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SIGN Guidelines for Scotland: BMD Versus FRAX Versus QFracture

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Abstract

Scottish Intercollegiate Guidelines Network (SIGN) recently issued guidance on the management of osteoporosis and the prevention of fragility fractures. The aim of this paper was to critically review the guidance. The SIGN guidance utilises risk factors for fracture as an initial step for assessment, but recommends treatment only in individuals with a T-score of −2.5. There are many problems with the sole use of BMD as the sole gateway to treatment. Moreover, the assessment tools to determine risk (FRAX or QFracture) are not designed to detect osteoporosis but rather fracture risk. Whereas SIGN assumes that FRAX overestimates fracture probability, there are compelling reasons to believe that the disparity is related to the inadequate calibration of QFracture. The disparities make the use of a single threshold for BMD testing problematic. The SIGN guidance for men at high risk of fracture provides a set of confused and inconsistent recommendations that are in direct conflict with regulatory authorizations and is likely to increase further the large treatment gap in men. For women, the number of women eligible for treatment (i.e. with osteoporosis) is 81,700 with the use of FRAX but only 12,300 with QFracture representing 8.2 and 1.2 % of the total population at risk, respectively. We conclude that serious problems with the SIGN guidance preclude its implementation.

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Authors and Affiliations

  1. Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK

    John A. Kanis, Helena Johansson, Anders Odén & Eugene V. McCloskey

  2. Cambridge Biomedical Campus, Cambridge, UK

    Juliet Compston

  3. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

    Cyrus Cooper & Nicholas C. Harvey

Authors
  1. John A. Kanis
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  2. Juliet Compston
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  3. Cyrus Cooper
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  4. Nicholas C. Harvey
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  5. Helena Johansson
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  6. Anders Odén
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  7. Eugene V. McCloskey
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Corresponding author

Correspondence to John A. Kanis.

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Conflict of interest

Professor Kanis led the team that developed FRAX as director of the WHO Collaborating Centre for Metabolic Bone Diseases; he has no financial interest in FRAX. Professors McCloskey, Oden, Harvey and Dr Johansson are members of the FRAX team. Professor Compston is Chairman of the National Osteoporosis Guideline Group, UK of which Professors Cooper, Kanis and McCloskey are members of its advisory body.

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Kanis, J.A., Compston, J., Cooper, C. et al. SIGN Guidelines for Scotland: BMD Versus FRAX Versus QFracture. Calcif Tissue Int 98, 417–425 (2016). https://doi.org/10.1007/s00223-015-0092-4

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  • DOI: https://doi.org/10.1007/s00223-015-0092-4

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