title: SIGN Guidelines for Scotland: BMD Versus FRAX Versus QFracture.
abstract: Scottish Intercollegiate Guidelines Network (SIGN) recently issued guidance on the management of osteoporosis and the prevention of fragility fractures. The aim of this paper was to critically review the guidance. The SIGN guidance utilises risk factors for fracture as an initial step for assessment, but recommends treatment only in individuals with a T-score of -2.5. There are many problems with the sole use of BMD as the sole gateway to treatment. Moreover, the assessment tools to determine risk (FRAX or QFracture) are not designed to detect osteoporosis but rather fracture risk. Whereas SIGN assumes that FRAX overestimates fracture probability, there are compelling reasons to believe that the disparity is related to the inadequate calibration of QFracture. The disparities make the use of a single threshold for BMD testing problematic. The SIGN guidance for men at high risk of fracture provides a set of confused and inconsistent recommendations that are in direct conflict with regulatory authorizations and is likely to increase further the large treatment gap in men. For women, the number of women eligible for treatment (i.e. with osteoporosis) is 81,700 with the use of FRAX but only 12,300 with QFracture representing 8.2 and 1.2 % of the total population at risk, respectively. We conclude that serious problems with the SIGN guidance preclude its implementation.
authors.affiliation: Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK. w.j.pontefract@sheffield.ac.uk.
authors.forename: John A
authors.initials: JA
authors.lastname: Kanis
authors.affiliation: Cambridge Biomedical Campus, Cambridge, UK.
authors.forename: Juliet
authors.initials: J
authors.lastname: Compston
authors.affiliation: MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
authors.forename: Cyrus
authors.initials: C
authors.lastname: Cooper
authors.affiliation: MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
authors.forename: Nicholas C
authors.initials: NC
authors.lastname: Harvey
authors.affiliation: Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
authors.forename: Helena
authors.initials: H
authors.lastname: Johansson
authors.affiliation: Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
authors.forename: Anders
authors.initials: A
authors.lastname: Odén
authors.affiliation: Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
authors.forename: Eugene V
authors.initials: EV
authors.lastname: McCloskey
mesh_terms: D000465:Algorithms; D015519:Bone Density; D005260:Female; D006801:Humans; D008297:Male; D058866:Osteoporotic Fractures / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012307:Risk Factors; D012606:Scotland
keywords: Assessment guidelines; FRAX; QFracture; QFracture osteoporosis; Scotland