201
|
A join point regression analysis of trends in mortality due to osteoporosis in Spain. Sci Rep 2019; 9:4264. [PMID: 30862942 PMCID: PMC6414692 DOI: 10.1038/s41598-019-40806-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 02/20/2019] [Indexed: 02/07/2023] Open
Abstract
Osteoporosis is a major health problem in terms of fracture probability and disability. The aim of this ecological study is to identify the temporal trends in osteoporosis mortality in Spain from 1999 to 2015. Data on the Spanish population and number of deaths due to osteoporosis were obtained from the Spanish National Institute for Statistics. Age-adjusted mortality rates were estimated. Join point regression was used to identify the years when changes in mortality s and annual percentage change in mortality rates took place. Women presented a greater mortality rate decrease (p < 0.001), though this mortality difference by sex was reduced by half at the end of the period. The higher the age, the faster the mortality rate declined in women, while no clear pattern could be identified in men. In women, significant changes in trends were identified in three age groups (50-54, 60-64 and 80-84 years old). A sustained decrease in osteoporosis-associated mortality was found in women aged 75-79 and ≥85 years and men aged 60-64. In conclusion, mortality caused by osteoporosis in Spain is decreasing faster in the older age ranges especially in women.
Collapse
|
202
|
Revised FRAX®-based intervention thresholds for the management of osteoporosis among postmenopausal women in Sri Lanka. Arch Osteoporos 2019; 14:33. [PMID: 30850909 DOI: 10.1007/s11657-019-0585-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/01/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED This paper revised the fixed intervention thresholds (ITs) based on the Sri Lankan fracture risk assessment tool (FRAX) published in 2013 and introduced new ITs, hybrid and two-tier, aiming to help clinicians in the management of postmenopausal osteoporosis. The hybrid and two-tier ITs have a better discriminatory power than age-dependent and revised fixed ITs. INTRODUCTION This study revised the Sri Lankan FRAX®-based intervention thresholds (ITs) previously published in 2013. METHOD Age-dependent ITs were estimated, from 50-80 years with 5-year intervals, using a Sri Lankan FRAX® algorithm for a woman with a BMI of 24.8 kg/m2 and history of prior fragility fracture without other clinical risk factors. Data of 653 postmenopausal women were used in estimating fixed, hybrid, and two-tier ITs. ITs were determined using the ROC curve and partial Youden index. New ITs were validated using data of 356 postmenopausal women who underwent DXA and 62 women who had a recent fragility fracture. Women in the two groups (n = 653 and n = 356) came from the Southern Province and had undergone DXA in our state-owned tertiary care hospital as a part of their routine clinical assessment. RESULTS The mean (SD) age and BMI of the subjects (n = 653) were 62 (8) years and 24.8 (1.2) kg/m2, respectively. Age-dependent ITs of major osteoporotic fracture risk (MOFR) and hip fracture risk (HFR) ranged from 2.7 to 18% and from 0.4 to 7.1%. The best fixed ITs for women aged 50-80 years were 9% for MOFR and 3% for HFR. In the hybrid method, MOFR of 6% and HFR of 2% were found appropriate for women aged < 70 years. These were combined with age-dependent ITs for women aged 70 years and above. In the two-tier system, two sets of ITs were calculated (ITs of MOFR/HFR for women aged < 70 years and ≥ 70 years were 6%/2% and 12%/5%, respectively). When age-dependent ITs were considered the reference standard, sensitivities of the fixed, hybrid, and two-tier ITs were 0.63, 0.73, and 0.74, respectively. The specificities were 0.76, 0.86, and 0.80 in the same order. Sensitivities of the age-dependent, fixed, hybrid, and two-tier ITs in identifying a woman with an incident fracture were 26%, 48%, 61%, and 61%, respectively. CONCLUSIONS The new fixed MOFR is slightly lower than the previous value and hybrid and two-tier ITs perform better than age-dependent and fixed ITs.
Collapse
|
203
|
Banefelt J, Åkesson KE, Spångéus A, Ljunggren O, Karlsson L, Ström O, Ortsäter G, Libanati C, Toth E. Risk of imminent fracture following a previous fracture in a Swedish database study. Osteoporos Int 2019; 30:601-609. [PMID: 30680431 PMCID: PMC6422949 DOI: 10.1007/s00198-019-04852-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/10/2019] [Indexed: 01/03/2023]
Abstract
This study examined the imminent risk of a future fracture within 1 and 2 years following a first fracture in women aged 50 years and older and assessed independent factors associated with risk of subsequent fractures. The study highlights the need to intervene rapidly after a fracture to prevent further fractures. INTRODUCTION This study aims to determine the imminent risk of subsequent fractures within 1 and 2 years following a first fracture and to assess independent factors associated with subsequent fractures. METHODS Retrospective, observational cohort study of women aged ≥ 50 years with a fragility fracture was identified from Swedish national registers. Clinical/demographic characteristics at the time of index fracture and cumulative fracture incidences up to 12 and 24 months following index fracture were calculated. Risk factors for subsequent fracture were identified using multivariate regression analysis. RESULTS Two hundred forty-two thousand one hundred eight women (mean [SD] age 74 [12.5] years) were included. The cumulative subsequent fracture incidence at 12 months was 7.1% (95% confidence interval [CI], 6.9-7.2) and at 24 months was 12.0% (95% CI, 11.8-12.1). The rate of subsequent fractures was highest in the first month (~ 15 fractures per 1000 patient-years) and remained steady between 4 and 24 months (~ 5 fractures/1000 patient-years). Higher age was an independent risk factor for imminent subsequent fractures (at 24 months, sub-distribution hazard ratio [HR], 3.07; p < 0.001 for women 80-89 years [reference 50-59 years]). Index vertebral fracture was a strong independent risk factor for subsequent fracture (sub-distribution HR, 2.72 versus hip fracture; p < 0.001 over 12 months; HR, 2.23; p < 0.001 over 24 months). CONCLUSIONS Our findings highlight the need to intervene rapidly after any fragility fracture in postmenopausal women. The occurrence of a fragility fracture provides healthcare systems with a unique opportunity to intervene to reduce the increased risk of subsequent fractures.
Collapse
Affiliation(s)
| | - K E Åkesson
- Department of Clinical Sciences Malmö, Clinical and Molecular Osteoporosis Research, Lund University, Malmö, Sweden
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
| | - A Spångéus
- Linköping University, Linköping University Hospital, Linköping, Sweden
| | - O Ljunggren
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | | | - O Ström
- Quantify Research, Stockholm, Sweden
- Karolinska Institutet, Stockholm, Sweden
| | | | - C Libanati
- UCB Biopharma Sprl, Allée de la Recherche 60, 1070, Brussels, Belgium
| | - E Toth
- UCB Biopharma Sprl, Allée de la Recherche 60, 1070, Brussels, Belgium.
| |
Collapse
|
204
|
Higher Mortality in Men Compared with Women following Distal Radius Fracture in Population Aged 50 Years or Above: Are Common Distal Radius Fracture Classifications Useful in Predicting Mortality? BIOMED RESEARCH INTERNATIONAL 2019; 2019:5359204. [PMID: 30809543 PMCID: PMC6364117 DOI: 10.1155/2019/5359204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/06/2019] [Indexed: 12/11/2022]
Abstract
Introduction Distal radius fractures (DRF) are one of the most common fractures with growing incidence in developed countries and are a reliable predictor of another osteoporotic fracture. Data concerning DRF mortality are conflicting and vague. Usefulness of common DRF classification systems in predicting mortality is unexplored. Methods We identified all patients hospitalized between January 1st 2008 and May 30th 2015 with isolated distal radius fracture, aged 50 y/o or above, in a 1st level trauma center in Poland. Fractures were evaluated according to AO, Frykman, and Fernandez classifications. Mortality ratios and long-term survival analysis with Kaplan-Meier estimator and log-rank tests with univariate and multivariate Cox proportional hazards model were used. Results We enrolled 1308 consecutive patients. The average age of the entire cohort was 72.5 ± 12 years. The study group consisted of 256 men (19.6%) with mean age 66 ± 12 y/o and 1052 women (80.4%) with mean age 74 ± 12 y/o. Men were statistically younger at the time of the fracture than women (p<0.0001). After 1-year follow-up the overall study group mortality ratio was 4.5%, being 2.2-fold higher in men compared to women. In long-term survival analysis, excess men mortality remained significant. Factors associated with higher mortality at any point of the study were age (HR: 1.08, 95%CI: 1.07-1.10, p<0.000001), male sex (HR: 1.92, 95%CI: 1.34-2.77; p<0.001), AO type A (HR: 1.64 95%CI 1.19-2.25, p<0.01), and Frykman type I (HR: 2.12 95%CI: 1.36-3.29, p<0.001). Conclusion Distal radius fractures are connected with premature mortality. Men have higher mortality compared with women following distal radius fracture in population aged 50 years or above. Simple extra articular fractures classified as AO type A or Frykman type I may be predictors of higher mortality in DRF cohort.
Collapse
|
205
|
Kanis JA, Johansson H, Harvey NC, Lorentzon M, Liu E, Borgström F, McCloskey EV. Correspondence in response to OSIN-D-18-00831 quantifying imminent risk. Osteoporos Int 2019; 30:525-526. [PMID: 30617532 DOI: 10.1007/s00198-018-4796-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/03/2018] [Indexed: 11/26/2022]
Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, 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
| | - M Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - E Liu
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - F Borgström
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mellanby Centre for Bone Research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| |
Collapse
|
206
|
The Fracture Risk Assessment Tool (FRAX®) predicts fracture risk in patients with chronic kidney disease. Kidney Int 2019; 95:447-454. [DOI: 10.1016/j.kint.2018.09.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/13/2018] [Accepted: 09/20/2018] [Indexed: 11/22/2022]
|
207
|
Abstract
Fractures resulting from osteoporosis become increasingly common in women after age 55 years and men after age 65 years, resulting in substantial bone-associated morbidities, and increased mortality and health-care costs. Research advances have led to a more accurate assessment of fracture risk and have increased the range of therapeutic options available to prevent fractures. Fracture risk algorithms that combine clinical risk factors and bone mineral density are now widely used in clinical practice to target high-risk individuals for treatment. The discovery of key pathways regulating bone resorption and formation has identified new approaches to treatment with distinctive mechanisms of action. Osteoporosis is a chronic condition and long-term, sometimes lifelong, management is required. In individuals at high risk of fracture, the benefit versus risk profile is likely to be favourable for up to 10 years of treatment with bisphosphonates or denosumab. In people at a very high or imminent risk of fracture, therapy with teriparatide or abaloparatide should be considered; however, since treatment duration with these drugs is restricted to 18-24 months, treatment should be continued with an antiresorptive drug. Individuals at high risk of fractures do not receive adequate treatment and strategies to address this treatment gap-eg, widespread implementation of Fracture Liaison Services and improvement of adherence to therapy-are important challenges for the future.
Collapse
Affiliation(s)
| | - Michael R McClung
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA; Mary MacKillop Institute for Health, Australian Catholic University, Melbourne, VIC, Australia
| | - William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
208
|
Skolbekken JA. Online risk numbers – helpful, meaningless or simply wrong? Reflections on online risk calculators. Health (London) 2019; 23:401-417. [DOI: 10.1177/1363459319826183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
209
|
Cherian KE, Kapoor N, Paul TV. Utility of FRAX (fracture risk assessment tool) in primary care and family practice setting in India. J Family Med Prim Care 2019; 8:1824-1827. [PMID: 31334139 PMCID: PMC6618219 DOI: 10.4103/jfmpc.jfmpc_385_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The prevalence of osteoporosis in postmenopausal women is about 35 to 50% and the mortality associated with hip fractures is about 20%. Despite these figures, osteoporosis continues to be under diagnosed in the primary care setting. One of the reasons for this is attributed to the poor availability of DXA (Dual Energy X-ray Absorptiometry) scanners in rural areas. The fracture risk assessment tool (FRAX) is an online web-based tool that takes into account multiple factors that help in predicting the 10-year risk of developing hip or major osteoporotic fractures. The tool was developed and validated in independent cohorts. The advantages of using the FRAX tool are that, it is inexpensive, easily available, and does not need the technical expertise that is required in the use of a DXA scanner. Besides these merits, it is a tool that is easy to use for the rural health care worker as well as the family physician in identifying those subjects at risk for developing osteoporotic fractures. These benefits make it a suitable fracture prediction tool in the primary care setting in India.
Collapse
Affiliation(s)
- Kripa Elizabeth Cherian
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
210
|
Hiligsmann M, Reginster JY, Tosteson ANA, Bukata SV, Saag KG, Gold DT, Halbout P, Jiwa F, Lewiecki EM, Pinto D, Adachi JD, Al-Daghri N, Bruyère O, Chandran M, Cooper C, Harvey NC, Einhorn TA, Kanis JA, Kendler DL, Messina OD, Rizzoli R, Si L, Silverman S. Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts' consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the US branch of the International Osteoporosis Foundation. Osteoporos Int 2019; 30:45-57. [PMID: 30382319 PMCID: PMC6331734 DOI: 10.1007/s00198-018-4744-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023]
Abstract
Economic evaluations are increasingly used to assess the value of health interventions, but variable quality and heterogeneity limit the use of these evaluations by decision-makers. These recommendations provide guidance for the design, conduct, and reporting of economic evaluations in osteoporosis to improve their transparency, comparability, and methodologic standards. INTRODUCTION This paper aims to provide recommendations for the conduct of economic evaluations in osteoporosis in order to improve their transparency, comparability, and methodologic standards. METHODS A working group was convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis to make recommendations for the design, conduct, and reporting of economic evaluations in osteoporosis, to define an osteoporosis-specific reference case to serve a minimum standard for all economic analyses in osteoporosis, to discuss methodologic challenges and initiate a call for research. A literature review, a face-to-face meeting in New York City (including 11 experts), and a review/approval by a larger group of experts worldwide (including 23 experts in total) were conducted. RESULTS Recommendations on the type of economic evaluation, methods for economic evaluation, modeling aspects, base-case analysis and population, excess mortality, fracture costs and disutility, treatment characteristics, and model validation were provided. Recommendations for reporting economic evaluations in osteoporosis were also made and an osteoporosis-specific checklist was designed that includes items to report when performing an economic evaluation in osteoporosis. Further, 12 minimum criteria for economic evaluations in osteoporosis were identified and 12 methodologic challenges and need for further research were discussed. CONCLUSION While the working group acknowledges challenges and the need for further research, these recommendations are intended to supplement general and national guidelines for economic evaluations, improve transparency, quality, and comparability of economic evaluations in osteoporosis, and maintain methodologic standards to increase their use by decision-makers.
Collapse
Affiliation(s)
- M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - S V Bukata
- UCLA Orthopaedic Center, Santa Monica, CA, USA
| | - K G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - D T Gold
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - F Jiwa
- Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - D Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, USA
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - J D Adachi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - O Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- UKNIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - T A Einhorn
- New York University Langone Health, New York, USA
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - D L Kendler
- University of British Columbia, Vancouver, Canada
| | - O D Messina
- Cosme Argerich Hospital and IRO medical research centre, Buenos Aires, Argentina
| | - R Rizzoli
- Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - L Si
- The George Institute for Global Health, University of New South Wales, Kensington, NH, Australia
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - S Silverman
- Cedars-Sinai Medical Center, UCLA School of Medicine and the OMC Clinical Research Center, Los Angeles, CA, USA
| |
Collapse
|
211
|
Kanis JA, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019; 30:3-44. [PMID: 30324412 PMCID: PMC7026233 DOI: 10.1007/s00198-018-4704-5] [Citation(s) in RCA: 853] [Impact Index Per Article: 170.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis. 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 2013. This manuscript updates these in a European setting. METHODS Systematic reviews were updated. RESULTS The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use.
Collapse
Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
212
|
Affiliation(s)
- W D Leslie
- Department of Medicine, University of Manitoba, C5121 - 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| |
Collapse
|
213
|
Choi ST, Kwon SR, Jung JY, Kim HA, Kim SS, Kim SH, Kim JM, Park JH, Suh CH. Prevalence and Fracture Risk of Osteoporosis in Patients with Rheumatoid Arthritis: A Multicenter Comparative Study of the FRAX and WHO Criteria. J Clin Med 2018; 7:jcm7120507. [PMID: 30513848 PMCID: PMC6306752 DOI: 10.3390/jcm7120507] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 11/16/2022] Open
Abstract
(1) Background: We evaluated the prevalence and fracture risk of osteoporosis in patients with rheumatoid arthritis (RA), and compared the fracture risk assessment tool (FRAX) criteria and bone mineral density (BMD) criteria established by the World Health Organization (WHO). (2) Methods: This retrospective cross-sectional study, which included 479 RA patients in 5 hospitals, was conducted between January 2012 and December 2016. The FRAX criteria for high-risk osteoporotic fractures were calculated including and excluding the BMD values, respectively. The definition of high risk for fracture by FRAX criteria and BMD criteria by WHO was 10-year probability of ≥ 20% for major osteoporotic fracture or ≥ 3% for hip fracture, and T score ≤ −2.5 or Z score ≤ −2.0, respectively. (3) Results: The mean age was 61.7 ± 11.9 years. The study included 426 female patients (88.9%), 353 (82.9%) of whom were postmenopausal. Osteoporotic fractures were detected in 81 (16.9%) patients. The numbers of candidates for pharmacological intervention using the FRAX criteria with and without BMD and the WHO criteria were 226 (47.2%), 292 (61%), and 160 (33.4%), respectively. Only 69.2%–77% of the patients in the high-risk group using the FRAX criteria were receiving osteoporosis treatments. The following were significant using the WHO criteria: female (OR 3.55, 95% CI 1.46–8.63), age (OR 1.1, 95% CI 1.08–1.13), and BMI (OR 0.8, 95% CI 0.75–0.87). Glucocorticoid dose (OR 1.09, 95% CI 1.01–1.17), age (OR 1.09, 95% CI 1.06–1.12), and disease duration (OR 1.01, 95% CI 1–1.01) were independent risk factors for fracture. (4) Conclusions: The proportion of RA patients with a high risk of osteoporotic fractures was 33.4%–61%. Only 69.2%–77% of candidate patients were receiving osteoporotic treatments while applying FRAX criteria. Independent risk factors for osteoporotic fractures in RA patients were age, the dose of glucocorticoid, and disease duration.
Collapse
Affiliation(s)
- Sang Tae Choi
- Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul 06973, Korea.
| | - Seong-Ryul Kwon
- Division of Rheumatology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea.
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon 16499, Korea.
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon 16499, Korea.
| | - Sung-Soo Kim
- Division of Rheumatology, Department of Internal Medicine, Ulsan University College of Medicine, Gangneung Asan Hospital, Gangneung 25440, Korea.
| | - Sang Hyon Kim
- Division of Rheumatology, Department of Internal Medicine, Keimyung University College of Medicine, Daegu 41931, Korea.
| | - Ji-Min Kim
- Division of Rheumatology, Department of Internal Medicine, Keimyung University College of Medicine, Daegu 41931, Korea.
| | - Ji-Ho Park
- Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul 06973, Korea.
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon 16499, Korea.
| |
Collapse
|
214
|
Nakada T, Teranishi M, Ueda Y, Sone M. Fracture probability assessed using FRAX® in elderly women with benign paroxysmal positional vertigo. Auris Nasus Larynx 2018; 45:1173-1177. [DOI: 10.1016/j.anl.2018.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 01/01/2023]
|
215
|
Harvey NC, Odén A, Orwoll E, Lapidus J, Kwok T, Karlsson MK, Rosengren BE, Ribom E, Cooper C, Cawthon PM, Kanis JA, Ohlsson C, Mellström D, Johansson H, McCloskey E. Measures of Physical Performance and Muscle Strength as Predictors of Fracture Risk Independent of FRAX, Falls, and aBMD: A Meta-Analysis of the Osteoporotic Fractures in Men (MrOS) Study. J Bone Miner Res 2018; 33:2150-2157. [PMID: 30011086 PMCID: PMC6272117 DOI: 10.1002/jbmr.3556] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/23/2018] [Accepted: 07/07/2018] [Indexed: 11/17/2022]
Abstract
Measures of muscle mass, strength, and function predict risk of incident fractures, but it is not known whether this risk information is additive to that from FRAX (fracture risk assessment tool) probability. In the Osteoporotic Fractures in Men (MrOS) Study cohorts (Sweden, Hong Kong, United States), we investigated whether measures of physical performance/appendicular lean mass (ALM) by DXA predicted incident fractures in older men, independently of FRAX probability. Baseline information included falls history, clinical risk factors for falls and fractures, femoral neck aBMD, and calculated FRAX probabilities. An extension of Poisson regression was used to investigate the relationship between time for five chair stands, walking speed over a 6 m distance, grip strength, ALM adjusted for body size (ALM/height2 ), FRAX probability (major osteoporotic fracture [MOF]) with or without femoral neck aBMD, available in a subset of n = 7531), and incident MOF (hip, clinical vertebral, wrist, or proximal humerus). Associations were adjusted for age and time since baseline, and are reported as hazard ratios (HRs) for first incident fracture per SD increment in predictor using meta-analysis. 5660 men in the United States (mean age 73.5 years), 2764 men in Sweden (75.4 years), and 1987 men in Hong Kong (72.4 years) were studied. Mean follow-up time was 8.7 to 10.9 years. Greater time for five chair stands was associated with greater risk of MOF (HR 1.26; 95% CI, 1.19 to 1.34), whereas greater walking speed (HR 0.85; 95% CI, 0.79 to 0.90), grip strength (HR 0.77; 95% CI, 0.72 to 0.82), and ALM/height2 (HR 0.85; 95% CI, 0.80 to 0.90) were associated with lower risk of incident MOF. Associations remained largely similar after adjustment for FRAX, but associations between ALM/height2 and MOF were weakened (HR 0.92; 95% CI, 0.85 to 0.99). Inclusion of femoral neck aBMD markedly attenuated the association between ALM/height2 and MOF (HR 1.02; 95% CI, 0.96 to 1.10). Measures of physical performance predicted incident fractures independently of FRAX probability. Whilst the predictive value of ALM/height2 was substantially reduced by inclusion of aBMD requires further study, these findings support the consideration of physical performance in fracture risk assessment. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.
Collapse
Affiliation(s)
- Nicholas C Harvey
- Medical Research Council (MRC) Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University of Southamptonand University Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Anders Odén
- Centre for Bone and Arthritis Research (CBAR)Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
| | - Eric Orwoll
- Oregon Health & Science UniversityPortlandORUSA
| | - Jodi Lapidus
- Department of Public Health and Preventive MedicineDivision of BiostatisticsOregon Health and Science UniversityPortlandORUSA
| | - Timothy Kwok
- Department of Medicine & Therapeutics and School of Public HealthThe Chinese University of Hong KongHong KongThe People's Republic of China
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research UnitLund University, Lund, Sweden; and Department of OrthopedicsSkane University HospitalMalmöSweden
| | - Björn E Rosengren
- Clinical and Molecular Osteoporosis Research UnitLund University, Lund, Sweden; and Department of OrthopedicsSkane University HospitalMalmöSweden
| | - Eva Ribom
- Department of Surgical SciencesUniversity of UppsalaUppsalaSweden
| | - Cyrus Cooper
- Medical Research Council (MRC) Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University of Southamptonand University Hospital Southampton NHS Foundation TrustSouthamptonUK
- National Institute for Health Research (NIHR) Biomedical Research CentreUniversity of OxfordOxfordUK
| | - Peggy M Cawthon
- Research InstituteCalifornia Pacific Medical CenterSan FranciscoCAUSA
- Department of Epidemiology and BiostatisticsUniversity of California–San FranciscoSan FranciscoCAUSA
| | - John A Kanis
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
- Institute for Health and AgingCatholic University of AustraliaMelbourneAustralia
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research (CBAR)Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Dan Mellström
- Centre for Bone and Arthritis Research (CBAR)Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Helena Johansson
- Centre for Bone and Arthritis Research (CBAR)Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
- Institute for Health and AgingCatholic University of AustraliaMelbourneAustralia
| | - Eugene McCloskey
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
- Centre for Integrated Research in Musculoskeletal Ageing (CIMA)Mellanby Centre for Bone ResearchUniversity of SheffieldSheffieldUK
| |
Collapse
|
216
|
|
217
|
Weidlinger S, Stute P. Management der prämaturen Ovarialinsuffizienz. GYNAKOLOGISCHE ENDOKRINOLOGIE 2018. [DOI: 10.1007/s10304-018-0201-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
218
|
Rubin KH, Möller S, Holmberg T, Bliddal M, Søndergaard J, Abrahamsen B. A New Fracture Risk Assessment Tool (FREM) Based on Public Health Registries. J Bone Miner Res 2018; 33:1967-1979. [PMID: 29924428 DOI: 10.1002/jbmr.3528] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/25/2018] [Accepted: 06/06/2018] [Indexed: 12/25/2022]
Abstract
Some conditions are already known to be associated with an increased risk of osteoporotic fractures. Other conditions may also be significant indicators of increased risk. The aim of the current study was to identify conditions for inclusion in a fracture prediction model (fracture risk evaluation model [FREM]) for automated case finding of high-risk individuals of hip or major osteoporotic fractures (MOFs). We included the total population of Denmark aged 45+ years (N = 2,495,339). All hospital diagnoses from 1998 to 2012 were used as possible conditions; the primary outcome was MOFs during 2013. Our cohort was split randomly 50/50 into a development and a validation dataset for deriving and validating the predictive model. We applied backward selection on ICD-10 codes (International Classification of Diseases and Related Health Problems, 10th Revision) by logistic regression to develop an age-adjusted and sex-stratified model. The FREM for MOFs included 38 and 43 risk factors for women and men, respectively. Testing FREM for MOFs in the validation cohort showed good accuracy; it produced receiver-operating characteristic (ROC) curves with an area under the ROC curve (AUC) of 0.750 (95% CI, 0.741 to 0.795) and 0.752 (95% CI, 0.743 to 0.761) for women and men, respectively. The FREM for hip fractures included 32 risk factors for both genders and showed an even higher accuracy in the validation cohort as AUCs of 0.874 (95% CI, 0.869 to 0.879) and 0.851 (95% CI, 0.841 to 0.861) for women and men were found, respectively. We have developed and tested a prediction model (FREM) for identifying men and women at high risk of MOFs or hip fractures by using solely existing administrative data. The FREM could be employed either at the point of care integrated into electronic patient record systems to alert physicians or deployed centrally in a national case-finding strategy where patients at high fracture risk could be invited to a focused DXA program. © 2018 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Katrine Hass Rubin
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Sören Möller
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Teresa Holmberg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Mette Bliddal
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Jens Søndergaard
- The Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Bo Abrahamsen
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark.,Department of Medicine, Holbaek Hospital, Holbaek, Denmark
| |
Collapse
|
219
|
Leslie WD, Johansson H, McCloskey EV, Harvey NC, Kanis JA, Hans D. Comparison of Methods for Improving Fracture Risk Assessment in Diabetes: The Manitoba BMD Registry. J Bone Miner Res 2018; 33:1923-1930. [PMID: 29953670 PMCID: PMC6193547 DOI: 10.1002/jbmr.3538] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 06/02/2018] [Accepted: 06/22/2018] [Indexed: 01/09/2023]
Abstract
Type 2 diabetes is a risk factor for fracture independent of FRAX (fracture risk assessment) probability. We directly compared four proposed methods to improve the performance of FRAX for type 2 diabetes by: (1) including the rheumatoid arthritis (RA) input to FRAX; (2) making a trabecular bone score (TBS) adjustment to FRAX; (3) reducing the femoral neck T-score input to FRAX by 0.5 SD; and (4) increasing the age input to FRAX by 10 years. We examined major osteoporotic fractures (MOFs) and hip fractures (HFs) over a mean of 8.3 years observation among 44,543 women and men 40 years of age or older (4136 with diabetes) with baseline lumbar spine and hip DXA from 1999 through 2016. Controlled for unadjusted FRAX probability, diabetes was associated with an increased risk for MOFs and HFs. All four FRAX adjustments attenuated the effect of diabetes, but a residual effect of diabetes was seen on MOF risk after TBS adjustment, and on HF risk after the RA and TBS adjustments. Among those with diabetes, unadjusted FRAX risk underestimated MOF (observed/predicted ratio 1.15; 95% CI, 1.03 to 1.28), but this was no longer significant after applying the diabetes adjustments. HF risk was more severely underestimated (observed/predicted ratio 1.85; 95% CI, 1.51 to 2.20) and was only partially corrected with the diabetes adjustments (still significant for the RA and TBS adjustments). Among those with diabetes, there was moderate reclassification based upon a fixed MOF cut-off of 20% (4.1% to 7.1%) or fixed HF cut-off of 3% (5.7% to 16.5%). Net reclassification improvement increased for MOF with each of the diabetes adjustments (range 3.9% to 5.6% in the diabetes subgroup). In conclusion, each of the proposed methods for addressing limitations in the ability of FRAX to assess fracture risk in individuals with diabetes was found to improve performance, though no single method was optimal in all settings. © 2018 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helena Johansson
- Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia.,Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, 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
| | - John A Kanis
- Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia.,Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Didier Hans
- Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
220
|
Abstract
This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008. INTRODUCTION Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments. METHODS The method used in this paper is literature review. RESULTS FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population. CONCLUSION FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.
Collapse
Affiliation(s)
- John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Research Institute, Australian Catholic University, Melbourne, Australia.
| | - Helena Johansson
- Mary McKillop Research Institute, Australian Catholic University, 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
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Mellanby Centre for Bone Research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| |
Collapse
|
221
|
Sale JEM, Gray M, Mancuso D, Inrig T, Boire G, Beaulieu MC, Funnell L, Bogoch E. Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines. Rheumatol Int 2018; 38:2193-2208. [PMID: 30367203 DOI: 10.1007/s00296-018-4181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/19/2018] [Indexed: 11/25/2022]
Abstract
We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.
Collapse
Affiliation(s)
- Joanna E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, 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.
| | - Matthew Gray
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Daniel Mancuso
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Gilles Boire
- Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Room 3853, Sherbrooke, QC, J1H 5N4, Canada
| | - Marie-Claude Beaulieu
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12e Avenue North, Sherbrooke, QC, J1H 5N4, Canada
| | - Larry Funnell
- Osteoporosis Canada, 1200 Eglinton Avenue East, Suite 500, Toronto, ON, M3C 1H9, Canada
| | - Earl Bogoch
- Department of Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| |
Collapse
|
222
|
Lenchik L, Weaver AA, Ward RJ, Boone JM, Boutin RD. Opportunistic Screening for Osteoporosis Using Computed Tomography: State of the Art and Argument for Paradigm Shift. Curr Rheumatol Rep 2018; 20:74. [PMID: 30317448 DOI: 10.1007/s11926-018-0784-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Osteoporosis is disproportionately common in rheumatology patients. For the past three decades, the diagnosis of osteoporosis has benefited from well-established practice guidelines that emphasized the use of dual x-ray absorptiometry (DXA). Despite these guidelines and the wide availability of DXA, approximately two thirds of eligible patients do not undergo testing. One strategy to improve osteoporosis testing is to employ computed tomography (CT) examinations obtained as part of routine patient care to "opportunistically" screen for osteoporosis, without additional cost or radiation exposure to patients. This review examines the role of opportunistic CT in the evaluation of osteoporosis. RECENT FINDINGS Recent evidence suggests that opportunistic measurement of bone attenuation (radiodensity) using CT has sensitivity comparable to DXA. More importantly, such an approach has been shown to predict osteoporotic fractures. The paradigm shift of using CTs obtained for other reasons to opportunistically screen for osteoporosis promises to substantially improve patient care.
Collapse
Affiliation(s)
- Leon Lenchik
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Ashley A Weaver
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Robert J Ward
- Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - John M Boone
- University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA
| | - Robert D Boutin
- University of California Davis School of Medicine, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA
| |
Collapse
|
223
|
Su Y, Woo JW, Kwok TCY. The Added Value of SARC-F to Prescreening Using FRAX for Hip Fracture Prevention in Older Community Adults. J Am Med Dir Assoc 2018; 20:83-89. [PMID: 30314676 DOI: 10.1016/j.jamda.2018.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/15/2018] [Accepted: 08/15/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To examine the potential added value of a simple 5-item questionnaire for sarcopenia screening (SARC-F) to the Fracture Risk Assessment Tool (FRAX) for hip fracture risk prediction, in order to identify at-risk older adults for screening with dual-energy x-ray absorptiometry (DXA). DESIGN A prospective cohort study. SETTING AND PARTICIPANTS Two thousand Chinese men and 2000 Chinese women aged 65 years or older were recruited from local communities and were prospectively followed up for about 10 years. MEASURES Areal bone mineral density (BMD) of hip and lumbar spine were measured by DXA at baseline. Ten-year FRAX probability of hip fracture was calculated using the baseline risk factors. Information from the baseline questionnaire was extracted to calculate a modified SARC-F score. The independent predictive values of SARC-F and FRAX questionnaire were evaluated using multivariate survival analysis. The added predictive values of SARC-F to FRAX for pre-DXA screening were examined. RESULTS During the follow-up, 63 (3.2%) men and 69 (3.5%) women had at least 1 incident hip fracture. SARC-F had an independent value of FRAX for hip fracture risk prediction, with an adjusted hazard ratio [95% confidence interval (CI)] of 1.24 (1.02, 1.52) and 1.15 (0.99, 1.13) in men and women, respectively. Compared with using FRAX, using SARC-F in conjunction with FRAX made the sensitivity for prediction rise from 58.7% to 76.2% in men and from 69.6% to 78.3% in women, with a nondecreased area under receiver operating characteristic curve of 0.67. Prescreening using FRAX in conjunction with SARC-F could save more than half of the DXA assessment than with no prescreening. CONCLUSIONS/IMPLICATIONS SARC-F is associated with a modest increase in hip fracture risk, especially in men. Conjoint evaluation for sarcopenia in addition to FRAX screening may help identify older adults at higher risk of hip fracture for more intensive screening and/or preventive interventions.
Collapse
Affiliation(s)
- Yi Su
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jean W Woo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China; Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Timothy C Y Kwok
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China; Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
| |
Collapse
|
224
|
FRAX Calculated without BMD Resulting in a Higher Fracture Risk Than That Calculated with BMD in Women with Early Breast Cancer. J Osteoporos 2018; 2018:4636028. [PMID: 30631415 PMCID: PMC6304589 DOI: 10.1155/2018/4636028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/20/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study was to investigate the importance of including the measurement of bone mineral density (BMD) in reliable fracture risk assessment for women diagnosed with early nonmetastatic breast cancer (EBC) before AI treatment if zoledronic acid is not an option. MATERIAL AND METHODS One hundred and sixteen women with EBC were included in the study before initiating AI treatment. Most participants were osteopenic. The 10-year probability of hip fracture and major osteoporotic fracture was calculated with and without BMD based on clinical information collected at baseline using the fracture risk assessment (FRAX) tool. To compare data, the nonparametric tests were used. RESULTS There was a significant difference (p<0.001) in the number of high-risk and low-risk FRAX score of hip fracture between before and after including BMD values. The high-risk category decreased by 50.9%, while the low-risk category increased by 42.9%. In FRAX score of major osteoporotic the findings were similar (p<0.001): The high-risk and moderate-risk category decreased by 70.4% and 4.9%, respectively, while the low-risk category increased by 43.8% when including BMD value. When stratified by age, patients aged 65 years or older were at a significantly (p<0.001) higher risk of suffering a hip or major osteoporotic fracture, highlighting the importance of including BMD measurements in this age group. CONCLUSIONS Our data support that DXA scanning of women with EBC should be performed to avoid overestimation of osteoporosis before AI treatment. It is particularly important in patients older than 65 years of age and when zoledronic acid is not an option.
Collapse
|
225
|
Hamoda H. The British Menopause Society and Women's Health Concern recommendations on the management of women with premature ovarian insufficiency. Post Reprod Health 2018; 23:22-35. [PMID: 28381102 DOI: 10.1177/2053369117699358] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
226
|
Kužma M, Hans D, Koller T, Némethová E, Jackuliak P, Killinger Z, Resch H, Payer J. Less strict intervention thresholds for the FRAX and TBS-adjusted FRAX predict clinical fractures in osteopenic postmenopausal women with no prior fractures. J Bone Miner Metab 2018; 36:580-588. [PMID: 28884422 DOI: 10.1007/s00774-017-0864-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/03/2017] [Indexed: 01/03/2023]
Abstract
Little is known about the clinical relevance of treating post-menopausal women with no prior history of fragility fracture and bone mineral densities (BMD) within the osteopenic range. In recent years, in addition to BMD and FRAX fracture probability assessments, a surrogate measure of bone micro-architecture quality, called the trabecular bone score (TBS), has been proven to predict future fragility fractures independently of both BMD and the FRAX. In this retrospective analysis of a follow-up study, we compared three risk assessment instruments-the FRAX, the TBS, and a TBS-adjusted FRAX score-in their ability, to predict future fragility fractures over a minimum of five years of follow-up among post-menopausal osteopenic women with no prior fragility fractures. We also sought to determine if more- versus less-stringent criteria were better when stratifying patients into higher-risk patients warranting osteoporosis-targeted intervention versus lower-risk patients in whom intervention would usually be deemed unnecessary. Over a mean 5.2 years follow-up, 18 clinical fragility fractures were documented among 127 women in the age 50 years and older (mean age = 66.1). On multivariate analysis utilizing regression models and Kaplan-Meier curve analysis, less-stringent criteria for the FRAX and TBS-adjusted FRAX were capable of predicting future fractures (with sensitivity/specificity of 83/31; 39/77 and 78/50% for TBS, FRAX and TBS-adjusted FRAX, respectively), while more-stringent criteria were incapable of doing so (with sensitivity/specificity of 56/60; 39/77 and 39/74 for TBS, FRAX and TBS-adjusted FRAX, respectively). Neither TBS threshold alone was a significant predictor of future fracture in our study. However, hazard ratio analysis revealed slight superiority of the TBS-adjusted FRAX over the FRAX alone (HR = 3.09 vs. 2.79). Adjusting the FRAX tool by incorporating the TBS may be useful to optimize the detection of post-menopausal osteopenic women with no prior fractures who warrant osteoporosis-targeted therapy.
Collapse
Affiliation(s)
- Martin Kužma
- Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia.
| | - Didier Hans
- Center of Bone Diseases, Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Tomáš Koller
- Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Eva Némethová
- Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Peter Jackuliak
- Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Zdenko Killinger
- Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Heinrich Resch
- St. Vincent Hospital Vienna, Academic Teaching Hospital of the Medical University of Vienna, Vienna, Austria
| | - Juraj Payer
- Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| |
Collapse
|
227
|
Leslie WD, Seeman E, Morin SN, Lix LM, Majumdar SR. The diagnostic threshold for osteoporosis impedes fracture prevention in women at high risk for fracture: A registry-based cohort study. Bone 2018; 114:298-303. [PMID: 30008396 DOI: 10.1016/j.bone.2018.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/28/2022]
Abstract
The diagnostic threshold for osteoporosis, a bone mineral density (BMD) T-score ≤ -2.5, signals an increased risk for fracture. However, most fragility fractures arise among the majority of women with 'osteopenia' or 'normal' BMD. We hypothesized that a BMD T-score of -2.5, even if not intended as a treatment threshold, paradoxically may create disincentive to initiating treatment of women with osteopenia or normal BMD at high risk for fracture. From a population-based BMD registry covering the Province of Manitoba, Canada, we identified 3735 untreated women aged ≥ 50 years undergoing BMD screening in 2006-2015 found to qualify for Osteoporosis Canada guidelines-based treatment. The main outcome was prescription of an approved osteoporosis medications in the year after BMD testing ascertained from a population-based pharmacy database. We estimated adjusted odds ratios (OR, 95% confidence interval [CI]) for treatment initiation based on BMD, major fracture history (non-traumatic vertebral, hip or multiple fractures), age, and calendar year (to examine the impact of treatment guidelines published in 2010). Among these women, 50% (1853) initiated treatment: 71% with osteoporosis, 21% with osteopenia, and 5% with normal BMD with similar values in those with a prior major fracture (71%, 19%, 5%, respectively). Compared to women with osteoporosis, adjusted ORs for treatment of high risk women with osteopenia or normal BMD alone were 0.10 (95% CI 0.09-0.12) and 0.02 (95% CI 0.01-0.04), respectively, and no higher in women with a prior major fracture (OR 1.00, 95% CI 0.84-1.19) or following introduction of treatment guidelines (p = 0.294). In summary, we found evidence that the diagnostic threshold for osteoporosis may serve as a disincentive to initiation of treatment in many women at high risk for incident fracture.
Collapse
Affiliation(s)
- William D Leslie
- Dept. of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Ego Seeman
- Dept. of Endocrinology and Medicine, Austin Health, University of Melbourne, Australia; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
| | | | - Lisa M Lix
- Dept. of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Sumit R Majumdar
- Department of Internal Medicine, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
228
|
Hoff M, Skurtveit S, Meyer HE, Langhammer A, Søgaard AJ, Syversen U, Skovlund E, Abrahamsen B, Forsmo S, Schei B. Anti-osteoporosis drug use: too little, too much, or just right? The HUNT study, Norway. Osteoporos Int 2018; 29:1875-1885. [PMID: 29774403 DOI: 10.1007/s00198-018-4560-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 05/01/2018] [Indexed: 10/16/2022]
Abstract
UNLABELLED Use of anti-osteoporotic drugs (AODs) was examined in a Norwegian population 50-85 years. Among them with Fracture Risk Assessment Tool (FRAX) score for major osteoporotic fracture ≥ 20, 25% of the women and 17% of the men received AODs. The strongest predictors for AODs were high age in women and use of glucocorticoids among men. INTRODUCTION To examine the use of anti-osteoporotic drugs (AODs) and to identify predictors for prescriptions. METHODS Data were obtained from the Nord-Trøndelag Health Study (HUNT3) performed in 2006-2008 and the Norwegian Prescription Database, including 15,075 women and 13,386 men aged 50-85 years. Bone mineral density (BMD) in the femoral neck was measured in a subgroup of 4538 women and 2322 men. High fracture risk was defined as a FRAX score for major osteoporotic fracture (MOF) ≥ 20%; in the subgroup with BMD, high risk was in addition defined as FRAXMOF ≥ 20% or T-score ≤ - 2.5. Hazard ratios (HRs) for predictors of incident use of AODs within 2 years after HUNT3 were estimated by Cox' proportional hazards model. RESULTS Among individuals with FRAX MOF ≥ 20%, 25% of the women and 17% of the men were treated with AODs. Among those with FRAX MOF < 20%, 3% and 1% were treated, respectively. In the subgroup with BMD measurement, 24% of the women and 16% of the men at high risk of fractures were treated, compared to 3 and 1% in women and men not fulfilling the criteria. In women, high age was the strongest predictor for treatment (HR 3.84: 95% confidence interval 2.81-5.24), followed by use of glucocorticoids (GCs) (2.68:1.84-3.89). In men, predictors were use of GCs (5.28: 2.70-10.35) followed by multimorbidity (3.16:1.31-7.63). In the subgroup with BMD, T-score ≤ - 2.5 was the strongest predictor (women 3.98:2.67-5.89; men 13.31:6.17-28.74). CONCLUSIONS This study suggests an undertreatment of AODs in individuals at high risk of fracture.
Collapse
Affiliation(s)
- M Hoff
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway.
| | - S Skurtveit
- Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - H E Meyer
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - A Langhammer
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - A J Søgaard
- Norwegian Institute of Public Health, Oslo, Norway
| | - U Syversen
- Department of Endocrinology, St. Olavs Hospital, Trondheim, Norway
- Institute of Cancer Research and Molecular Medicine, NTNU, Trondheim, Norway
| | - E Skovlund
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - B Abrahamsen
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
- Odense Patient Data Explorative Network, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - S Forsmo
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - B Schei
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Gynecology, St. Olavs Hospital, Trondheim, Norway
| |
Collapse
|
229
|
Harvey NC, McCloskey E, Kanis JA, Compston J, Cooper C. Cost-effective but clinically inappropriate: new NICE intervention thresholds in osteoporosis (Technology Appraisal 464). Osteoporos Int 2018; 29:1511-1513. [PMID: 29947864 PMCID: PMC6037288 DOI: 10.1007/s00198-018-4505-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/19/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To comment on the latest technology appraisal of the National Institute for Clinical Excellence (NICE) in osteoporosis. METHODS Review of NICE Technology Appraisal (TA464) on bisphosphonate use in osteoporosis. RESULTS The NICE appraisal on bisphosphonate use in osteoporosis indicates that treatment with oral bisphosphonates may be instituted at a FRAX 10-year probability of major osteoporotic fracture above 1%. Implementation would mean that all women aged 50 years or older are deemed eligible for treatment, a position that would increase the burden of rare long-term side effects across the population. CONCLUSION Cost-effectiveness thresholds for low-cost interventions should not be used to set intervention thresholds but rather to validate the implementation of clinically driven intervention thresholds.
Collapse
Affiliation(s)
- 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
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - 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
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
- Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia.
| | - J Compston
- Cambridge Biomedical Campus, Cambridge, UK
| | - C 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, Tremona Road, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| |
Collapse
|
230
|
Kanis JA, Cooper C, Rizzoli R, Reginster JY. Review of the guideline of the American College of Physicians on the treatment of osteoporosis. Osteoporos Int 2018; 29:1505-1510. [PMID: 29869039 PMCID: PMC6037298 DOI: 10.1007/s00198-018-4504-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/11/2018] [Indexed: 10/14/2022]
Abstract
This review, endorsed by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, summarizes several failings of the recent guidelines of the American College of Physicians (ACP) on the treatment of low bone density or osteoporosis to prevent fractures. INTRODUCTION The ACP recently issued guidelines for the treatment of low bone density or osteoporosis to prevent fractures. METHODS Literature review and critical review of the ACP guidelines. RESULTS The guideline is lacking in scope due to the endorsement of treatment based on T-scores rather than fracture risk assessment and in failure to adequately consider anabolic therapies. CONCLUSIONS The ACP guideline appears outdated.
Collapse
Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - 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, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| |
Collapse
|
231
|
McCloskey E, Johansson H, Harvey NC, Shepstone L, Lenaghan E, Fordham R, Harvey I, Howe A, Cooper C, Clarke S, Gittoes N, Heawood A, Holland R, Marshall T, O'Neill TW, Peters TJ, Redmond N, Torgerson D, Kanis JA. Management of Patients With High Baseline Hip Fracture Risk by FRAX Reduces Hip Fractures-A Post Hoc Analysis of the SCOOP Study. J Bone Miner Res 2018; 33:1020-1026. [PMID: 29480960 PMCID: PMC6004119 DOI: 10.1002/jbmr.3411] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 11/11/2022]
Abstract
The Screening for Osteoporosis in Older Women for the Prevention of Fracture (SCOOP) study was a community-based screening intervention in women aged 70 to 85 years in the United Kingdom. In the screening arm, licensed osteoporosis treatments were recommended in women identified to be at high risk of hip fracture using the FRAX risk assessment tool (including bone mineral density measurement). In the control arm, standard care was provided. Screening led to a 28% reduction in hip fractures over 5 years. In this planned post hoc analysis, we wished to examine for interactions between screening effectiveness on fracture outcome (any, osteoporotic, and hip fractures) on the one hand and baseline FRAX 10-year probability of hip fracture on the other. All analyses were conducted on an intention-to-treat basis, based on the group to which women were randomized, irrespective of whether screening was completed. Of 12,483 eligible participants, 6233 women were randomized to screening, with treatment recommended in 898 (14.4%). No evidence of an effect or interaction was observed for the outcomes of any fracture or osteoporotic fracture. In the screening arm, 54 fewer hip fractures were observed than in the control arm (164 versus 218, 2.6% versus 3.5%), and commensurate with treatment being targeted to those at highest hip fracture risk, the effect on hip fracture increased with baseline FRAX hip fracture probability (p = 0.021 for interaction); for example, at the 10th percentile of baseline FRAX hip probability (2.6%), there was no evidence that hip fractures were reduced (hazard ratio [HR] = 0.93; 95% confidence interval [CI] 0.71 to 1.23), but at the 90th percentile (16.6%), there was a 33% reduction (HR = 0.67; 95% CI 0.53 to 0.84). Prior fracture and parental history of hip fracture positively influenced screening effectiveness on hip fracture risk. We conclude that women at high risk of hip fracture based on FRAX probability are responsive to appropriate osteoporosis management. © 2018 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Eugene McCloskey
- Mellanby Centre for Bone ResearchCentre for Integrated Research in Musculoskeletal AgeingUniversity of Sheffieldand Sheffield Teaching Hospitals Foundation TrustSheffieldUK
| | | | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit and NIHR Southampton Nutrition Biomedical Research CentreUniversity of Southamptonand University Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Lee Shepstone
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | | | - Ric Fordham
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Ian Harvey
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Amanda Howe
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit and NIHR Southampton Nutrition Biomedical Research CentreUniversity of Southamptonand University Hospital Southampton NHS Foundation TrustSouthamptonUK
- NIHR Musculoskeletal Biomedical Research UnitUniversity of OxfordOxfordUK
| | - Shane Clarke
- Department of RheumatologyUniversity Hospitals BristolBristolUK
| | - Neil Gittoes
- Centre for EndocrinologyDiabetes, and MetabolismQueen Elizabeth HospitalBirminghamUK
| | | | - Richard Holland
- Leicester Medical SchoolCentre for MedicineUniversity of LeicesterLeicesterUK
| | | | - Terence W O'Neill
- Arthritis Research UK Centre for EpidemiologyManchester Academic Health Science CentreThe University of Manchesterand NIHR Manchester Biomedical Research CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
| | - Tim J Peters
- Bristol Medical SchoolUniversity of BristolBristolUK
| | - Niamh Redmond
- Bristol Medical SchoolUniversity of BristolBristolUK
| | | | - John A Kanis
- Centre for Metabolic Bone DiseasesUniversity of Sheffield, Sheffield, UKand Australian Catholic UniversityMelbourneAustralia
| | | |
Collapse
|
232
|
Ramanau H, Chernyanin I, Rudenka E, Lesnyak O, Zakroyeva A, Bilezikian JP, Johansson H, Harvey NC, McCloskey EV, Kanis JA. Epidemiology of hip fracture in Belarus: development of a country-specific FRAX model and its comparison to neighboring country models. Arch Osteoporos 2018; 13:42. [PMID: 29666948 PMCID: PMC5904235 DOI: 10.1007/s11657-018-0454-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/25/2018] [Indexed: 02/03/2023]
Abstract
Fracture probabilities resulting from the newly generated FRAX model for Belarus based on regional estimates of the hip fracture incidence were compared with FRAX models of neighboring countries. Differences between the country-specific FRAX patterns and the rank orders of fracture probabilities were modest. OBJECTIVE This paper describes the epidemiology of hip fractures in Belarus that was used to develop the country-specific fracture prediction FRAX® tool and illustrates its features compared to models for the neighboring countries of Poland, Russia, and Lithuania. METHODS We carried out a population-based study in a region of Belarus (the city of Mozyr) representing approximately 1.2% of the country's population. We aimed to identify all hip fractures in 2011-2012 from hospital registers and primary care sources. Age- and sex-specific incidence and national mortality rates were incorporated into a FRAX model for Belarus. Fracture probabilities were compared with those derived from FRAX models in neighboring countries. RESULTS The estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 8250 in 2015 and is predicted to increase to 12,918 in 2050. The annual incidence of fragility hip fractures in individuals aged 50 years or more was 24.6/10,000 for women and 14.6/10,000 for men, standardized to the world population. The comparison with FRAX models in neighboring countries showed that hip fracture probabilities in men and women in Belarus were similar to those in Poland, Russia, and Lithuania. The difference in incidence rates between the surveys including or excluding data from primary care suggested that 29.1% of patients sustaining a hip fracture were not hospitalized and, therefore, did not receive specialized medical care. CONCLUSION A substantial proportion of hip fractures in Belarus does not come to hospital attention. The FRAX model should enhance accuracy of determining fracture probability among the Belarus population and help guide decisions about treatment.
Collapse
Affiliation(s)
- H Ramanau
- Gomel State Medical University, 5 Lange Street, 246050, Gomel, Belarus
| | - I Chernyanin
- Mozyr Central City polyclinic, 14a Kotlovtsa Street, 247760, Mozyr, Belarus
| | - E Rudenka
- Belarusian State Medical University, 83 Dzerzhinski Ave., 220116, Minsk, Belarus
| | - O Lesnyak
- North West State Medical University named after I.I.Mechnikov, 41, Kirochnaya Street, St. Petersburg, 191015, Russia
| | - A Zakroyeva
- Ural State Medical University, 3 Repina Street, Yekaterinburg, 620028, Russia
| | - J P Bilezikian
- College of Physicians & Surgeons, Columbia University, 630 W. 168th Street, New York, NY, 10032, USA
| | - H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
| |
Collapse
|
233
|
Leslie WD, Shevroja E, Johansson H, McCloskey EV, Harvey NC, Kanis JA, Hans D. Risk-equivalent T-score adjustment for using lumbar spine trabecular bone score (TBS): the Manitoba BMD registry. Osteoporos Int 2018; 29:751-758. [PMID: 29392355 PMCID: PMC5993188 DOI: 10.1007/s00198-018-4405-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/22/2018] [Indexed: 12/29/2022]
Abstract
UNLABELLED Lumbar spine trabecular bone score (TBS) can be used to modify the output from the fracture risk assessment tool, FRAX, to enhance fracture prediction. An alternative approach for using TBS in clinical practice, based upon an adjustment to the bone mineral density (BMD) T-score, may be helpful in regions where intervention guidelines and/or reimbursement are primarily based on BMD T-score. INTRODUCTION The aim of this study is to develop an approach for using TBS in clinical practice based upon a "risk-equivalent" adjustment to the BMD T-score. METHODS We identified 45,185 women age 40 years and older with baseline spine and hip DXA, TBS, and FRAX probabilities including femoral neck BMD. Incident major osteoporotic fractures (MOF, n = 3925) were identified from population-based health services data (mean follow-up 7.4 years comprising 335,910 person-years). Cox proportional hazards models adjusted for age and BMI were first used to estimate the risk for MOF from BMD T-score alone, then after including TBS and a multiplicative age interaction term. From the parameter estimates, we developed a TBS offset to the BMD T-score based upon change in TBS that would give the same risk as a unit change in BMD T-score for the femoral neck, total hip, and lumbar spine. RESULTS All BMD measurements, TBS, and the age interaction term independently predicted MOF (p < 0.001). Measures of risk stratification and model fit were improved for the TBS-adjusted BMD T-score versus the unadjusted BMD T-score (p < 0.001). There was a high level of agreement between MOF probability estimated from TBS-adjusted MOF FRAX probability and FRAX probability using the "risk-equivalent" femoral BMD T-score: MOF probability r2 = 0.98, slope = 1.02, intercept = - 0.3; hip probability r2 = 0.95, slope = 1.07, intercept = 0.0. CONCLUSIONS The BMD-independent effect of lumbar spine TBS on fracture risk can be estimated as a simple offset to the BMD T-score.
Collapse
Affiliation(s)
- W D Leslie
- Department of Internal Medicine, University of Manitoba, (C5121) 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
| | - E Shevroja
- Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, 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
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia
| | - D Hans
- Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
234
|
Harvey NC, Odén A, Orwoll E, Lapidus J, Kwok T, Karlsson MK, Rosengren BE, Ljunggren Ö, Cooper C, McCloskey E, Kanis JA, Ohlsson C, Mellström D, Johansson H. Falls Predict Fractures Independently of FRAX Probability: A Meta-Analysis of the Osteoporotic Fractures in Men (MrOS) Study. J Bone Miner Res 2018; 33:510-516. [PMID: 29220072 PMCID: PMC5842893 DOI: 10.1002/jbmr.3331] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 10/13/2017] [Accepted: 10/28/2017] [Indexed: 11/22/2022]
Abstract
Although prior falls are a well-established predictor of future fracture, there is currently limited evidence regarding the specific value of falls history in fracture risk assessment relative to that of other clinical risk factors and bone mineral density (BMD) measurement. We therefore investigated, across the three Osteoporotic Fractures in Men (MrOS) Study cohorts, whether past falls predicted future fracture independently of FRAX and whether these associations varied with age and follow-up time. Elderly men were recruited from MrOS Sweden, Hong Kong, and USA. Baseline data included falls history (over the preceding 12 months), clinical risk factors, BMD at femoral neck, and calculated FRAX probabilities. An extension of Poisson regression was used to investigate the associations between falls, FRAX probability, and incident fracture, adjusting for age, time since baseline, and cohort in base models; further models were used to investigate interactions with age and follow-up time. Random-effects meta-analysis was used to synthesize the individual country associations. Information on falls and FRAX probability was available for 4365 men in USA (mean age 73.5 years; mean follow-up 10.8 years), 1823 men in Sweden (mean age 75.4 years; mean follow-up 8.7 years), and 1669 men in Hong Kong (mean age 72.4 years; mean follow-up 9.8 years). Rates of past falls were similar at 20%, 16%, and 15%, respectively. Across all cohorts, past falls predicted incident fracture at any site (hazard ratio [HR] = 1.69; 95% confidence interval [CI] 1.49, 1.90), major osteoporotic fracture (MOF) (HR = 1.56; 95% CI 1.33, 1.83), and hip fracture (HR = 1.61; 95% CI 1.27, 2.05). Relationships between past falls and incident fracture remained robust after adjustment for FRAX probability: adjusted HR (95% CI) any fracture: 1.63 (1.45, 1.83); MOF: 1.51 (1.32, 1.73); and hip: 1.54 (1.21, 1.95). In conclusion, past falls predicted incident fracture independently of FRAX probability, confirming the potential value of falls history in fracture risk assessment. © 2017 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.
Collapse
Affiliation(s)
- Nicholas C Harvey
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of Southampton and University Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Anders Odén
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
| | - Eric Orwoll
- Oregon Health and Science UniversityPortlandORUSA
| | - Jodi Lapidus
- Department of Public Health and Preventive Medicine, Division of BiostatisticsOregon Health and Science UniversityPortlandORUSA
| | - Timothy Kwok
- Department of Medicine and Therapeutics and School of Public HealthThe Chinese University of Hong KongHong Kong
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences MalmoLund University and Department of Orthopedics, Skane University HospitalMalmoSweden
| | - Björn E Rosengren
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences MalmoLund University and Department of Orthopedics, Skane University HospitalMalmoSweden
| | - Östen Ljunggren
- Department of Medical SciencesUniversity of UppsalaUppsalaSweden
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of Southampton and University Hospital Southampton NHS Foundation TrustSouthamptonUK
- NIHR Oxford Biomedical Research CentreUniversity of OxfordOxfordUK
| | - Eugene McCloskey
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
- Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone ResearchUniversity of SheffieldSheffieldUK
| | - John A Kanis
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
- Institute for Health and AgingCatholic University of AustraliaMelbourneAustralia
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Dan Mellström
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Helena Johansson
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
- Institute for Health and AgingCatholic University of AustraliaMelbourneAustralia
| |
Collapse
|
235
|
Clark P, Denova-Gutiérrez E, Zerbini C, Sanchez A, Messina O, Jaller JJ, Campusano C, Orces CH, Riera G, Johansson H, Kanis JA. FRAX-based intervention and assessment thresholds in seven Latin American countries. Osteoporos Int 2018; 29:707-715. [PMID: 29273826 DOI: 10.1007/s00198-017-4341-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
UNLABELLED Age-specific intervention and assessment thresholds were developed for seven Latin American countries. The intervention threshold ranged from 1.2% (Ecuador) to 27.5% (Argentina) at the age of 50 and 90 years, respectively. In the Latin American countries, FRAX offers a substantial advance for the detection of subjects at high fracture risk. INTRODUCTION Intervention thresholds are proposed using the Fracture Risk Assessment (FRAX) tool. We recommended their use to calculate the ten-year probability of fragility fracture (FF) in both, men and women with or without the inclusion of bone mineral density (BMD). The purpose of this study is to compute FRAX-based intervention and BMD assessment thresholds for seven Latin American countries in men and women ≥ 40 years. METHODS The intervention threshold (IT) was set at a 10-year probability of a major osteoporotic fracture (MOF) equivalent to a woman with a prior FF and a body mass index (BMI) equal to 25.0 kg/m2 without BMD or other clinical risk factors. The lower assessment threshold was set at a 10-year probability of a MOF in women with BMI equal to 25.0 kg/m2, no previous fracture and no clinical risk factors. The upper assessment threshold was set at 1.2 times the IT. RESULTS For the seven LA countries, the age-specific IT varied from 1.5 to 27.5% in Argentina, 3.8 to 25.2% in Brazil, 1.6 up to 20.0% in Chile, 0.6 to 10.2% in Colombia, 0.9 up to 13.6% in Ecuador, 2.6 to 20.0% in Mexico, and 0.7 up to 22.0% in Venezuela at the age of 40 and 90 years, respectively. CONCLUSIONS In the LA countries, FRAX-based IT offers a substantial advance for the detection of men and women at high fracture risk, particularly in the elderly. The heterogeneity of IT between the LA countries indicates that country-specific FRAX models are appropriate rather than a global LA model.
Collapse
Affiliation(s)
- P Clark
- Clinical Epidemiology Research Unit, Hospital Infantil de México Federico Gomez, Dr. Márquez #164, Col. Doctores, Mexico City, Mexico
- School of Medicine, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico
| | - E Denova-Gutiérrez
- Clinical Epidemiology Research Unit, Hospital Infantil de México Federico Gomez, Dr. Márquez #164, Col. Doctores, Mexico City, Mexico.
- School of Medicine, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico.
| | - C Zerbini
- Centro Paulista de Investigação Clinica, São Paulo, Brazil
| | - A Sanchez
- Centro de Endocrinología, Rosario, Argentina
| | - O Messina
- Servicio de Reumatología, Hospital Argerich, Buenos Aires, Argentina
- Unidad de Postgrado en Reumatología, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - J J Jaller
- Centro de Reumatología y Ortopedia, Barranquilla, Colombia
| | - C Campusano
- Clínica de la Universidad de los Andes, Santiago, Chile
| | - C H Orces
- Department of Medicine, Laredo Medical Center, Laredo, TX, USA
| | - G Riera
- Unidad Metabolica, Universidad de Carabobo, Valencia, Venezuela
| | - H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
- Medical School, Sheffield, UK Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, England
| |
Collapse
|
236
|
Leslie WD, Majumdar SR, Morin SN, Lix LM, Schousboe JT, Ensrud KE, Johansson H, McCloskey EV, Kanis JA. Performance of FRAX in clinical practice according to sex and osteoporosis definitions: the Manitoba BMD registry. Osteoporos Int 2018; 29:759-767. [PMID: 29404625 DOI: 10.1007/s00198-018-4415-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED Among 62,275 women and 6455 men, FRAX stratified risk for incident major osteoporotic fracture (MOF) and incident hip fracture (HF) without sex interaction. Performance was good in those with osteoporosis regardless of how this was defined. INTRODUCTION Some studies have reported that FRAX performance differs according to sex and/or osteoporosis definitions. We evaluated whether the performance of FRAX to predict incident MOF and HF in women and men was affected by the presence or absence of osteoporosis defined by World Health Organization (WHO) or National Osteoporosis Foundation (NOF) criteria. METHODS We studied women and men age ≥ 40 years with baseline hip and spine DXA scans (1996-2013). Individuals were classified into four non-overlapping subgroups: osteoporosis by WHO criteria, osteoporosis exclusively by NOF criteria, high fracture risk by FRAX (MOF ≥ 20% or HF ≥ 3%, without osteoporosis), and low fracture risk (MOF < 20% and HF < 3% without osteoporosis). In each subgroup, we evaluated stratification (hazard ratios [HR]) and calibration (observed vs predicted 10-year fracture probability) for incident fracture. RESULTS The population included 62,275 women (5345 MOF and 1471 HF) and 6455 men (405 MOF and 108 HF). FRAX scores were strongly predictive of MOF (HR per SD: women 2.12, 95% CI 2.06-2.18; men 1.89, 95% CI 1.73-2.08; sex interaction p value = 0.97) and HF (women 4.78, 95% CI 4.44-5.14; men 4.20, 95% CI 3.22-5.49; sex interaction p value = 0.71). FRAX scores gave similar HRs for MOF among the four subgroups (subgroup interaction p value 0.34 for women, 0.22 for men). Observed versus predicted 10-year MOF and HF probability for the defined subgroups demonstrated a high level of concordance for women and men (all r2 ≥ 0.9). CONCLUSIONS FRAX was a strong and consistent predictor of MOF and HF in both women and men and performed well in those with osteoporosis whether defined by WHO or NOF criteria.
Collapse
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
| | | | - K E Ensrud
- University of Minnesota, Minneapolis, USA
| | - H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| |
Collapse
|
237
|
Oka R, Ohira M, Suzuki S, Yoshida T, Koide H, Tanaka T, Tatsuno I. Fracture risk assessment tool (FRAX) and for the diagnosis of osteoporosis in Japanese middle-aged and elderly women: Chiba bone survey. Endocr J 2018; 65:193-202. [PMID: 29151451 DOI: 10.1507/endocrj.ej17-0331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Osteoporosis not only increases bone fracture risk but also affects survival in postmenopausal women. Although osteoporosis is diagnosed based on low bone mineral density (BMD) determined by dual energy X-ray absorptiometry (DXA), BMD measurement is sometimes difficult because DXA is not widely available in the community. The Fracture Risk Assessment tool (FRAX) can predict 10-year major osteoporotic fracture risk and hip fracture risk with or without femoral neck BMD. The FRAX has not been investigated adequately in community-dwelling Japanese women. We administered the FRAX tool in 13,421 Japanese women who underwent DXA-based forearm BMD measurement in Chiba Bone Survey, a population-based, multicenter, cross-sectional study of postmenopausal osteoporosis conducted in Chiba, Japan. Mean age was 57.77 ± 9.24 years. Mean forearm BMD was 87.94 ± 17.00% of young adult mean (YAM). Mean FRAX major osteoporotic fracture risk without femoral neck BMD was 7.06 ± 5.22%. BMD decreased and percentage of osteoporosis increased from age 55 onward. Age distribution of percentage of subjects with FRAX major osteoporotic fracture risk >15% was similar to that of percentage of osteoporosis subjects. We identified the cutoff value of FRAX major osteoporotic fracture risk for diagnosis of osteoporosis as 7.2%. With this cutoff, the positive likelihood ratio was over 1.0 at age 55 and above but accuracy was low. In conclusion, FRAX without femoral neck BMD reflects bone status, and may be useful to diagnose osteoporosis in Japanese women aged 55 and above, although the sensitivity was low for osteoporosis screening, especially in middle-aged women.
Collapse
Affiliation(s)
- Rena Oka
- Department of Diabetes, Endocrine and Metabolism, Toho University Graduate School of Medicine, Tokyo, Japan
- Center of Diabetes, Endocrinology, and Metabolism, Sakura Hospital, Toho University, Chiba, Japan
| | - Masahiro Ohira
- Center of Diabetes, Endocrinology, and Metabolism, Sakura Hospital, Toho University, Chiba, Japan
| | - Sawako Suzuki
- Department of Clinical Cell Biology & Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomohiko Yoshida
- Department of Medicine, Chiba Aoba Municipal Hospital, 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 of Diabetes, Endocrinology, and Metabolism, Sakura Hospital, Toho University, Chiba, Japan
| |
Collapse
|
238
|
Kastner M, Perrier L, Munce SEP, Adhihetty CC, Lau A, Hamid J, Treister V, Chan J, Lai Y, Straus SE. Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis. Osteoporos Int 2018; 29:5-17. [PMID: 29043392 DOI: 10.1007/s00198-017-4248-0] [Citation(s) in RCA: 25] [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: 02/15/2017] [Accepted: 09/26/2017] [Indexed: 01/06/2023]
Abstract
Osteoporosis is affecting over 200 million people worldwide. Despite available guidelines, care for these patients remains sub-optimal. We developed an osteoporosis tool to address the multiple dimensions of chronic disease management. Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment, so we are revising this tool to include multiple chronic conditions including an update of evidence about osteoporosis. Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis. We searched bibliometric databases for randomized controlled trials (RCTs) in any language evaluating osteoporosis disease management interventions in adults at risk for osteoporosis. Reviewer pairs independently screened citations and full-text articles, extracted data, and assessed risk of bias. Analysis included random effects meta-analysis. Primary outcomes were osteoporosis investigations and treatment, and fragility fractures. Fifty-five RCTs and one companion report were included in the analysis representing 165,703 patients. Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications, and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations. No significant impact was found for any type of intervention to reduce fracture. Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment. Patient education appears to be an important component in osteoporosis disease management.
Collapse
Affiliation(s)
- M Kastner
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - L Perrier
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - S E P Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - C C Adhihetty
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - A Lau
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - J Hamid
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - V Treister
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - J Chan
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Y Lai
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - S E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
239
|
The application of the FRIDEX calibration of the FRAX tool to determine the absolute risk of osteoporotic fracture among Spanish women. ACTA ACUST UNITED AC 2017; 15:e68-e69. [PMID: 29221875 DOI: 10.1016/j.reuma.2017.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/21/2017] [Indexed: 11/21/2022]
|
240
|
Silva DMW, Borba VZC, Kanis JA. Evaluation of clinical risk factors for osteoporosis and applicability of the FRAX tool in Joinville City, Southern Brazil. Arch Osteoporos 2017; 12:111. [PMID: 29224172 DOI: 10.1007/s11657-017-0405-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/24/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Clinical risk factors for fracture in Southern Brazil are similar to those used in Fracture Risk Assessment Tool (FRAX®). Age-dependent intervention thresholds had higher accuracy than a fixed cut-off point. INTRODUCTION Access to bone mineral density testing is wanted for a large part of the Brazilian population. The FRAX® has an option to calculate the risk of fracture without this costly evaluation but relies on the clinical risk factors (CRFs) identified in the source cohorts used to generate FRAX. OBJECTIVE The aims of this study were to determine whether the CRFs used in FRAX are also risk indicators for individuals in Southern Brazil and to evaluate possible intervention thresholds for treatment in Brazil. METHODS We determined the CRFs for hip fractures in women and men aged 50 years and more with a hip fracture and controls in Joinville, Southern Brazil (April 1, 2010, and March 31, 2012). For intervention thresholds, we determined the accuracy of using the fixed thresholds of National Osteoporosis Foundation (NOF), USA, compared with the age-dependent thresholds of the National Osteoporosis Guideline Group (NOGG), UK. RESULTS CRFs that were significant for hip fracture were very similar to FRAX, apart from chronic obstructive pulmonary disease and malabsorptive intestinal disease. FRAX based on the NOGG and NOF models had an accuracy of 64.2 and 58.7%, respectively. CONCLUSION CRFs used in FRAX® were similar to those in the Southern Brazil. The NOGG model seems to be more accurate to discriminate patients with increased fracture risk in this population compared to the NOF model, but not significantly.
Collapse
Affiliation(s)
- Dalisbor Marcelo Weber Silva
- Medical School of Univille, Universidade da Região de Joinville, Rua Plácido Gomes, 520, Anita Garibaldi, Joinville, SC, Brazil.
| | | | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia
| |
Collapse
|
241
|
Binkley N, Besuyen R, Fuerst T, Skillern L, Hans D. Is drug-induced bone loss acceptable in premenopausal women? A practical fracture risk modeling exercise. Osteoporos Int 2017; 28:3501-3513. [PMID: 29018923 DOI: 10.1007/s00198-017-4258-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 10/05/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Premenopausal bone loss increases fracture risk later in life. Depending on peak values, varying degrees of bone mass and microarchitectural loss can be tolerated. We suggest that risk-benefit assessments of drugs that cause premenopausal bone loss be individualized considering baseline status and subsequent BMD and TBS loss. INTRODUCTION It is logical that drug-induced loss of bone mass and microarchitecture in young adults increase fracture risk later in life. However, no existing data quantify how drug-induced bone loss in younger adults impacts fracture risk later in life. As such, no guidance exists to address the question "How much, if any, drug-induced bone loss in premenopausal women is acceptable?" Thus, we performed a systematic fracture risk modeling exercise examining various degrees of bone loss, and estimated the impact on 10-year major osteoporosis-related fracture risk later in life. METHODS The FRAX® tool was used in conjunction with BMD and trabecular bone score (TBS) adjustment to estimate major osteoporotic fracture probability later in life resulting from varying degrees of hypothetical premenopausal drug-induced BMD and TBS loss. The resulting 10-year fracture probabilities were assessed against the US and the UK treatment guidance to determine the amount of premenopausal BMD and TBS loss that would result in a recommendation to initiate medical treatment to reduce fracture risk later in life that would not otherwise have been recommended in the absence of premenopausal bone loss. RESULTS For women whose peak bone mass is between the 5th and 50th percentiles, varying degrees of BMD and TBS loss could be tolerated without reaching treatment thresholds. The degree of tolerable bone loss was primarily dependent on baseline bone status. Those whose peak BMD and TBS are in the 50th percentile or above could tolerate a 10% reduction in BMD and TBS without reaching treatment thresholds by age 75, whereas those in the 5th percentile would reach treatment thresholds by age 75 with no drug-induced reduction in BMD or TBS. Women in the 25th percentile could tolerate a 4% BMD loss and 2% TBS decline without reaching treatment thresholds by age 75. CONCLUSIONS For clinicians and regulatory bodies to assess the consequence of drug-induced premenopausal bone loss, we propose an individualized approach considering both loss of BMD and TBS in concert with baseline bone status and the resultant effect on fracture risk in later life using the assumption that such losses are irreversible.
Collapse
Affiliation(s)
- N Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin, 2870 University Ave, Suite 100, Madison, WI, 53705, USA.
| | - R Besuyen
- Astellas Pharma B.V, Leiden, The Netherlands
| | - T Fuerst
- BioClinica, Inc., Newark, CA, USA
| | - L Skillern
- Astellas Pharma B.V, Leiden, The Netherlands
| | - D Hans
- Center of Bone diseases, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
242
|
Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017; 12:43. [PMID: 28425085 PMCID: PMC5397452 DOI: 10.1007/s11657-017-0324-5] [Citation(s) in RCA: 500] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management.
Collapse
Affiliation(s)
- J. Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - A. Cooper
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - N. Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
| | - C. Gregson
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
| | - N. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - S. Hope
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
| | - J. A. Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
| | | | - K. E. S. Poole
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - D. M. Reid
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
| | - P. Selby
- Metabolic Bone Disease, University of Manchester, Manchester, UK
| | | | | | - N. Vine
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - The National Osteoporosis Guideline Group (NOGG)
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
- Metabolic Bone, University of Sheffield, Sheffield, UK
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
- Metabolic Bone Disease, University of Manchester, Manchester, UK
- National Osteoporosis Society, Camerton, UK
| |
Collapse
|
243
|
Screening for osteoporosis following non-vertebral fractures in patients aged 50 and older independently of gender or level of trauma energy-a Swiss trauma center approach. Arch Osteoporos 2017; 12:38. [PMID: 28391563 DOI: 10.1007/s11657-017-0334-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/03/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Screening in a standardized manner for osteoporosis in non-vertebral fracture patients aged 50 and older independently of both gender and level of trauma energy yielded the indication for osteoporotic therapy for every fourth male high-energy fracture patient. PURPOSE This study aimed to identify the rate of osteoporosis in patients of both genders after fracture independently of the underlying level of trauma energy. METHODS A random cohort of patients aged 50 or older with non-vertebral fractures participated in a standardized diagnostic protocol to evaluate the indication for treatment of osteoporosis (number needed to screen (NNS)). Univariate and multivariate analysis as well as correlation testing were performed to determine statistical relationships. Significance was set at p < 0.05. RESULTS Of 478 fracture patients with a mean age of 69.3 ± 11.8 years, 317 (66.3%) were female and 161 (33.7%) male. One hundred nineteen patients (24.9%) sustained high-energy fractures (HEFs) and 359 (75.1%) low-energy fractures (LEFs). Twenty-eight percent of males and 47% of females qualified as osteoporotic in densitometry (dual-energy X-ray absorptiometry (DXA)), resulting in a NNS of 2.1 for women and 3.6 for men. The indication for treatment of osteoporosis increased to an NNS of 1.5 for females and 2.4 for males if the fracture risk assessment tool (FRAX) was included in the diagnostics (DXA and FRAX). With regard to the energy of trauma, the NNS for treatment following DXA and FRAX was 1.5 for LEF and 2.9 for HEF. Subgroup analysis revealed that HEF males within the decennia 50+ and 80+ had an NNS of around 3, i.e., comparable to females and about twice as high as LEF patients. CONCLUSIONS These preliminary findings appear to confirm the pragmatic approach to screening in a standardized manner for osteoporosis in all non-vertebral fracture patients aged 50 and older-independently of both gender and level of trauma energy.
Collapse
|
244
|
Harvey NC, McCloskey E, Kanis JA, Compston J, Cooper C. Bisphosphonates in osteoporosis: NICE and easy? Lancet 2017; 390:2243-2244. [PMID: 29165263 PMCID: PMC5724749 DOI: 10.1016/s0140-6736(17)32850-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/06/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Nicholas C Harvey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | - Eugene McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Institute for Health and Aging, Catholic University of Australia, Melbourne, VIC, Australia
| | | | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
| |
Collapse
|
245
|
Epidemiology of Bone Fracture in Female Trauma Patients Based on Risks of Osteoporosis Assessed using the Osteoporosis Self-Assessment Tool for Asians Score. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14111380. [PMID: 29137199 PMCID: PMC5708019 DOI: 10.3390/ijerph14111380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/09/2017] [Accepted: 11/11/2017] [Indexed: 02/07/2023]
Abstract
Background: Osteoporotic fractures are defined as low-impact fractures resulting from low-level trauma. However, the exclusion of high-level trauma fractures may result in underestimation of the contribution of osteoporosis to fractures. In this study, we aimed to investigate the fracture patterns of female trauma patients with various risks of osteoporosis based on the Osteoporosis Self-Assessment Tool for Asians (OSTA) score. Methods: According to the data retrieved from the Trauma Registry System of a Level I trauma center between 1 January 2009 and 31 December 2015, a total of 6707 patients aged ≥40 years and hospitalized for the treatment of traumatic bone fracture were categorized as high-risk (OSTA < -4, n = 1585), medium-risk (-1 ≥ OSTA ≥ -4, n = 1985), and low-risk (OSTA > -1, n = 3137) patients. Two-sided Pearson's, chi-squared, or Fisher's exact tests were used to compare categorical data. Unpaired Student's t-test and Mann-Whitney U-test were used to analyze normally and non-normally distributed continuous data, respectively. Propensity-score matching in a 1:1 ratio was performed with injury mechanisms as adjusted variables to evaluate the effects of OSTA-related grouping on the fracture patterns. Results: High- and medium-risk patients were significantly older, had higher incidences of comorbidity, and were more frequently injured from a fall and bicycle accident than low-risk patients did. Compared to low-risk patients, high- and medium-risk patients had a higher injury severity and mortality. In the propensity-score matched population, the incidence of fractures was only different in the extremity regions between high- and low-risk patients as well as between medium- and low-risk patients. The incidences of femoral fractures were significantly higher in high-risk (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.73-4.24; p < 0.001) and medium-risk patients (OR, 1.4; 95% CI, 1.24-1.54; p < 0.001) than in low-risk patients. In addition, high-risk patients had significantly lower odds of humeral, radial, patellar, and tibial fractures; however, such lower odds were not found in medium- risk than low-risk patients. Conclusions: The fracture patterns of female trauma patients with high- and medium-risk osteoporosis were different from that of low-risk patients exclusively in the extremity region.
Collapse
|
246
|
Curtis EM, Moon RJ, Harvey NC, Cooper C. The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide. Bone 2017; 104:29-38. [PMID: 28119181 PMCID: PMC5420448 DOI: 10.1016/j.bone.2017.01.024] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 02/08/2023]
Abstract
Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm and humerus. Substantial geographic variation has been noted in the incidence of osteoporotic fractures worldwide, with Western populations (North America, Europe and Oceania), reporting increases in hip fracture throughout the second half of the 20th century, with a stabilisation or decline in the last two decades. In developing populations however, particularly in Asia, the rates of osteoporotic fracture appears to be increasing. The massive global burden consequent to osteoporosis means that fracture risk assessment should be a high priority among health measures considered by policy makers. The WHO operational definition of osteoporosis, based on a measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), has been used globally since the mid-1990s. However, although this definition identifies those at greatest individual risk of fracture, in the population overall a greater total number of fractures occur in individuals with BMD values above the threshold for osteoporosis diagnosis. A number of web-based tools to enable the inclusion of clinical risk factors, with or without BMD, in fracture prediction algorithms have been developed to improve the identification of individuals at high fracture risk, the most commonly used globally being FRAX®. Access to DXA, osteoporosis risk assessment, case finding and treatment varies worldwide, but despite such advances studies indicate that a minority of men and women at high fracture risk receive treatment. Importantly, research is ongoing to demonstrate the clinical efficacy and cost-effectiveness of osteoporosis case finding and risk assessment strategies worldwide. The huge burden caused by osteoporosis related fractures to individuals, healthcare systems and societies should provide a clear impetus for the progression of such approaches.
Collapse
Affiliation(s)
- Elizabeth M Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK
| | - Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK; Paediatric Endocrinology, Southampton University Hospitals NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK; NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK; NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford OX3 7LD, UK.
| |
Collapse
|
247
|
Johansson H, Azizieh F, Al Ali N, Alessa T, Harvey NC, McCloskey E, Kanis JA. FRAX- vs. T-score-based intervention thresholds for osteoporosis. Osteoporos Int 2017; 28:3099-3105. [PMID: 28782072 PMCID: PMC5881885 DOI: 10.1007/s00198-017-4160-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Many current guidelines for the assessment of osteoporosis, including those in Kuwait, initiate fracture risk assessment in men and women using BMD T-score thresholds. We compared the Kuwaiti guidelines with FRAX-based age-dependent intervention thresholds equivalent to that in women with a prior fragility fracture. FRAX-based intervention thresholds identified women at higher fracture probability than fixed T-score thresholds, particularly in the elderly. PURPOSE A FRAX® model been recently calibrated for Kuwait, but guidance is needed on how to utilise fracture probabilities in the assessment and treatment of patients. METHODS We compared age-specific fracture probabilities, equivalent to women with no clinical risk factors and a prior fragility fracture (without BMD), with the age-specific fracture probabilities associated with femoral neck T-scores of -2.5 and -1.5 SD, in line with current guidelines in Kuwait. Upper and lower assessment thresholds for BMD testing were additionally explored using FRAX. RESULTS When a BMD T-score of -2.5 SD was used as an intervention threshold, FRAX probabilities of a major osteoporotic fracture in women aged 50 years were approximately twofold higher than those in women of the same age but with an average BMD. The increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 83 years or more, a T-score of -2.5 SD was associated with a lower probability of fracture than that of the age-matched general population with no clinical risk factors. The same phenomenon was observed from the age of 66 years at a T-score of -1.5 SD. A FRAX-based intervention threshold, defined as the 10-year probability of a major osteoporotic fracture in a woman of average BMI with a previous fracture, rose with age from 4.3% at the age of 50 years to 23%, at the age of 90 years, and identified women at increased risk at all ages. Qualitatively comparable findings were observed in the case of hip fracture probability and in men. CONCLUSION Intervention thresholds based on BMD alone do not optimally target women at higher fracture risk than those on age-matched individuals without clinical risk factors, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a 'fracture threshold' consistently target women at higher fracture risk, irrespective of age.
Collapse
Affiliation(s)
- H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - F Azizieh
- Department of Mathematics and Natural Sciences, Gulf University for Science and Technology, Mubarak Al-Abdullah, Kuwait City, Kuwait
| | - N Al Ali
- Unit of Endocrinology & Metabolism, Al-Amiri Hospital, Kuwait City, Kuwait
| | - T Alessa
- Endocrinology, Diabetes & Metabolism, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - 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
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
| |
Collapse
|
248
|
Goldshtein I, Ish-Shalom S, Leshno M. Impact of FRAX-based osteoporosis intervention using real world data. Bone 2017; 103:318-324. [PMID: 28778597 DOI: 10.1016/j.bone.2017.07.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To estimate the implications and accuracy of the most common fracture prevention strategies: (1) fixed threshold by the National Osteoporosis Foundation (NOF), (2) age-dependent threshold by the National Osteoporosis Guideline Group (NOGG) and (3) osteoporotic bone mineral density (BMD). METHODS A retrospective cohort of all 50-90years old female members in a nationally representative payer provider healthcare organization in Israel, with 10years of follow-up on incident events of major osteoporotic fractures. Since events are less frequent than non-events, balanced accuracy (the average between the accuracy obtained for patients with and without events) was used to measure performance. RESULTS Overall among 141,320 women NOF and NOGG would recommend therapy for 17.3% and 2.8% respectively, with NOF exhibiting higher balanced accuracy: 74.1% vs. 54.2% for incident hip fractures detection and 60.0% vs. 51.6% for a composite outcome of major osteoporotic fractures. In patients with available BMD (n=16,578) the treatment intervention criteria of NOF, NOGG, osteoporotic femur neck or vertebral BMD were met by 30.5%, 9.3% and 24.6% of the population, with balanced accuracy of 70.1%, 56.5% and 62.3% respectively for hip fractures and 61.4%, 52.8%, 58.1% for major osteoporotic fractures. At the age of 75years or older the NOF hip fracture risk threshold (3%) was exceeded in most women regardless of risk factors other than age. CONCLUSIONS In this large population-based study, detection of patients at high risk of sustaining a major osteoporotic fracture within 10 years was more accurate with the NOF fixed threshold criteria as compared with the age-varying NOGG or BMD-only. However, special consideration and further studies are warranted in patients aged 75years or older with preserved bone density, which may benefit from non-medicinal interventions.
Collapse
Affiliation(s)
- Inbal Goldshtein
- Tel Aviv University, Faculty of Management, Israel; Maccabi Healthcare Services, Institute for Research and Innovation, Israel.
| | | | - Moshe Leshno
- Tel Aviv University, Faculty of Management, Israel; Tel Aviv Souraski Medical Center, Gastroenterology and Liver Diseases Institute, Israel
| |
Collapse
|
249
|
Marques A, Lucas R, Simões E, Verstappen SMM, Jacobs JWG, da Silva JAP. Do we need bone mineral density to estimate osteoporotic fracture risk? A 10-year prospective multicentre validation study. RMD Open 2017; 3:e000509. [PMID: 29018567 PMCID: PMC5623321 DOI: 10.1136/rmdopen-2017-000509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/30/2017] [Accepted: 08/25/2017] [Indexed: 02/01/2023] Open
Abstract
Objective Evaluate the performance of FRAX®, with and without bone mineral densitometry (BMD), in predicting the occurrence of fragility fractures over 10 years. Methods Participants aged ≥40 years at baseline, with a complete set of data and a minimum of 8.5 years of follow-up were identified from three cohorts (n=2626). Ten-year fracture risk at baseline were estimated with FRAX® and assessed by comparison with observed fractures and receiver operating characteristic analysis. Results During a mean (SD) follow-up of 9.12 (1.5) years, 178 participants suffered a major osteoporotic (MOP) fracture and 28 sustained a hip fracture. The predictive performance of FRAX® was superior to that of BMD alone for both MOP and hip fractures. The area under the curve (AUC) of FRAX® without BMD was 0.76 (95% CI 0.72 to 0.79) for MOP fractures and 0.78 (95% CI 0.69 to 0.86) for hip fractures. No significant improvements were found when BMD was added to clinical variables to predict either MOP (0.78, 95% CI 0.74 to 0.82, p=0.25) or hip fractures (0.79, 95% CI 0.69 to 0.89, p=0.72). AUCs for FRAX® (with and without BMD) were greater for men than for women. FRAX®, with and without BMD, tended to underestimate the number of MOP fractures and to overestimate the number of hip fractures in females. In men, the number of observed fractures were within the 95% CI of the number predicted, both with and without BMD. Conclusion FRAX® without BMD provided good fracture prediction. Adding BMD to FRAX® did not improve the performance of the tool in the general population.
Collapse
Affiliation(s)
- Andréa Marques
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal.,Coimbra Nursing School, Esenfc, Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Raquel Lucas
- EPIUnit - Institute of Public Health and Porto Medical School, University of Porto, Porto, Portugal
| | | | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands
| | - Jose A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal
| |
Collapse
|
250
|
Leslie WD, Majumdar SR, Morin SN, Lix LM, Johansson H, Oden A, McCloskey EV, Kanis JA. FRAX for fracture prediction shorter and longer than 10 years: the Manitoba BMD registry. Osteoporos Int 2017; 28:2557-2564. [PMID: 28593449 DOI: 10.1007/s00198-017-4091-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/14/2017] [Indexed: 12/26/2022]
Abstract
UNLABELLED In a large clinical registry for the province of Manitoba, Canada, FRAX predicted incident MOF and hip fracture from 1 to 15 years following baseline assessment. A simple linear rescaling of FRAX outputs seems useful for predicting both short- and long-term fracture risk in this population. INTRODUCTION FRAX® estimates 10-year probability of major osteoporotic fracture (MOF) and hip fracture. We examined FRAX predictions over intervals shorter and longer than 10 years. METHODS Using a population-based clinical registry for Manitoba, Canada, we identified 62,275 women and 6455 men 40 years and older with baseline dual-energy X-ray absorptiometry scans and FRAX scores. Incident MOF and hip fracture were assessed up to 15 years from population-based data. We assessed agreement between estimated fracture probability from 1 to 15 years using linearly rescaled FRAX scores and observed cumulative fracture probability. The gradient of risk for FRAX probability and incident fracture was examined overall and for 5-year intervals. RESULTS FRAX predicted incident MOF and hip fracture for all time intervals. There was no attenuation in the gradient of risk for MOF even for years >10. Gradient of risk was slightly lower for hip fracture prediction in years >10 vs years <5, though HRs remained high. Linear agreement was seen in the relationships between observed vs predicted (rescaled) FRAX probabilities (R 2 0.95-1.00). Among women, there was near-perfect linearity in MOF predictions. Deviations from linearity, with a slightly higher observed than predicted MOF probability, were most evident in the first years following a fracture event and after 10 years for hip fracture prediction in women using FRAX with BMD. Simulations showed that results were robust to large differences in fracture rates and moderate differences in mortality rates. CONCLUSIONS FRAX predicts incident MOF and hip fracture up to 15 years and could be adapted to predict fracture over time periods shorter and longer term than 10 years in populations with fracture and mortality epidemiology similar to Canada.
Collapse
Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), St Boniface Hospital, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | | | | | - L M Lix
- Department of Medicine (C5121), St Boniface Hospital, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - A Oden
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| |
Collapse
|