Issued in 2008, the institute's guidance on primary fracture prevention recommends alendronate (Fosamax and Fosavance) as first-line agents, with etidronate (Didronel) and risedronate to be used in certain cases of intolerance, contraindication or non-adherence to alendronate.
If a woman can't take any of these bisphosphonates, strontium ranelate (Protelos) is recommended under certain circumstances as a possible alternative.
The guidance on secondary fracture prevention follows the same principles, with the addition of raloxifene (Evista) and teriparatide (Forsteo) as possible third- and fourth-line treatments, respectively.
Court appeals against the guidance by the National Osteoporosis Society and Servier, manufacturer of Protelos, contested that women unable to take bisphosphonates would remain unprotected from fracture until their bone mineral density declined sufficiently to qualify them for third-line treatment.
As a result of the appeals, NICE was ordered to review its recommendations and divulge the underlying economic model. However, the reviewers concluded that the model was an appropriate basis for the guidance.
Since no further appeals were subsequently lodged, the original guidance was re-issued in January 2010.