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What is NOGG?

The National Osteoporosis Guideline Group* (NOGG) was established to provide a clinical guideline for the management of men and women at high fracture risk, particularly to address the need to integrate the expression of a patient's fracture risk as a 10-year probability (the output from FRAX^®) with current clinical management of osteoporosis. This included the need to define thresholds for BMD measurement and treatment.

The NOGG Guideline has been produced with the support of the Bone Research Society, British Geriatric Society, British Orthopaedic Association, British Society of Rheumatology, Primary Care Rheumatology Society, Royal College of Physicians, Society of Endocrinology, National Osteoporosis Society, Osteoporosis 2000 and Osteoporosis Dorset.

Aims of NOGG

Given the development of FRAX^® algorithms to calculate an individual's 10-year probability of fracture, the Group wished to:

• Provide assessment thresholds for the use of BMD i.e. the fracture probabilities at which a BMD test might or might not be recommended.
• Revise intervention thresholds, based on the existing RCP case-finding strategy, to provide the fracture probability at which intervention is recommended.

Why do we need revised assessment and intervention thresholds?

In the UK, guidance for the identification of patients at high fracture risk has been provided by the Royal College of Physicians (RCP) [RCP 1999, 2000, 2002]. Since the development of the RCP guidelines, it has become apparent that the presence of several of the risk factors used to trigger a bone mineral density (BMD) test is associated with a fracture risk greater than can be accounted for by BMD alone. Thus, the assessment of fracture risk should take account of those clinical risk factors (CRFs) that contribute to fracture risk in addition to BMD, since this increases the detection rate of individuals who would fracture.

FRAX^®

The FRAX^® tool for the assessment of fracture risk (www.shef.ac.uk/FRAX) integrates clinical risk factors, with or without femoral neck BMD, to calculate the 10-year probability of a major osteoporotic fracture (clinical spine, hip, forearm or proximal humerus) and hip fracture for several countries, including the UK.

Clinical use of FRAX^® and NOGG Guideline

The guideline is based on an opportunistic case finding strategy in which physicians are alerted to the possibility of osteoporosis and high fracture risk by the presence of clinical risk factors (CRFs) associated with fracture. Briefly the guideline states that:

• Postmenopausal women with a prior fragility fracture should be considered for treatment without the need for further risk assessment, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.
• Assessment by the FRAX tool should be undertaken in:
  • Men aged 50 years or more (with or without fracture) but with a WHO risk factor or a BMI < 19kg/m².
  • All postmenopausal women without fracture but with a WHO risk factor or a BMI < 19kg/m².

Following the assessment of fracture risk using FRAX, the patient may be classified to be at low, intermediate or high risk.

• Low risk - reassure and reassess in 5 years or less depending on the clinical context.
• Intermediate risk - measure BMD and recalculate the fracture risk to determine whether an individual's risk lies above or below the intervention threshold.
• High risk - can be considered for treatment without the need for BMD, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.

NB - These thresholds are for guidance only and the final decision to assess BMD or to initiate therapeutic intervention lies with the individual clinician.

Management algorithm for the assessment of patients at risk of fracture:

The members of NOGG are Prof JE Compston (Chair), Dr AL Cooper, Prof C Cooper, Prof R Francis, Prof D Marsh, Prof EV McCloskey, Prof JA Kanis, Prof D Reid, Dr P Selby and Mrs M Wilkins.

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