dr Colin Perry (Methodologist), Specialist
Registrar (Endocrinology), Glasgow Royal Infirmary; Dr Nigel Raby,
Consultant Radiologist, Western Infirmary, Glasgow; Professor David
Reid, Consultant Rheumatologist, Foresterhill, Aberdeen; Dr Mary Scott,
General Practitioner, Dunfermline; Mrs Anne Simpson, National
Osteoporosis Society Coordinator for Scotland

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All members of the Scottish Intercollegiate Guidelines Network (SIGN)
guideline development groups are required to complete a declaration of
interests, both personal and non-personal. A personal interest involves
payment to the individual concerned (e.g., consultancies or other
fee-paid work commissioned by or shareholdings in the pharmaceutical
industry); a non-personal interest involves payment which benefits any
group, unit, or department for which the individual is responsible
(e.g., endowed fellowships or other pharmaceutical industry support).
Details of the declarations of interest of any guideline development
group member(s) are available from the SIGN executive.

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Scottish Intercollegiate
Guidelines Network (SIGN) Web site:

-   [HTML
    format](http://www.sign.ac.uk/guidelines/fulltext/71/index.html)

-   [Portable Document Format
    (PDF)](http://www.sign.ac.uk/pdf/sign71.pdf)

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Quick reference guide: Management of osteoporosis. A national
    clinical guideline. Scottish Intercollegiate Guidelines
    Network, 2003. 2 p. Available in Portable Document Format (PDF) from
    the [Scottish Intercollegiate Guidelines Network (SIGN) Web
    site](http://www.sign.ac.uk/pdf/qrg71.pdf).

-   SIGN 50: A guideline developer´s handbook. Edinburgh (Scotland):
    Scottish Intercollegiate Guidelines Network. (SIGN publication; no.
    50). Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/index.html).

-   Appraising the quality of clinical guidelines. The SIGN guide to the
    AGREE (Appraisal of Guidelines Research & Evaluation) guideline
    appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate
    Guidelines Network, 2001. Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/agreeguide/index.html).

#### PATIENT RESOURCES

The following is available:

-   Information for discussion with patients and carers. In: Management
    of osteoporosis. A national clinical guideline. Edinburgh
    (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003
    Jun. 45 p. (SIGN publication; no. 71).

Electronic copies: Available from the [Scottish Intercollegiate
Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/guidelines/fulltext/71/section9.html).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on April 26, 2004. The
information was verified by the guideline developer on July 15, 2004.

#### COPYRIGHT STATEMENT

Scottish Intercollegiate Guidelines Network (SIGN) guidelines are
subject to copyright; however, SIGN encourages the downloading and use
of its guidelines for the purposes of implementation, education, and
audit.

Users wishing to use, reproduce, or republish SIGN material for
commercial purposes must seek prior approval for reproduction in any
medium. To do this, please contact <sara.twaddle@nhs.net>.

Additional copyright information is available on the [SIGN Web
site](http://www.sign.ac.uk/guidelines/published/copyright.html).

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008