Physicians should favor prescribing alendronate for secondary prevention of osteoporotic fragility fractures unless patients cannot take the medication, the clinical effectiveness agency for England and Wales has ruled.
The National Institute for Health and Clinical Excellence's final assessment of preventive drugs for postmenopausal women “who have osteoporosis and have sustained a clinically apparent osteoporotic fragility fracture” also allows other bisphosphonates—along with strontium ranelate, raloxifene, and teriparatide—if patients are intolerant to alendronate, have a contraindication, or cannot comply with the instructions for taking alendronate.
In the event that patients cannot take alendronate, NICE's guideline recommends risedronate and etidronate. A patient's intolerance to etidronate and risedronate allows physicians to move on to strontium ranelate and raloxifene, provided the patient has additional risk factors or meets a stricter bone mineral density threshold.
Teriparatide is recommended if patients have a contraindication, intolerance, or unsatisfactory response to the other drugs and have a combination of very low T scores and at least two fragility fractures.
Alendronate, the least expensive medication (at £53.56 for once-weekly tablets for the generic version), was the most cost effective and was no less effective than were alternatives in preventing fragility fractures in the population, according to the NICE panel that assessed the medications.
But the panel was able to develop thresholds for the use of alternative medications, based on age, clinical risk factors, and T scores, that would not increase the National Health Service's costs by more than £30,000 per quality-adjusted life-year gained.
For example, women aged 55-59 years must have a T score of −3 to qualify for the use of risedronate or etidronate if they do not have an independent risk factor, whereas women aged 70 years or older must have a T score of only −2.5. Women aged 50-54 years do not qualify for any of the alternative medications unless they have an independent clinical risk factor.
The guideline assumes patients are receiving adequate calcium and vitamin D. It also states that a dual-energy x-ray absorptiometry scan may not be necessary for patients 75 years and older, or patients with body mass index lower than 22 kg/m