DEXA Scan: Additional Information

Use the online FRAX assessment tool on www.sheffield.ac.uk/FRAX to see management recommendations in line with the NOGG guidelines. Alternatively, the recommendations can be accessed after manually entering the 10-year risk for major osteoporotic fracture and the 10-year risk for hip fracture, provided above, on www.nogg.org.uk/manual-data-entry. If there is discordance between the recommendations, based on the two probabilities, the highest risk category can be used to guide intervention. The FRAX score may underestimate the fracture risk of some patients due to additional risk factors not captured by FRAX. Clinical judgement and/or adjustments to FRAX probabilities should be used in those cases (https://www.nogg.org.uk/full-guideline/section-3-fracture-risk-assessment-and-case-finding).

Consider investigations for secondary causes of osteoporosis for patients with a new diagnosis of osteoporosis and/or fragility fracture as per NOGG (see Table 3 on www.nogg.org.uk/full-guideline/section-3-fracture-risk-assessment-and-case-finding). These investigations should also be considered for patients who sustain fragility fracture(s) or have a declining BMD despite treatment.

Vertebral fractures can be asymptomatic. Consider X-rays of the thoracic and lumbar spine in patients with osteoporosis and suspicion of vertebral fracture (e.g. thoracic kyphosis, height loss ≥ 4 cm, acute back pain) or at high risk (e.g. long-term oral glucocorticoid therapy), as vertebral fracture assessment (VFA) is not currently performed with DXA examinations.

Anti-resorptive treatment is the first-line treatment option for most patients with a fracture risk above the intervention threshold (www.nogg.org.uk/full-guideline/section-6-pharmacological-treatment-options). For patients initiating oral bisphosphonate treatment, the duration of treatment is usually 5 years. The duration should be extended to 10 years for patients with age ≥ 70 years, a history of vertebral or hip fractures, and concurrent steroid treatment (≥7.5mg prednisolone/ day or equivalent); www.nogg.org.uk/full-guideline/section-7-strategies-management-osteoporosis-and-fracture-risk.

Consider asking for a specialist rheumatology opinion via Advice & Refer for patients who may be eligible and benefit from anabolic treatment: men or women with a BMD T-Score ≤-3.5 (at the hip or spine) and history of fractures (consider screening for asymptomatic vertebral fractures); postmenopausal women with osteoporosis and a vertebral fracture over the last 24 months; postmenopausal women with osteoporosis, a major osteoporotic fracture (hip, spine, humerus or forearm) over the last 24 months and either a history of vertebral fractures or a very high fracture risk quantified by FRAX (https://www.nogg.org.uk/sites/nogg/download/NOGG-ROS-Romosozumab-statement-May-2022.pdf; https://www.nice.org.uk/guidance/ta161/chapter/1-Guidance). Other reasons for considering requesting a specialist opinion include the occurrence of fragility fracture(s) during bisphosphonate treatment, contraindications or intolerance to oral bisphosphonate treatment, bone mass below the expected range for age in premenopausal women and men younger than 50, history of atypical femoral fractures, glucocorticoid treatment in patients at very high risk of fracture, or patients at very high fracture risk (especially with vertebral fractures) for consideration of parenteral treatments.

Lifestyle recommendations should be given to all patients with osteoporosis or at risk of fragility fracture (www.nogg.org.uk/full-guideline/section-5-non-pharmacological-management-osteoporosis). These include advice on smoking cessation and alcohol moderation (≤ 2 units daily), adequate intake of calcium (minimum 700 mg daily via diet or otherwise by supplementation) and vitamin D (supplementation of at least 800 IU daily for patients with history/at risk of vitamin D insufficiency and patients with osteoporosis/ on osteoporosis treatments), advice on healthy diet and weight-bearing and muscle strengthening exercise, and a falls assessment for patients with osteoporosis and fragility fractures, with exercise interventions to reduce the risk of falls for those at high risk.

FOLLOW-UP: The need for and timing of a repeat DXA scan should be judged on a case-by-case basis but the following recommendations should be considered for postmenopausal women and men aged 50 years or older (www.nogg.org.uk/full-guideline/section-7-strategies-management-osteoporosis-and-fracture-risk).

• Reassess patients on bisphosphonate treatment with FRAX and DXA, no later than after 5 years of oral treatment and 3 years of intravenous treatment. These should be repeated earlier if a new fragility fracture occurs or the risk factors change (e.g. initiation of steroids).

• The FRAX and DXA assessments should be repeated again after 10 years of oral bisphosphonate treatment and 6 years of zoledronate, if the patient has remained on treatment.

• A repeat FRAX assessment and DXA are recommended after 18-24 months from pausing oral bisphosphonate treatment (24 months for alendronate and 18 months for risedronate/ibandronate) and after 3 years from pausing zoledronate treatment. These should be repeated earlier if a new fragility fracture occurs.

• Patients with FRAX probability near to, but below the intervention threshold who have not started treatment would benefit from reassessment with FRAX and DXA after 2 years, or after 1 year if there are risk factors for rapid bone loss such as steroids, androgen deprivation treatment, and aromatase inhibitors.

• Patients with low fracture risk and none of the above risk factors should be reassessed with FRAX and DXA at 5 years or earlier depending on the clinical context.