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McCloskey E, Tan ATH, Schini M. Update on fracture risk assessment in osteoporosis. Curr Opin Endocrinol Diabetes Obes 2024; 31:141-148. [PMID: 38809256 DOI: 10.1097/med.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW The assessment of fracture risk is playing an ever-increasing role in osteoporosis clinical management and informing international guidelines for osteoporosis. FRAX, a fracture risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used since 2008. In this review, we recap the development and limitations of intervention thresholds and the role of absolute fracture risk. RECENT FINDINGS There is an increasing awareness of disparities and inequities in the setting of intervention thresholds in osteoporosis. The limitations of the simple use of prior fracture or the DXA-derived BMD T -score threshold are increasingly being discussed; one solution is to use fracture risk or probabilities in the setting of such thresholds. This approach also permits more objective assessment of high and very high fracture risk to enable physicians to make choices not just about the need to treat but what agents to use in individual patients. SUMMARY Like all clinical tools, FRAX has limitations that need to be considered, but the use of fracture risk in deciding who to treat, when to treat and what agent to use is a mechanism to target treatment equitably to those at an increased risk of fracture.
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Affiliation(s)
- Eugene McCloskey
- Division of Clinical Medicine, School of Medicine and Population Health
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - Andre T H Tan
- Fast and Chronic Programmes, Alexandra Hospital, Queenstown
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Marian Schini
- Division of Clinical Medicine, School of Medicine and Population Health
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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Naseri A, Bakhshayeshkaram M, Salehi S, Heydari ST, Dabbaghmanesh MH, Dabbaghmanesh MM. FRAX-derived intervention and assessment thresholds for osteoporosis in ten Middle Eastern countries. Arch Osteoporos 2024; 19:41. [PMID: 38780743 DOI: 10.1007/s11657-024-01397-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
This study established FRAX-based age-specific assessment and intervention thresholds for ten Middle Eastern countries where FRAX is currently available, but the lack of specific thresholds has limited its usefulness. The intervention thresholds ranged from 0.6 (Saudi Arabia) to 36.0% (Syria) at the ages of 40 and 90 years, respectively. INTRODUCTION Developing fracture risk assessment tools allows physicians to select patients for therapy based on their absolute fracture risk instead of relying solely on bone mineral density (BMD). The most widely used tool is FRAX, currently available in ten Middle Eastern countries. This study aimed to set FRAX-derived assessment and intervention thresholds for individuals aged 40 or above in ten Middle Eastern countries. METHODS The age-specific 10-year probabilities of a major osteoporotic fracture (MOF) for a woman with a BMI of 25.0 kg/m2, without BMD and clinical risk factors except for prior fracture, were calculated as intervention Threshold (IT). The upper and lower assessment thresholds were set at 1.2 times the IT and an age-specific 10-year probability of a MOF in a woman with a BMI of 25.0 kg/m2, without BMD, prior fracture, and other clinical risk factors, respectively. IT is utilized to determine treatment or reassurance when BMD facilities are unavailable. However, with BMD facilities, assessment thresholds can offer treatment, reassurance, or bone densitometry based on MOF probability. RESULTS The age-specific IT varied from 0.9 to 11.0% in Abu Dhabi, 2.9 to 10% in Egypt, 2.7 to 14.0% in Iran, 1.0 to 28.0% in Jordan, 2.7 to 27.0% in Kuwait, 0.9 to 35.0% in Lebanon, 1.0 to 16.0% in Palestine, 4.1 to 14% in Qatar, 0.6 to 3.7% in Saudi Arabia, and 0.9 to 36.0% in Syria at the age of 40 and 90 years, respectively. CONCLUSIONS FRAX-based IT in Middle Eastern countries provides an opportunity to identify individuals with high fracture risk.
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Affiliation(s)
- Arzhang Naseri
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marzieh Bakhshayeshkaram
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Salehi
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Taghi Heydari
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Dabbaghmanesh
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Shiraz University of Medical Sciences, Shiraz, Iran.
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Schini M, Johansson H, Harvey NC, Lorentzon M, Kanis JA, McCloskey EV. An overview of the use of the fracture risk assessment tool (FRAX) in osteoporosis. J Endocrinol Invest 2024; 47:501-511. [PMID: 37874461 PMCID: PMC10904566 DOI: 10.1007/s40618-023-02219-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
FRAX®, a simple-to-use fracture risk calculator, was first released in 2008 and since then has been used increasingly worldwide. By calculating the 10-year probabilities of a major osteoporotic fracture and hip fracture, it assists clinicians when deciding whether further investigation, for example a bone mineral density measurement (BMD), and/or treatment is needed to prevent future fractures. In this review, we explore the literature around osteoporosis and how FRAX has changed its management. We present the characteristics of this tool and describe the use of thresholds (diagnostic and therapeutic). We also present arguments as to why screening with FRAX should be considered. FRAX has several limitations which are described in this review. This review coincides with the release of a version, FRAXplus, which addresses some of these limitations.
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Affiliation(s)
- M Schini
- Department of Oncology & Metabolism, Metabolic Bone Centre, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK.
| | - H Johansson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - M Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - J A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - E V McCloskey
- Department of Oncology & Metabolism, Metabolic Bone Centre, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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Gani LU, Sritara C, Blank RD, Chen W, Gilmour J, Dhaliwal R, Gill R. Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry. J Clin Densitom 2024; 27:101440. [PMID: 38007875 DOI: 10.1016/j.jocd.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.
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Affiliation(s)
- Linsey U Gani
- Department of Endocrinology, Changi General Hospital, Singapore.
| | - Chanika Sritara
- Nuclear Medicine Division, Department of Diagnostic and Therapeutic Radiology. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - WeiWen Chen
- Department of Endocrinology, St Vincent's Hospital Sydney, Australia
| | - Julia Gilmour
- Division of Endocrinology, St Michael's Hospital, Department of Medicine, University of Toronto
| | - Ruban Dhaliwal
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School
| | - Ranjodh Gill
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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Jia H, Qu W, Cai X, Li M, Qian Y, Jiang Z, Zhang Z. Assessment for bone health in patients with differentiated thyroid carcinoma after postoperative thyroid-stimulating hormone suppression therapy: a new fracture risk assessment algorithm. Front Endocrinol (Lausanne) 2023; 14:1286947. [PMID: 38075039 PMCID: PMC10698692 DOI: 10.3389/fendo.2023.1286947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose The fracture risk assessment tool (FRAX) is used to assess the 10-year risk of major site and hip fractures; however, whether this tool can be applied to patients receiving levothyroxine-based thyroid-stimulating hormone (TSH) suppressive therapy for postoperative differentiated thyroid cancer (DTC) patients is yet to be clarified. Methods and design A total of 64 patients with DTC following thyroidectomy and oral levothyroxine for TSH suppression therapy and 30 gender- and age-matched controls were collected. The fracture risk was compared between the affected groups with different TSH levels. FRAX was used to calculate the fracture risk with and without bone mineral density (BMD). The TSH level was converted to an age-weighted score to estimate the fracture risk of postoperatively differentiated thyroid cancer patients. The sensitivity, specificity, and area under the AUC curve of the traditional FRAX and the new algorithm for osteoporosis diagnosis were compared. The dual-energy X-ray bone mineral density measurement T score was used as the gold standard to diagnose osteoporosis. Results There were 24 patients in the T ≥ -1-2.5 group, 23 in the -2.5 < T < -1 group, and 17 in the T ≤ -2.5 group. The T score of BMD in the disease group was significantly lower than that in the control group (p < 0.05). The risk of MOF and hip fracture without a T score were significantly different under various TSH levels (p < 0.05). The area under the curve (AUC) of FRAX without BMD for predicting major osteoporotic fractures (PMOF) and major hip fractures (PHF) was 0.694 and 0.683, respectively. The cutoff values were 2.15% and 0.25%, respectively. The AUC of FRAX with BMD for PMOF and PHF was 0.976 and 0.989, respectively, and the cutoff values were 4.15% and 1.1%, respectively. The AUC of FRAX without BMD for PMOF and PHF was 0.708 and 0.72, respectively, and the cutoff values were 5.5% and 1.55%, respectively. Conclusions FRAX is suitable for postoperative DTC patients after TSH suppressive therapy. In the absence of BMD, TSH weighted by age can improve the specificity of FRAX in the diagnosis of osteoporosis in this population.
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Affiliation(s)
- Huiran Jia
- Endocrinology Department, Postgraduate Training Base of Jinzhou Medical University, Jinzhou, Liaoning, China
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
| | - Wei Qu
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
| | - Xiaoting Cai
- Endocrinology Department, Postgraduate Training Base of Jinzhou Medical University, Jinzhou, Liaoning, China
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
| | - Meiye Li
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
| | - Ying Qian
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
| | - Zhaoshun Jiang
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
| | - Zongjing Zhang
- Endocrinology Department, The 960th Hospital of the People’s Liberation Army Joint Logistics Support Force, Jinan, China
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Guzmán-Herrera S, Morales-Sánchez MA, Peralta-Pedrero ML, de Peña-Ortiz J, Cruz FJS. Dose-Adjusted FRAX Score in Pemphigus Vulgaris Treatment. Indian J Dermatol 2023; 68:698-700. [PMID: 38371552 PMCID: PMC10869003 DOI: 10.4103/ijd.ijd_1061_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Affiliation(s)
- Saúl Guzmán-Herrera
- From the Research and Education Unit, Centro Dermatológico "Dr. Ladislao de la Pascua", Dr. José María Vertiz 464, Buenos Aires, Cuauhtémoc, Ciudad de México, Mexico E-mail:
| | - Martha A Morales-Sánchez
- From the Research and Education Unit, Centro Dermatológico "Dr. Ladislao de la Pascua", Dr. José María Vertiz 464, Buenos Aires, Cuauhtémoc, Ciudad de México, Mexico E-mail:
| | - María L Peralta-Pedrero
- From the Research and Education Unit, Centro Dermatológico "Dr. Ladislao de la Pascua", Dr. José María Vertiz 464, Buenos Aires, Cuauhtémoc, Ciudad de México, Mexico E-mail:
| | - Josefina de Peña-Ortiz
- From the Research and Education Unit, Centro Dermatológico "Dr. Ladislao de la Pascua", Dr. José María Vertiz 464, Buenos Aires, Cuauhtémoc, Ciudad de México, Mexico E-mail:
| | - Fermín J S Cruz
- From the Research and Education Unit, Centro Dermatológico "Dr. Ladislao de la Pascua", Dr. José María Vertiz 464, Buenos Aires, Cuauhtémoc, Ciudad de México, Mexico E-mail:
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Brazell CJ, Carry PM, Holmes KS, Salton RL, Hadley-Miller N, Georgopoulos G. Pediatric and Adult Fracture Incidence: A Decreasing Trend With Increasing Hospital Admissions. Orthopedics 2023; 46:e369-e375. [PMID: 37018620 DOI: 10.3928/01477447-20230329-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Large-scale studies examining fracture trends and epidemiological data are lacking. The purpose of this study was to evaluate the incidence of fractures presenting to US emergency departments using the National Electronic Injury Surveillance System. A total of 7,109,078 pediatric and 13,592,548 adult patients presenting to US emergency departments with a fracture between 2008 and 2017 were analyzed for patterns. Fractures accounted for 13.9% of pediatric injuries and 15% of adult injuries. Among children, fracture incidence was highest in the group 10 to 14 years old and most frequently involved the forearm (19.0%). Fracture incidence was highest in adults 80 years and older and most frequently involved the lower trunk (16.2%). On average, the rate of pediatric fractures decreased by 2.34% per year (95% CI, 0.25% increase to 4.88% decrease; P=.0757). Among adults, fracture incidence increased 0.33% per year (95% CI, 2.34% decrease to 2.85% increase; P=.7892). This change was significantly different between the pediatric and adult populations (P=.0152). There was an increase in the annual proportion of adults with fractures who were admitted (odds ratio per 1-year increase, 1.05; 95% CI, 1.03-1.07; P<.0001). There was no change in the proportion of pediatric patients with fractures who were admitted (odds ratio, 1.02; 95% CI, 0.99-1.05; P=.0606). The incidence of fractures decreased in pediatric patients yet was relatively stable in adult patients. Conversely, the proportion of patients with fractures who were admitted increased, particularly among adults. These findings may suggest that less severe fractures are presenting elsewhere, falsely inflating the observed rise in admissions. [Orthopedics. 2023;46(6):e369-e375.].
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Diacinti D, Diacinti D, Iannacone A, Pepe J, Colangelo L, Nieddu L, Kripa E, Orlandi M, De Martino V, Minisola S, Cipriani C. Bone Marrow Adipose Tissue Is Increased in Postmenopausal Women With Postsurgical Hypoparathyroidism. J Clin Endocrinol Metab 2023; 108:e807-e815. [PMID: 36856793 DOI: 10.1210/clinem/dgad116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023]
Abstract
CONTEXT Suppression of bone turnover, greater trabecular volume, and normal-high normal all-site bone mineral density (BMD) are hallmarks of postsurgical hypoparathyroidism (HypoPT). Impairment in the trabecular microarchitecture with possible higher risk of vertebral fractures (VF) in women with postmenopausal HypoPT has also been described. Currently, no data on bone marrow adipose tissue (BMAT) are available in HypoPT. OBJECTIVE To assess BMAT by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H-MRS) in postmenopausal women with chronic postsurgical HypoPT. METHODS This cross-sectional pilot study, conducted at an ambulatory referral center, included 29 postmenopausal women (mean age 66 ± 8.4 years) with postsurgical HypoPT and 31 healthy postmenopausal women (mean age 63 ± 8.5). Lumbar spine MRI was performed and BMAT was measured by applying PRESS sequences on the L3 body. Lumbar spine, femoral neck, and total hip BMD were measured by dual x-ray absorptiometry (DXA); site-matched spine trabecular bone score (TBS) was calculated by TBS iNsight (Medimaps, Switzerland); VF assessment was performed with lateral thoracic and lumbar spine DXA. RESULTS Fat content (FC) and saturation level (SL%) were higher (P <.0001 and P <.001), while water content (W) was lower in HypoPT compared to controls (P <.0001). FC significantly correlated with years since menopause and body weight (P <.05) in HypoPT, while TBS negatively correlated with FC and SL% (P <.05) and positively with residual lipids (RL) and W (P <.05). CONCLUSION We demonstrate for the first time that BMAT is increased in postmenopausal women with postsurgical hypoparathyroidism and negatively associated with trabecular microarchitecture.
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Affiliation(s)
- Davide Diacinti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
- Department of Diagnostic and Molecular Imaging, Radiology and Radiotherapy, University Hospital Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Daniele Diacinti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Antonio Iannacone
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Luciano Colangelo
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Luciano Nieddu
- Faculty of Economics, UNINT University, Via Cristoforo Colombo 200, 00147 Rome, Italy
| | - Endi Kripa
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Martina Orlandi
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Viviana De Martino
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Iconaru L, Charles A, Baleanu F, Moreau M, Surquin M, Benoit F, de Filette J, Karmali R, Body JJ, Bergmann P. Selection for treatment of patients at high risk of fracture by the short versus long term prediction models - data from the Belgian FRISBEE cohort. Osteoporos Int 2023; 34:1119-1125. [PMID: 37022466 DOI: 10.1007/s00198-023-06737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/27/2023] [Indexed: 04/07/2023]
Abstract
Our imminent model was less sensitive but more selective than FRAX® in the choice of treatment to prevent imminent fractures. This new model decreased NNT by 30%, which could reduce the treatment costs. In the Belgian FRISBEE cohort, the effect of recency further decreased the selectivity of FRAX®. PURPOSE We analyzed the selection for treatment of patients at high risk of fracture by the Belgian FRISBEE imminent model and the FRAX® tool. METHODS We identified in the FRISBEE cohort subjects who sustained an incident MOF (mean age 76.5 ± 6.8 years). We calculated their estimated 10-year risk of fracture using FRAX® before and after adjustment for recency and the 2-year probability of fracture using the FRISBEE model. RESULTS After 6.8 years of follow-up, we validated 480 incident and 54 imminent MOFs. Of the subjects who had an imminent fracture, 94.0% had a fracture risk estimated above 20% by the FRAX® before correction for recency and 98.1% after adjustment, with a specificity of 20.2% and 5.9%, respectively. The sensitivity and specificity of the FRISBEE model at 2 years were 72.2% and 55.4%, respectively, for a threshold of 10%. For these thresholds, 47.3% of the patients were identified at high risk in both models before the correction, and 17.2% of them had an imminent MOF. The adjustment for recency did not change this selection. Before the correction, 34.2% of patients were selected for treatment by FRAX® only, and 18.8% would have had an imminent MOF. This percentage increased to 47% after the adjustment for recency, but only 6% of those would suffer a MOF within 2 years. CONCLUSION In our Belgian FRISBEE cohort, the imminent model was less sensitive but more selective in the selection of subjects in whom an imminent fracture should be prevented, resulting in a lower NNT. The correction for recency in this elderly population further decreased the selectivity of FRAX®. These data should be validated in additional cohorts before using them in everyday practice.
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Affiliation(s)
- L Iconaru
- Department of Endocrinology, CHU Brugmann, Université Libre de Bruxelles, Place van Gehuchten 4, 1020 Laeken, Brussels, Belgium.
| | - A Charles
- Laboratoire de Recherche Translationnelle, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - F Baleanu
- Department of Endocrinology, CHU Brugmann, Université Libre de Bruxelles, Place van Gehuchten 4, 1020 Laeken, Brussels, Belgium
| | - M Moreau
- Data Centre, Inst. J. Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - M Surquin
- Department of Internal Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - F Benoit
- Department of Internal Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - J de Filette
- Department of Endocrinology, CHU Brugmann, Université Libre de Bruxelles, Place van Gehuchten 4, 1020 Laeken, Brussels, Belgium
| | - R Karmali
- Department of Endocrinology, CHU Brugmann, Université Libre de Bruxelles, Place van Gehuchten 4, 1020 Laeken, Brussels, Belgium
- Department of Internal Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - J J Body
- Department of Endocrinology, CHU Brugmann, Université Libre de Bruxelles, Place van Gehuchten 4, 1020 Laeken, Brussels, Belgium
- Laboratoire de Recherche Translationnelle, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
- Department of Internal Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Bergmann
- Laboratoire de Recherche Translationnelle, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
- Department of Nuclear Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Li N, Beaudart C, Cauley JA, Ing SW, Lane NE, Reginster JY, Silverman S, Singer AJ, Hiligsmann M. Cost Effectiveness Analyses of Interventions for Osteoporosis in Men: A Systematic Literature Review. PHARMACOECONOMICS 2023; 41:363-391. [PMID: 36738425 PMCID: PMC10020287 DOI: 10.1007/s40273-022-01239-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 05/06/2023]
Abstract
BACKGROUND Osteoporosis is often considered to be a disease of women. Over the last few years, owing to the increasing clinical and economic burden, the awareness and imperative for identifying and managing osteoporosis in men have increased substantially. With the approval of agents to treat men with osteoporosis, more economic evaluations have been conducted to assess the potential economic benefits of these interventions. Despite this concern, there is no specific overview of cost-effectiveness analyses for the treatment of osteoporosis in men. OBJECTIVES This study aims (1) to systematically review economic evaluations of interventions for osteoporosis in men; (2) to critically appraise the quality of included studies and the source of model input data; and (3) to investigate the comparability of results for studies including both men and women. METHODS A literature search mainly using MEDLINE (via Ovid) and Embase databases was undertaken to identify original articles published between 1 January, 2000 and 30 June, 2022. Studies that assessed the cost effectiveness of interventions for osteoporosis in men were included. The Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases and the International Osteoporosis Foundation osteoporosis-specific guideline was used to assess the quality of design, conduct, and reporting of included studies. RESULTS Of 2973 articles identified, 25 studies fulfilled the inclusion criteria, classified into economic evaluations of active drugs (n = 8) or nutritional supplements (n = 4), intervention thresholds (n = 5), screening strategies (n = 6), and post-fracture care programs (n = 2). Most studies were conducted in European countries (n = 15), followed by North America (n = 9). Bisphosphonates (namely alendronate) and nutritional supplements were shown to be generally cost effective compared with no treatment in men over 60 years of age with osteoporosis or prior fractures. Two other studies suggested that denosumab was cost effective in men aged 75 years and older with osteoporosis compared with bisphosphates and teriparatide. Intervention thresholds at which bisphosphonates were found to be cost effective varied among studies with a 10-year probability of a major osteoporotic fracture that ranged from 8.9 to 34.2% for different age categories. A few studies suggested cost effectiveness of screening strategies and post-fracture care programs in men. Similar findings regarding the cost effectiveness of drugs and intervention thresholds in women and men were captured, with slightly greater incremental cost-effectiveness ratios in men. The quality of the studies included had an average score of 18.8 out of 25 (range 13-23.5). Hip fracture incidence and mortality risk were mainly derived from studies in men, while fracture cost, treatment efficacy, and disutility were commonly derived from studies in women or studies combining both sexes. CONCLUSIONS Anti-osteoporosis drugs and nutritional supplements are generally cost effective in men with osteoporosis. Screening strategies and post-fracture care programs also showed economic benefits for men. Cost-effectiveness and intervention thresholds were generally similar in studies conducted in both men and women, with slightly greater incremental cost-effectiveness ratios in men.
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Affiliation(s)
- Nannan Li
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Charlotte Beaudart
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Jane A Cauley
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven W Ing
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nancy E Lane
- Department of Medicine, University of California at Davis, School of Medicine, Sacramento, CA, USA
| | - Jean-Yves Reginster
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
- Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Stuart Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Andrea J Singer
- Departments of Obstetrics and Gynecology and Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands.
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11
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Pickhardt PJ, Correale L, Hassan C. AI-based opportunistic CT screening of incidental cardiovascular disease, osteoporosis, and sarcopenia: cost-effectiveness analysis. Abdom Radiol (NY) 2023; 48:1181-1198. [PMID: 36670245 DOI: 10.1007/s00261-023-03800-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To assess the cost-effectiveness and clinical efficacy of AI-assisted abdominal CT-based opportunistic screening for atherosclerotic cardiovascular (CV) disease, osteoporosis, and sarcopenia using artificial intelligence (AI) body composition algorithms. METHODS Markov models were constructed and 10-year simulations were performed on hypothetical age- and sex-specific cohorts of 10,000 U.S. adults (base case: 55 year olds) undergoing abdominal CT. Using expected disease prevalence, transition probabilities between health states, associated healthcare costs, and treatment effectiveness related to relevant conditions (CV disease/osteoporosis/sarcopenia) were modified by three mutually exclusive screening models: (1) usual care ("treat none"; no intervention regardless of opportunistic CT findings), (2) universal statin therapy ("treat all" for CV prevention; again, no consideration of CT findings), and (3) AI-assisted abdominal CT-based opportunistic screening for CV disease, osteoporosis, and sarcopenia using automated quantitative algorithms for abdominal aortic calcification, bone mineral density, and skeletal muscle, respectively. Model validity was assessed against published clinical cohorts. RESULTS For the base-case scenarios of 55-year-old men and women modeled over 10 years, AI-assisted CT-based opportunistic screening was a cost-saving and more effective clinical strategy, unlike the "treat none" and "treat all" strategies that ignored incidental CT body composition data. Over a wide range of input assumptions beyond the base case, the CT-based opportunistic strategy was dominant over the other two scenarios, as it was both more clinically efficacious and more cost-effective. Cost savings and clinical improvement for opportunistic CT remained for AI tool costs up to $227/patient in men ($65 in women) from the $10/patient base-case scenario. CONCLUSION AI-assisted CT-based opportunistic screening appears to be a highly cost-effective and clinically efficacious strategy across a broad array of input assumptions, and was cost saving in most scenarios.
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Affiliation(s)
- Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Heatlh, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Loredana Correale
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Cesare Hassan
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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12
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Belaya Z, Rozhinskaya L, Dedov I, Drapkina O, Fadeev V, Golounina O, Lesnyak O, Mamedova E, Melnichenko G, Petraikin A, Rodionova S, Skripnikova I, Tkacheva O, Toroptsova N, Yureneva S, Kanis JA. A summary of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis. Osteoporos Int 2023; 34:429-447. [PMID: 36651943 DOI: 10.1007/s00198-022-06667-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/29/2022] [Indexed: 01/19/2023]
Abstract
UNLABELLED Key statements of the Russian clinical guidelines on the diagnosis and treatment of osteoporosis are summarized. They were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis and approved by the Russian Ministry of Health. PURPOSE To summarize key statements of the Russian clinical practice guidelines for the diagnosis and treatment of osteoporosis. METHODS The Russian clinical guidelines on the diagnosis and treatment of osteoporosis were developed by a task force representing the key Russian professional associations involved in the management of osteoporosis: These comprised the Russian Association of Endocrinologists, the Russian Association for Osteoporosis, the Association of Rheumatologists of Russia, the Association of Orthopedic surgeons and Traumatologists of Russia, the Russian Association of Gynecologists-Endocrinologists, and the Russian Association of Gerontologists and Geriatrics. The guidelines are based on a systematic literature review and principles of evidence-based medicine and were compiled in accordance with the requirements for clinical recommendations developed by the Ministry of Health of the Russian Federation. RESULTS Key statements included in the Russian guidelines of osteoporosis approved by the Russian Ministry of Health in 2021 are summarized. The statements are graded based on levels of evidence and supported by short comments. The guidelines are focused on the current approach to screening, diagnosis, differential diagnosis, and treatment of osteoporosis. CONCLUSION These guidelines are a practical tool for general practitioners, as well as medical specialists, primarily endocrinologists, rheumatologists, orthopedic surgeons, and other physicians who are involved in the management of patients with osteoporosis.
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Affiliation(s)
- Zhanna Belaya
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia.
| | - Liudmila Rozhinskaya
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Ivan Dedov
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Oksana Drapkina
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Valentin Fadeev
- Department of Endocrinology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Olga Golounina
- Department of Endocrinology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Olga Lesnyak
- Family Medicine Department-Western State Medical University Named After I.I. Mechnikov, St. Petersburg, Russia
| | - Elizaveta Mamedova
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Galina Melnichenko
- Neuroendocrinology and Bone Diseases, Endocrinology Research Centre, Moscow, Russia
| | - Alexey Petraikin
- Department of Radiation Diagnostics, Research and Practical Clinical Center for Diagnostics, Telemedicine Technologies of Moscow Health Care Department, Moscow, Russia
| | - Svetlana Rodionova
- National Medical Research Center of Traumatology and Orthopedics named after. N.N. Priorov, Moscow, Russia
| | - Irina Skripnikova
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Olga Tkacheva
- Russian National Research Medical University Named After N.I. Pirogov, Moscow, Russia
| | | | - Svetlana Yureneva
- Department of Gynecological Endocrinology, National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After V.I. Kulakov, Moscow, Russia
| | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Center for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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13
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Rolland Y, Cruz-Jentoft AJ. Editorial: Sarcopenia: Keeping on Search for the Best Operational Definition. J Nutr Health Aging 2023; 27:202-204. [PMID: 36973928 DOI: 10.1007/s12603-023-1099-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Affiliation(s)
- Y Rolland
- Professor Yves Rolland, MD, PhD, Gérontopôle de Toulouse, Institut du Vieillissement, 37 allées Jules Guesdes, 31000 Toulouse, France, + 33 5 61 70 77 21, E-mail:
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14
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Reid IR. Doctors won't treat patients for conditions they don't have. Osteoporos Int 2023; 34:11-13. [PMID: 36357612 DOI: 10.1007/s00198-022-06580-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Ian R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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15
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Lott A, Pflug EM, Parola R, Egol KA, Konda SR. Predicting the Subsequent Contralateral Hip Fracture: Is FRAX the Answer? J Orthop Trauma 2022; 36:599-603. [PMID: 36399671 DOI: 10.1097/bot.0000000000002441] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To (1) determine the ability of the Fracture Risk Assessment Tool (FRAX) to identify the probability of contralateral hip fractures within 2 years of index fracture and (2) identify independent risk factors for a subsequent hip fracture. DESIGN Retrospective. SETTING Urban, academic medical center. PATIENTS This study included a consecutive series of patients treated for unilateral hip fractures between September 2015 and July 2019. RESULTS Eight hundred thirty-two consecutive patients were included in the analysis with a mean age of 81.2 ± 9.9 years. Thirty-one (3.7%) patients sustained a contralateral hip fracture within 2 years with these patients sustaining the second fracture at a mean 294.1 days ± 197.7 days. The average FRAX score for the entire cohort was 11.9 ± 7.4, and the area under receiving operating characteristic curve (AUROC) for FRAX score was 0.682 (95% CI, 0.596-0.767). Patients in the high-risk FRAX group had a >7% risk of contralateral hip fracture within 2 years. Independent risk factors for contralateral hip fracture risk included patient age 80 years or older and decreasing BMI. CONCLUSIONS This study demonstrates the strong ability of the FRAX score to triage patients at risk of subsequent contralateral hip fracture within 2 years. In this high-risk FRAX group, patients age older than 80 years and who have decreasing BMI after their index fracture have a 12.5% increased risk of fracture within 2 years which is 4× higher than the current World Health Organization 10-year 3% hip fracture risk standard used to initiate pharmacologic treatment. Therefore, high-risk patients identified using this methodology should be targeted more aggressively with preventative measures including social, medical, and potentially surgical interventions. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ariana Lott
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY
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16
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Reid IR. EXTENSIVE EXPERTISE IN ENDOCRINOLOGY: Osteoporosis management. Eur J Endocrinol 2022; 187:R65-R80. [PMID: 35984345 DOI: 10.1530/eje-22-0574] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
Fractures occur in about half of older White women, and almost a third of older White men. However, 80% of the older individuals who have fractures do not meet the bone density definition of osteoporosis, suggesting that this definition is not an appropriate threshold for offering treatment. Fracture risk can be estimated based on clinical risk factors with or without bone density. A combination of calculated risk, fracture history, and bone density is used in treatment decisions. Medications available for reducing fracture risk act either to inhibit bone resorption or to promote bone formation. Romosozumab is unique in that it has both activities. Bisphosphonates are the most widely used interventions because of their efficacy, safety, and low cost. Continuous use of oral bisphosphonates for >5 years increases the risk of atypical femoral fractures, so is usually punctuated with drug holidays of 6-24 months. Denosumab is a further potent anti-resorptive agent given as 6-monthly s.c. injections. It is comparable to the bisphosphonates in efficacy and safety but has a rapid offset of effect after discontinuation so must be followed by an alternative drug, usually a bisphosphonate. Teriparatide stimulates both bone formation and resorption, substantially increases spine density, and reduces vertebral and non-vertebral fracture rates, though data for hip fractures are scant. Treatment is usually limited to 18-24 months, followed by the transition to an anti-resorptive. Romosozumab is given as monthly s.c. injections for 1 year, followed by an anti-resorptive. This sequence prevents more fractures than anti-resorptive therapy alone. Because of cost, anabolic drugs are usually reserved for those at very high fracture risk. 25-hydroxyvitamin D levels should be maintained above 30 nmol/L, using supplements if sunlight exposure is limited. Calcium intake has little effect on bone density and fracture risk but should be maintained above 500 mg/day using dietary sources.
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Affiliation(s)
- Ian R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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17
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LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2022; 33:2049-2102. [PMID: 35478046 PMCID: PMC9546973 DOI: 10.1007/s00198-021-05900-y] [Citation(s) in RCA: 279] [Impact Index Per Article: 139.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/19/2021] [Indexed: 12/16/2022]
Abstract
Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.
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Affiliation(s)
- M. S. LeBoff
- Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA 02115 USA
| | - S. L. Greenspan
- University of Pittsburgh Medical Center, 1110 Kaufmann Building, 3471 Fifth Ave, Pittsburgh, PA 15213 USA
| | - K. L. Insogna
- Yale School of Medicine, 333 Cedar St, New Haven, CT 06520 USA
| | - E. M. Lewiecki
- University of New Mexico Health Sciences Center, 300 Oak St NE, Albuquerque, NM 87106 USA
| | - K. G. Saag
- University of Alabama at Birmingham, 1720 2nd Avenue South, FOT 820, Birmingham, AL 35294 USA
| | - A. J. Singer
- MedStar Georgetown University Hospital and Georgetown University Medical Center, 3800 Reservoir Road NW, 3rd Floor, Washington, DC 20007 USA
| | - E. S. Siris
- Columbia University Irving Medical Center, 180 Fort Washington Ave, Suite 9-903, New York, NY 10032 USA
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18
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Shar A, Aboutalebianaraki N, Misiti K, Sip YYL, Zhai L, Razavi M. A novel ultrasound-mediated nanodroplet-based gene delivery system for osteoporosis treatment. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2022; 41:102530. [PMID: 35104672 DOI: 10.1016/j.nano.2022.102530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/30/2021] [Accepted: 01/15/2022] [Indexed: 06/14/2023]
Abstract
This project aimed to develop, optimize, and test an ultrasound-responsive targeted nanodroplet system for the delivery of osteoporosis-related silencing gene Cathepsin K small interfering RNA (CTSK siRNA) for osteoporosis treatment. The nanodroplet (ND) is composed of a gas core made from perfluorocarbon, stabilized with albumin, encapsulated with CTSK siRNA, and embedded with alendronate (AL) for bone targeting (CTSK siRNA-ND-AL). Following the development, the responsiveness of CTSK siRNA-ND-AL to a therapeutic ultrasound probe was examined. The results of biocompatibility tests with human bone marrow-derived mesenchymal stem cells proved no significant cell death (P > 0.05). When the CTSK siRNA-ND-AL was supplemented with human osteoclast precursors, they suppressed osteoclastogenesis. Thus, this project establishes the potential of nanotechnology and ultrasound to deliver genes into the osteoclasts. This research also presents a novel ultrasound responsive and targeted nanodroplet platform that can be used as a gene and drug delivery system for various diseases including cancer.
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Affiliation(s)
- Angela Shar
- Biionix™ (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA; Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Nadia Aboutalebianaraki
- Biionix™ (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA; Department of Material Sciences and Engineering, University of Central Florida, Orlando, Florida, USA
| | - Kaylee Misiti
- Biionix™ (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Yuen Yee Li Sip
- Department of Material Sciences and Engineering, University of Central Florida, Orlando, Florida, USA; Nanoscience Technology Center, University of Central Florida, Orlando, Florida, USA
| | - Lei Zhai
- Nanoscience Technology Center, University of Central Florida, Orlando, Florida, USA; Department of Chemistry, University of Central Florida, Orlando, Florida, USA
| | - Mehdi Razavi
- Biionix™ (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA; Department of Material Sciences and Engineering, University of Central Florida, Orlando, Florida, USA.
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19
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Reid IR, Billington EO. Drug therapy for osteoporosis in older adults. Lancet 2022; 399:1080-1092. [PMID: 35279261 DOI: 10.1016/s0140-6736(21)02646-5] [Citation(s) in RCA: 215] [Impact Index Per Article: 107.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/14/2021] [Accepted: 11/11/2021] [Indexed: 02/07/2023]
Abstract
The goal of osteoporosis management is to prevent fractures. Several pharmacological agents are available to lower fracture risk, either by reducing bone resorption or by stimulating bone formation. Bisphosphonates are the most widely used anti-resorptives, reducing bone turnover markers to low premenopausal concentrations and reducing fracture rates (vertebral by 50-70%, non-vertebral by 20-30%, and hip by ~40%). Bisphosphonates bind avidly to bone mineral and have an offset of effect measured in months to years. Long term, continuous use of oral bisphosphonates is usually interspersed with drug holidays of 1-2 years, to minimise the risk of atypical femoral fractures. Denosumab is a monoclonal antibody against RANKL that potently inhibits osteoclast development and activity. Denosumab is administered by subcutaneous injection every 6 months. Anti-fracture effects of denosumab are similar to those of the bisphosphonates, but there is a pronounced loss of anti-resorptive effect from 7 months after the last injection, which can result in clusters of rebound vertebral fractures. Two classes of anabolic drugs are now available to stimulate bone formation. Teriparatide and abaloparatide both target the parathyroid hormone-1 receptor, and are given by daily subcutaneous injection for up to 2 years. Romosozumab is an anti-sclerostin monoclonal antibody that stimulates bone formation and inhibits resorption. Romosozumab is given as monthly subcutaneous injections for 1 year. Head-to-head studies suggest that anabolic agents have greater anti-fracture efficacy and produce larger increases in bone density than anti-resorptive drugs. The effects of anabolic agents are transient, so transition to anti-resorptive drugs is required. The optimal strategy for cycling anabolics, anti-resorptives, and off-treatment periods remains to be determined.
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Affiliation(s)
- Ian R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Auckland District Health Board, Auckland, New Zealand.
| | - Emma O Billington
- Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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20
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Abstract
Osteoporosis is a skeletal disease characterized by low bone density and poor bone quality that weakens bones and increases the risk of fractures. Serious consequences of fractures include disability, loss of independence, and death. Despite the availability of clinical tools to evaluate fracture risk and medications to reduce fracture risk, many or most patients at risk, even those with a recent fracture, are not being treated. This represents a large osteoporosis treatment gap that has reached a crisis level. Importantly, the treatment gap is not evenly distributed among populations of different race/ethnicity. Black women are less likely to have bone density testing when indicated, are less likely to be treated, and have worse outcomes after a fracture than White women. This is a review and update of race-based disparities and inequalities, with suggestions for interventions to optimize patient care.
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Affiliation(s)
- E Michael Lewiecki
- E. Michael Lewiecki, MD, New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM
- Sarah F. Erb, FNP-C, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Sarah F Erb
- E. Michael Lewiecki, MD, New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM
- Sarah F. Erb, FNP-C, University of New Mexico Health Sciences Center, Albuquerque, NM
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21
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McCloskey EV, Harvey NC, Johansson H, Lorentzon M, Liu E, Vandenput L, Leslie WD, Kanis JA. Fracture risk assessment by the FRAX model. Climacteric 2022; 25:22-28. [PMID: 34319212 DOI: 10.1080/13697137.2021.1945027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
The introduction of the FRAX algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. FRAX integrates the influence of several well-validated risk factors for fracture with or without the use of bone mineral density. Since age-specific rates of fracture and death differ across the world, FRAX models are calibrated with regard to the epidemiology of hip fracture (preferably from national sources) and mortality (usually United Nations sources). Models are currently available for 73 nations or territories covering more than 80% of the world population. FRAX has been incorporated into more than 80 guidelines worldwide, although the nature of this application has been heterogeneous. The limitations of FRAX have been extensively reviewed. Arithmetic procedures have been proposed in order to address some of these limitations, which can be applied to conventional FRAX estimates to accommodate knowledge of dose exposure to glucocorticoids, concurrent data on lumbar spine bone mineral density, information on trabecular bone score, hip axis length, falls history, type 2 diabetes, immigration status and recency of prior fracture.
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Affiliation(s)
- E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
| | - M Lorentzon
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Sweden
| | - E Liu
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
| | - L Vandenput
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Sweden
| | - W D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, VIC, Australia
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22
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Sribenjalak D, Charoensri S, Pongchaiyakul C. An optimal intervention threshold of FRAX in postmenopausal Thai women. Arch Osteoporos 2022; 17:21. [PMID: 35072805 DOI: 10.1007/s11657-022-01058-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/29/2021] [Indexed: 02/03/2023]
Abstract
This study was designed to determine a FRAX intervention threshold in postmenopausal Thais, based on a history of hip fracture. The optimal FRAX thresholds for hip fracture were 4.9% (without BMD) and 4% (with BMD), while the thresholds for major osteoporotic fracture were 9.8% (without BMD) and 8.9% (with BMD). INTRODUCTION Fracture Risk Assessment Tool (FRAX) has been widely used as an intervention threshold for initiating osteoporosis treatment. However, there is a lack of data to validate the threshold in Thai population. METHODS A cross-sectional study was conducted from January 2014 to February 2019. Postmenopausal women in the Northeast of Thailand whom has bone mineral density (BMD) measured using dual-energy X-ray absorptiometry (DXA) in the study period were recruited. Participants who had previously received anti-osteoporotic treatment were not eligible. FRAX score, both with and without BMD, was calculated using a Thai reference. Prevalent hip fracture was identified by reviewing the ICD-10 diagnosis from the hospital database during the study period. The receiver operating characteristic (ROC) curve and Youden index were used to determine the FRAX threshold in predicting hip fracture, based on the rationale that women with a prevalent hip fracture would be eligible for treatment. RESULTS A total of 2872 postmenopausal Thai women were recruited, with 45 sustained a recent hip fracture. In association with hip fracture, the optimal FRAX thresholds for hip fracture without and with BMD were 4.9% and 4%, respectively, with 71.1% sensitivity and 83.3% specificity, and 82.2% sensitivity and 78.6% specificity, while the optimal FRAX thresholds for major osteoporotic fracture (MOF) without and with BMD were 9.8% and 8.9%, respectively, with 75.6% sensitivity and 77.0% specificity, and 86.7% sensitivity and 70.9% specificity. CONCLUSION An optimal intervention threshold based on FRAX of hip fracture and MOF in postmenopausal Thai women is slightly different from the standard recommendation, which confirmed the marked variations of thresholds across ethnicities. The proposed threshold should be considered as new cutoff for initiating osteoporosis treatment in postmenopausal Thais.
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Affiliation(s)
- Dueanchonnee Sribenjalak
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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23
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Vescini F, Chiodini I, Falchetti A, Palermo A, Salcuni AS, Bonadonna S, De Geronimo V, Cesareo R, Giovanelli L, Brigo M, Bertoldo F, Scillitani A, Gennari L. Management of Osteoporosis in Men: A Narrative Review. Int J Mol Sci 2021; 22:ijms222413640. [PMID: 34948434 PMCID: PMC8705761 DOI: 10.3390/ijms222413640] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 12/12/2022] Open
Abstract
Male osteoporosis is a still largely underdiagnosed pathological condition. As a consequence, bone fragility in men remains undertreated mainly due to the low screening frequency and to controversies in the bone mineral density (BMD) testing standards. Up to the 40% of overall osteoporotic fractures affect men, in spite of the fact that women have a significant higher prevalence of osteoporosis. In addition, in males, hip fractures are associated with increased morbidity and mortality as compared to women. Importantly, male fractures occur about 10 years later in life than women, and, therefore, due to the advanced age, men may have more comorbidities and, consequently, their mortality is about twice the rate in women. Gender differences, which begin during puberty, lead to wider bones in males as compared with females. In men, follicle-stimulating hormones, testosterone, estrogens, and sex hormone-binding levels, together with genetic factors, interact in determining the peak of bone mass, BMD maintenance, and lifetime decrease. As compared with women, men are more frequently affected by secondary osteoporosis. Therefore, in all osteoporotic men, a complete clinical history should be collected and a careful physical examination should be done, in order to find clues of a possible underlying diseases and, ultimately, to guide laboratory testing. Currently, the pharmacological therapy of male osteoporosis includes aminobisphosphonates, denosumab, and teriparatide. Hypogonadal patients may be treated with testosterone replacement therapy. Given that the fractures related to mortality are higher in men than in women, treating male subjects with osteoporosis is of the utmost importance in clinical practice, as it may impact on mortality even more than in women.
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Affiliation(s)
- Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, 33100 Udine, Italy; (F.V.); (A.S.S.)
| | - Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, 20149 Milan, Italy; (A.F.); (S.B.)
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122 Milan, Italy;
- Correspondence:
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, 20149 Milan, Italy; (A.F.); (S.B.)
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, 00128 Rome, Italy;
| | - Antonio Stefano Salcuni
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, 33100 Udine, Italy; (F.V.); (A.S.S.)
| | - Stefania Bonadonna
- Istituto Auxologico Italiano, IRCCS, 20149 Milan, Italy; (A.F.); (S.B.)
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122 Milan, Italy;
| | | | - Roberto Cesareo
- Center of Metabolic Disease, S.M. Goretti Hospital, 04100 Latina, Italy;
| | - Luca Giovanelli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122 Milan, Italy;
| | - Martina Brigo
- Department of Medicine, University of Verona, 37129 Verona, Italy; (M.B.); (F.B.)
| | - Francesco Bertoldo
- Department of Medicine, University of Verona, 37129 Verona, Italy; (M.B.); (F.B.)
| | - Alfredo Scillitani
- Unit of Endocrinology, Ospedale “Casa Sollievo della Sofferenza”, IRCCS, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy;
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24
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Sosa-Henríquez M, Torregrosa O, Déniz A, Saavedra P, Ortego N, Turrión A, Pérez Castrillón JL, Díaz-Curiel M, Gómez-Alonso C, Martínez G, Antonio Blázquez J, Olmos-Martínez JM, Etxebarria Í, Caeiro JR, Mora-Peña D. Multiple vertebral fractures after suspension of denosumab. A series of 56 cases. Int J Clin Pract 2021; 75:e14550. [PMID: 34145944 DOI: 10.1111/ijcp.14550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Denosumab is a monoclonal antibody approved for the treatment of postmenopausal osteoporosis. The withdrawal of denosumab produces an abrupt loss of bone mineral density and may cause multiple vertebral fractures (MVF). OBJECTIVE The objective of this study is to study the clinical, biochemical, and densitometric characteristics in a large series of postmenopausal women who suffered MVF after denosumab withdrawal. Likewise, we try to identify those factors related to the presence of a greater number of vertebral fractures (VF). PATIENTS AND METHODS Fifty-six patients (54 women) who suffered MVF after receiving denosumab at least for three consecutive years and abruptly suspended it. A clinical examination was carried out. Biochemical bone remodelling markers (BBRM) and bone densitometry at the lumbar spine and proximal femur were measured. VF were diagnosed by magnetic resonance imaging MRI, X-ray, or both at dorsal and lumbar spine. RESULTS Fifty-six patients presented a total of 192 VF. 41 patients (73.2%) had not previously suffered VF. After discontinuation of the drug, a statistically significant increase in the BBRM was observed. In the multivariate analysis, only the time that denosumab was previously received was associated with the presence of a greater number of VF (P = .04). CONCLUSIONS We present the series with the largest number of patients collected to date. 56 patients accumulated 192 new VF. After the suspension of denosumab and the production of MVF, there was an increase in the serum values of the BBRM. The time of denosumab use was the only parameter associated with a greater number of fractures.
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Affiliation(s)
- Manuel Sosa-Henríquez
- University of Las Palmas de Gran Canaria, Investigation Group on Osteoporosis and Bone Mineral Metabolism, Hospital University Insular, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Oscar Torregrosa
- Internal Medicine Service, Hospital General University Elche, Elche, Alicante, Spain
| | - Alejandro Déniz
- Endocrinology Section, Hospital University Insular, Las Palmas de Gran Canaria, Spain
| | - Pedro Saavedra
- Mathematics Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Norberto Ortego
- Internal Medicine, Hospital University San Cecilio, Granada, Spain
| | - Ana Turrión
- Rheumatology Service, Hospital University Salamanca, Salamanca, Spain
| | | | - Manuel Díaz-Curiel
- Internal Medicine Service, Hospital University Fundación Jiménez Díaz, Madrid, Spain
| | - Carlos Gómez-Alonso
- Internal Medicine Service, Hospital University Central Asturias, Oviedo, Spain
| | | | | | | | | | - José Ramón Caeiro
- Orthopaedic Surgery Department, University Hospital of Santiago de Compostela, La Coruña, Spain
| | - Damián Mora-Peña
- Internal Medicine Service, Hospital Virgen de la Luz, Cuenca, Spain
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25
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Russell N, Grossmann M. Management of bone and metabolic effects of androgen deprivation therapy. Urol Oncol 2021; 39:704-712. [DOI: 10.1016/j.urolonc.2018.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 07/20/2018] [Accepted: 10/03/2018] [Indexed: 12/13/2022]
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Baleanu F, Iconaru L, Charles A, Kinnard V, Fils JF, Moreau M, Karmali R, Surquin M, Benoit F, Mugisha A, Paesmans M, Laurent MR, Bergmann P, Body JJ. Independent External Validation of FRAX and Garvan Fracture Risk Calculators: A Sub-Study of the FRISBEE Cohort. JBMR Plus 2021; 5:e10532. [PMID: 34532617 PMCID: PMC8441269 DOI: 10.1002/jbm4.10532] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/04/2021] [Accepted: 06/30/2021] [Indexed: 01/24/2023] Open
Abstract
Probabilistic models including clinical risk factors with or without bone mineral density (BMD) have been developed to estimate the 5‐ or 10‐year absolute fracture risk. We investigated the performance of the FRAX and Garvan tools in a well‐characterized population‐based cohort of 3560 postmenopausal, volunteer women, aged 60 to 85 years at baseline, included in the Fracture Risk Brussels Epidemiological Enquiry (FRISBEE) cohort, during 5 years of follow‐up. Baseline data were used to calculate the estimated 10‐year risk of hip and major osteoporotic fractures (MOFs) for each participant using FRAX (Belgium). We computed the 5‐year risk according to the Garvan model with BMD. For calibration, the predicted risk of fracture was compared with fracture incidence across a large range of estimated fracture risks. The accuracy of the calculators to predict fractures was assessed using the area under the receiver operating characteristic curves (AUC). The FRAX tool was well calibrated for hip fractures (slope 1.09, p < 0.001; intercept −0.001, p = 0.46), but it consistently underestimated the incidence of major osteoporotic fractures (MOFs) (slope 2.12, p < 0.001; intercept −0.02, p = 0.06). The Garvan tool was well calibrated for “any Garvan” fractures (slope 1.05, p < 0.001; intercept 0.01, p = 0.37) but largely overestimated the observed hip fracture rate (slope 0.32, p < 0.001; intercept 0.006, p = 0.05). The predictive value for hip fractures was better for FRAX (AUC: 0.841, 95% confidence interval [CI] 0.795–0.887) than for Garvan (AUC: 0.769, 95% CI 0.702–0.836, p = 0.01). The Garvan AUC for “any Garvan” fractures was 0.721 (95% CI 0.693–0.749) and FRAX AUC for MOFs was 0.708 (95% CI 0.675–0.741). In conclusion, in our Belgian cohort, FRAX estimated quite well hip fractures but underestimated MOFs, while Garvan overestimated hip fracture risk but showed a good estimation of “any Garvan” fractures. Both models had a good discriminatory value for hip fractures but only a moderate discriminatory ability for MOFs or “any Garvan” fractures. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Felicia Baleanu
- Department of Endocrinology, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Laura Iconaru
- Department of Endocrinology, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Alexia Charles
- Department of Clinical Research, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Virginie Kinnard
- Department of Geriatrics, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | | | - Michel Moreau
- Data Centre, Institute Jules Bordet Université Libre de Bruxelles Brussels Belgium
| | - Rafik Karmali
- Department of Endocrinology, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Murielle Surquin
- Department of Geriatrics, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Florence Benoit
- Department of Geriatrics, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Aude Mugisha
- Department of Geriatrics, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Marianne Paesmans
- Data Centre, Institute Jules Bordet Université Libre de Bruxelles Brussels Belgium
| | - Michaël R Laurent
- Centre for Metabolic Bone Diseases University Hospitals Leuven Leuven Belgium.,Imelda Hospital Bonheiden Belgium
| | - Pierre Bergmann
- Department of Nuclear Medicine, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
| | - Jean-Jacques Body
- Department of Endocrinology, CHU Brugmann Université Libre de Bruxelles Brussels Belgium
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Chandran M, Kwee A. Treatment indications and thresholds of intervention: consensus and controversies in osteoporosis. Climacteric 2021; 25:29-36. [PMID: 34313165 DOI: 10.1080/13697137.2021.1951205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A few indications for treatment and thresholds for intervention in osteoporosis have been propounded in the literature and recommended in guidelines. These include a bone mineral density (BMD) T-score ≤ -2.5, fracture probability-based scores and the presence of a fragility fracture. A low BMD is associated with an increased risk of fracture. However, a BMD T-score of ≤ -2.5 on its own does not capture fracture risk in its entirety. Fracture risk assessment tools that are based on clinical risk factors arose from the misgivings about using BMD T-scores in isolation to assess fracture risk. Algorithms such as FRAX, Garvan etc, integrate various clinical risk factors with or without BMD to compute the probability of a hip fracture or a major osteoporotic fracture over a finite period. These probabilities do not yield distinctive thresholds by themselves and need to be interpreted wisely and adopted by consensus. Evidence exists to show that treatment can decrease the risk of sustaining a second fracture. Therefore, patients with a fragility fracture should be considered for treatment. In this narrative interview, we will explore the strengths and limitations of some of these indications for treatment and will discuss the various points of contention surrounding them.
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Affiliation(s)
- M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - A Kwee
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
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28
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Chandran M, Mitchell PJ, Amphansap T, Bhadada SK, Chadha M, Chan DC, Chung YS, Ebeling P, Gilchrist N, Habib Khan A, Halbout P, Hew FL, Lan HPT, Lau TC, Lee JK, Lekamwasam S, Lyubomirsky G, Mercado-Asis LB, Mithal A, Nguyen TV, Pandey D, Reid IR, Suzuki A, Chit TT, Tiu KL, Valleenukul T, Yung CK, Zhao YL. Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region. Osteoporos Int 2021; 32:1249-1275. [PMID: 33502559 PMCID: PMC8192320 DOI: 10.1007/s00198-020-05742-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/11/2020] [Indexed: 01/07/2023]
Abstract
UNLABELLED Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care. PURPOSE Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development. METHODS We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards. RESULTS Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines. CONCLUSION The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.
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Affiliation(s)
- M Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, 20, College Road, Academia, Singapore, 169856, Singapore.
| | - P J Mitchell
- Synthesis Medical NZ Limited, Pukekohe, Auckland, New Zealand
| | - T Amphansap
- Department of Orthopedics, Police General Hospital, Bangkok, Thailand
| | - S K Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M Chadha
- Department of Endocrinology, Hinduja Hospital and Research Centre, Mumbai, India
| | - D-C Chan
- Internal Medicine, National University Hospital Chu-Tung Branch, Chinese Taipei, Taiwan
| | - Y-S Chung
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, South Korea
| | - P Ebeling
- Department of Medicine in the School of Clinical Sciences, Monash Health, Melbourne, Australia
| | - N Gilchrist
- Canterbury District Health Board, Christchurch, New Zealand
| | - A Habib Khan
- Section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - F L Hew
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | - H-P T Lan
- Musculoskeletal and Metabolic Unit, Biomedical Research Center, Pham Ngoc Thach University of Medicine, Bone and Muscle Research Group, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - T C Lau
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - J K Lee
- Department of Orthopedics, Beacon International Specialist Centre, Petaling Jaya, Malaysia
| | - S Lekamwasam
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | | | - L B Mercado-Asis
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - A Mithal
- Endocrinology, Diabetes Division, Mithal, M. Max Healthcare - Pan-Max, Gurgaon, India
| | - T V Nguyen
- Genetics and Epidemiology of Osteoporosis Laboratory, Bone Biology Division, Garvan Institute of Medical Reseach, Sydney, Australia
| | - D Pandey
- Department of Orthopaedics, National Trauma Centre, Kathmandu, Nepal
| | - I R Reid
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Suzuki
- Department of Endocrinology, School of Medicine, Fujita Health University, Toyoake, Japan
| | - T T Chit
- East Yangon General Hospital, Yangon, Myanmar
| | - K L Tiu
- Polytrauma and Fragility Fracture team, Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - T Valleenukul
- Department of Orthopedics, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - C K Yung
- Department of Endocrinology and Patient Safety Unit, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam
| | - Y L Zhao
- Department of Obstetrics and Gynecology, Beijing United Family Hospital, Beijing, China
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Li Y, Chen M, Lv H, Yin P, Zhang L, Tang P. A novel machine-learning algorithm for predicting mortality risk after hip fracture surgery. Injury 2021; 52:1487-1493. [PMID: 33386157 DOI: 10.1016/j.injury.2020.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/04/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although several risk stratification models have been developed to predict hip fracture mortality, efforts are still being placed in this area. Our aim is to (1) construct a risk prediction model for long-term mortality after hip fracture utilizing the RSF method and (2) to evaluate the changing effects over time of individual pre- and post-treatment variables on predicting mortality. METHODS 1330 hip fracture surgical patients were included. Forty-five admission and in-hospital variables were analyzed as potential predictors of all-cause mortality. A random survival forest (RSF) algorithm was applied in predictors identification. Cox regression models were then constructed. Sensitivity analyses and internal validation were performed to assess the performance of each model. C statistics were calculated and model calibrations were further assessed. RESULTS Our machine-learning RSF algorithm achieved a c statistic of 0.83 for 30-day prediction and 0.75 for 1-year mortality. Additionally, a COX model was also constructed by using the variables selected by RSF, c statistics were shown as 0.75 and 0.72 when applying in 2-year and 4-year mortality prediction. The presence of post-operative complications remained as the strongest risk factor for both short- and long-term mortality. Variables including fracture location, high serum creatinine, age, hypertension, anemia, ASA, hypoproteinemia, abnormal BUN, and RDW became more important as the length of follow-up increased. CONCLUSION The RSF machine-learning algorithm represents a novel approach to identify important risk factors and a risk stratification models for patients undergoing hip fracture surgery is built through this approach to identify those at high risk of long-term mortality.
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Affiliation(s)
- Yi Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China
| | - Ming Chen
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China
| | - Houchen Lv
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China
| | - Pengbin Yin
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China.
| | - Licheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China.
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China.
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Saul D, Drake MT. Update on Approved Osteoporosis Therapies Including Combination and Sequential Use of Agents. Endocrinol Metab Clin North Am 2021; 50:179-191. [PMID: 34023037 DOI: 10.1016/j.ecl.2021.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Osteoporosis is characterized by reduced bone mass leading to diminished skeletal integrity and an increased risk for fracture. Multiple agents exist that are effective for the treatment of osteoporosis. These can be broadly categorized into those that reduce the risk for additional loss of bone mass (anti-resorptive agents) and those that augment existing bone mass (anabolic agents). This article reviews the different medications within each class, and discusses more recent data regarding the combination and sequential use of these medications for optimization of skeletal health in patients at high risk for fracture.
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Affiliation(s)
- Dominik Saul
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA; Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA; Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University of Göttingen, Robert-Koch-Str. 40, Göttingen 37075, Germany
| | - Matthew T Drake
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA; Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA.
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Ross EL, Zuromski KL, Reis BY, Nock MK, Kessler RC, Smoller JW. Accuracy Requirements for Cost-effective Suicide Risk Prediction Among Primary Care Patients in the US. JAMA Psychiatry 2021; 78:642-650. [PMID: 33729432 PMCID: PMC7970389 DOI: 10.1001/jamapsychiatry.2021.0089] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/17/2021] [Indexed: 12/30/2022]
Abstract
Importance Several statistical models for predicting suicide risk have been developed, but how accurate such models must be to warrant implementation in clinical practice is not known. Objective To identify threshold values of sensitivity, specificity, and positive predictive value that a suicide risk prediction method must attain to cost-effectively target a suicide risk reduction intervention to high-risk individuals. Design, Setting, and Participants This economic evaluation incorporated published data on suicide epidemiology, the health care and societal costs of suicide, and the costs and efficacy of suicide risk reduction interventions into a novel decision analytic model. The model projected suicide-related health economic outcomes over a lifetime horizon among a population of US adults with a primary care physician. Data analysis was performed from September 19, 2019, to July 5, 2020. Interventions Two possible interventions were delivered to individuals at high predicted risk: active contact and follow-up (ACF; relative risk of suicide attempt, 0.83; annual health care cost, $96) and cognitive behavioral therapy (CBT; relative risk of suicide attempt, 0.47; annual health care cost, $1088). Main Outcomes and Measures Fatal and nonfatal suicide attempts, quality-adjusted life-years (QALYs), health care sector costs and societal costs (in 2016 US dollars), and incremental cost-effectiveness ratios (ICERs) (with ICERs ≤$150 000 per QALY designated cost-effective). Results With a specificity of 95% and a sensitivity of 25%, primary care-based suicide risk prediction could reduce suicide death rates by 0.5 per 100 000 person-years (if used to target ACF) or 1.6 per 100 000 person-years (if used to target CBT) from a baseline of 15.3 per 100 000 person-years. To be cost-effective from a health care sector perspective at a specificity of 95%, a risk prediction method would need to have a sensitivity of 17.0% or greater (95% CI, 7.4%-37.3%) if used to target ACF and 35.7% or greater (95% CI, 23.1%-60.3%) if used to target CBT. To achieve cost-effectiveness, ACF required positive predictive values of 0.8% for predicting suicide attempt and 0.07% for predicting suicide death; CBT required values of 1.7% for suicide attempt and 0.2% for suicide death. Conclusions and Relevance These findings suggest that with sufficient accuracy, statistical suicide risk prediction models can provide good health economic value in the US. Several existing suicide risk prediction models exceed the accuracy thresholds identified in this analysis and thus may warrant pilot implementation in US health care systems.
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Affiliation(s)
- Eric L. Ross
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Kelly L. Zuromski
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Ben Y. Reis
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jordan W. Smoller
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Psychiatric and Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston
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Cipriani C, Minisola S, Bilezikian JP, Diacinti D, Colangelo L, Piazzolla V, Angelozzi M, Nieddu L, Pepe J, Diacinti D. Vertebral Fracture Assessment in Postmenopausal Women With Postsurgical Hypoparathyroidism. J Clin Endocrinol Metab 2021; 106:1303-1311. [PMID: 33567075 PMCID: PMC8063231 DOI: 10.1210/clinem/dgab076] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Hypoparathyroidism is a rare endocrine disorder whose skeletal features include suppression of bone turnover and greater volume and width of the trabecular compartment. Few and inconsistent data are available on the prevalence of vertebral fractures (VF). OBJECTIVE To evaluate the prevalence of VF assessed by vertebral fracture assessment (VFA) in postmenopausal women with chronic postsurgical hypoparathyroidism. DESIGN Cross-sectional study. SETTING Ambulatory referral center. PATIENTS OR OTHER PARTICIPANTS Fifty postmenopausal women (mean age 65.4 ± 9 years) with chronic postsurgical hypoparathyroidism and 40 age-matched healthy postmenopausal women (mean age 64.2 ± 8.6). MAIN OUTCOME MEASURES Lumbar spine, femoral neck, and total hip bone mineral density were measured by dual X-ray absorptiometry (Hologic Inc., USA) in all subjects. Site-matched spine trabecular bone score was calculated by TBS iNsight (Medimaps, Switzerland). Assessment of VF was made by VFA (iDXA, Lunar GE, USA) using the semiquantitative method and the algorithm-based qualitative assessment. RESULTS All-site BMD values were higher in the hypoparathyroid vs the control group. By VFA, we observed a 16% prevalence of VF in hypoparathyroid women vs 7.5% in control subjects. Among those with hypoparathyroidism who fractured, 5 (62.5%) had grade 1 wedge, 2 (25%) had grade 2 wedge, and 1 (12.5%) had grade 2 wedge and grade 2 biconcave VF. In the hypoparathyroid group, 57% with VFs and 32% without VFs had symptoms of hypoparathyroidism. CONCLUSION We demonstrate for the first time that in postmenopausal women with chronic postsurgical hypoparathyroidism, VFs are demonstrable by VFA despite normal BMD.
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Affiliation(s)
- Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
- Corresponding Author: Cristiana Cipriani, Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy. E-mail:
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - John P Bilezikian
- Division of Endocrinology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Davide Diacinti
- Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Italy
- Department of Diagnostic and Molecular Imaging, Radiology and Radiotherapy, University Tor Vergata, Rome, Italy
| | - Luciano Colangelo
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
- Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Italy
| | - Valentina Piazzolla
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Maurizio Angelozzi
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Luciano Nieddu
- Faculty of Economics, UNINT University, Via Cristoforo Colombo, Rome, Italy
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Daniele Diacinti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena, Rome, Italy
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FRAX-based osteoporosis treatment guidelines for resource-poor settings in India. Arch Osteoporos 2021; 16:69. [PMID: 33852082 DOI: 10.1007/s11657-021-00931-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/09/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Using the FRAX® model for India, thresholds for osteoporosis evaluation and treatment without bone mineral density measurement were derived and were validated in a cohort of 300 patients. We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis in India. PURPOSE Our study aimed to formulate population-specific intervention thresholds for treatment of osteoporosis in India which can be used even without dual X-ray absorptiometry (DXA). METHODS Using the FRAX® model for India, thresholds for different age groups for men and women were calculated without bone mineral density (BMD) measurement. The lower assessment threshold (LAT) was based on the 10-year probability of a major osteoporosis fracture (MOF) or hip fracture (HF) equivalent to patients without clinical risk factors. The intervention threshold (IT) was based on the 10-year probability equivalent to patients with fracture. The upper assessment threshold (UAT) was set at 1.2 times the IT. Probability-based thresholds for no intervention (LAT), treatment initiation (UAT) and BMD assessment (between LAT and UAT) were derived. The thresholds were validated in a cohort of 300 patients who were referred for BMD testing. RESULTS Graphs for age, gender, BMI and ethnic-specific LAT, IT and UAT for MOF and HF are derived. In the validation cohort, BMD testing to initiate/defer treatment was required in only 32.3% patients. The intervention thresholds derived without BMD testing were valid in 98.7% patients. Use of National Osteoporosis Foundation (NOF) guidelines would have resulted in overtreatment in 56/300 (18.6%) patients. CONCLUSION We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis. Adopting these cut-offs will ensure that those requiring osteoporosis treatment will not be denied of it just because of lack of a DXA machine and will also help avoid overtreatment.
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Varney E, Abou Elkassem A, Khan M, Parker E, Nichols T, Joyner D, Lirette ST, Howard-Claudio C, Smith AD. Prospective validation of a rapid CT-based bone mineral density screening method using colored spinal images. Abdom Radiol (NY) 2021; 46:1752-1760. [PMID: 33044652 DOI: 10.1007/s00261-020-02791-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/18/2020] [Accepted: 09/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To prospectively validate a method to accurately and rapidly differentiate normal from abnormal spinal bone mineral density (BMD) using colored abdominal CT images. METHODS For this prospective observational study, 196 asymptomatic women ≥ 50 years of age presenting for screening mammograms underwent routine nonenhanced CT imaging of the abdomen. The CT images were processed with software designed to generate sagittal colored images with green vertebral trabecular bone indicating normal BMD and red indicating abnormal BMD (low BMD or osteoporosis). Four radiologists evaluated L1/L2 BMD on sagittal images using visual assessment of grayscale images, quantitative measurements of mean vertebral attenuation, and visual assessment of colored images. Mean BMD values at L1/L2 using quantitative CT with a phantom served as the reference standard. The average accuracy and time of interpretation were calculated. Inter-observer agreement was assessed using intraclass correlation coefficient (ICC). RESULTS Mean attenuation at L1/L2 was highly correlated with mean BMD (r = 0.96/0.91, p < 0.001 for both). The average accuracy and mean time to assess BMD among four readers for differentiating normal from abnormal BMD was 66% and 6.0 s using visual assessment of grayscale images, 88% and 15.2 s using quantitative measurements of mean vertebral attenuation, and 92% and 2.1 s using visual assessment of colored images (p < 0.001 and p < 0.001, respectively). Inter-observer agreement was poor using visual assessment of grayscale images (ICC:0.31), good using quantitative measurements of mean vertebral attenuation (ICC:0.73), and excellent using visual assessment of colored images (ICC:0.90). CONCLUSION Detection of abnormal BMD using colored abdominal CT images was highly accurate, rapid, and had excellent inter-observer agreement.
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Affiliation(s)
- Elliot Varney
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Asser Abou Elkassem
- Department of Radiology, University of Alabama at Birmingham, JTN 405, 619 19th Street South, Birmingham, AL, 35249-6830, USA.
| | - Majid Khan
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ellen Parker
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Todd Nichols
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - David Joyner
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Seth T Lirette
- Center for Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Andrew D Smith
- Department of Radiology, University of Alabama at Birmingham, JTN 405, 619 19th Street South, Birmingham, AL, 35249-6830, USA
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Cauley JA, Shoback DM. Bone age is not just for kids. eLife 2021; 10:66916. [PMID: 33650970 PMCID: PMC7924936 DOI: 10.7554/elife.66916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 11/26/2022] Open
Abstract
More informed discussions between physicians and older adults about the consequences of an initial osteoporotic fracture could encourage more patients to consider treatments that protect against future fracture.
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Affiliation(s)
- Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, United States
| | - Dolores M Shoback
- Endocrine Research Unit, San Francisco Department of Veterans Affairs Medical Center, Department of Medicine, University of California, San Francisco, San Francisco, United States
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Belaya ZE, Rozhinskaya LY, Grebennikova TA, Kanis JA, Pigarova EA, Rodionova SS, Toroptsova NV, Nikitinskaya OA, Skripnikova IA, Drapkina OМ, Ershova OV, Biryukova EV, Lesnyak OМ, Tsoriev TТ, Belova KY, Marchenkova LА, Dzeranova LK, Dreval’ AV, Mamedova EO, Tkacheva ON, Dudinskaya EN, Nikankina LV, Farba LY, Chernova TO, Yureneva SV, Yakushevskaya OV, Ilyukhina OB, Kryukova IV, Tarbaeva NV, Petryaykin AV, Zagorodniy NV, Mel’nichenko GА, Dedov II. Summary of the draft federal clinical guidelines for osteoporosis. ACTA ACUST UNITED AC 2021. [DOI: 10.14341/osteo12710] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A summary of the draft federal clinical guidelines on osteoporosis developed by members of the Russian Association of Endocrinologists, the Russian Association for Osteoporosis, the Association of Rheumatologists of Russia, the Association of Traumatologists and Orthopedists of Russia, the Russian Association for Menopause and the Russian Association of Gerontologists and Geriatrics is presented. The recommendations were developed from the perspective of evidence-based medicine, in accordance with the requirements for compiling clinical recommendations of the Ministry of Health of Russia published in 2019. A significant place is given to screening of primary osteoporosis in adults, differential diagnosis with other metabolic diseases of the skeleton, modern methods of diagnosing osteoporosis, principles of prescribing pathogenetic treatment, features of sequential and combination therapy, disease prevention and rehabilitation. Clinical recommendations will be useful both to general practitioners and physicians, as well as to narrow specialists, primarily endocrinologists, rheumatologists, orthopedic traumatologists, nephrologists, obstetrician-gynecologists and neurologists, since osteoporosis is a multifactorial and multidisciplinary disease.
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Affiliation(s)
| | | | | | - John A. Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield; Catholic University of Australia, Melbourne
| | | | | | | | | | | | | | | | - Elena V. Biryukova
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Olga М. Lesnyak
- North-Western State Medical University named after I.I. Mechnikov
| | | | - Kseniya Y. Belova
- Yaroslavl State Medical University; Clinical emergency hospital named. N. V. Soloviev
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Alexey V. Petryaykin
- Scientific and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Department of Health
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Chandran M. AACE/ACE Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis-2020 Update: Risk Stratification and Intervention Thresholds. Endocr Pract 2021; 27:378. [PMID: 33577970 DOI: 10.1016/j.eprac.2021.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore.
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Francis J, Toh LS, Sellappans R, Loo JSE. Awareness of osteoporosis risk assessment tools and screening recommendations among community pharmacists in Malaysia. Int J Clin Pharm 2021; 43:604-612. [PMID: 33507463 DOI: 10.1007/s11096-020-01169-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Abstract
Background The incidence of osteoporosis in Malaysia is increasing due to a fast-ageing population. Because of its silent nature, various osteoporosis risk assessment tools exist to detect high-risk patients and facilitate referrals for bone mineral density measurements. As an accessible point of contact, community pharmacists would benefit from the utilization of these tools and familiarity with guideline recommendations for osteoporosis screening. Aim This study aimed to investigate the awareness of osteoporosis risk assessment tools, practice behaviour towards osteoporosis, and knowledge of guideline recommendations among community pharmacists in the Klang Valley, Malaysia. Setting Community pharmacies. Methods This study was a cross-sectional study which sampled 284 community pharmacists practicing in the Klang Valley, using a stratified sampling approach. The study was conducted using a self-administered questionnaire which was divided into three sections: demographic data, knowledge of osteoporosis risk assessment tools and guideline recommendations, and practice behaviour towards osteoporosis. Practice behaviour was assessed with 15 items using a 5-point Likert scale. Main outcome measure. Proportion of respondents aware of osteoporosis risk assessment tools and respondent knowledge on guideline recommendations for osteoporosis screening. Results A total of 284 community pharmacists participated in the study. 84.1% of the respondents were aware of at least one risk assessment tool. However, only a small proportion of pharmacists (14.9%) regularly used these tools in their practice. Respondents perceived these tools to be relevant and beneficial, but perception towards their accessibility, ease-of-use, and administration time was mixed, suggesting unfamiliarity. Respondents preferred to conduct clinical assessments based on risk factors, with respondents identifying a mean of 10.1 ± 3.4 out of 15 risk factors. However, several clinically relevant risk factors were frequently unidentified. Knowledge of guideline recommendations among respondents was low. Conclusion There is some awareness of osteoporosis risk assessment tools but use in practice remains low among community pharmacists in Malaysia. There is potential to increase the use of these tools and knowledge of recommendations for osteoporosis screening and referral among community pharmacists.
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Affiliation(s)
- Jezreel Francis
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, No. 1 Jalan Taylors, 47500, Subang Jaya, Selangor, Malaysia
| | - Li Shean Toh
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Renukha Sellappans
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, No. 1 Jalan Taylors, 47500, Subang Jaya, Selangor, Malaysia
| | - Jason S E Loo
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, No. 1 Jalan Taylors, 47500, Subang Jaya, Selangor, Malaysia.
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Chandran M, Ganesan G, Tan K, Reginster JY, Hiligsmann M. Cost-effectiveness of FRAX®-based intervention thresholds for management of osteoporosis in Singaporean women. Osteoporos Int 2021; 32:133-144. [PMID: 32797250 PMCID: PMC7755873 DOI: 10.1007/s00198-020-05536-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022]
Abstract
UNLABELLED Cost-effectiveness analysis of FRAX® intervention thresholds (ITs) in Singaporean women > 50 years of age showed that generic alendronate was cost-effective at age-dependent major osteoporotic fracture (MOF) IT from the ages of 65 years for both full and real-world adherence whilst hip fracture (HF) ITs were cost-effective from the ages of 60 and 65 years. Alendronate was cost-effective irrespective of age only at fixed MOF IT of 14% and HF IT of 3.5%. INTRODUCTION FRAX®-based intervention thresholds (ITs) were recently identified for osteoporosis management in Singapore. This study aimed to assess the cost-effectiveness of ITs in Singaporean women over the age of 50 years. METHODS A validated Markov microsimulation model was used to estimate the lifetime healthcare costs (SGD2019) per quality-adjusted life-years (QALY) of generic alendronate compared with no treatment. Cost-effectiveness of age-dependent FRAX® major osteoporotic fracture (MOF) and hip fracture (HF) ITs was explored. In addition, ITs that would lead to cost-effectiveness were computed. Fracture incidence and cost data were obtained from the Ministry of Health and a previously published Singaporean study. A cost-effectiveness threshold of SGD 62,500/QALY gained was used, based conservatively on 0.7 times the Singapore GDP per capita. RESULTS Generic alendronate was shown to be cost-effective at MOF ITs from the ages of 65 years, while HF ITs were cost-effective from the ages of 60 and 65 years, assuming full and real-world adherence, respectively. A 14% MOF and a 3.5% HF ITs were required for alendronate to be cost-effective above 50 years. CONCLUSION This study suggests that the treatment of Singaporean women with alendronate is cost-effective at age-dependant FRAX® intervention thresholds at 65 years and older. Furthermore, identifying women at any age above 50 years with a 10-year risk of MOF or HF of 14% or 3.5% would lead to efficient use of resources. Cost-effective access to therapy for patients at high fracture probability based on FRAX® could contribute to reduce the growing burden of osteoporotic fractures in Singapore.
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Affiliation(s)
- M. Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - G. Ganesan
- Ministry of Health, Singapore, Singapore
| | - K.B. Tan
- Ministry of Health, Singapore, Singapore
- School of Public Health, National University of Singapore, Singapore, Singapore
| | - J.-Y. Reginster
- Center for Investigation in Bone and Articular Cartilage, University of Liege, Liège, Belgium
| | - M. Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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Ito K. Cost-effectiveness of Screening for Osteoporosis in Older Men With a History of Falls. JAMA Netw Open 2020; 3:e2027584. [PMID: 33258906 PMCID: PMC7708999 DOI: 10.1001/jamanetworkopen.2020.27584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/06/2020] [Indexed: 12/01/2022] Open
Abstract
Importance Falls and osteoporosis share the potential clinical end point of fractures among older patients. To date, few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures. Objective To assess the cost-effectiveness of screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) followed by osteoporosis treatment in older men with a history of falls. Design, Setting, and Participants In this economic evaluation, a Markov model was developed to simulate the incidence of major osteoporotic fractures in a hypothetical cohort of community-dwelling men aged 65 years who had fallen at least once in the past year. Data sources included literature published from January 1, 1946, to July 31, 2020. The model adopted a societal perspective, a lifetime horizon, a 1-year cycle length, and a discount rate of 3% per year for both health benefits and costs. The analysis was designed and conducted from October 1, 2019, to September 30, 2020. Interventions Screening with DXA followed by treatment for men diagnosed with osteoporosis compared with usual care. Main Outcomes and Measures Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained. Results Among the hypothetical cohort of men aged 65 years, the screening strategy had an ICER of $33 169/QALY gained and was preferred over usual care at the willingness-to-pay threshold of $100 000/QALY gained. The number needed to screen to prevent 1 hip fracture was 1876; to prevent 1 major osteoporotic fracture, 746. The screening strategy would become more effective and less costly than usual care for men 77 years and older. The ICER for the screening strategy did not substantially change across a wide range of assumptions tested in all other deterministic sensitivity analyses. At a willingness-to-pay threshold of $50 000/QALY gained, screening was cost-effective in 56.0% of simulations; at $100 000/QALY gained, 90.8% of simulations; and at $200 000/QALY gained, 99.6% of simulations. Conclusions and Relevance These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources. Fall history could be a useful cue to trigger assessment for osteoporosis in men.
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Affiliation(s)
- Kouta Ito
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester
- Meyers Primary Care Institute, Worcester, Massachusetts
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Abstract
INTRODUCTION Preclinical, clinical, and population-based studies have provided evidence that anti-diabetic drugs affect bone metabolism and may affect the risk of fracture in diabetic patients. AREAS COVERED An overview of the skeletal effects of anti-diabetic drugs used in type 2 diabetes is provided. Searches on AdisInsight, PubMed, and Medline databases were conducted up to 1st July 2020. The latest evidence from randomized clinical trials and population-based studies on the skeletal safety of the most recent drugs (DPP-4i, GLP-1RA, and SGLT-2i) is provided. EXPERT OPINION Diabetic patients present with a higher risk of fracture for a given bone mineral density suggesting a role of bone quality in the etiology of diabetic fracture. Bone quality is difficult to assess in human clinical practice and the use of preclinical models provides valuable information on diabetic bone alterations. As several links have been established between bone and energy homeostasis, it is interesting to study the safety of anti-diabetic drugs on the skeleton. So far, evidence for the newest molecules suggests a neutral fracture risk, but further studies, especially in different types of patient populations (patients at risk or with history of cardiovascular disease, renal impairment, neuropathy) are required to fully appreciate this matter.
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Affiliation(s)
- Guillaume Mabilleau
- Groupe Etude Remodelage Osseux et biomatériaux, GEROM, UPRES EA 4658, UNIV Angers, SFR ICAT 4208, Institut de Biologie en Santé , Angers, France
- Service Commun d'Imagerie et Analyses Microscopiques, SCIAM, UNIV Angers, SFR ICAT 4208, Institut de Biologie en Santé , Angers, France
- Bone pathology unit, Angers University hospital , Angers Cedex, France
| | - Béatrice Bouvard
- Groupe Etude Remodelage Osseux et biomatériaux, GEROM, UPRES EA 4658, UNIV Angers, SFR ICAT 4208, Institut de Biologie en Santé , Angers, France
- Rheumatology department, Angers University Hospital , Angers Cedex, France
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Christensen DL, Nappo KE, Wolfe JA, Tropf JG, Berge MJ, Wheatley BM, Saxena S, Yow BG, Tintle SM. Ten-year fracture risk predicted by proximal femur Hounsfield units. Osteoporos Int 2020; 31:2123-2130. [PMID: 32594205 DOI: 10.1007/s00198-020-05477-y] [Citation(s) in RCA: 4] [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: 10/01/2019] [Accepted: 05/25/2020] [Indexed: 12/28/2022]
Abstract
UNLABELLED Colon cancer screening occurs at younger ages than osteoporosis screening. Bone density measurements using virtual colonoscopy performed for colon cancer screening can provide an early warning sign of patients at potential risk for osteoporosis-related fractures. Earlier identification may improve treatment and potentially fracture prevention. INTRODUCTION Opportunistic osteoporosis screening with computed tomography colonography (CTC) offers an opportunity to capitalize on earlier colorectal cancer screening to identify patients at risk of future fractures. The purpose of this study is to evaluate 10-year fracture and specifically hip fracture risk based on Hounsfield units (HU) obtained from CTC. METHODS We identified all CTC scans between 2004 and 2007 of patients 40 years and older with 10 years minimum follow-up. Hounsfield units were measured within the proximal femur and fractures identified via worldwide military records. Patients were stratified into two cohorts based on the presence or lack of a fracture in the wrist, spine, hip, or proximal humerus. Hounsfield unit measurements were compared between groups using Student's t test and the HU threshold was calculated that best approximated an 80% sensitivity to optimally screen patients for fracture risk. The odds ratio, negative predictive value, 10-year incidence of fracture, and survival curves were calculated. RESULTS We identified 3711 patients with 183 fractures over 10 years. The HU threshold that corresponded with an 80% sensitivity to identify fractures was 112 HU. The negative predictive value (NPV) for overall fractures and hip fractures was over 97%. The 10-year fracture incidence was higher in patients below 112 HU compared to those above for both overall fractures (6.3% vs 1.7%) and hip fractures (2.7% vs 0.07%). The 112 HU threshold corresponds with an odds ratio for overall fracture and hip fractures of 2.5 (95% confidence interval (CI), 1.7-3.6) and 24.5 (95% CI, 3.3-175.5), respectively. CONCLUSION In the 10 years following CTC, patients who experienced a fracture had lower hip HU. Decreasing HU on CTC may be an early warning sign of fracture potential.
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Affiliation(s)
- D L Christensen
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - K E Nappo
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - J A Wolfe
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - J G Tropf
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - M J Berge
- Department of Radiology, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - B M Wheatley
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - S Saxena
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - B G Yow
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - S M Tintle
- Department of Surgery Orthopaedic Service, Walter Reed National Military Medical Center, Uniformed Services University-Walter Reed, 8901 Rockville Pike, Bethesda, MD, 20889, USA.
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Smith AD. Automated Screening for Future Osteoporotic Fractures on Abdominal CT: Opportunistic or an Outstanding Opportunity? Radiology 2020; 297:73-74. [DOI: 10.1148/radiol.2020202900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew D. Smith
- From the Department of Radiology, University of Alabama School of Medicine, 619 19th St S, JTN 452, Birmingham, AL 35249-6830
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Singh V, Pal AK, Biswas D, Ghosh A, Singh BP. Identification of patients at high risk of fragility fractures in an Indian clinical setting using FRAX. Arch Osteoporos 2020; 15:131. [PMID: 32808058 DOI: 10.1007/s11657-020-00807-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/12/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A case-control study was done to decipher whether the FRAX tool was useful in India. Several values around the mean and median of the FRAX score of the case group were assessed to calculate sensitivity, specificity, positive predictive value, negative predictive value, Youden's index and odds ratio, and to detect high-risk individuals. PURPOSE The Fracture Risk Assessment Tool (FRAX) appears useful to diagnose fragility fractures. The study aims to answer whether the FRAX tool has utility in India. METHODS One hundred ten cases with a history of recent fragility fractures and 84 controls with no fractures were included in the study. FRAX scores without bone mineral density (BMD), and also with it, of participants were calculated. Several cutoff FRAX scores were chosen around mean and median FRAX score of cases. The odds ratio was calculated along with sensitivity, specificity, positive predictive value, negative predictive value and Youden's index. The most ideal cutoff was chosen to construct a hypothetical model to detect individuals at high risk. RESULTS The FRAX score with BMD and without BMD exhibited relatively high specificity and moderate to low sensitivity implying that FRAX scores above cutoff have diagnostic value. Cutoffs at which FRAX score without BMD exhibited high specificity (> 90%) were chosen to construct a hypothetical model. Patients with FRAX score without BMD in the intermediate range be advised dual-energy X-ray absorptiometry (DEXA) followed by recalculation of FRAX score with BMD. DEXA scan T score less than - 2.5 or FRAX score with BMD above the cutoff at which specificity was high (> 80%) were included to construct the hypothetical model. Patients with low FRAX score could be followed up. The hypothetical model was applied to the case group to analyse its detection potential. CONCLUSION FRAX has utility in India. It cuts the cost of screening and limits the use of expensive investigation.
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Affiliation(s)
- Vaibhav Singh
- Department of Orthopaedics, IPGME&R and SSKM Hospital, Kolkata, India.
| | - Ananda Kisor Pal
- Department of Orthopaedics, IPGME&R and SSKM Hospital, Kolkata, India
| | - Dibyendu Biswas
- Department of Orthopaedics, IPGME&R and SSKM Hospital, Kolkata, India
| | - Alakendu Ghosh
- Department of Rheumatology, IPGME&R and SSKM Hospital, Kolkata, India
| | - Brijesh P Singh
- Department of Statistics, Banaras Hindu University, Varanasi, India
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Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE. Endocr Pract 2020; 26:1-46. [PMID: 32427503 DOI: 10.4158/gl-2020-0524suppl] [Citation(s) in RCA: 468] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.
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Miller AS, Ferastraoaru V, Tabatabaie V, Gitlevich TR, Spiegel R, Haut SR. Are we responding effectively to bone mineral density loss and fracture risks in people with epilepsy? Epilepsia Open 2020; 5:240-247. [PMID: 32524049 PMCID: PMC7278536 DOI: 10.1002/epi4.12392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/07/2020] [Accepted: 03/26/2020] [Indexed: 11/10/2022] Open
Abstract
Objective A 2007 study performed at Montefiore Medical Center (Bronx, NY) identified high prevalence of reduced bone density in an urban population of patients with epilepsy and suggested that bone mineralization screenings should be regularly performed for these patients. We conducted a long-term follow-up study to determine whether bone mineral density (BMD) loss, osteoporosis, and fractures have been successfully treated or prevented. Methods In the current study, patients from the 2007 study who had two dual-energy absorptiometry (DXA) scans performed at least 5 years apart were analyzed. The World Health Organization (WHO) criteria to diagnose patients with osteopenia or osteoporosis were used, and each patient's probability of developing fractures was calculated with the Fracture Risk Assessment Tool (FRAX). Results The median time between the first and second DXA scans for the 81 patients analyzed was 9.4 years (range 5-14.7). The median age at the first DXA scan was 41 years (range 22-77). Based on WHO criteria, 79.0% of patients did not have worsening of bone density, while 21.0% had new osteopenia or osteoporosis; many patients were prescribed treatment for bone loss. Older age, increased duration of anti-epileptic drug (AED) usage, and low body mass index (BMI) were risk factors for abnormal BMDs. Based on the first DXA scan, the FRAX calculator estimated that none of the patients in this study had a 10-year risk of more than 20% for developing major osteoporotic fracture (hip, spine, wrist, or humeral fracture). However, in this population, 11 patients (13.6%) sustained a major osteoporotic fracture after their first DXA scan. Significance Despite being routinely screened and frequently treated for bone mineral density loss and fracture prevention, many patients with epilepsy suffered new major osteoporotic fractures. This observation is especially important as persons with epilepsy are at high risk for falls and traumas.
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Affiliation(s)
- Amitai S Miller
- Department of Neurology Albert Einstein College of Medicine and Montefiore Medical Center Bronx NY USA
| | - Victor Ferastraoaru
- Department of Neurology Albert Einstein College of Medicine and Montefiore Medical Center Bronx NY USA
| | - Vafa Tabatabaie
- Department of Endocrinology Albert Einstein College of Medicine and Montefiore Medical Center Bronx NY USA
| | | | - Rebecca Spiegel
- Department of Neurology Stony Brook Medicine Stony Brook NY USA
| | - Sheryl R Haut
- Department of Neurology Albert Einstein College of Medicine and Montefiore Medical Center Bronx NY USA
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Sanchez-Rodriguez D, Bergmann P, Body JJ, Cavalier E, Gielen E, Goemaere S, Lapauw B, Laurent MR, Rozenberg S, Honvo G, Beaudart C, Bruyère O. The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women. Maturitas 2020; 139:69-89. [PMID: 32747044 DOI: 10.1016/j.maturitas.2020.05.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium. METHODS The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts. RESULTS Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered. CONCLUSION BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.
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Affiliation(s)
- D Sanchez-Rodriguez
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium; Geriatrics Department, Rehabilitation Research Group, Hospital del Mar Medical Research Institute (IMIM), Universitat Pompeu Fabra, Barcelona, Spain.
| | - P Bergmann
- Department of Radioisotopes, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - J J Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - E Cavalier
- Department of Clinical Chemistry, UnilabLg, University of Liège, CHU de Liège, Liège, Belgium
| | - E Gielen
- Gerontology and Geriatrics Section, Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, University Hospitals, Leuven, Belgium
| | - S Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - M R Laurent
- Geriatrics Department, Imelda Hospital, Bonheiden, Belgium
| | - S Rozenberg
- Department of Gynaecology-Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - G Honvo
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - C Beaudart
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - O Bruyère
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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Wu KL, Wu CH, Chang YF, Lin YT, Hsu JC. Budget impact analysis of osteoporosis medications for primary prevention of fractures in Taiwan. J Bone Miner Metab 2020; 38:316-327. [PMID: 31709455 DOI: 10.1007/s00774-019-01061-5] [Citation(s) in RCA: 6] [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: 08/17/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Taiwan's national health insurance currently only covers the use of osteoporosis drugs for the secondary prevention of fractures and does not provide coverage for primary prevention. The purpose of this study is to develop a model for analyzing the budgetary impact of the use of osteoporosis medications of primary prevention. METHODS The budget impact model in this study is the "actual medication cost" minus the "medical expenses for all types of fractures that can be avoided by taking osteoporosis medications." We developed six possible insurance payment plans for primary prevention based on the age of the patients and T-scores and performed eleven steps to estimate the budget impact of each payment plan. RESULTS The results of this study indicated that there may be 71,220 (T-score ≤ - 3.0, 75 + y/o) to 157,515 (T-score ≤ - 2.5, 65 + y/o) people using the drugs, and the budget impact may be US$26.28-58.98 million in 2019. However, the payment plans may avoid 492-766 fracture events and save medical expenditures for fracture treatment by US$1.30-2.02 million. The average costs for primary prevention within a year will be US$53,386-77,006. CONCLUSION The budget impact of using osteoporosis medications to primary prevention of fractures is significant, but it can be compensated due to savings in fracture treatment costs.
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Affiliation(s)
- Kun-Ling Wu
- Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
- Outpatient Clinic Department, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Geriatrics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yin-Fan Chang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yun-Ting Lin
- Department of Pharmacy, College of Medicine, National Cheng Kung University, No. 1 Daxue Rd., East Dist., Tainan, Taiwan
| | - Jason C Hsu
- Department of Pharmacy, College of Medicine, National Cheng Kung University, No. 1 Daxue Rd., East Dist., Tainan, Taiwan.
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Hiligsmann M, Williams SA, Fitzpatrick LA, Silverman SS, Weiss R, Reginster JY. Cost-effectiveness of sequential treatment with abaloparatide followed by alendronate vs. alendronate monotherapy in women at increased risk of fracture: A US payer perspective. Semin Arthritis Rheum 2020; 50:394-400. [PMID: 32160943 DOI: 10.1016/j.semarthrit.2020.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/06/2019] [Accepted: 02/08/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Emerging evidence supports sequential therapy with anabolic followed by antiresorptive in patients at high-risk of fragility fractures. This study assessed the cost-effectiveness of sequential treatment with abaloparatide (ABL) followed by alendronate (ALN) [(ABL/ALN)] compared to ALN monotherapy and to sequential treatment starting with antiresorptive therapy (ALN/ABL/ALN). METHODS A previously validated Markov microsimulation model was used to estimate the cost-effectiveness of sequential ABL/ALN compared to ALN monotherapy and to sequential ALN/ABL/ALN from a lifetime US payer perspective. In line with practice guidelines, patients were assumed to receive ABL for 18 months followed by 5 years of ALN, or ALN monotherapy for 5 years, or a sequence of ALN for 2 years followed by 18 months of ABL and then by 3 years ALN. Evaluation was conducted for patients aged 50-80 years old with a BMD T-score ≤-3.5 and without a history of prior fracture, or with a T-score between -2.5 and -3.5 and a history of ≥ 1 osteoporotic fracture. RESULTS Sequential ABL/ALN was cost-effective (threshold of US$150,000 per QALY) vs generic ALN monotherapy in women ≥60 years with a BMD T-score ≤-3.5 and in women with BMD T-score between -2.5 and -3.5 and history of osteoporotic fracture. In all simulated populations, sequential ABL/ALN therapy was dominant (lower costs, more QALYs) compared with sequential ALN/ABL/ALN, resulting from limited effect of ABL in patients previously treated with an antiresorptive agent. CONCLUSIONS Sequential ABL/ALN therapy is cost-effective vs ALN monotherapy for US postmenopausal women aged ≥60 years at increased risk of fractures.
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Affiliation(s)
- Mickael Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.
| | | | | | - Stuart S Silverman
- Cedar-Sinai Medical Center and UCLA School of Medicine, Los Angeles, CA, United States
| | | | - Jean-Yves Reginster
- Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium; Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, Riyadh, KSA, Saudi Arabia
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Cui L, He T, Jiang Y, Li M, Wang O, Jiajue R, Chi Y, Xu Q, Xing X, Xia W. Predicting the intervention threshold for initiating osteoporosis treatment among postmenopausal women in China: a cost-effectiveness analysis based on real-world data. Osteoporos Int 2020; 31:307-316. [PMID: 31754756 PMCID: PMC7010623 DOI: 10.1007/s00198-019-05173-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 09/18/2019] [Indexed: 01/21/2023]
Abstract
UNLABELLED This study built a micro-simulation Markov model to determine the treatment threshold of osteoporosis in postmenopausal women in Mainland China. Treatment with zoledronate is cost-effective when FRAX-based (Fracture risk assessment tool) fracture probability is over 7%. INTRODUCTION The purpose of this study is to estimate FRAX-based fracture probabilities in Mainland China using real-world data, at which intervention could be cost-effective. METHODS We developed a micro-simulation Markov model to capture osteoporosis states and relevant morbidities including hip fracture, vertebral fracture, and wrist fracture. Baseline characteristics including incidences of osteoporosis and distribution of risk factors were derived from the Peking Vertebral Fracture study, the largest prospective cohort study of postmenopausal women in Mainland China. We projected incidences of fractures and deaths by age groups under two treatment scenarios: 1) no treatment, and 2) zoledronate. We also projected total quality-adjusted life-years (QALY) and total costs including fracture management and osteoporosis drugs for cost-effectiveness analysis. Cost-effective intervention thresholds were calculated based on the Chinese FRAX model. RESULTS Treatment with zoledronate was cost-effective when the 10-year probability of major osteoporotic fracture based on FRAX was above 7%. The FRAX threshold increased by age from 51 to 65 years old, and decreased in elder age groups, ranging from 4% to 9%. CONCLUSIONS Using real-world data, our model indicated that widespread use of zoledronate was of both clinical and economic benefit among Chinese postmenopausal women. Using a FRAX-based intervention threshold of 7% with zoledronate should permit cost-effective access to therapy to patients and contribute to reducing the disease burden of osteoporosis in Mainland China.
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Affiliation(s)
- L Cui
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - T He
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Y Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - M Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - O Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - R Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Y Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Q Xu
- Department of Orthopedics, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - X Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - W Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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