Special Article
Recommendations by the Spanish Society of Rheumatology on OsteoporosisRecomendaciones de la Sociedad Española de Reumatología sobre osteoporosis

https://doi.org/10.1016/j.reumae.2018.09.011Get rights and content

Abstract

Objective

To update the recommendations on osteoporosis (OP) of the Spanish Society of Rheumatology (SER) based on the best possible evidence.

Methods

A panel of nine expert rheumatologists in OP was created, previously selected by the SER through an open call. The phases of the work were: identification of the key areas for updating the previous consensus, analysis and synthesis of the scientific evidence (using the SIGN levels of evidence) and formulation of recommendations based on this evidence and consensus techniques.

Results

This revision of the recommendations implies an update in the diagnostic evaluation and treatment of OP. It proposes some criteria to consider the high risk of fracture and some indications to start treatment. The recommendations also address issues related to the safety of treatments and the management of special situations such as inflammatory diseases and treatment with glucocorticoids.

Conclusions

We present an update of SER recommendations on OP.

Resumen

Objetivo

Actualizar las recomendaciones sobre osteoporosis (OP) de la Sociedad Española de Reumatología (SER) basadas en la mejor evidencia posible.

Métodos

Se creó un panel formado por nueve reumatólogos expertos en OP previamente seleccionados por la SER mediante una convocatoria abierta. Las fases del trabajo fueron: identificación de las áreas claves para la actualización del consenso anterior, análisis y síntesis de la evidencia científica (utilizando los niveles de evidencia del SIGN) y formulación de recomendaciones a partir de esta evidencia y de técnicas de consenso.

Resultados

Esta revisión de las recomendaciones comporta una actualización en la evaluación diagnóstica de la OP y de su tratamiento. Propone unos criterios para considerar alto riesgo de fractura y unas indicaciones para iniciar tratamiento. Las recomendaciones abordan también cuestiones relativas a la seguridad de los tratamientos y al manejo de situaciones especiales como las enfermedades inflamatorias y el tratamiento con glucocorticoides.

Conclusiones

Se presenta la actualización de las recomendaciones SER sobre OP.

Section snippets

Introduction and objectives

Osteoporosis (OP) is a diffuse skeletal disorder characterised by a general reduction in bone strength leading to a higher risk of fracture due to fragility.

In Spain and in other countries the rate of fragility fractures is increasing, mainly due to higher life expectancies.1 One study reported that in 2010 2.4 million Spaniards (1.9 million women and 0.5 men) over 50 suffered from OP,2 and as a consequences of this there were 204,000 new fractures at a cost of 2842 million euros (2.8%of the

Design

Qualitative synthesis of scientific evidence and consensus techniques have been used in this project which reflect the agreement by experts based on their clinical experience and scientific evidence.

Procedural stages

A series of steps were taken during the development of the recommendations document, which were:

  • 1.

    Creation of the work group. The document began with the formation of a panel of experts formed by 9 SER member rheumatologists. They were selected through an open call to all SER members. The Clinical

Results

There is a total of 28 formulated recommendations on OP (Table 1).

Definition and diagnosis

OP is a diffuse skeletal disease characterised by a reduction in bone resistance which leads to a higher risk of fragility fractures. The concept of “bone resistance” encompasses factors relating both to bone mineral density (BMD) and the quality of the bone tissue.6

A fragility fracture is that brought on by a low impact trauma. A fall, standing up or being seated would be included in this concept. The most frequent and relevant fractures are those of the proximal femur, the spine and the

Non pharmacological therapies

Recommendation: Included in the prevention of primary and secondary osteoporosis and fractures is the recommendation for a healthy lifestyle, consisting of a balanced diet and regular physical exercise, not smoking, limiting alcohol consumption and using preventative measures against falls (RR: √; AL: 100%).

Several studies have concluded that the first step to the prevention of OP and the avoidance of fractures is to maintain healthy life habits.53, 54, 55, 56, 57 Evidence suggests that

Fragility fracture

Recommendation: It is recommended that all patients’ ≥50 years of age with a recent fragility fracture be assessed systematically to prevent further fractures (RR: D; AL: 100%).

Patients with fragility fracture have a significant increase in the risk of further fractures. However, it is normal that fewer than 25% of them start treatment for OP after a fracture.4 The term “imminent fracture risk” has recently been introduced to refer to patients with recent fractures, fragile elderly people with

New treatments

Two new drugs for OP treatment: romosozumab and abaloparatide are currently in an advanced phase of clinical development.

Romosozumab is a humanised IgG2 monoclonal antibody which links and blocks sclerostin. It is administered monthly subcutaneously for a year, followed by denosumab or alendronic acid for a further year and has shown a significant reduction in the incidence of new vertebral and non vertebral fractures.225, 226 in one of the studies an increase in the rate of serious adverse

Conclusion

As mentioned in the introduction, the aim of this document was to provide an update on the new advances in the different aspects of OP relating to clinical practice: diagnosis, evaluation, treatment and follow-up.

The document is based on a critical review of the previous consenus,5 the best available scientific evidence and expert clinical experience. This was a joint task between panel members and the SER Unit of Research which, together with SER reviewers, carried out an extensive systematic

Conflict of interests

Antonio Naranjo Hernández received financing from Amgen, Lilly and FAES for attendance to courses/congresses, fees from Amgen for congress presentations and grants from FHOEMO-Amgen and Lilly to contract staff and provide IT teams to the service.

María Pilar Aguado Acín received financing from Lilly for attendance to congresses; fees from Alexion, Faes, Lilly and de Rubió for presentations and financing for educational programmes in the Rheumatology Unit.

Luis Arboleya Rodríguez received

Acknowledgements

The group of experts of this study wish to express their gratitude to Mercedes Guerra Rodríguez, the SER documentalist for her collaboration in search strategies and to Dr. Hye Sang Park for her collaboration in the RS report reviews. They also wish to thank Dr. Federico Diaz González, director of the SER Research Unit, for his participation in the final manuscript review and for contributing to maintaining the independence of this document.

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    Please cite this article as: Naranjo Hernández A, Díaz del Campo Fontecha P, Aguado Acín MP, Arboleya Rodríguez L, Casado Burgos E, Castañeda S, et al. Recomendaciones de la Sociedad Española de Reumatología sobre osteoporosis. Reumatol Clin. 2019;15:188–210.

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