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Jonathan Bayly is correct in reminding us that the guidance from the National Osteoporosis Guidelines Group (NOGG) should be critically appraised.1 It is not however, a rival to NICE but seeks to provide a user-friendly guideline to include men, steroid-induced osteoporosis, the newer bisphosphonates, recombinant human parathyroid hormone, and also to include the World Health Organisation Fracture Risk Assessment Tool (FRAX™). Since NOGG is web-based it is relatively easy to keep it constantly updated.
Guidelines are dependant upon published studies. These studies, which are expensive, at present recruit patients that are at very high risk of developing the endpoint in question, but are otherwise relatively uncomplicated. The studies are comparatively short and are not powered to study the long-term side effects.
These relatively short-term controlled studies are then extrapolated to the real world of free roaming patients, with comorbidities, co-prescribing with its associated drug interactions, and poor medication compliance. These patients may also be in a different age range to those in the randomised controlled studies. Further studies are required after the pivotal randomised controlled studies and granting of a product licence, to study medications in the true environments in which they are used.
However, because we do not have the best data this must not be an excuse to do nothing. ‘The care gap is wide and not getting any narrower.’1 We now have the opportunity with a user-friendly tool, to focus on the end organ damage of fracture remembering that osteoporosis is a very important risk factor, but nevertheless, only a surrogate marker.
I am a member of NOGG-the National Osteoporosis Guideline Group.