Comment on: NICE guidance does not tally with clinical practice—a district general experience: reply

SIR, Many thanks for giving us the opportunity to comment on the observations of Yeap [1] on our letter [2]. His observations are valid about BMD not being the best marker for osteoporosis. It is, however, a flawed assumption that a prior fragility fracture is the only marker for future fracture. We know that what is frequently reported as a fragility fracture in the elderly might not be so [3]. Yeap advocates the recently published European guidance for the management of osteoporosis in post-menopausal women, which propose that treatment can be instigated after a fragility fracture, with or without BMD assessment [4]. This is pragmatic advice that may be partly related to the limited provision of dual energy X-ray absorbtiometry services. Our data included all fragility fractures including hip, wrist, vertebra and rib, while most of the data quoted in the literature is based on vertebral and or hip fractures, but did not include all other fractures. Many studies have shown that BMD is still a good marker for future fracture risk [5], and therefore finding a normal BMD in a patient who has sustained a fracture should make us re-evaluate the fracture and determine whether it was indeed low trauma. Fractures themselves are sometimes due to a combination of skeletal fragility and fall risk [6] and a possible unmeasured confounder in our findings was fall risk. This was emphasized in the European Prospective Osteoporosis Study [7]. It could be argued that falls risk should be assessed separately when new guidelines are produced.