To the Editor: We have carefully read Dr. Alkhenizan’s comments regarding our article. He makes valid points for structuring evidence-based guidelines, and we certainly agree with the importance of linking recommendations to their level of evidence. Our article, however, was meant as a summarized document to help our local physicians in assessing and treating patients with suspected or documented osteoporosis. The methodology, therefore, was only briefly mentioned. The task force members had indeed reviewed most of the major published international guidelines, including the Canadian guidelines that Dr Alkhenizan mentioned. We also reviewed guidelines made by other reputable groups like the US Preventive Services Task Force and the NIH (see references 2, 15, 29, and the list of guidelines and reviews on the same page). The major drug trials were also reviewed (references 3, 4, 5, 18, 24, 26, 27, 28), in addition to an important recent meta-analysis of all available drugs (references 19 and 25). The level of evidence in each of these international recommendations—whenever available-was noted. Our task force recommendations were therefore based on the above review of evidence, not on subjective experience, and only those recommendations with high level of evidence were considered.
We might differ from other guidelines, however, by taking local data and local culture into account. We have reviewed most data available from the region and incorporated the information in our final recommendations. Although high quality guidelines for certain diseases might well serve physicians in many different regions, we argue that this is not the case in osteoporosis! Indeed, a blind adoption of an international recommendation without taking in account local data and circumstances might have adverse consequences on patients and public health resources. The specific reasons for this were explained in length in our article. One example is whether to screen all postmenopausal women at or after age 65 with BMD (level 1 evidence) or to modify this recommendation to account for an earlier development of osteoporosis in our population (according to local studies). Also, we felt it important to account for the clear difference in physical activities and therefore risk of falling between elderly females (above 65) in this region compared to the West. A more reasonable recommendation in our view would be to start screening at an earlier age, and to incorporate risk factors to identify those at higher risk instead of drawing a fixed line that might fit other societies. In contrast, the use of anti-resorptive agents in patients with osteopenia without good evidence that it would decrease fracture rates seem less reasonable in a society with widespread osteopenia but lower fracture rates than the West. A reasonable recommendation in our view again would be to be more conservative in this group, and only to use such expensive treatment when there are fractures or high risk factors. Some international guidelines have recommended treatment for such patients.
In fact, there are significant differences in the recommendations made by reputable international groups which make it impossible for a practitioner to decide which one to follow. These differences are partially due to different circumstances, resources, views, and even interests. Our task force final recommendations were, therefore, in general agreement with other international evidence-based guidelines. Modifications were only made when felt necessary by reviewing local data.
Finally our attempt was, to our knowledge, the first of its kind in this region that attempted to deal with this ever expanding and often confusing health problem. The guidelines are far from perfect, and obviously are limited by sparse local data and missing information on local risk factors and BMD/fracture correlation. Nevertheless, the guidelines have been very well received by local and even international specialists and practitioners, and are largely adopted by the Saudi Osteoporosis Society, which is in the process of formulating national guidelines.