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Bar M, Ott SM, Lewiecki EM, Sarafoglou K, Wu JY, Thompson MJ, Vaux JJ, Dean DR, Saag KG, Hashmi SK, Inamoto Y, Dholaria BR, Kharfan-Dabaja MA, Nagler A, Rodriguez C, Hamilton BK, Shah N, Flowers MED, Savani BN, Carpenter PA. Bone Health Management After Hematopoietic Cell Transplantation: An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant 2020; 26:1784-1802. [PMID: 32653624 DOI: 10.1016/j.bbmt.2020.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/14/2022]
Abstract
Bone health disturbances commonly occur after hematopoietic cell transplantation (HCT) with loss of bone mineral density (BMD) and avascular necrosis (AVN) foremost among them. BMD loss is related to pretransplantation chemotherapy and radiation exposure and immunosuppressive therapy for graft-versus-host-disease (GVHD) and results from deficiencies in growth or gonadal hormones, disturbances in calcium and vitamin D homeostasis, as well as osteoblast and osteoclast dysfunction. Although the pathophysiology of AVN remains unclear, high-dose glucocorticoid exposure is the most frequent association. Various societal treatment guidelines for osteoporosis exist, but the focus is mainly on menopausal-associated osteoporosis. HCT survivors comprise a distinct population with unique comorbidities, making general approaches to bone health management inappropriate in some cases. To address a core set of 16 frequently asked questions (FAQs) relevant to bone health in HCT, the American Society of Transplant and Cellular Therapy Committee on Practice Guidelines convened a panel of experts in HCT, adult and pediatric endocrinology, orthopedics, and oral medicine. Owing to a lack of relevant prospective controlled clinical trials that specifically address bone health in HCT, the answers to the FAQs rely on evidence derived from retrospective HCT studies, results extrapolated from prospective studies in non-HCT settings, relevant societal guidelines, and expert panel opinion. Given the heterogenous comorbidities and needs of individual HCT recipients, answers to FAQs in this article should be considered general recommendations, with good medical practice and judgment ultimately dictating care of individual patients. Readers are referred to the Supplementary Material for answers to additional FAQs that did not make the core set.
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Affiliation(s)
- Merav Bar
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington.
| | - Susan M Ott
- Department of Medicine, University of Washington, Seattle, Washington
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico; Bone Health TeleECHO, UNM Health Sciences Center, Albuquerque, New Mexico
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Divisions of Endocrinology and Genetics & Metabolism, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Experimental & Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota
| | - Joy Y Wu
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew J Thompson
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jonathan J Vaux
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - David R Dean
- Department of Oral Medicine, University of Washington School of Dentistry, Seattle, Washington
| | - Kenneth G Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Shahrukh K Hashmi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Bhagirathbhai R Dholaria
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Arnon Nagler
- Bone Marrow Transplantation Department, Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Cesar Rodriguez
- Department of Internal Medicine Hematology and Oncology, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Nina Shah
- Division of Hematology-Oncology, University of California, San Francisco, California
| | - Mary E D Flowers
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Bipin N Savani
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
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152
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Affiliation(s)
- Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK. .,NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK. .,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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153
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High rates of undiagnosed and untreated osteoporosis in postmenopausal women receiving medical services in the area of Upper Silesia. MENOPAUSE REVIEW 2020; 19:72-79. [PMID: 32802017 PMCID: PMC7422288 DOI: 10.5114/pm.2020.97844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/08/2020] [Indexed: 11/17/2022]
Abstract
Introduction High social cost and high risk of disability make postmenopausal osteoporosis one of major public health problem in the 21st century. The aim of this study was to assess frequency of undiagnosed and untreated osteoporosis in postmenopausal women in the Upper Silesia Region of Poland. Additionally, we compare estimation of the 10-year probability of major osteoporotic fractures (MOF) and hip fractures (HF) based on fracture risk assessment tool (FRAX) with and without bone mineral density (BMD). Material and methods The survey included 450 postmenopausal women (age 65 ±11 years). A detailed questionnaire included demographic and anthropometric data, comorbidity, history of previous low-energy fractures, family medical history, and treatment for osteoporosis. The FRAX calculator was used to estimate the risk of MOF and HF. Results Osteoporosis was previously diagnosed in 23.7% women. Of those 70.2% were receiving vitamin D, 27% calcium preparations, 33% bisphosphonates, and 22% were untreated. Only 42.2% women with previous fractures had been diagnosed with osteoporosis and 42.8% received any treatment. 12.5% women with FRAX-BMD ≥ 10% had no risk factors of osteoporosis and < 10% risk of MOF and HF in FRAX without BMD. Conclusions Osteoporosis often remains undiagnosed and untreated in postmenopausal women. There is a great need to popularize FRAX without BMD calculator among physicians, especially GPs, as the risk calculation justify the implementation of antiosteoporotic therapy. Women with burden of risk factors of fractures and borderline FRAX without BMD values, should be referred to a densitometry examination, as having greater risk of fracture than shown by FRAX without BMD.
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154
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Fan Z, Li X, Zhang X, Yang Y, Fei Q, Guo A. Comparison of OSTA, FRAX and BMI for Predicting Postmenopausal Osteoporosis in a Han Population in Beijing: A Cross Sectional Study. Clin Interv Aging 2020; 15:1171-1180. [PMID: 32764904 PMCID: PMC7381824 DOI: 10.2147/cia.s257166] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/30/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To validate the efficacies of three screening tools including the Osteoporosis Self-Assessment Tool for Asians (OSTA), Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD), and body mass index (BMI) for predicting postmenopausal osteoporosis (OP) and to define the ideal thresholds for avoidance of dual-energy X-ray absorptiometry (DXA) scanning in a Han Chinese population in Beijing. Patients and Methods A total of 2055 community-dwelling Han Beijing postmenopausal females aged ≥45 years were enrolled in this study. All participants completed a questionnaire, and BMD was measured by DXA. OP was defined by a T-score at least -2.5 SD less than that of average young adults in different diagnostic criteria [lumbar spine, femoral neck, total hip, worst hip, WHO]. The abilities of the OSTA, FRAX, and BMI to predict OP were analyzed by receiver operating characteristic (ROC) curves. Sensitivity, specificity, and area under the ROC curves (AUC) were calculated. Ideal thresholds for identifying OP were proposed. Results The prevalence of OP ranged from 8.1% to 28.4% according to different diagnostic criteria. The AUC range for the OSTA (0.758-0.849) was similar to the FRAX (0.728-0.855), which revealed that both tools predicted OP reliably. The AUC range for BMI was 0.643-0.682, suggesting limited predictive value. According to WHO criteria, the AUC values for the FRAX for hip fracture risk (FRAX-HF) and for the OSTA were 0.796 and 0.798, with corresponding sensitivities of 74.79% and 69.64% and specificities of 70.45% and 75.07%, respectively. At defined thresholds, the FRAX-HF and OSTA allowed avoidance of DXA in 42.4-37.6% of participants, at a cost of missing only 7.2-8.6% of individuals with OP. Conclusion The OSTA and FRAX-HF may be reliable and effective tools for identifying postmenopausal OP in the Han Beijing population without BMD.
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Affiliation(s)
- Zihan Fan
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaoyu Li
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaodong Zhang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ai Guo
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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155
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Compston JE, Drake MT. Defining Very High Fracture Risk: Is FRAX Fit for Purpose? J Bone Miner Res 2020; 35:1399-1403. [PMID: 32696997 DOI: 10.1002/jbmr.4134] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
| | - Matthew T Drake
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, and Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA
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156
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Morato-Martínez M, López-Plaza B, Santurino C, Palma-Milla S, Gómez-Candela C. A Dairy Product to Reconstitute Enriched with Bioactive Nutrients Stops Bone Loss in High-Risk Menopausal Women without Pharmacological Treatment. Nutrients 2020; 12:nu12082203. [PMID: 32722015 PMCID: PMC7468696 DOI: 10.3390/nu12082203] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 01/06/2023] Open
Abstract
Osteoporosis is a multifactorial disease characterized by the loss of bone mass and deterioration of the internal structure of the bone, increasing the risk of fractures, and is becoming an economic and social problem. The main treatment is pharmacological, however, the population demands other therapies, such as foods with nutrients beneficial to bone health. Seventy-eight healthy menopausal women at risk of osteoporosis or untreated osteopenia were recruited for a randomized, parallel, double-blind clinical trial with two intervention groups: one group consumed a serving a day of the experimental enriched product (experimental group (EG)) and the other group (control group (CG)) consumed the same product without enrichment. The main objective was to compare the effect of consuming a dairy preparation to reconstitute, similar to yogurt when prepared, enriched in calcium, vitamin D, vitamin K, vitamin C, zinc, magnesium, L-leucine and probiotic (Lactobacillus plantarum 3547) on bone metabolism markers for 24 weeks. The EG showed a significantly increased bone mass compared to the CG (0.01 ± 0.03 vs. −0.01 ± 0.03 kg; p < 0.05). In addition, the EG maintained their bone mineral density (BMD) compared to the CG, whose BMD significantly decreased at the end of the study. For biochemical markers, the EG significantly increased the serum levels of the N-terminal propeptide of type I collagen (P1NP) bone formation marker (13.19 ± 25.17 vs. −4.21 ± 15.62 ng/mL; p < 0.05), and decreased the carbo-terminal telopeptide of type I collagen (CTx) bone resorption marker compared to the CG (−0.05 ± 0.19 vs. 0.04 ± 0.14 ng/mL; p < 0.05). On the other hand, the EG exhibited a significantly decreased systolic and diastolic blood pressure compared to the start of the study. Finally, the EG significantly increased their dietary calcium and vitamin D intake compared to the CG. In conclusion, the regular consumption of a dairy product to reconstitute enriched with bioactive nutrients improves bone health markers in menopausal women at risk of osteoporosis without pharmacological treatment.
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Affiliation(s)
- Marina Morato-Martínez
- Nutrition Department, La Paz University Hospital Institute for Health Research (IdiPAZ), Autonomous University of Madrid, 28046 Madrid, Spain; (M.M.-M.); (S.P.-M.); (C.G.-C.)
| | - Bricia López-Plaza
- Nutrition Research Group, La Paz University Hospital Institute for Health Research (IdiPAZ), 28046 Madrid, Spain;
- Correspondence: ; Tel.: +34-917-277-000 (ext. 42507)
| | - Cristina Santurino
- Nutrition Research Group, La Paz University Hospital Institute for Health Research (IdiPAZ), 28046 Madrid, Spain;
| | - Samara Palma-Milla
- Nutrition Department, La Paz University Hospital Institute for Health Research (IdiPAZ), Autonomous University of Madrid, 28046 Madrid, Spain; (M.M.-M.); (S.P.-M.); (C.G.-C.)
| | - Carmen Gómez-Candela
- Nutrition Department, La Paz University Hospital Institute for Health Research (IdiPAZ), Autonomous University of Madrid, 28046 Madrid, Spain; (M.M.-M.); (S.P.-M.); (C.G.-C.)
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157
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Al-Saleh Y, Al-Daghri NM, Sabico S, Alessa T, Al Emadi S, Alawadi F, Al Qasaabi S, Alfutaisi A, Al Izzi M, Mukhaimer J, Suhaili AR, Reginster JY, Sulimani R. Diagnosis and management of osteoporosis in postmenopausal women in Gulf Cooperation Council (GCC) countries: consensus statement of the GCC countries' osteoporosis societies under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Arch Osteoporos 2020; 15:109. [PMID: 32700153 DOI: 10.1007/s11657-020-00778-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/25/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A consensus platform is provided by the experts of the Gulf Cooperation Council (GCC) countries' respective osteoporosis societies, on which specific guidelines can be developed further for regional use on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis. INTRODUCTION Guidance is provided in a Gulf Cooperation Council (GCC) country setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis, which is an adaptation of the European guidance by Kanis et al., jointly published by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). The respective osteoporosis societies of the Gulf Cooperation Council (GCC) countries assembled for a unifying consensus on the diagnosis and management of osteoporosis in postmenopausal women for the region. METHODS The Chair for Biomarkers of Chronic Diseases (CBCD) in King Saud University (KSU), Riyadh, Kingdom of Saudi Arabia (KSA), in cooperation with the Saudi Osteoporosis Society (SOS), hosted regional experts and respective leaders from different GCC osteoporosis societies, together with an adviser from the ESCEO. An assembly of experts representing the different osteoporosis societies from Saudi Arabia, the UAE, Bahrain, Oman, and Kuwait gathered on February 15-16, 2019 in Riyadh, KSA for the formulation of a general osteoporosis consensus for the region. RESULTS The following areas were covered: diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; and hip fractures, vitamin D, recommendation on which FRAX tool to follow, and the importance of country-specific FRAX® and fracture liaison services for secondary fracture prevention. CONCLUSIONS A platform is provided on which specific guidelines can be developed for regional use in GCC.
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Affiliation(s)
- Yousef Al-Saleh
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, PO Box 2455, Riyadh, 11451, Kingdom of Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 22490, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia.,Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, 14611, Saudi Arabia
| | - Nasser M Al-Daghri
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, PO Box 2455, Riyadh, 11451, Kingdom of Saudi Arabia.
| | - Shaun Sabico
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, PO Box 2455, Riyadh, 11451, Kingdom of Saudi Arabia
| | - Thamer Alessa
- Division of Endocrinology, Diabetes and Metabolism, Jaber Al-Ahmad Hospital, Kuwait City, Kuwait
| | - Samar Al Emadi
- Department of Medicine, Hamad General Hospital, Doha, Qatar
| | | | | | | | | | | | | | - Jean-Yves Reginster
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, PO Box 2455, Riyadh, 11451, Kingdom of Saudi Arabia.,Department of Public Health, Epidemiology and Health Economics, University of Liège, 4000, Liège, Belgium
| | - Riad Sulimani
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
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158
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Forgetta V, Keller-Baruch J, Forest M, Durand A, Bhatnagar S, Kemp JP, Nethander M, Evans D, Morris JA, Kiel DP, Rivadeneira F, Johansson H, Harvey NC, Mellström D, Karlsson M, Cooper C, Evans DM, Clarke R, Kanis JA, Orwoll E, McCloskey EV, Ohlsson C, Pineau J, Leslie WD, Greenwood CMT, Richards JB. Development of a polygenic risk score to improve screening for fracture risk: A genetic risk prediction study. PLoS Med 2020; 17:e1003152. [PMID: 32614825 PMCID: PMC7331983 DOI: 10.1371/journal.pmed.1003152] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Since screening programs identify only a small proportion of the population as eligible for an intervention, genomic prediction of heritable risk factors could decrease the number needing to be screened by removing individuals at low genetic risk. We therefore tested whether a polygenic risk score for heel quantitative ultrasound speed of sound (SOS)-a heritable risk factor for osteoporotic fracture-can identify low-risk individuals who can safely be excluded from a fracture risk screening program. METHODS AND FINDINGS A polygenic risk score for SOS was trained and selected in 2 separate subsets of UK Biobank (comprising 341,449 and 5,335 individuals). The top-performing prediction model was termed "gSOS", and its utility in fracture risk screening was tested in 5 validation cohorts using the National Osteoporosis Guideline Group clinical guidelines (N = 10,522 eligible participants). All individuals were genome-wide genotyped and had measured fracture risk factors. Across the 5 cohorts, the average age ranged from 57 to 75 years, and 54% of studied individuals were women. The main outcomes were the sensitivity and specificity to correctly identify individuals requiring treatment with and without genetic prescreening. The reference standard was a bone mineral density (BMD)-based Fracture Risk Assessment Tool (FRAX) score. The secondary outcomes were the proportions of the screened population requiring clinical-risk-factor-based FRAX (CRF-FRAX) screening and BMD-based FRAX (BMD-FRAX) screening. gSOS was strongly correlated with measured SOS (r2 = 23.2%, 95% CI 22.7% to 23.7%). Without genetic prescreening, guideline recommendations achieved a sensitivity and specificity for correct treatment assignment of 99.6% and 97.1%, respectively, in the validation cohorts. However, 81% of the population required CRF-FRAX tests, and 37% required BMD-FRAX tests to achieve this accuracy. Using gSOS in prescreening and limiting further assessment to those with a low gSOS resulted in small changes to the sensitivity and specificity (93.4% and 98.5%, respectively), but the proportions of individuals requiring CRF-FRAX tests and BMD-FRAX tests were reduced by 37% and 41%, respectively. Study limitations include a reliance on cohorts of predominantly European ethnicity and use of a proxy of fracture risk. CONCLUSIONS Our results suggest that the use of a polygenic risk score in fracture risk screening could decrease the number of individuals requiring screening tests, including BMD measurement, while maintaining a high sensitivity and specificity to identify individuals who should be recommended an intervention.
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Affiliation(s)
- Vincenzo Forgetta
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | | | - Marie Forest
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Audrey Durand
- School of Computer Science, McGill University, Montréal, Québec, Canada
| | - Sahir Bhatnagar
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - John P. Kemp
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Maria Nethander
- Bioinformatics Core Facility, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Evans
- California Pacific Medical Center Research Institute, San Francisco, California, United States of America
| | - John A. Morris
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Douglas P. Kiel
- Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Broad Institute of MIT & Harvard University, Boston, Massachusetts, United States of America
| | | | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, United Kingdom
- Australian Catholic University, Melbourne, Victoria, Australia
| | - Nicholas C. Harvey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Dan Mellström
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Karlsson
- Department of Orthopaedics and Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - David M. Evans
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom
| | - John A. Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, United Kingdom
- Australian Catholic University, Melbourne, Victoria, Australia
| | - Eric Orwoll
- Bone and Mineral Unit, Oregon Health & Science University, Portland, Oregon, United States of America
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Eugene V. McCloskey
- Mellanby Centre for Bone Research, Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield and Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joelle Pineau
- School of Computer Science, McGill University, Montréal, Québec, Canada
| | - William D. Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Celia M. T. Greenwood
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Human Genetics, McGill University, Montréal, Québec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montréal, Québec, Canada
| | - J. Brent Richards
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Human Genetics, McGill University, Montréal, Québec, Canada
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, United Kingdom
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159
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Javaid MK, Sami A, Lems W, Mitchell P, Thomas T, Singer A, Speerin R, Fujita M, Pierroz DD, Akesson K, Halbout P, Ferrari S, Cooper C. A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: a position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network. Osteoporos Int 2020; 31:1193-1204. [PMID: 32266437 PMCID: PMC7280347 DOI: 10.1007/s00198-020-05377-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/03/2020] [Indexed: 12/23/2022]
Abstract
The International Osteoporosis Foundation (IOF) Capture the Fracture® Campaign with the Fragility Fracture Network (FFN) and National Osteoporosis Foundation (NOF) has developed eleven patient-level key performance indicators (KPIs) for fracture liaison services (FLSs) to guide quality improvement. INTRODUCTION Fracture Liaison Services (FLSs) are recommended worldwide to reduce fracture risk after a sentinel fracture. Given not every FLS is automatically effective, the IOF Capture the Fracture working group has developed and implemented the Best Practice Framework to assess the organisational components of an FLS. We have now developed a complimentary KPI set that extends this assessment of performance to the patient level. METHODS The Capture the Fracture working group in collaboration with the Fragility Fracture Network Secondary Fragility Fracture Special Interest Group and National Osteoporosis Foundation adapted existing metrics from the UK-based Fracture Liaison Service Database Audit to develop a patient-level KPI set for FLSs. RESULTS Eleven KPIs were selected. The proportion of patients: with non-spinal fractures; with spine fractures (detected clinically and radiologically); assessed for fracture risk within 12 weeks of sentinel fracture; having DXA assessment within 12 weeks of sentinel fracture; having falls risk assessment; recommended anti-osteoporosis medication; commenced of strength and balance exercise intervention within 16 weeks of sentinel fracture; monitored within 16 weeks of sentinel fracture; started anti-osteoporosis medication within 16 weeks of sentinel fracture; prescribed anti-osteoporosis medication 52 weeks after sentinel fracture. The final KPI measures data completeness for each of the other KPIs. For these indicators, levels of achievement were set at the < 50%, 50-80% and > 80% levels except for treatment recommendation where a level of 50% was used. CONCLUSION This KPI set compliments the existing Best Practice Framework to support FLSs to examine their own performance using patient-level data. By using this KPI set for local quality improvement cycles, FLSs will be able to efficiently realise the full potential of secondary fracture prevention and improved clinical outcomes for their local populations.
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Affiliation(s)
- M K Javaid
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK.
| | - A Sami
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK
| | - W Lems
- VU University Medical Center, Amsterdam, The Netherlands
| | - P Mitchell
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK
- School of Medicine, Sydney Campus, The University of Notre Dame Australia, 140 Broadway, Sydney, NSW, 2007, Australia
| | - T Thomas
- Department of Rheumatology, Hôpital Nord, CHU de Saint-Etienne, and INSERM U1059, University of Lyon, Saint-Etienne, France
| | - A Singer
- Department of Medicine, MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA
| | - R Speerin
- Fragility Fracture Network, Zürich, Switzerland
- Musculoskeletal Network, NSW Agency for Clinical Innovation, Chatswood, Australia
| | - M Fujita
- International Osteoporosis Foundation, Nyon, Switzerland
| | - D D Pierroz
- International Osteoporosis Foundation, Nyon, Switzerland
| | - K Akesson
- Department of Orthopaedics, Skane University Hospital, Malmö, Sweden
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - S Ferrari
- Division of Bone Disease, Department of Internal Medicine Specialties, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - C Cooper
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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160
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Leslie WD, Morin SN, Lix LM, Binkley N. Targeted bone density testing for optimizing fracture prevention in Canada. Osteoporos Int 2020; 31:1291-1297. [PMID: 32052071 DOI: 10.1007/s00198-020-05335-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/05/2020] [Indexed: 10/25/2022]
Abstract
UNLABELLED The Canadian FRAX® tool used without bone mineral density (BMD) is highly sensitive for identifying individuals qualifying for pharmacotherapy based upon an intervention threshold of 20% for major osteoporotic fracture risk (MOF) computed with BMD. INTRODUCTION This analysis was performed to inform initial BMD testing as part of Osteoporosis Canada's Guidelines Update for women and men at average risk, assuming a pharmacotherapy intervention threshold of 20% for FRAX® MOF computed with BMD. METHODS Women and men age 50 + without previous low-trauma fracture or high-risk medication use were identified in a BMD registry for the province of Manitoba, Canada. Fracture probability assessments with the Canadian FRAX® tool were computed without and with BMD (denoted MOF-clinical and MOF-BMD, respectively). RESULTS The study population consisted of 50,700 women (mean age 65.5 ± 9.4 years) and 4152 men (69.2 ± 10.0 years). FRAX MOF-clinical score was > 10% in 33.8% of women and 13.3% of men (P < 0.001). The median (interquartile range [IQR]) age for MOF-clinical to reach 10% in women was 70 (69-72) and 65 years (62-67) years in the absence and presence of additional FRAX clinical risk factors, respectively. In men, comparable ages were 83 years [82-86] and 76 [70-78] years. Using MOF-BMD of 20% as the intervention threshold, 4.3% of women and 0.7% of men qualified for treatment. MOF-clinical > 10% had high sensitivity to identify those qualifying for treatment (99.3% in women and 99.1% in men). An age-based rule ("BMD testing is indicated at age 70 if no additional FRAX clinical risk factors are present, or at age 65 if one or more clinical risk factors exists") gave similarly high sensitivity (women 99.9% and men > 99.9%). CONCLUSIONS FRAX without BMD offers an effective strategy to identify individuals meeting the current Canadian treatment threshold based upon FRAX® with BMD (≥ 20%). Moreover, this can be operationalized using simple age cutoffs of 70 years in the absence of additional clinical risk factors and 65 years in the presence of additional clinical risk factors.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | | | - L M Lix
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
| | - N Binkley
- University of Wisconsin, Madison, WI, USA
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Osteoporosis treatment considerations based upon fracture history, fracture risk assessment, vertebral fracture assessment, and bone density in Canada. Arch Osteoporos 2020; 15:93. [PMID: 32577922 DOI: 10.1007/s11657-020-00775-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/19/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Among 39,475 women, age 65 years and older, use of fracture history, major osteoporotic fracture (MOF) probability from FRAX®, vertebral fracture assessment (VFA), and bone mineral density (BMD) T-score stratified women into different levels of risk. The majority of women identified as being at high risk from fracture history, FRAX MOF-BMD > 20%, or vertebral fracture on VFA had a BMD T-score in the osteoporotic range. PURPOSE To inform criteria for pharmacologic treatment in women age 65 years and older, we examined subgroups defined from fracture history, MOF calculated with BMD (MOF-BMD), VFA, and BMD T-score using the population-based Manitoba BMD Program registry. METHODS The study population consisted of women age > 65 years was divided into mutually exclusive subgroups based upon fracture history, MOF-BMD ≥ 20%, vertebral fracture on VFA, and osteoporotic BMD T-score. Healthcare records were assessed for the presence of fracture diagnosis codes occurring after DXA assessment. For each subgroup, we estimated the proportion of individuals with BMD T-score in the osteoporotic range, predicted versus observed 10-year MOF probability, hazard ratio (HR) for MOF, and number needed to treat (NNT) for 3 years to prevent a fracture event. RESULTS The study population consisted of 39,475 women (median age 72 years). The majority of women (76.8%) selected as being at high risk based on fracture history, MOF-BMD > 20%, or vertebral fracture on VFA had a BMD T-score in the osteoporotic range. During a median follow-up of 8 years, 5169 (13.1%) sustained one or more incident MOF. Fracture rates and HRs generally paralleled the FRAX prediction, except in women with a positive VFA where predicted risk based upon clinical risk factors prior to VFA underestimated the observed risk. NNT differed by the risk subgroup, and showed a gradient of decreasing NNT (consistent with greater benefit) in individuals with the highest fracture risk. CONCLUSIONS Fracture history, fracture probability from FRAX, targeted vertebral fracture assessment (VFA), and BMD T-score can stratify older women into different levels of risk and treatment benefit. These results are expected to inform clinical practice guidelines in Canada.
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Bhattarai HK, Shrestha S, Rokka K, Shakya R. Vitamin D, Calcium, Parathyroid Hormone, and Sex Steroids in Bone Health and Effects of Aging. J Osteoporos 2020; 2020:9324505. [PMID: 32612801 PMCID: PMC7317615 DOI: 10.1155/2020/9324505] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/27/2020] [Indexed: 12/26/2022] Open
Abstract
Bone health of the elderly is a major global health concern, since about 1 in 3 women and 1 in 5 men suffer from bone loss and fractures, often called osteoporosis, in old age. Bone health is a complex issue affected by multiple hormones and minerals. Among all the hormones involved in bone health, calcitriol (also vitamin D), parathyroid, and sex hormones (especially estrogen) have been discussed in this review paper. We have discussed the metabolism of these hormones and their effects on bone health. Vitamin D can be obtained from diet or formed from 7-dehydrocholesterol found under the skin in the presence of sunlight. The active form, calcitriol, causes dimerization of vitamin D receptor and acts on the bones, intestine, and kidney to regulate the level of calcium in blood. Similarly, parathyroid hormone is secreted when the serum level of calcium is low. It helps regulate the level of blood calcium through calcitriol. Sex hormones regulate bone modeling at an early age and remodeling later in life. Loss of ovarian function and a decrement in the level of production of estrogen are marked by bone loss in elderly women. In the elderly, various changes in the calcium and vitamin D metabolism, such as decrease in the production of vitamin D, decrease in dietary vitamin D, decreased renal production, increased production of excretory products, decrease in the level of VDR, and decreased calcium absorption by the intestines, can lead to bone loss. When the elderly are diagnosed with osteoporosis, medications that directly target bone such as bisphosphonates, RANK ligand inhibitors, estrogen and estrogen analogues, estrogen receptor modulators, and parathyroid hormone receptor agonists are used. Additionally, calcium and vitamin D supplements are prescribed.
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Affiliation(s)
| | - Shreya Shrestha
- Department of Biotechnology, Kathmandu University, Dhulikhel, Nepal
| | - Kabita Rokka
- Department of Biotechnology, Kathmandu University, Dhulikhel, Nepal
| | - Rosy Shakya
- Department of Biotechnology, Kathmandu University, Dhulikhel, Nepal
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163
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Rochira V. Late-onset Hypogonadism: Bone health. Andrology 2020; 8:1539-1550. [PMID: 32469467 DOI: 10.1111/andr.12827] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Bone health is underdiagnosed and undermanaged in men. Bone loss occurs in men with hypogonadism and in aging men. Thus, patients with a diagnosis of late-onset hypogonadism (LOH) are at risk of osteoporosis and osteoporotic fractures. OBJECTIVES To provide an update on research data and clinical implications regarding bone health in men with LOH by reviewing literature articles on this issue. MATERIALS AND METHODS A thorough search of listed publications in PubMed on bone health in older men with hypogonadism was performed, and other articles derived from these publications were further identified. RESULTS Late-onset Hypogonadism may be associated with reduced bone mineral density (BMD). In a pathophysiological perspective, the detrimental effects of testosterone (T) deficiency on BMD are partly ascribed to relative estrogen deficiency and both serum T and serum estradiol (E2) need to be above 200 ng/dL and 20 pg/mL to prevent bone loss. The effects of exogenous T on BMD are controversial, but most of the studies confirm that testosterone replacement therapy (TRT) increases BMD and prevents further bone loss in men with hypogonadism. No data are available on TRT and the prevention of fractures. DISCUSSION AND CONCLUSION In men with documented LOH, a specific clinical workup should be addressed to the diagnosis of osteoporosis in order to program subsequent follow-up and consider specific bone active therapy. TRT should be started according to guidelines of male hypogonadism while keeping in mind that it may also have positive effects also on bone health in men with LOH.
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Affiliation(s)
- Vincenzo Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Department of Medical Specialties, Azienda Ospedaliero-Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
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164
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Wang LJ, Cai HQ. Let-7b downgrades CCND1 to repress osteogenic proliferation and differentiation of MC3T3-E1 cells: An implication in osteoporosis. Kaohsiung J Med Sci 2020; 36:775-785. [PMID: 32533643 DOI: 10.1002/kjm2.12236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 02/10/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
The aim of this study was to reveal the effect of let-7b on osteoporosis (OP). Synthetic let-7b mimics or inhibitors were transfected into MC3T3-E1 cells. The expression of let-7b in MC3T3-E1 and its effect on cell viability, apoptosis, and the apoptosis-related proteins (Bcl-2, Bax, and cleaved caspase-9) were tested by CCK-8 assay, flow cytometry and Western blot, severally. The osteogenic differentiation markers (Runx2 and Osterix) and Wnt/β-catenin pathway related markers (β-catenin and C-myc) were detected by qRT-PCR and Western blot. The relationships between let-7b and cyclin D1 (CCND1) were confirmed by luciferase reporter assay. The differentiation and mineralization of MC3T3-E1 cells were analyzed by alkaline phosphatase (ALP) activity assay and alizarin red staining. The outcomes indicated that overexpression/ablation of let-7b repressed/facilitated MC3T3-E1 cell viability and accelerated/suppressed MC3T3-E1 cell apoptosis. Besides, a remarkable decrease/augment of Bcl-2 protein expression and the distinct fortify/reduction of Bax and cleaved caspase-9 expression levels were observed in let-7b mimics/inhibitors group in MC3T3-E1 cells. Moreover, we discovered that let-7b overexpression/ablation retrained/facilitated the mRNA and protein expression of Runx2 and Osterix. It was confirmed that CCND1 was a downstream target of let-7b and was negatively modulated by let-7b. In addition, high-expression/deficiency of let-7b inhibited/increased the expression levels of β-catenin and C-myc in MC3T3-E1 cells. Taken together, our study revealed that let-7b overexpression/depletion repressed/accelerated MC3T3-E1 cell proliferation, differentiation, and mineralization while promoted/suppressed MC3T3-E1 cell apoptosis through targeting CCND1, which might be adjusted by Wnt/β-catenin pathway. Our findings might offer a basis for developing novel targets for OP treatment.
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Affiliation(s)
- Li-Juan Wang
- Department of endocrinology, the Second Hospital of Jilin University, Jilin, People's Republic of China
| | - Han-Qing Cai
- Department of endocrinology, the Second Hospital of Jilin University, Jilin, People's Republic of China
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165
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Brief Report: Low Sensitivity of the Fracture Risk Assessment Tool in Young HIV-Infected Patients: Time to Revise Our Screening Strategy. J Acquir Immune Defic Syndr 2020; 82:439-442. [PMID: 31714423 DOI: 10.1097/qai.0000000000002177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The burden of reduced bone mineral density (BMD) is high among HIV-infected patients. As a screening strategy, current guidelines recommend calculating a Fracture Risk Assessment Tool (FRAX) score in patients aged 40-49 years. Patients with a 10-year risk of a major osteoporotic fracture ≥10% should undergo dual-energy x-ray absorptiometry (DXA) to assess BMD. The aim of this study was to establish the sensitivity of this threshold to identify patients with risk of osteoporosis in this age category-as a surrogate marker for high fracture risk. METHODS The study group consisted of patients aged 50-59 years and living with HIV for at least 10 years who recently underwent dual-energy x-ray absorptiometry (DXA). A clinical risk factor-based FRAX score was calculated using patient characteristics from 10 years earlier. In this way, we assessed which patients would have undergone DXA while they were 40-49 year old. RESULTS The cohort consisted of 126 patients; 23 patients (18.3%) had osteoporosis. Ten years before the DXA, none of them met the guideline threshold of a 10-year major osteoporotic fracture probability of ≥10%, resulting in a sensitivity of 0% in this cohort. There was no difference between the median FRAX score between patients who developed osteoporosis and those who did not (3.3% vs. 3.4%. P = 0.55). CONCLUSIONS FRAX lacks sensitivity to determine which HIV-infected patients aged 40-49 years should undergo BMD testing to identify reduced BMD. Its role should be limited to treatment decisions.
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Papaioannou A, Adachi JD, Berger C, Jiang Y, Barron R, McGinley JS, Wirth RJ, Anastassiades TP, Davison KS, Hanley DA, Ioannidis G, Kaiser SM, Kovacs CS, Leslie WD, Morin SN, Prior JC, Towheed T, Goltzman D. Testing a theoretical model of imminent fracture risk in elderly women: an observational cohort analysis of the Canadian Multicentre Osteoporosis Study. Osteoporos Int 2020; 31:1145-1153. [PMID: 32034452 DOI: 10.1007/s00198-020-05330-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
Abstract
UNLABELLED We examined the underlying relationship between fracture risk factors and their imminent risk. Results suggested that having past year fracture, worse past year general health, worse past year physical functioning, and lower past year BMD T-score directly predicted higher imminent fracture risk. Past year falls indirectly predicted imminent risk through physical functioning and general health. INTRODUCTION This study aimed to examine direct and indirect effects of several factors on imminent (1 year) fracture risk. METHODS Data from women age 65 and older from population-based Canadian Multicentre Osteoporosis Study were used. Predictors were identified from study years 5 and 10, and imminent fracture data (1-year fracture) came from years 6 and 11 (year 5 predicts year 6, year 10 predicts year 11). A structural equation model (SEM) was used to test the theoretical construct. General health and physical functioning were measured as latent variables using items from the 36-Item Short Form Health Survey (SF-36) and bone mineral density (BMD) T-score was a latent variable based on observed site-specific BMD data (spine L1-L4, femoral neck, total hip). Observed variables were fractures and falls. Model fit was evaluated using root mean square error of approximation (RMSEA), Tucker Lewis index (TLI), and comparative fit index (CFI). RESULTS The analysis included 3298 women. Model fit tests showed that the SEM fit the data well; χ2(172) = 1122.10 < .001, RMSEA = .03, TLI = .99, CFI = .99. Results suggested that having past year fracture, worse past year general health, worse past year physical functioning, and lower past year BMD T-score directly predicted higher risk of fracture in the subsequent year (p < .001). Past year falls had a statistically significant but indirect effect on imminent fracture risk through physical functioning and general health (p < .001). CONCLUSIONS We found several direct and indirect pathways that predicted imminent fracture risk in elderly women. Future studies should extend this work by developing risk scoring methods and defining imminent risk thresholds.
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Affiliation(s)
| | - J D Adachi
- McMaster University, Hamilton, ON, Canada
| | - C Berger
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Y Jiang
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA.
| | - R Barron
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
| | - J S McGinley
- Vector Psychometric Group, LLC, Chapel Hill, NC, USA
| | - R J Wirth
- Vector Psychometric Group, LLC, Chapel Hill, NC, USA
| | | | - K S Davison
- University of Victoria, Victoria, BC, Canada
| | - D A Hanley
- Cumming School of Medicine, University of Calgary, Calgary, AL, Canada
| | | | - S M Kaiser
- Dalhousie University, Halifax, NS, Canada
| | - C S Kovacs
- Memorial University of Newfoundland, St. John's, NL, Canada
| | - W D Leslie
- University of Manitoba, Winnipeg, MB, Canada
| | - S N Morin
- McGill University, Montreal, QC, Canada
| | - J C Prior
- University of British Columbia, Vancouver, BC, Canada
| | - T Towheed
- Queen's University, Kingston, ON, Canada
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167
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Rajan R, Paul J, Cherian KE, Asha HS, Kapoor N, Paul TV. FRAX® with or without BMD and TBS predicts fragility fractures in community-dwelling rural southern Indian postmenopausal women. Arch Osteoporos 2020; 15:82. [PMID: 32483672 DOI: 10.1007/s11657-020-00756-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 05/11/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study from southern India showed that FRAX® with or without BMD or TBS predicted fragility vertebral fractures at a cut-off of ≥ 9% for major osteoporotic fracture and ≥ 2.5% for hip fracture with sensitivities of 77-88% and specificities of 55-72%. PURPOSE There is limited information available with regard to utility of Fracture Risk Assessment Tool (FRAX® tool) in predicting fragility fractures in Indian postmenopausal women. We studied the performance of 3 categories: FRAX® (without BMD), FRAX® (with BMD), and FRAX® (with BMD and TBS) in predicting fragility vertebral fractures in rural postmenopausal women. MATERIAL AND METHODS It was a cross-sectional study conducted at a south Indian tertiary care center. Rural postmenopausal women (n = 301) were recruited by simple random sampling. The risk for major osteoporotic fracture (MOF) and hip fracture (HF) was calculated individually for the 3 categories. The BMD (at lumbar spine and femoral neck) and vertebral fractures were assessed by a DXA (dual energy X-ray absorptiometry) scanner and TBS by TBS iNsight software. ROC curves were constructed, and area under curve (AUC), sensitivity and specificity of FRAX® scores, which would best predict prevalent vertebral fractures (moderate to severe), was computed. RESULTS The mean (SD) age was 65.6(5.1) years. The prevalence of osteoporosis at spine was 45%, and femoral neck was 32.6%. Moderate to severe vertebral fractures was seen in 29.2% of subjects. The performance of all 3 categories for FRAX® (MOF) and FRAX® (HF) were good (AUC was 0.798, 0.806, and 0.800, respectively, for MOF) at a cut-off score of ≥ 9, and at a cut-off of ≥ 2.5 for HF, it was 0.818, 0.775, and 0.770, respectively. At these cut-offs, sensitivities were 77-89%, and specificities were 55-72% for predicting prevalent vertebral fractures. CONCLUSION All three categories of FRAX® showed good performance in predicting fractures in Indian postmenopausal women. Thus, it may be utilized for decision regarding treatment and referral for osteoporosis.
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Affiliation(s)
- Remya Rajan
- Department of Endocrinology, Christian Medical College, Vellore, India
| | - Jinson Paul
- Department of Endocrinology, Christian Medical College, Vellore, India
| | | | | | - Nitin Kapoor
- Department of Endocrinology, Christian Medical College, Vellore, India
| | - Thomas V Paul
- Department of Endocrinology, Christian Medical College, Vellore, India.
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168
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Sanchez-Rodriguez D, Bergmann P, Body JJ, Cavalier E, Gielen E, Goemaere S, Lapauw B, Laurent MR, Rozenberg S, Honvo G, Beaudart C, Bruyère O. The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women. Maturitas 2020; 139:69-89. [PMID: 32747044 DOI: 10.1016/j.maturitas.2020.05.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium. METHODS The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts. RESULTS Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered. CONCLUSION BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.
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Affiliation(s)
- D Sanchez-Rodriguez
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium; Geriatrics Department, Rehabilitation Research Group, Hospital del Mar Medical Research Institute (IMIM), Universitat Pompeu Fabra, Barcelona, Spain.
| | - P Bergmann
- Department of Radioisotopes, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - J J Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - E Cavalier
- Department of Clinical Chemistry, UnilabLg, University of Liège, CHU de Liège, Liège, Belgium
| | - E Gielen
- Gerontology and Geriatrics Section, Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, University Hospitals, Leuven, Belgium
| | - S Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - M R Laurent
- Geriatrics Department, Imelda Hospital, Bonheiden, Belgium
| | - S Rozenberg
- Department of Gynaecology-Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - G Honvo
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - C Beaudart
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - O Bruyère
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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Ohira M, Suzuki S, Yoshida T, Koide H, Tanaka T, Tatsuno I. Fracture Risk Assessment Tool May Not Indicate Bone Fragility in Women With Type 2 Diabetes. Am J Med Sci 2020; 360:552-559. [PMID: 32376002 DOI: 10.1016/j.amjms.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/17/2020] [Accepted: 04/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Diabetes carries a known risk of bone fracture despite high bone mineral density (BMD). The fracture risk assessment tool (FRAX) predicts the 10-year major osteoporotic fracture risk and hip fracture risk. We investigated the effects of clinical parameters on the FRAX score and evaluated the validity of FRAX for evaluating current bone fragility in diabetes subjects. MATERIALS AND METHODS Forty-seven thousand, three hundred eighty-nine Japanese women participated in the Chiba bone survey, a population-based, multicenter, cross-sectional study of postmenopausal osteoporosis; we estimated FRAX scores without BMD and compared scores between subjects with and without type 2 diabetes. RESULTS Mean FRAX major osteoporotic fracture risk was significantly higher in the diabetes group. A multiple regression model demonstrated some clinical parameters that affected the FRAX score and, after adjusting for such parameters, the FRAX score was not significantly different between the diabetes and nondiabetes groups, although the type 2 diabetes rate was significantly higher in subjects with a fracture in the past 5 years, which reflected current bone fragility. After adjusting for clinical parameters, the diabetes rate remained significantly higher in subjects with a fracture in the past 5 years, confirming that type 2 diabetes influences current bone fragility. Our study demonstrated that type 2 diabetes truly carries a risk of bone fracture, but adjusted FRAX major osteoporotic fracture risk is not significantly different between subjects with and without type 2 diabetes. CONCLUSIONS The FRAX major osteoporotic fracture risk without BMD does not correctly indicate current bone fragility in Japanese middle-aged women with type 2 diabetes.
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Affiliation(s)
- Masahiro Ohira
- Center for Diabetes, Endocrinology, and Metabolism, Toho University Sakura Medical Center, Chiba, Japan
| | - Sawako Suzuki
- Department of Clinical Cell Biology & Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomohiko Yoshida
- Department of Diabetes, Metabolism and Endocrinology, International University of Health and Welfare, Chiba, Japan
| | - Hisashi Koide
- Department of Clinical Cell Biology & Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Tanaka
- Department of Clinical Cell Biology & Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ichiro Tatsuno
- Center for Diabetes, Endocrinology, and Metabolism, Toho University Sakura Medical Center, Chiba, Japan.
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Lorentzon M. The Importance and Possible Clinical Impact of Measuring Trabecular and Cortical Bone Microstructure to Improve Fracture Risk Prediction. J Bone Miner Res 2020; 35:831-832. [PMID: 31910297 DOI: 10.1002/jbmr.3940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Mattias Lorentzon
- Sahlgrenska University Hospital, Region Västra Götaland, Geriatric Medicine, Mölndal, Sweden.,Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
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171
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Wang Y, Yu S, Hsu C, Tsai C, Cheng T. Underestimated fracture risk in postmenopausal women-application of the hybrid intervention threshold. Osteoporos Int 2020; 31:475-483. [PMID: 31696272 DOI: 10.1007/s00198-019-05201-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/16/2019] [Indexed: 01/07/2023]
Abstract
UNLABELLED This study evaluated the fragility fracture risk of Taiwanese postmenopausal women with osteopenia. With the incorporation of FRAX and hybrid intervention threshold (HIT), 25% of the participants had high fracture risk. We suggest intervention for fragility fracture for postmenopausal women should be guided by FRAX and HIT instead of bone mineral density alone. INTRODUCTION To explore the risk of fragility fracture in Taiwanese postmenopausal women with osteopenia using the hybrid intervention threshold (HIT) and Fracture Risk Assessment tool (FRAX). METHODS The Taiwan Osteoporosis Association (TOA) conducted a nationwide bone mineral density (BMD) survey between 2008 and 2011 using a bus equipped with a dual-energy X-ray absorptiometry (DXA) machine. All participants completed a structured questionnaire, which included the elements in the FRAX. Based on the results, the group made up of postmenopausal women with osteopenia was identified. In order to explore the risk of fragility fracture by HIT and FRAX among Taiwan postmenopausal women with osteopenia, the 10-year probability of fracture (FRAX score) and individual intervention threshold (IIT) in this group were calculated. If the FRAX score of a participant was higher than or equal to the IIT or fixed intervention threshold (FIT), the participant was considered as above the HIT (HIT could be reached by being over a threshold at either major osteoporotic fracture or hip fracture) and categorized as having a high FRAX fracture risk. RESULTS A total of 13,068 postmenopausal women were enrolled in the program. A total of 5743 (43.9%) participants had osteopenia, of which 1434 (25.0%) had high FRAX fracture risk. CONCLUSIONS One quarter of Taiwanese postmenopausal women with osteopenia had high fragility fracture risk evaluated by FRAX and HIT. Due to the poor sensitivity of BMD for fragility fracture, we suggest that intervention for fragility fracture for postmenopausal women should also be guided by FRAX and HIT instead of BMD alone.
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Affiliation(s)
- Y Wang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan
| | - S Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan
| | - C Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan
| | - C Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan.
| | - T Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan.
- College of Medicine, Chang Gung University, No. 123, Dapi Road, Niaosung District, 83301, Kaohsiung City, Taiwan.
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172
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Hsu CY, Wu CH, Yu SF, Su YJ, Chiu WC, Chen YC, Lai HM, Chen JF, Ko CH, Chen JF, Cheng TT. Novel algorithm generating strategy to identify high fracture risk population using a hybrid intervention threshold. J Bone Miner Metab 2020; 38:213-221. [PMID: 31583541 DOI: 10.1007/s00774-019-01046-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/02/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The aim of this study was to develop an algorithm to identify high-risk populations of fragility fractures in Taiwan. MATERIALS AND METHODS A total of 16,539 postmenopausal women and men (age ≥ 50 years) were identified from the Taiwan Osteoporosis Survey database. Using the Taiwan FRAX® tool, the 10-year probability of major osteoporotic fracture (MOF) and hip fracture (HF) and the individual intervention threshold (IIT) of each participant were calculated. Subjects with either a probability above the IIT or those with MOF ≥ 20% or HF ≥ 9% were included as group A. Subjects with a bone mineral density (BMD) T-score at femoral neck based on healthy subjects of ≤ - 2.5 were included in group B. We tested several cutoff points for MOF and HF so that the number of patients in group A and group B were similar. A novel country-specific hybrid intervention threshold along with an algorithm was generated to identify high fracture risk individuals. RESULTS 3173 (19.2%) and 3129 (18.9%) participants were categorized to groups A and B, respectively. Participants in group B had a significantly lower BMD (p < 0.001), but clinical characteristics, especially the 10-year probability of MOF (p < 0.001) or HF (p < 0.001), were significantly worse in group A. We found the algorithm generated from the hybrid intervention threshold is practical. CONCLUSION The strategy of generating an algorithm for fracture prevention by novel hybrid intervention threshold is more efficient as it identifies patients with a higher risk of fragility fracture and could be a template for other country-specific policies.
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Affiliation(s)
- Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Yu-Jih Su
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Han-Ming Lai
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan.
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A decade of FRAX: how has it changed the management of osteoporosis? Aging Clin Exp Res 2020; 32:187-196. [PMID: 32043227 DOI: 10.1007/s40520-019-01432-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/21/2019] [Indexed: 01/14/2023]
Abstract
The fracture risk assessment tool, FRAX®, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, 71 models have been made available for 66 countries covering more than 80% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. The application of FRAX in assessment guidelines has been heterogeneous with the adoption of several different approaches in setting intervention thresholds. Whereas most guidelines adopt a case-finding strategy, the case for FRAX-based community screening in the elderly is increasing. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future.
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174
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Curtis EM, Woolford S, Holmes C, Cooper C, Harvey NC. General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal. Curr Osteoporos Rep 2020; 18:38-46. [PMID: 32103393 PMCID: PMC7067731 DOI: 10.1007/s11914-020-00566-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied. RECENT FINDINGS A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.
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Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK.
| | - Stephen Woolford
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Claire Holmes
- Rheumatology Department, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
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175
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Leslie WD, Morin SN, Lix LM, Martineau P, Bryanton M, McCloskey EV, Johansson H, Harvey NC, Kanis JA. Reassessment Intervals for Transition From Low to High Fracture Risk Among Adults Older Than 50 Years. JAMA Netw Open 2020; 3:e1918954. [PMID: 31922559 PMCID: PMC6991318 DOI: 10.1001/jamanetworkopen.2019.18954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Fracture risk scores are used to identify individuals at high risk of major osteoporotic fracture or hip fracture for antiosteoporosis treatment. For those not meeting treatment thresholds at baseline, the optimal interval for reassessing fracture risk is uncertain. OBJECTIVE To examine reassessment intervals for transition from low to high fracture risk under guidelines-defined treatment thresholds. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included persons aged 50 years or older with fracture risk below treatment thresholds at baseline who had fracture risk reassessed at least 1 year later. Data were obtained from a population-based bone mineral density registry (baseline assessment during 1996-2015; reassessment to 2016) in the Province of Manitoba, Canada. Primary analysis was performed from May to June 2019. Analysis for the revision was performed in October 2019. MAIN OUTCOMES AND MEASURES The primary outcome was time to transition from low (below the treatment threshold) to high fracture risk (treatment-qualifying risk score using osteoporosis clinical practice guidelines strategies for Canada, the United States, and the United Kingdom). RESULTS The study population consisted of 10 564 individuals (94.1% women; mean [SD] age at baseline, 63.2 [8.2] years). At the time of reassessment (a mean [SD] interval of 5.2 [2.9] years between initial and subsequent fracture risk assessment), 690 (6.6%) had reached the fixed major osteoporotic fracture treatment threshold of 20%, 1546 (16.2%) had reached the fixed hip treatment threshold of 3%, and 932 (9.4%) had reached the age-dependent major osteoporotic fracture treatment threshold. Among those below 25% of the treatment threshold at baseline for each guideline, few (0%-3.0%) reached guidelines-defined high fracture risk at follow-up. In contrast, among those at the upper end of the scale for each guideline (75%-99% of the treatment threshold at baseline), 30.6% to 74.4% reached guidelines-defined high fracture risk. An increased number of clinical risk factors was associated with increased likelihood of reaching guidelines-defined high fracture risk (range for 3 guidelines, 17.1%-28.2%) compared with unchanged or decreased clinical risk factors (range for 3 guidelines, 3.3%-12.8%) (P < .001). Estimated time for 10% of the population to reach treatment-qualifying high fracture risk ranged from fewer than 3 years to more than 15 years. CONCLUSIONS AND RELEVANCE The findings suggest that baseline fracture risk (as a fraction of the treatment threshold) and change in clinical risk factors can identify individuals with low and high probability of guidelines-defined high fracture risk during follow-up, thereby potentially helping to inform the reassessment interval.
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Affiliation(s)
- William D. Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suzanne N. Morin
- Division of General Internal Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lisa M. Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patrick Martineau
- Section of Nuclear Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Harvard Medical School, Boston, Massachusetts
| | - Mark Bryanton
- Section of Nuclear Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eugene V. McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Nicholas C. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - John A. Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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176
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Lesnyak O, Zakroyeva A, Lobanchenko O, Johansson H, Liu E, Lorentzon M, Harvey NC, McCloskey E, Kanis JA. A surrogate FRAX model for the Kyrgyz Republic. Arch Osteoporos 2020; 15:68. [PMID: 32377964 PMCID: PMC7203583 DOI: 10.1007/s11657-020-00743-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/27/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED The hip fracture rates from Kazakhstan were used to create a surrogate FRAX® model for the Kyrgyz Republic. INTRODUCTION The International Society for Clinical Densitometry and International Osteoporosis Foundation recommend utilizing a surrogate FRAX model, based on the country-specific risk of death, and fracture data based on a country where fracture rates are considered to be representative of the index country. OBJECTIVE This paper describes a surrogate FRAX model for the Kyrgyz Republic. METHODS The FRAX model used the incidence of hip fracture from the neighbouring country of Kazakhstan and the death risk for the Kyrgyz Republic. RESULTS Compared with the model for Kazakhstan, the surrogate model gave somewhat higher 10-year fracture probabilities for men between 60 and 80 years of age and lower probabilities for men above the age of 80. For women the probabilities were similar up to the age of 75-80 years and then lower. There were very close correlations in fracture probabilities between the surrogate and authentic models (1.00) so that the use of the Kyrgyz model had little impact on the rank order of risk. It was estimated that 2752 hip fractures arose in 2015 in individuals over the age of 50 years in the Kyrgyz Republic, with a predicted increase by 207% to 8435 in 2050. CONCLUSION The surrogate FRAX model for the Kyrgyz Republic provides the opportunity to determine fracture probability among the Kyrgyz population and help guide decisions about treatment.
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Affiliation(s)
- O. Lesnyak
- Mechnikov North West State Medical University, St. Petersburg, Russia
| | - A. Zakroyeva
- Ural State Medical University, Yekaterinburg, Russia
| | - O. Lobanchenko
- I.K. Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyz Republic
| | - H. Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - E. Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - M. Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - N. C. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - E. McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - J. A. Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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177
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Kanis JA, Harvey NC, McCloskey E, Bruyère O, Veronese N, Lorentzon M, Cooper C, Rizzoli R, Adib G, Al-Daghri N, Campusano C, Chandran M, Dawson-Hughes B, Javaid K, Jiwa F, Johansson H, Lee JK, Liu E, Messina D, Mkinsi O, Pinto D, Prieto-Alhambra D, Saag K, Xia W, Zakraoui L, Reginster JY. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int 2020; 31:1-12. [PMID: 31720707 PMCID: PMC7018677 DOI: 10.1007/s00198-019-05176-3] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/18/2019] [Indexed: 01/26/2023]
Abstract
Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures. INTRODUCTION The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach. METHODS Clinical perspective and updated literature search. RESULTS The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK
- MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing Mellanby, Sheffield, UK
| | - O Bruyère
- World Health Organization Collaborating Center for the Public Health Aspects of Musculoskeletal Health and Aging, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - N Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Via Giustiniani, 2, 35128, Padova, Italy
| | - M Lorentzon
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - G Adib
- Syrian National Osteoporosis Society, Damascus, Syria
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Dept., College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - C Campusano
- Clinica Universidad de los Andes and Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | - M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20, College Road, Singapore, 169856, Singapore
| | - B Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - K Javaid
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - F Jiwa
- Chair of the Committee of Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - J K Lee
- Beacon International Specialist Centre, Petaling Jaya, Malaysia
| | - E Liu
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - D Messina
- IRO Medical Research Center, Buenos Aires and Rheumatology section, Cosme Argerich, Buenos Aires, Argentina
| | - O Mkinsi
- Department of Rheumatology, Ibn Rochd University Hospital, Casablanca, Morocco
| | - D Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - D Prieto-Alhambra
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
- GREMPAL Research Group, CIBERFes and Idiap Jordi Gol, Instituto de Salud Carlos III and Universitat Autonoma de Barcelona, Barcelona, Spain
| | - K Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - W Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No. 1, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - L Zakraoui
- Service de Rhumatologie, University Tunis Manar and Hôpital Mongi-Slim, la Marsa, Tunisia
| | - J -Y Reginster
- Chair for Biomarkers of Chronic Diseases, Biochemistry Dept., College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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178
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Issayeva S, Lesnyak O, Zakroyeva A, Issayeva B, Dilmanova D, Johansson H, Liu E, Lorentzon M, Harvey NC, McCloskey E, Kanis JA. Epidemiology of osteoporotic fracture in Kazakhstan and development of a country specific FRAX model. Arch Osteoporos 2020; 15:30. [PMID: 32108270 PMCID: PMC7046573 DOI: 10.1007/s11657-020-0701-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/15/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Retrospective and prospective population-based survey in a region of the Republic of Kazakhstan determined the incidence of fractures at the hip, proximal humerus and distal forearm. The hip fracture rates were used to create a FRAX® model to enhance fracture risk assessment in Kazakhstan. OBJECTIVE This paper describes the epidemiology of osteoporotic fractures in the Republic of Kazakhstan that was used to develop a country specific FRAX® tool for fracture prediction. METHODS We carried out a retrospective population-based survey in Taldykorgan in the Republic of Kazakhstan representing approximately 1% of the country's population. Hip, forearm and humerus fractures were identified retrospectively in 2015 and 2016 from hospital registers and the trauma centre. Hip fractures were prospectively identified in 2017 from the same sources and additionally from primary care data. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Kazakhstan. Fracture probabilities were compared with those from neighbouring countries having FRAX models. RESULTS The difference in hip fracture incidence between the retrospective and prospective survey indicated that approximately 25% of hip fracture cases did not come to hospital attention. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 11,690 and is predicted to increase by 140% to 28,000 in 2050. Hip fracture incidence was a good predictor of forearm and humeral fractures in men but not in women. CONCLUSION The FRAX model should enhance accuracy of determining fracture probability among the Kazakh population and help guide decisions about treatment.
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Affiliation(s)
- S Issayeva
- Asfendiyarov National Medical University, 94, Tole Bi Street, Almaty, Kazakhstan, 050000
| | - O Lesnyak
- Mechnikov North West State Medical University, 41, Kirochnaya Street, 191015, St. Petersburg, Russia
| | - A Zakroyeva
- Ural State Medical University, 3, Repina Street, 620028, Yekaterinburg, Russia
| | - B Issayeva
- Asfendiyarov National Medical University, 94, Tole Bi Street, Almaty, Kazakhstan, 050000
| | - D Dilmanova
- Asfendiyarov National Medical University, 94, Tole Bi Street, Almaty, Kazakhstan, 050000
| | - H Johansson
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - E Liu
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - M Lorentzon
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - J A Kanis
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
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Abstract
Since its development in 2008, FRAX has booked its place in the standard day to day management of osteoporosis. The FRAX tool has been appreciated for its simplicity and applicability for use in primary care, but criticised for the same reason, as it does not take into account exposure response. To address some of these limitations, relatively simple arithmetic procedures have been proposed to be applied to the conventional FRAX estimates of hip and major fracture probabilities aiming at adjustment of the probability assessment. However, as the list of these adjustments got longer, this has reflected on its implementation in the standard practice and gave FRAX a patchy look. Consequently, raises the need to re-think of the current FRAX and whether a second generation of the tool is required to address the perceived limitations of the original FRAX. This article will discuss both point of views of re-adjustment and re-thinking.
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Affiliation(s)
- Yasser El Miedany
- grid.13097.3c0000 0001 2322 6764King’s College London, London, England
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180
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Lesnyak O, Ismailov S, Shakirova M, Alikhanova N, Zakroyeva A, Abboskhujaeva L, Johansson H, Harvey NC, McCloskey E, Kanis JA. Epidemiology of hip fracture and the development of a FRAX model for Uzbekistan. Arch Osteoporos 2020; 15:119. [PMID: 32728952 PMCID: PMC7391387 DOI: 10.1007/s11657-020-00792-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/21/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A prospective population-based survey in a region of the Republic of Uzbekistan determined the incidence of fractures at the hip. The hip fracture rates were used to create a FRAX® model to facilitate fracture risk assessment in Uzbekistan. OBJECTIVE This paper describes the epidemiology of hip fracture in the Republic of Uzbekistan that was used to develop a country-specific FRAX® tool for fracture prediction. METHODS During a 1-year (2016/17) prospective population-based survey in the Pap district of the Republic of Uzbekistan, hip fractures were prospectively identified from hospital registers, trauma centres and primary care and community sources. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Uzbekistan. Fracture probabilities were compared with those from neighbouring Kazakhstan and Kyrgystan. RESULTS Approximately 41% of hip fracture cases did not come to medical attention, and two thirds of patients overall were not admitted to hospital. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 16,764 and is predicted to increase more than three-fold to 60,272 in 2050. FRAX-based probabilities were higher in Uzbekistan than Kazakhstan or Kyrgystan. CONCLUSION The FRAX model should enhance accuracy of determining fracture probability among the Uzbek population and help guide decisions about treatment.
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Affiliation(s)
- O Lesnyak
- Mechnikov North West State Medical University, St. Petersburg, Russia
| | - S Ismailov
- Republican Medical Center for Endocrinology, Tashkent, Uzbekistan
| | - M Shakirova
- Republican Medical Center for Endocrinology, Tashkent, Uzbekistan
| | - N Alikhanova
- Republican Medical Center for Endocrinology, Tashkent, Uzbekistan
| | - A Zakroyeva
- Ural State Medical University, 3 Repina street, Yekaterinburg, Russia
| | - L Abboskhujaeva
- Republican Medical Center for Endocrinology, Tashkent, Uzbekistan
| | - H Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - NC Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - JA Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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181
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Epidemiology of hip fractures in Bulgaria: development of a country-specific FRAX model. Arch Osteoporos 2020; 15:28. [PMID: 32108268 PMCID: PMC7046566 DOI: 10.1007/s11657-020-0710-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/29/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED A retrospective population-based survey was undertaken in a region of Bulgaria to determine the incidence of hip fracture. The estimated number of hip fractures nationwide for 2015 was 9322 and is predicted to increase to 11,398 in 2050. The hip fracture rates were used to create a FRAX model. OBJECTIVE To describe the epidemiology of hip fractures in Bulgaria, which was then used to develop the country-specific fracture prediction FRAX® tool. METHODS We carried out a retrospective population-based survey in Stara Zagora, Bulgaria, representing approximately 4.6% of the country's population. We identified hip fractures occurring in 2015, 2016 and 2017 from hospital registers and primary care sources held by the regional health insurance agency. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Bulgaria. Fracture probabilities were compared with those from neighbouring countries having FRAX models. RESULTS The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 9322 and is predicted to increase to 11,398 in 2050. FRAX-based probabilities were higher in Bulgaria than those in Serbia or Romania, lower than those in Turkey and similar to those in Greece. CONCLUSION The FRAX model should enhance accuracy of determining fracture probability among the Bulgarian population and help guide decisions about treatment.
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182
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Kanis JA, Chandran M, Chionh SB, Ganeson G, Harvey NC, Koh WP, Kwok T, Lau TC, Liu E, Lorentzon M, McCloskey EV, Tan KB, Vandenput L, Johansson H. Use of age-dependent FRAX-based intervention thresholds for Singapore. Arch Osteoporos 2020; 15:104. [PMID: 32700118 PMCID: PMC7376084 DOI: 10.1007/s11657-020-00782-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Assessment and treatment pathways based on age-specific intervention thresholds in Singapore using FRAX paths can be used to identify patients at high risk of fracture and avoid unnecessary treatment in those at low risk. PURPOSE Intervention thresholds for the treatment of osteoporosis have been based historically on the measurement of bone mineral density. The development of FRAX® has permitted a more accurate assessment of fracture risk. The aim of the present study was to explore treatment paths and characteristics of women selected for treatment in Singapore based on FRAX. METHODS The approach to the setting of intervention and assessment thresholds used the methodology adopted by the National Osteoporosis Guideline Group for FRAX-based guidelines in the UK but based on the epidemiology of fracture and death in Singapore. The methodology was applied to women age 50 years or more drawn from the population-based Singapore Chinese Health Study (SCHS) cohort. Missing data for the calculation of FRAX was simulated using data from Chinese cohorts from Hong Kong. RESULTS Intervention thresholds expressed as a 10-year probability of a major osteoporotic fracture ranged from 2.9% at the age of 50 years increasing to 32% at the age of 90 years. A total of 1927 of 29,323 women (7%) had a prior fragility fracture and would be eligible for treatment for this reason. An additional 3019 women (10.3%) would be eligible for treatment on the basis of age-dependent thresholds. The mean BMD T-score of women so selected was -2.94. CONCLUSION Probability-based assessment of fracture risk using age-specific intervention thresholds was developed for Singapore to help guide decisions about treatment.
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Affiliation(s)
- John A. Kanis
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Manju Chandran
- grid.163555.10000 0000 9486 5048Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore, Singapore
| | - Siok Bee Chionh
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ganga Ganeson
- grid.415698.70000 0004 0622 8735Division of Policy, Research and Evaluation, Ministry of Health, Singapore, Singapore
| | - Nicholas C Harvey
- grid.5491.90000 0004 1936 9297MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Woon-Puay Koh
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore ,grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Singapore, 117549 Singapore
| | - Timothy Kwok
- grid.415197.f0000 0004 1764 7206Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China ,grid.10784.3a0000 0004 1937 0482Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Tang Ching Lau
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Enwu Liu
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Mattias Lorentzon
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,grid.8761.80000 0000 9919 9582Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V McCloskey
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.11835.3e0000 0004 1936 9262MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Kelvin Bryan Tan
- grid.415698.70000 0004 0622 8735Ministry of Health Singapore, Singapore, Singapore
| | - Liesbeth Vandenput
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,grid.8761.80000 0000 9919 9582Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Borgström F, Karlsson L, Ortsäter G, Norton N, Halbout P, Cooper C, Lorentzon M, McCloskey EV, Harvey NC, Javaid MK, Kanis JA. Fragility fractures in Europe: burden, management and opportunities. Arch Osteoporos 2020; 15:59. [PMID: 32306163 PMCID: PMC7166207 DOI: 10.1007/s11657-020-0706-y] [Citation(s) in RCA: 350] [Impact Index Per Article: 87.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/28/2020] [Indexed: 02/06/2023]
Abstract
UNLABELLED This report provides an overview and a comparison of the burden and management of fragility fractures in the largest five countries of the European Union plus Sweden (EU6). In 2017, new fragility fractures in the EU6 are estimated at 2.7 million with an associated annual cost of €37.5 billion and a loss of 1.0 million quality-adjusted life years. INTRODUCTION Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fractures, which in turn, represent the main consequence of the disease. This report provides an overview and a comparison of the burden and management of fragility fractures in the largest five EU countries and Sweden (designated the EU6). METHODS A series of metrics describing the burden and management of fragility fractures were defined by a scientific steering committee. A working group performed the data collection and analysis. Data were collected from current literature, available retrospective data and public sources. Different methods were applied (e.g. standard statistics and health economic modelling), where appropriate, to perform the analysis for each metric. RESULTS Total fragility fractures in the EU6 are estimated to increase from 2.7 million in 2017 to 3.3 million in 2030; a 23% increase. The resulting annual fracture-related costs (€37.5 billion in 2017) are expected to increase by 27%. An estimated 1.0 million quality-adjusted life years (QALYs) were lost in 2017 due to fragility fractures. The current disability-adjusted life years (DALYs) per 1000 individuals age 50 years or more were estimated at 21 years, which is higher than the estimates for stroke or chronic obstructive pulmonary disease. The treatment gap (percentage of eligible individuals not receiving treatment with osteoporosis drugs) in the EU6 is estimated to be 73% for women and 63% for men; an increase of 17% since 2010. If all patients who fracture in the EU6 were enrolled into fracture liaison services, at least 19,000 fractures every year might be avoided. CONCLUSIONS Fracture-related burden is expected to increase over the coming decades. Given the substantial treatment gap and proven cost-effectiveness of fracture prevention schemes such as fracture liaison services, urgent action is needed to ensure that all individuals at high risk of fragility fracture are appropriately assessed and treated.
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Affiliation(s)
- Fredrik Borgström
- Medical Management Centre, Department of Learning Informatics, Management and Ethics, Karolinska Institute, Solna, Sweden ,Quantify Research, Stockholm, Sweden
| | | | | | | | | | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK ,National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Mattias Lorentzon
- Mary MacKillop Health Institute, Catholic University of Australia, Melbourne, Australia ,Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V. McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX UK ,MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Nicholas C. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Muhamamd K. Javaid
- National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - John A. Kanis
- Mary MacKillop Health Institute, Catholic University of Australia, Melbourne, Australia ,Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX UK
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Parsons CM, Harvey N, Shepstone L, Kanis JA, Lenaghan E, Clarke S, Fordham R, Gittoes N, Harvey I, Holland R, Redmond NM, Howe A, Marshall T, Peters TJ, Torgerson D, O'Neill TW, McCloskey E, Cooper C. Systematic screening using FRAX ® leads to increased use of, and adherence to, anti-osteoporosis medications: an analysis of the UK SCOOP trial. Osteoporos Int 2020; 31:67-75. [PMID: 31606826 PMCID: PMC6952271 DOI: 10.1007/s00198-019-05142-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/20/2019] [Indexed: 12/01/2022]
Abstract
UNLABELLED In the large community-based SCOOP trial, systematic fracture risk screening using FRAX® led to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care. INTRODUCTION In the SCreening of Older wOmen for Prevention of fracture (SCOOP) trial, we investigated the effect of the screening intervention on subsequent long-term self-reported adherence to anti-osteoporosis medications (AOM). METHODS SCOOP was a primary care-based UK multicentre trial of screening for fracture risk. A total of 12,483 women (70-85 years) were randomised to either usual NHS care, or assessment using the FRAX® tool ± dual-energy X-ray absorptiometry (DXA), with medication recommended for those found to be at high risk of hip fracture. Self-reported AOM use was obtained by postal questionnaires at 6, 12, 24, 36, 48 and 60 months. Analysis was limited to those who initiated AOM during follow-up. Logistic regression was used to explore baseline determinants of adherence (good ≥ 80%; poor < 80%). RESULTS The mean (SD) age of participants was 75.6 (4.2) years, with 6233 randomised to screening and 6250 to the control group. Of those participants identified at high fracture risk in the screening group, 38.2% of those on treatment at 6 months were still treated at 60 months, whereas the corresponding figure for the control group was 21.6%. Older age was associated with poorer adherence (OR per year increase in age 0.96 [95% CI 0.93, 0.99], p = 0.01), whereas history of parental hip fracture was associated with greater rate adherence (OR 1.67 [95% CI 1.23, 2.26], p < 0.01). CONCLUSIONS Systematic fracture risk screening using FRAX® leads to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care.
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Affiliation(s)
- C M Parsons
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - N Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | | | - S Clarke
- Bristol Medical School, University of Bristol, Bristol, UK
| | - R Fordham
- University of East Anglia, Norwich, UK
| | - N Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital, Birmingham, UK
| | - I Harvey
- University of East Anglia, Norwich, UK
| | - R Holland
- University of East Anglia, Norwich, UK
| | - N M Redmond
- Bristol Medical School, University of Bristol, Bristol, UK
- NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - A Howe
- University of East Anglia, Norwich, UK
| | | | - T J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - T W O'Neill
- Arthritis Research UK Centre for Epidemiology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mellanby Centre for Bone Research, Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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185
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Leslie WD, Morin SN, Lix LM, Binkley N. Comparison of treatment strategies and thresholds for optimizing fracture prevention in Canada: a simulation analysis. Arch Osteoporos 2019; 15:4. [PMID: 31858278 DOI: 10.1007/s11657-019-0660-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/02/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED This comparison of osteoporosis treatment strategies and intervention thresholds highlights tradeoffs in terms of number of individuals qualifying for treatment and estimated fractures prevented. PURPOSE The current analysis was performed to inform the following key question as part of the Osteoporosis Canada's Osteoporosis Guidelines Update: "What is the best strategy to identify those at high fracture risk for pharmacotherapy in order to prevent the most fractures, considering both population and patient perspectives?" METHODS The study population consisted of 66,878 women age 50 years and older (mean age 66.0 ± 9.7 years) with documented fracture probability assessment (FRAX) and fracture outcomes. Fractures over the next 5 years were identified through linked administrative healthcare data. We estimated the fraction of the population that would warrant treatment and the number of fractures avoided per 1000 person-years according to multiple strategies and thresholds. Strategies were then rank ordered using 19 metrics. RESULTS During mean 4.4 years, 863 (3.5%) sustained one or more major osteoporotic fractures (MOF), 212 (0.8%) sustained a hip fracture, and 1210 (4.9%) sustained any incident fracture. For woman age 50-64 years, the highest ranked strategy was treatment based upon total hip T score ≤ -2.5, but several other strategies fell within 0.5 overall ranking. For women age 65 years and older, MOF > 20% was the highest ranked strategy with no closely ranked strategies. Pooling both age subgroups gave MOF > 20% as the highest ranked strategy, with several other strategies within 0.5 overall ranking. CONCLUSIONS Choice of treatment strategy and threshold for osteoporosis management strongly influences the number of individuals for whom pharmacologic treatment would be recommended and on estimated fracture rates in the population. This evidence-based approach to comparing these strategies will help to inform guidelines development in Canada and may be on interest elsewhere.
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Affiliation(s)
- William D Leslie
- Department of Medicine, University of Manitoba, C5121-409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | | | - Lisa M Lix
- Department of Medicine, University of Manitoba, C5121-409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
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186
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Lekamwasam S. The diversity of Fracture Risk Assessment Tool (FRAX)-based intervention thresholds in Asia. Osteoporos Sarcopenia 2019; 5:104-108. [PMID: 31938728 PMCID: PMC6953527 DOI: 10.1016/j.afos.2019.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/02/2019] [Accepted: 12/05/2019] [Indexed: 01/22/2023] Open
Abstract
Fracture Risk Assessment Tool (FRAX), introduced in 2008, is the most frequently used fracture risk calculator. Many Asian countries have developed own FRAX models to suit their country needs. Only a few Asian countries, however, have developed country-specific intervention thresholds to demarcate high-risk patients. A wide variation is seen in these intervention thresholds partly due to the different approaches used in developing the cutoff values. This paper discusses the diversity of the intervention thresholds in Asian countries and possible reasons. It also discusses the future directions for the countries in the Asian region.
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Affiliation(s)
- Sarath Lekamwasam
- Population Health Research Center, Department of Medicine, Faculty of Medicine, Galle, Sri Lanka
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187
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Leslie WD, Morin SN, Lix LM, Martineau P, Bryanton M, McCloskey EV, Johansson H, Harvey NC, Kanis JA. Fracture prediction from self-reported falls in routine clinical practice: a registry-based cohort study. Osteoporos Int 2019; 30:2195-2203. [PMID: 31372711 DOI: 10.1007/s00198-019-05106-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/21/2019] [Indexed: 11/30/2022]
Abstract
A simple question construct regarding number of falls in the previous year, ascertained by a single question, was strongly associated with incident fractures in routine clinical practice using a population-based dual-energy X-ray absorptiometry (DXA) registry. INTRODUCTION There is conflicting evidence from research cohorts that falls independently increase fracture risk. We examined the independent effects of falls on subsequent fractures in a large clinical registry of bone mineral density (BMD) results for the Province of Manitoba, Canada that has been systematically collecting self-reported falls information since September 1, 2012. METHODS The study population consisted of 24,943 women and men aged 40 years and older (mean age 65.5 ± 10.2 years) with fracture probability assessment (FRAX), self-reported falls for the previous year (categorized as none, 1, 2, or > 3) and fracture outcomes. Adjusted hazard ratios (HR) with 95 confidence intervals (CI) for time to fracture were estimated using Cox proportional hazards models. RESULTS During mean observation time of 2.7 ± 1.0 years, 863 (3.5%) sustained one or more major osteoporotic fractures (MOF), 212 (0.8%) sustained a hip fracture, and 1210 (4.9%) sustained any incident fracture. Compared with no falls in the previous year (referent), there was a gradient of increasing risk for fracture with increasing number of falls (all P < 0.001). Results showed minimal attenuation with covariate adjustment. When adjusted for baseline fracture probability (FRAX score with BMD) the HR for MOF increased from 1.49 (95% CI 1.25-1.78) for one fall to 1.74 (1.33-2.27) for two falls to 2.62 (2.06-3.34) for ≥ 3 falls. HRs were similar for any incident fracture and slightly greater for prediction of hip fracture, reaching 3.41 (95% CI 2.19-5.31) for ≥ 3 previous falls. CONCLUSIONS Self-report number of falls in the previous year is strongly associated with incident fracture risk in the routine clinical practice setting, and this risk is independent of age, sex, BMD, and baseline fracture probability. Moreover, there is dose-response with multiple falls (up to a maximum of 3) conferring greater risk than a single fall.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
| | | | - L M Lix
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - P Martineau
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
- Harvard Medical School, Boston, MA, USA
| | - M Bryanton
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
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Khashayar P, Keshtkar A, Ostovar A, Larijani B, Johansson H, Harvey NC, Lorentzon M, McCloskey E, Kanis JA. FRAX-based intervention and assessment thresholds for osteoporosis in Iran. Osteoporos Int 2019; 30:2225-2230. [PMID: 31372709 DOI: 10.1007/s00198-019-05078-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/01/2019] [Indexed: 12/28/2022]
Abstract
UNLABELLED We compared the utility of the current Iranian guidelines that recommend treatment in women with a T-score ≤ - 2.5 SD with a FRAX-based intervention threshold equivalent to women of average BMI with a prior fragility fracture. Whereas the FRAX-based intervention threshold identified women at high fracture probability, the T-score threshold was less sensitive, and the associated fracture risk decreased markedly with age. INTRODUCTION The fracture risk assessment algorithm FRAX® has been recently calibrated for Iran, but guidance is needed on how to apply fracture probabilities to clinical practice. METHODS The age-specific ten-year probabilities of a major osteoporotic fracture were calculated in women with average BMI to determine fracture probabilities at two potential intervention thresholds. The first comprised the age-specific fracture probabilities associated with a femoral neck T-score of - 2.5 SD, in line with current guidelines in Iran. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without BMD. The parsimonious use of BMD was additionally explored by the computation of upper and lower assessment thresholds for BMD testing. RESULTS When a BMD T-score ≤ - 2.5 SD was used as an intervention threshold, FRAX probabilities in women aged 50 years was approximately two-fold higher than in women of the same age but with an average BMD and no risk factors. The relative increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of - 2.5 SD was actually protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to women with a previous fracture rose with age from 4.9% at the age of 50 years to 17%, at the age of 80 years, and identified women at increased risk at all ages. CONCLUSION Intervention thresholds based on BMD alone do not effectively target women at high fracture risk, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a "fracture threshold" target women at high fracture risk.
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Affiliation(s)
- P Khashayar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Center for Microsystems Technology, Imec and Ghent University, 9052, Gent-Zwijnaarde, Belgium
| | - A Keshtkar
- Department of Health Sciences Education Development, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - A Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - B Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - H Johansson
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - M Lorentzon
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
- Geriatric Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - J A Kanis
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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Chen JF, Yu SF, Hsu CY, Chiu WC, Wu CH, Lai HM, Chen YC, Su YJ, Chen JF, Cheng TT. The role of bone mineral density in therapeutic decision-making using the Fracture Risk Assessment Tool (FRAX): a sub-study of the Taiwan OsteoPorosis Survey (TOPS). Arch Osteoporos 2019; 14:101. [PMID: 31650396 DOI: 10.1007/s11657-019-0653-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/16/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Fracture Risk Assessment Tool (FRAX)-based intervention threshold (IT) is widely applied for treatment decision-making; however, an IT based on FRAX without the measurement of bone mass density (BMD) has not been validated. The study demonstrated that estimates of fracture risk by FRAX without BMD were higher than those by FRAX with BMD in women with old age. INTRODUCTION BMD is an integral component for bone strength assessment, but age-specific impacts of BMD on fracture risk assessment and therapeutic decision-making remained unclear. We aimed to investigate whether using BMD measurement changed the interpretation of the FRAX-based fracture probability assessment and treatment decision. METHODOLOGY The database was provided by the Taiwanese Osteoporosis Association (TOA) which conducted a nationwide survey of BMD. We calculated the 10-year major and hip fracture probabilities using the FRAX for each participant, either with (FRAX + BMD) or without BMD (FRAX - BMD). Age-specific individual intervention thresholds (IITs) were established using the FRAX-based fracture risk, equivalent to a woman with a prior fracture. Participants whose FRAX scores of major fracture were greater than or equal to their IITs were deemed suitable for therapeutic intervention. RESULTS A total of 14,007 postmenopausal women were enrolled. Compared with FRAX + BMD, FRAX - BMD predicted lower FRAX scores in major and hip fractures in subjects aged 40-60 years; however, FRAX - BMD estimated higher risks for those aged 61-90 years. The therapeutic decision using FRAX - BMD was concordant to that using FRAX + BMD in 90.5% of the subjects, especially in the younger age group (40-70 years). FRAX - BMD identified more treatment candidates (7.7-16.4%) among those aged 71-90 years. CONCLUSIONS The FRAX scores are influenced by age, irrespective of the consideration of BMD. FRAX - BMD is able to identify more subjects for therapeutic intervention in the elderly population. We should reconsider the role of BMD at different ages for therapeutic decision-making.
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Affiliation(s)
- Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Han-Ming Lai
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Yu-Jih Su
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC.
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190
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Wang C, Liu J, Xiao L, Liu D, Yan W, Hu T, Li K, Hua X, Zeng X. Comparison of FRAX in postmenopausal Asian women with and without type 2 diabetes mellitus: a retrospective observational study. J Int Med Res 2019; 48:300060519879591. [PMID: 31617425 PMCID: PMC7783259 DOI: 10.1177/0300060519879591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To compare the fracture risk in postmenopausal Asian women with or without
type 2 diabetes mellitus (T2DM). Methods The study cohort comprised data from consecutive postmenopausal women with
T2DM that were retrieved from a prospectively maintained institutional
database from 2001 to 2009. Postmenopausal women without DM from the Medical
Examination Center from 2001 to 2009 formed the control cohort. The primary
endpoint was the World Health Organization Fracture Risk Algorithm (FRAX,
revised 2013) score. The secondary endpoint was bone mineral density
(BMD). Results There were 1014 individuals included for the assessment (T2DM, n=500 and
non-DM, n=514). Based on the FRAX model, the risk of major osteoporotic
fractures and hip fractures over the next 10 years was higher in the T2DM
group compared with the non-DM group. Compared with the T2DM group, the
non-DM group had a lower BMD. After adjusting for age, gender, history of
alcohol consumption, smoking status, body mass index, and low-density
lipoprotein, the differences were statistically significant. Conclusions Compared with postmenopausal women without DM, postmenopausal women with T2DM
had a significantly higher fracture risk calculated using the FRAX model.
Early intervention for postmenopausal women with T2DM may be necessary,
although T2DM is associated with a high BMD.
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Affiliation(s)
- Chen Wang
- Department of Anesthesiology, Pu'ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 76 Jiefang Avenue, Qiaokou District, Wuhan, Hubei, China
| | - Jun Liu
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China
| | - Li Xiao
- Department of Gynaecology and Obstetrics, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, No. 26, Shengli Street, Wuhan, Hubei, China
| | - Dan Liu
- Department of Internal Medicine, Amcare Primary Care & Out Patient Services Center, Building 3, Anhui Beili Yiyuan, Beiyuan Road, Chaoyang District, Beijing, China
| | - Wenjing Yan
- Operation Room, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, Gusao Shu No. 16, Jiang'an District, Wuhan, China
| | - Ting Hu
- Operation Room, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, Gusao Shu No. 16, Jiang'an District, Wuhan, China
| | - Kunhong Li
- Department of Anesthesiology, Pu'ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 76 Jiefang Avenue, Qiaokou District, Wuhan, Hubei, China
| | - Xiaociao Hua
- Department of Anesthesiology, The Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, No. 56, Lingyuan West Road, Guangzhou, China
| | - Xianshang Zeng
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China
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Lorentzon M, Branco J, Brandi ML, Bruyère O, Chapurlat R, Cooper C, Cortet B, Diez-Perez A, Ferrari S, Gasparik A, Herrmann M, Jorgensen NR, Kanis J, Kaufman JM, Laslop A, Locquet M, Matijevic R, McCloskey E, Minisola S, Pikner R, Reginster JY, Rizzoli R, Szulc P, Vlaskovska M, Cavalier E. Algorithm for the Use of Biochemical Markers of Bone Turnover in the Diagnosis, Assessment and Follow-Up of Treatment for Osteoporosis. Adv Ther 2019; 36:2811-2824. [PMID: 31440982 PMCID: PMC6822833 DOI: 10.1007/s12325-019-01063-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Indexed: 12/02/2022]
Abstract
Introduction Increased biochemical bone turnover markers (BTMs) measured in serum are associated with bone loss, increased fracture risk and poor treatment adherence, but their role in clinical practice is presently unclear. The aim of this consensus group report is to provide guidance to clinicians on how to use BTMs in patient evaluation in postmenopausal osteoporosis, in fracture risk prediction and in the monitoring of treatment efficacy and adherence to osteoporosis medication. Methods A working group with clinical scientists and osteoporosis specialists was invited by the Scientific Advisory Board of European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Results Serum bone formation marker PINP and resorption marker βCTX-I are the preferred markers for evaluating bone turnover in the clinical setting due to their specificity to bone, performance in clinical studies, wide use and relatively low analytical variability. BTMs cannot be used to diagnose osteoporosis because of low sensitivity and specificity, but can be of value in patient evaluation where high values may indicate the need to investigate some causes of secondary osteoporosis. Assessing serum levels of βCTX-I and PINP can improve fracture prediction slightly, with a gradient of risk of about 1.2 per SD increase in the bone marker in addition to clinical risk factors and bone mineral density. For an individual patient, BTMs are not useful in projecting bone loss or treatment efficacy, but it is recommended that serum PINP and βCTX-I be used to monitor adherence to oral bisphosphonate treatment. Suppression of the BTMs greater than the least significant change or to levels in the lower half of the reference interval in young and healthy premenopausal women is closely related to treatment adherence. Conclusion In conclusion, the currently available evidence indicates that the principal clinical utility of BTMs is for monitoring oral bisphosphonate therapy.
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192
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Liu J, Curtis EM, Cooper C, Harvey NC. State of the art in osteoporosis risk assessment and treatment. J Endocrinol Invest 2019; 42:1149-1164. [PMID: 30980341 PMCID: PMC6751157 DOI: 10.1007/s40618-019-01041-6] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm, and humerus. Over recent decades, it has evolved from being viewed as an inevitable consequence of ageing, to being recognised as a serious and eminently treatable disease. MATERIALS AND METHODS In this article, we review the literature pertaining to the epidemiology of osteoporosis, associated health burden, approaches to risk assessment and treatment. RESULTS Although there is some evidence that fracture incidence has reached a plateau, or even started to decline, in the developed world, an ageing population and adoption of westernised lifestyles in transitioning populations is leading to an increasing burden of osteoporosis across the world. Whilst the clinical definition of osteoporosis has been based solely on bone mineral density, the prediction of fracture at the individual level has been improved by consideration of clinical risk factors in tools such as FRAX®, derived from a greater understanding of the epidemiology of osteoporosis. Such advances in approaches to primary and secondary prevention of fractures, coupled with elucidation of the underlying biology, and the development of a range of highly effective antiosteoporosis medications, have enabled a step change in our ability to prevent osteoporosis-related fractures. However, there remains a substantial disparity between the number of individuals at high fracture risk and number treated globally. CONCLUSION Urgent work is needed at the level of health care systems, national and international policy, and in communication with patients and public, to ensure that all patients who should receive treatment for osteoporosis actually do so.
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Affiliation(s)
- J Liu
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - E M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
- NIHR Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK.
- NIHR Southampton Nutrition Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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193
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Fuggle NR, Curtis EM, Ward KA, Harvey NC, Dennison EM, Cooper C. Fracture prediction, imaging and screening in osteoporosis. Nat Rev Endocrinol 2019; 15:535-547. [PMID: 31189982 DOI: 10.1038/s41574-019-0220-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Osteoporosis is associated with increased fragility of bone and a subsequent increased risk of fracture. The diagnosis of osteoporosis is intimately linked with the imaging and quantification of bone and BMD. Scanning modalities, such as dual-energy X-ray absorptiometry or quantitative CT, have been developed and honed over the past half century to provide measures of BMD and bone microarchitecture for the purposes of clinical practice and research. Combined with fracture prediction tools such as Fracture Risk Assessment Tool (FRAX) (which use a combination of clinical risk factors for fracture to provide a measure of risk), these elements have led to a paradigm shift in the ability to diagnose osteoporosis and predict individuals who are at risk of fragility fracture. Despite these developments, a treatment gap exists between individuals who are at risk of osteoporotic fracture and those who are receiving therapy. In this Review, we summarize the epidemiology of osteoporosis, the history of scanning modalities, fracture prediction tools and future directions, including the most recent developments in prediction of fractures.
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Affiliation(s)
- Nicholas R Fuggle
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Kate A Ward
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- MRC Nutrition and Bone Health Research Group, Cambridge, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elaine M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- Victoria University of Wellington, Wellington, New Zealand
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK.
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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194
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deSouza NM, Achten E, Alberich-Bayarri A, Bamberg F, Boellaard R, Clément O, Fournier L, Gallagher F, Golay X, Heussel CP, Jackson EF, Manniesing R, Mayerhofer ME, Neri E, O'Connor J, Oguz KK, Persson A, Smits M, van Beek EJR, Zech CJ. Validated imaging biomarkers as decision-making tools in clinical trials and routine practice: current status and recommendations from the EIBALL* subcommittee of the European Society of Radiology (ESR). Insights Imaging 2019; 10:87. [PMID: 31468205 PMCID: PMC6715762 DOI: 10.1186/s13244-019-0764-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/28/2019] [Indexed: 12/12/2022] Open
Abstract
Observer-driven pattern recognition is the standard for interpretation of medical images. To achieve global parity in interpretation, semi-quantitative scoring systems have been developed based on observer assessments; these are widely used in scoring coronary artery disease, the arthritides and neurological conditions and for indicating the likelihood of malignancy. However, in an era of machine learning and artificial intelligence, it is increasingly desirable that we extract quantitative biomarkers from medical images that inform on disease detection, characterisation, monitoring and assessment of response to treatment. Quantitation has the potential to provide objective decision-support tools in the management pathway of patients. Despite this, the quantitative potential of imaging remains under-exploited because of variability of the measurement, lack of harmonised systems for data acquisition and analysis, and crucially, a paucity of evidence on how such quantitation potentially affects clinical decision-making and patient outcome. This article reviews the current evidence for the use of semi-quantitative and quantitative biomarkers in clinical settings at various stages of the disease pathway including diagnosis, staging and prognosis, as well as predicting and detecting treatment response. It critically appraises current practice and sets out recommendations for using imaging objectively to drive patient management decisions.
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Affiliation(s)
- Nandita M deSouza
- Cancer Research UK Imaging Centre, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 5PT, UK.
| | | | | | - Fabian Bamberg
- Department of Radiology, University of Freiburg, Freiburg im Breisgau, Germany
| | | | | | | | | | | | - Claus Peter Heussel
- Universitätsklinik Heidelberg, Translational Lung Research Center (TLRC), German Center for Lung Research (DZL), University of Heidelberg, Im Neuenheimer Feld 156, 69120, Heidelberg, Germany
| | - Edward F Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rashindra Manniesing
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Geert Grooteplein 10, 6525, GA, Nijmegen, The Netherlands
| | | | - Emanuele Neri
- Department of Translational Research, University of Pisa, Pisa, Italy
| | - James O'Connor
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | | | | | - Marion Smits
- Department of Radiology and Nuclear Medicine (Ne-515), Erasmus MC, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Edwin J R van Beek
- Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh Bioquarter, 47 Little France Crescent, Edinburgh, UK
| | - Christoph J Zech
- University Hospital Basel, Radiology and Nuclear Medicine, University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland
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195
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Penoni DC, Vettore MV, Torres SR, Farias MLF, Leão ATT. An investigation of the bidirectional link between osteoporosis and periodontitis. Arch Osteoporos 2019; 14:94. [PMID: 31444638 DOI: 10.1007/s11657-019-0643-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/14/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study investigated whether periodontitis affects systemic bone status and whether FRAX® is a screening tool for periodontal disease in elderly women. The findings showed that bone density was not influenced by periodontitis and highlighted that women with FRAX® score above the intervention threshold had greater chance to present severe periodontitis. PURPOSE This study investigated whether periodontal disease is a predictor for systemic bone loss among elderly women. The utilization of FRAX® as a screening tool for severe periodontitis was also evaluated in this population. METHODS Current bone mineral density (BMD) for lumbar spine and proximal femur was used as an indicator of "bone status." Number of interdental sites with severe clinical attachment loss, frequency of bleeding on probing, and percentage of tooth loss due to periodontitis represented "periodontal disease" that was tested as a predictor of bone loss in a structural equation modeling analysis involving 110 participants. The intake of antiosteoporosis medication was considered in the analysis. Four other different criteria for periodontitis classification were also tested. FRAX® for major fracture was calculated without BMD, and with intervention threshold set by age. Longitudinally, BMD changes up to 10 years were also obtained and checked for possible association with periodontitis. RESULTS Periodontal disease was not a predictor for worse systemic bone status according to the different periodontal disease classifications, and was not associated with BMD changes. Antiosteoporosis medication directly predicted periodontal disease and systemic bone status. Women with FRAX® score above the intervention threshold had higher chance for periodontitis in more advanced stages: III/IV (OR = 1.13, 95% CI [1.04 to 1.22], p = 0.03). CONCLUSION Periodontal disease did not constitute a predictor for reduced systemic bone density in the studied population of elderly women. On the other hand, FRAX® demonstrated to be a useful tool to suggest periodontal evaluation. Antiresorptive medication showed benefits on periodontal and bone status.
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Affiliation(s)
- D C Penoni
- Department of Preventive Dentistry, Odontoclínica Central da Marinha, Brazilian Navy, Rio de Janeiro, Brazil. .,Department of Dental Clinic, Division of Periodontics, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. .,, Rio de Janeiro, Brazil.
| | - M V Vettore
- Department of Social and Preventive Dentistry, Dental School, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - S R Torres
- Department of Oral Pathology and Diagnosis, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - M L F Farias
- Division of Endocrinology, Department of Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - A T T Leão
- Department of Dental Clinic, Division of Periodontics, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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196
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Gates M, Pillay J, Thériault G, Limburg H, Grad R, Klarenbach S, Korownyk C, Reynolds D, Riva JJ, Thombs BD, Kline GA, Leslie WD, Courage S, Vandermeer B, Featherstone R, Hartling L. Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review. Syst Rev 2019; 8:216. [PMID: 31443711 PMCID: PMC6706906 DOI: 10.1186/s13643-019-1094-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making. METHODS A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force. DISCUSSION Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.
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Affiliation(s)
- Michelle Gates
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Jennifer Pillay
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | | | - Heather Limburg
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Canada
| | | | | | - Donna Reynolds
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - John J. Riva
- Department of Family Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Brett D. Thombs
- Faculty of Medicine, McGill University and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | | | - William D. Leslie
- Department of Medicine (Endocrinology), University of Manitoba, Winnipeg, Canada
- Department of Radiology (Nuclear Medicine), University of Manitoba, Winnipeg, Canada
| | - Susan Courage
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
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197
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Assessing the risk of osteoporotic fractures: the Ecuadorian FRAX model. Arch Osteoporos 2019; 14:93. [PMID: 31440846 DOI: 10.1007/s11657-019-0644-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/12/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED The FRAX tool incorporates data on the incidence of fractures and mortality in each country. The epidemiology of fractures changes over time, this makes it necessary to update the specific FRAX model of each population. It is shown that there are differences between old and new FRAX models in older individuals. PURPOSE A new FRAX® model for Ecuador was released online in April 2019. This paper describes the data used to build the revised model, its characteristics, and how intervention and assessment thresholds were constructed. METHODS The national rates of hip fracture incidence standardized by age and sex from the age of 40 years for 2016 were used to synthesize a FRAX model for Ecuador. For other major fractures, Ecuadorian incidence rates were calculated using ratios obtained in Malmö, Sweden, for other major osteoporotic fractures. The new FRAX model was compared with the previous model released in 2012. Assessment and intervention thresholds were based on age-specific probabilities of a major osteoporotic fracture equivalent to women with a previous fracture. RESULTS Fracture incidence rates increase with age. The probability of hip or major fractures at 10 years increased in patients with a clinical risk factor, lower BMI, female sex, a higher age, and a lower BMD T-score. Compared to the previous model, the new FRAX model gave similar 10-year fracture probabilities in men and women age less than70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the two models (> 0.99) so that the revision had little impact on the rank order of risk. CONCLUSIONS The FRAX tool provides a country-specific fracture prediction model for Ecuador. This update of the model is based on the original FRAX methodology, which has been validated externally in several independent cohorts. The FRAX model is an evolving tool that is being continuously refined, as the databases of each country are updated with more epidemiological information.
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Leslie WD, Morin SN, Lix LM, Niraula S, McCloskey EV, Johansson H, Harvey NC, Kanis JA. Performance of FRAX in Women with Breast Cancer Initiating Aromatase Inhibitor Therapy: A Registry-Based Cohort Study. J Bone Miner Res 2019; 34:1428-1435. [PMID: 31069862 DOI: 10.1002/jbmr.3726] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/18/2019] [Accepted: 03/10/2019] [Indexed: 01/08/2023]
Abstract
FRAX was developed to predict 10-year probability of major osteoporotic fracture (MOF) and hip fracture in the general population. Aromatase inhibitors (AI) used in breast cancer induce loss in bone mineral density (BMD) and are reported to increase fracture risk. AI exposure is not a direct input to FRAX but is captured under "secondary osteoporosis". To inform use of FRAX in women treated with AI, we used a population-based registry for the Province of Manitoba, Canada, to identify women aged ≥40 years initiating AI for breast cancer with at least 12 months' AI exposure (n = 1775), women with breast cancer not receiving AI (n = 1016), and women from the general population (n = 34,205). Among AI users, fracture probability estimated without BMD (AI use coded as secondary osteoporosis) significantly overestimated risk (10-year observed/predicted ratio 0.56, 95% confidence interval [CI] 0.45-0.68; 10-year hip fracture observed/predicted ratio 0.33, 95% CI 0.18-0.49). However, when BMD was included in the fracture probability, there was no significant difference between observed and predicted fracture risk. In Cox proportional hazards models, FRAX stratified risk of MOF, hip, and any fracture equally well in all subgroups (p-interaction >0.1). When adjusted for FRAX score without BMD, with AI use coded as secondary osteoporosis, AI users were at significantly lower risk for MOF (hazard ratio [HR] = 0.78, 95% CI 0.64-0.95), hip fracture (HR = 0.46, 95% CI 0.29-0.73) and any fracture (HR = 0.75, 95% CI 0.63-0.89). AI use was no longer significantly associated with fractures when AI use was not entered as secondary osteoporosis in FRAX without BMD or when BMD was included in the FRAX calculation. In conclusion, FRAX scores stratify fracture risk equally well in women receiving AI therapy as in non-users, but including secondary osteoporosis as a risk factor for AI users overestimates fracture risk. Our results call this practice into question. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
| | | | - Lisa M Lix
- University of Manitoba, Winnipeg, Canada
| | | | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK.,Mary McKillop Health Institute, Catholic University of Australia, Melbourne, Australia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK.,Mary McKillop Health Institute, Catholic University of Australia, Melbourne, Australia
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199
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Leslie WD, Martineau P, Bryanton M, Lix LM. Which is the preferred site for bone mineral density monitoring as an indicator of treatment-related anti-fracture effect in routine clinical practice? A registry-based cohort study. Osteoporos Int 2019; 30:1445-1453. [PMID: 31016351 DOI: 10.1007/s00198-019-04975-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/14/2019] [Indexed: 01/12/2023]
Abstract
UNLABELLED Change in total hip bone mineral density (BMD) provides a robust indication of anti-fracture effect during treatment monitoring in routine clinical practice, whereas spine BMD change is not independently associated with fracture risk. PURPOSE The role of monitoring bone mineral density (BMD) as an indicator of an anti-fracture effect is controversial. Discordance between the spine and hip BMD is common and creates uncertainty in clinical practice. METHODS Using a population-based BMD Registry for the Province of Manitoba, Canada, we compared change in the spine and hip BMD as an indicator of treatment-related fracture risk reduction. The study cohort included 6093 women age > 40 years initiating osteoporosis treatment with two consecutive dual-energy X-ray absorptiometry (DXA) scans (mean interval 4.7 years). We computed change in the spine, total hip, and femur neck BMD between the first and second DXA scans as categorical (categorized as stable, detectable decrease, or detectable increase) and continuous measures. We modeled time to first incident fracture, ascertained from health services data, using Cox regression adjusted for baseline fracture probability. RESULTS During a mean follow-up of 12.1 years, 995 women developed incident major osteoporotic fractures (MOF) including 246 with hip fractures and 301 with clinical vertebral fractures. Women with a detectable decrease in total hip BMD compared with stable BMD experienced an increase in MOF (adjusted hazard ratio [aHR] 1.46, 95% confidence interval [CI] 1.25-1.70) while those with a detectable increase in total hip BMD experienced a decrease in MOF (aHR 0.71, 95% CI 0.61-0.83), and these results were not attenuated when adjusted for change in spine BMD. Similar results were seen for hip and clinical vertebral fracture outcomes, when BMD change was assessed as a continuous measure, and when femur neck BMD monitoring was used instead of total hip BMD monitoring. CONCLUSIONS Treatment-related increases in total hip BMD are associated with lower MOF, hip, and clinical vertebral fracture risk compared with stable BMD, while BMD decreases are associated with higher fracture risk. In contrast, spine BMD change is not independently associated with fracture risk.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - P Martineau
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
- Harvard University, Boston, USA
| | - M Bryanton
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
| | - L M Lix
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
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Sale JEM, Marwah A, Naeem F, Yu W, Meadows L. Evidence of patient beliefs, values, and preferences is not provided in osteoporosis clinical practice guidelines. Osteoporos Int 2019; 30:1325-1337. [PMID: 30859238 DOI: 10.1007/s00198-019-04913-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/20/2019] [Indexed: 01/13/2023]
Abstract
UNLABELLED We examined how patient beliefs, values, and preferences (BVPs) were included and conceptualized in international osteoporosis guidelines. The majority of guidelines did not mention BVPs. When mentioned, BVPs were conceptualized as preference for one medication over another. A broader conceptualization and inclusion of BVPs should be incorporated in osteoporosis guidelines. INTRODUCTION Our objectives were to determine (1) the extent to which osteoporosis guidelines reflected patients' beliefs, values, and preferences (BVPs); (2) how BVPs were conceptualized; and (3) the methods used to elicit BVPs in the references cited by the guidelines. METHODS We conducted a document analysis of English-language international osteoporosis guidelines based on the International Osteoporosis Foundation website. We examined each guideline and extracted all instances of statements pertaining to BVPs. The statements were reviewed by two independent researchers. Discrepancies in data extraction were resolved by the first author. We developed categories based on five common elements that represented the BVP statements. RESULTS Twenty-seven of 70 (39%) guidelines included 95 statements about patient BVPs. Of the 95 statements, 32 statements (14 guidelines) were classified under BVP related to the choice of pharmacotherapy or general treatment, 10 (7 guidelines) under BVP related to adherence to pharmacotherapy or treatment in general, 5 (5 guidelines) under BVP related to financial costs and benefits, 43 (19 guidelines) under other BVP mentioned but not supported by a reference to a primary study or systematic review, and 5 (3 guidelines) under other BVP mentioned and supported by at least one reference to a primary study or systematic review. Twenty-nine references were cited to reflect the BVPs mentioned, including an editorial and quantitative studies. CONCLUSIONS Twenty-seven (39%) of the guidelines included mention of patients' BVPs. In 19 guidelines, the importance of BVPs was mentioned but these statements were not supported by references to a primary study or systematic review. BVPs were most often (14 guidelines) conceptualized as preference for one medication over another. We suggest that qualitative data be included as evidence of BVPs in guidelines.
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Affiliation(s)
- J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.
| | - A Marwah
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - F Naeem
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - W Yu
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - L Meadows
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
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