DÄ internationalArchive3/2009The Diagnosis and Treatment of Primary Osteoporosis According to Current Guidelines: In reply

Correspondence

The Diagnosis and Treatment of Primary Osteoporosis According to Current Guidelines: In reply

Dtsch Arztebl Int 2009; 106(3): 39-40. DOI: 10.3238/arztebl.2009.0040

Peters, K M

LNSLNS We welcome the volume of feedback to our CME article and thank all our critical readers for their correspondence. An update of the guideline that the article was based on is under way, and these comments will be included. With reference to Pfeiffer and Minne: The association between frequency of falls and fracture rates is uncontroversial and was taken into consideration in the guidelines as well as in our article. However, thus far there has been no proof that exercise programs lower the rate of fracture. The cited studies provide epidemiological data and not data on interventions. We certainly agree that further studies are needed—however, these would have to be financed out of the public purse since the pharmaceutical industry is not interested.

The Federal Ministry of Education and Research and the German Research Foundation, as well as other foundations, would have to be convinced that this is a worthy cause.

For reasons of space we did not discuss special measures such as ortheses or kyphoplasty/vertebroplasty. We thank Pfeiffer and Minne for pointing this out and agree with them.

With reference to Schute: The note about the probably necessary basic medication was placed at the start of the therapy chapter, to leave no reader in doubt about its necessity.

In the context of the health survey Checkup 35, documenting height and weight, in addition to other cardiovascular risk factors, is useful, but prompting for earlier height measurements will result in inaccuracies such that this variable has not been recommended as a screening instrument in the guideline. Non–specific back pain is common in the population and shows no association with reduced bone density without fractures, hence it does not constitute an indication for specific diagnostic testing. For recommendations on how to proceed, we refer to the guideline on back pain of the German Society of General Practice and Family Medicine (DEGAM).

With reference to Hörr: In patients who are close to the threshold for a specific treatment, the entire context should be carefully elucidated and decisions should be made jointly. The application of guidelines is not a hindrance to a well argued decision pertaining to an individual case. However, the costs and risks associated with long term medicalization should be borne in mind. If the fracture risk remains below 30% for the following 10 years, the cost–benefit–risk relation quickly becomes unfavorable. In case of doubt, watchful waiting and intensifying the basic medication are an option. An imminent guideline on postmenopausal hormone therapy from the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG, the German Society for Obstetrics and Gynaecology) is due to evaluate the validity of the guidelines and recommendations cited by Hörr.

With reference to Schneider: Since almost all large therapeutic studies have been conducted on the basis of DXA measurements and only few data are available on therapeutic effects with other measuring methods, the evidence based recommendations can be furnished only with DXA values. Theoretical considerations are not getting us anywhere further in this context. In the individual case—for example, in a patient prone to unexplained fractures—the use of other measuring methods is wholly justified, however. DOI: 10.3238/arztebl.2009.0040


Prof. Dr. med. Klaus M. Peters
Rhein-Sieg-Klinik
Höhenstr. 30
51588 Nümbrecht, Germany
kpeters@dbkg.de

Conflict of interest statement
The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
1.
Becker A, Niebling W, Chenot JF, Kochen MM: Degam-Leitlinie Kreuzschmerzen. 2006 Omikron publishing Düsseldorf. http://www.degam.de/leitlinien/LL_Kreuz_Internet_druck.pdf
1. Becker A, Niebling W, Chenot JF, Kochen MM: Degam-Leitlinie Kreuzschmerzen. 2006 Omikron publishing Düsseldorf. http://www.degam.de/leitlinien/LL_Kreuz_Internet_druck.pdf