How to use Clinical Evidence to inform
clinical decision making
A case study using the CE review on fracture
prevention in postmenopausal women
Osteoporosis
Case study constructed for
purpose of Clinical Evidence
demonstration. Not based on a
patient seen by the author, or
on any particular individual
• Case history: 68-year-old white woman
• Presents to accident and emergency
department with right wrist pain, swelling,
and displacement following a fall onto
outstretched hand on the stairs at home
History
• Past medical history – asthma since childhood
(treated with corticosteroids aged 50–55), gastric
ulcer aged 45, menopause age 59, left wrist
fracture aged 67
• Family history – stroke in sister aged 65, hip
fracture in mother aged 78. Mother diagnosed
with osteoporosis
• Social history – lives alone, 2 children, retired,
smokes 5 cigarettes per day, occasional alcohol,
takes no exercise, fully mobile and able to
complete all ADLs (activities of daily living)
Examination
• On examination – wrist displaced, swollen, no
open wound
• No loss of sensation or vascular compromise
• X-ray – Colles’ fracture of distal radius present
N.B. The most common osteoporotic fractures
are vertebrae, wrists, and hips. Lifetime risk of
fracture in white women is 20% for spine, 15%
for wrist, and 18% for hip. There is an
exponential increase in fracture over 50 years
Investigations and treatment for presenting
problem
• Colles’ fracture treated conservatively with
cast and analgesia
• DEXA scan arranged as postmenopausal
woman with history of previous fracture,
corticosteroid use, and family history of
osteoporosis – osteoporosis diagnosed in this
patient
Further issues for you to consider...
• How can further fractures be prevented?
• Bisphosphonates are the most commonly
used treatment, but how useful are they?
• Are there any non-pharmacological
treatments that would help?
• Which of these options are most appropriate
for this particular person?
• How strong is the evidence for these options?
Bisphosphonates
Clinical question
Categorisation
of effectiveness
for each
bisphosphonate
we cover
Different
bisphosphonates for
which we have
searched for
systematic review or
randomised control
trial evidence
Click on the drug of interest to see the evidence base for the benefits and
harms…
… for example, alendronate
Here there is a
summary of
alendronate
compared
with placebo,
and with other
antiresorptive
drugs
Scrolling
down further
shows the
evidence
base behind
these
statements
Here we can see the
quality of the evidence
we have available to
make decisions on.
Clicking on the GRADE
table shows how these
quality assessments
were decided on
… GRADE table
This column
shows the
number of
studies and
participants
that the
GRADE
statement is
based on
Here, the
evidence was
RCTs or SRs,
gaining a
maximum of 4
points.
The GRADE depends
on the final score
once the numbers in
the table row are
added together. A
score of 4 means
high-quality
evidence; 3 is
moderate-quality, 2
is low-quality, etc
These 3 table
rows focus on
alendronate
In the ‘comments’ column we explain what we deducted or added points for
Other pharmacological treatments
Just as with
bisphosphonates,
click on the question
about other
pharmacological
treatments to see this
summary table, and
then click on
individual drugs to
see how they
compare with
placebo and each
other in terms of
benefits and harms
Non-pharmacological treatments
… and the same
for nonpharmacological
treatments!
Click on these icons
to read about our
categorisation of
interventions: they
are based on a
system derived by
the Cochrane
Collaboration
Pregnancy and
Childbirth group
Individual medicine
• Thinking about this person:
• Past medical history – previous fracture,
postmenopausal, corticosteroid use, gastric ulcer
• We can see from the review that alendronate,
(and other bisphosphonates) are associated with
gastric ulcers and erosions
• Therefore, we should consider other options, but
remember as well that this is not a
contraindication, but a caution about their use
Family history – stroke (raloxifene may
increase stroke risk)
What would be better?
Using Clinical Evidence to help answer the
patient’s questions…
• Questions your patient has…
• Several friends take HRT and have recommended this –
should she do the same?
• At present, she does not take any regular exercise, but
wonders whether this is important. She has heard that
exercise ‘strengthens the bones’, but is worried about
having a fall and getting another fracture
• Since the diagnosis she has been taking calcium and
vitamin D supplements as she hoped these would
reduce her fracture risk – are these a good use of
money and are they harmful in any way?
HRT
This may help answer the patient’s questions about
exercise. Although exercise has other beneficial effects,
the evidence here shows that, contrary to media reports,
there is not enough high-quality evidence to know
whether or not this is the case
From the ‘Key Points’
section, we see that
although HRT may
reduce fractures, the
risks of adverse effects
are thought to
outweigh the benefits.
From this, you can
advise the patient of
this, and suggest that
there are other options
that are as effective but
safer
Calcium and vitamin D
are covered in the Key
Points, but the patient
would like further
information…
The patient was keen to find
out more about calcium versus
vitamin D. She also wanted to
know whether there was any
harm in continuing to take
calcium supplements in the
absence of good evidence for
their use
Remember that you
can also find
patient information
leaflets on the
Clinical Evidence
website
Conclusions
• Risks of HRT outweigh the benefits
• We don’t know if exercise is beneficial
• Monotherapy with calcium or vitamin D has
not been shown to reduce fractures
• Bisphosphonates are effective but are
associated with gastric ulcers
• Raloxifene increases stroke risk