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Osteoporosis : secondary prevention of fragility fractures (OST)

Patients aged between 50 and 74 years (inclusive), with a fragility fracture on or after 1st April 2012, in whom osteoporosis is confirmed on DXA scan

Bone sparing agent codes - Prescibed after 1st October, i.e. in the preceding 6 months

fo1..% DISODIUM ETIDRONATE
fo4..% ALENDRONIC ACID
fo6..% RISEDRONATE SODIUM
fo8..% IBANDRONIC ACID
fv1..% RALOXIFENE HYDROCHLORIDE
fu3..% TERIPARATIDE
fu5..% STRONTIUM
fu9..% DENOSUMAB
fo7..% ZOLEDRONIC ACID
8BP1. Teriparatide therapy
8B6c. Intravenous bisphosphonate prophylaxis
8B6b. Osteoporosis medication prophylaxis
8BPW. Denosumab therapy
8BPX. Ibandronic acid therapy
8BPZ. Parathyroid hormone therapy
8BPY. Zoledronic acid therapy

Bone sparing agent therapy not indicated - added in the last 12 months

8I615 Bone sparing agent therapy not indicated (v28)

Bone sparing agent contra-indications: persistent

14LT. H/O: bisphosphonate allergy
ZV14K [V]Personal history of bisphosphonate allergy
14LT3 H/O alendronic acid allergy
14LT4 H/O risedronate sodium allergy
14LT1 H/O zoledronic acid monohydrate allergy
14LT2 H/O disodium etidronate allergy
14LT0 H/O ibandronic acid allergy
14La. H/O: raloxifene allergy
14Lb. H/O: teriparatide allergy
14Lc. H/O denosumab allergy
14LW. H/O: strontium ranelate allergy
ZV14H [V]Personal history of strontium ranelate allergy

Bone sparing agent cat1 contra-indications: expiring - added in the last 12 months

8I3e. Bisphosphonates declined
8I6R. Bisphosphonates not indicated
8I7E. Bisphosphonates not tolerated
8I2V. Bisphosphonates contraindicated
8I2V3 Alendronic acid contraindicated
8I3e3 Alendronic acid declined
8I6R3 Alendronic acid not indicated
8I7E3 Alendronic acid not tolerated
8I2V2 Disodium etidronate contraindicated
8I3e2 Disodium etidronate declined
8I6R2 Disodium etidronate not indicated
8I7E2 Disodium etidronate not tolerated
8I7E1 Zoledronic acid monohydrate not tolerated
8I2V0 Ibandronic acid contraindicated
8I2V1 Zoledronic acid monohydrate contraindicated
8I3e0 Ibandronic acid declined
8I3e1 Zoledronic acid monohydrate declined
8I6R0 Ibandronic acid not indicated
8I6R1 Zoledronic acid monohydrate not indicated
8I7E0 Ibandronic acid not tolerated
8I2V4 Risedronate sodium contraindicated
8I3e4 Risedronate sodium declined
8I6R4 Risedronate sodium not indicated
8I7E4 Risedronate sodium not tolerated
8I6p. Raloxifene not indicated
8I7P. Raloxifene not tolerated
8IEH. Raloxifene declined
8I2l. Raloxifene contraindicated
8I6q. Teriparatide not indicated
8I7Q. Teriparatide not tolerated
8IED. Teriparatide declined
8I2m. Teriparatide contraindicated
8I2p. Denosumab contraindicated
8IEW. Denosumab declined
8I612 Denosumab not indicated

8I7S. Denosumab not tolerated

8I3h. Strontium ranelate declined
8I6V. Strontium ranelate not indicated
8I7H. Strontium ranelate not tolerated
8I2Y. Strontium ranelate contraindicated

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Osteoporosis exception reporting codes

9hP.. Exception reporting: osteoporosis quality indicators
9hP0. Excepted from osteoporosis quality indicators: patient unsuitable
9hP1. Excepted from osteoporosis quality indicators: informed dissent

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Osteoporosis 002.1 Rationale

The management of osteoporosis includes lifestyle advice, such as advice on adequate nutrition, regular weight-bearing exercise, stopping smoking and avoiding alcohol, to reduce the risks of osteoporosis. Interventions for secondary prevention of fractures in patients who have had an osteoporotic fragility fracture include pharmacological intervention.

The SIGN guideline on management of osteoporosis addresses the pharmacological management in three groups of postmenopausal women: postmenopausal women with multiple vertebral fractures (DXA scan not essential but other destructive diseases should be excluded); postmenopausal women with osteoporosis determined by DXA scan and a history of at least one vertebral fracture; and postmenopausal women with osteoporosis determined by DXA scan with or without a previous non-vertebral fracture.

For all of these groups bonesparing agents are indicated to reduce subsequent fracture risk. NICE technology appraisal 161 states that the bone-sparing agent alendronate is recommended as a treatment option for the secondary prevention of osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis. When the decision has been made to initiate treatment with alendronate, the preparation prescribed should be chosen on the basis of the lowest acquisitioncost available. The bone-sparing agents risedronate and etidronate are recommended as alternative treatment options for the secondary prevention of osteoporotic fragility fractures in postmenopausal women:

Table 5: T-scores (SD) at (or below) which risedronate or etidronate is recommended when alendronate cannot be taken

Age (years)
Number of independent clinical risk factors for fracture*
0
1
2
50 - 54
-**
-3.0
-2.5
55 - 59
-3.0
-3.0
-2.5
60 - 64
-3.0
-3.0
-2.5
65 - 69
-3.0
-2.5
-2.5
70 or older
-2.5
-2.5
-2.5

* Independent clinical risk factors for fracture are parental history of hip fracture, alcohol intake of four or more units per day, and rheumatoid arthritis.
** Treatment with risedronate or etidronate is not recommended.

In deciding between risedronate and etidronate, clinicians and patients need to balance the overall proven effectiveness profile of the drugs against their tolerability and adverse effects in individual patients.

For more information see NICE technology appraisal 161, available from
www.nice.org.uk/guidance/TA161

The SIGN clinical guideline makes recommendations on men with a diagnosis of osteoporosis determined by DXA scan. It states that 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.

It is recommended that calcium and vitamin D supplementation are used in combination with bone-sparing agents. The guideline also recommends that patients who have had a fragility fracture who require treatment with a bone-sparing agent also receive appropriate calcium and/or vitamin D supplementation.

SIGN (2003) Management of osteoporosis. SIGN clinical guideline 71. Available from www.sign.ac.uk/guidelines/fulltext/71/index.html
NICE (2008) Alendronate, etidronate, risedronate, raloxifene, strontium ranelate, and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (amended January 2010 and January 2011). NICE technology appraisal guidance 161. Available from www.nice.org.uk/guidance/TA161
SIGN (2003) Management of osteoporosis. SIGN clinical guideline 71. Available from www.sign.ac.uk/guidelines/fulltext/71/index.html

Osteoporosis 002.2 Reporting and verification

See indicator wording for requirement criteria.

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Prepared By Jean Keenan