Guidelines on the management of osteoporosis associated with chronic liver disease
- 1Department of Gastroenterology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- 2Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrookes Hospital, Cambridge CB2 2QQ, UK
- Correspondence to:
J D Collier, Department of Gastroenterology, John Radcliffe Hospital, Oxford OX3 9DU, UK;
- Accepted 21 August 2001
- BMD, bone mineral density
- DXA, dual energy x ray absorptiometry
- PBC, primary biliary cirrhosis
- PSC, primary sclerosing cholangitis
- HRT, hormone replacement therapy
- SHBG, sex hormone binding globulin
- LH, luteinising hormone
- FSH, follicle stimulating hormone
1.0 BACKGROUND AND SCOPE OF GUIDELINES
An important complication of chronic liver disease is osteodystrophy which includes osteoporosis and the much rarer osteomalacia. Both conditions are associated with significant morbidity through fractures resulting in pain, deformity, and immobility. There is also a further significant increase in the risk of fractures following liver transplantation for end stage chronic liver disease.
Osteoporosis is defined as a “progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture” (World Health Organisation, 1994). Common fractures are vertebral compression fractures, fractures of the distal radius, and proximal femur.
Although guidelines on the prevention and management of osteoporosis, and specifically corticosteroid induced osteoporosis and osteoporosis in men, have recently been published, there is no consensus on how to manage osteoporosis in patients with chronic liver disease.1–3
The scope of these guidelines is to review the assessment and diagnosis of osteoporosis, the therapeutic agents available, and the way in which they can be used in patients with chronic liver disease to prevent osteoporosis with the aim of reducing fracture rate. A number of research priorities have also been identified.
2.0 FORMULATION OF GUIDELINES
2.1 Grading of recommendations and evidence level in patients with chronic liver disease
The guidelines developed are based on systematic review of the published literature. As not all recommendations are based on randomised controlled trials, the recommendations have been scored according to the following criteria.
Grade A: based on meta-analysis or at least one randomised controlled trial.
Grade B: based on at least one well designed but not necessarily controlled study including case control and comparative studies.
Grade C: based on expert reports or opinions.
2.2 Process of guideline formation
A systematic review of the literature was undertaken and draft guidelines prepared. The guidelines were then reviewed in a consensus workshop following which a final draft was prepared. The consensus workshop was supported by the …