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McCloskey E, Tan ATH, Schini M. Update on fracture risk assessment in osteoporosis. Curr Opin Endocrinol Diabetes Obes 2024:01266029-990000000-00098. [PMID: 38809256 DOI: 10.1097/med.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Gavilanez EL, Luis IN, Mario NG, Johansson H, Harvey NC, Lorentzon M, Liu E, Vandenput L, McCloskey EV, Kanis JA. An assessment of intervention thresholds for high fracture risk in Chile. Arch Osteoporos 2022; 18:11. [PMID: 36527508 DOI: 10.1007/s11657-022-01198-3] [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: 10/13/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
Assessment and treatment pathways using FRAX-based intervention thresholds in Chile can be used to identify patients at high risk of fracture and avoid unnecessary treatment in those at low fracture risk. PURPOSE The aim of the present study was to explore treatment paths and characteristics of women eligible for treatment in Chile based on major osteoporotic fracture (MOF) probabilities derived from FRAX®. METHODS Intervention and assessment thresholds were derived using methods adopted by the National Osteoporosis Guideline Group for FRAX-based guidelines in the UK but based on the epidemiology of fracture and death in Chile. Age-dependent and hybrid assessment and intervention thresholds were applied to 1998 women and 1122 men age 50 years or more drawn from participants in the National Health Survey 2016-2017. RESULTS Approximately 12% of men and women had a prior fragility fracture and would be eligible for treatment for this reason. Using age-dependent thresholds, an additional 2.6% of women (0.3% of men) were eligible for treatment in that MOF probabilities lay above the upper assessment threshold. A BMD test would be recommended in 5% of men and 38% of women. With hybrid thresholds, an additional 13% of women (3.6% of men) were eligible for treatment and BMD recommended in 11% of men and 42% of women. CONCLUSION The application of hybrid intervention thresholds ameliorates the disparity in fracture probabilities seen with age-dependent thresholds. Probability-based assessment of fracture risk, including the use of the hybrid intervention thresholds for Chile, is expected to help guide decisions about treatment.
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Affiliation(s)
- Enrique Lopez Gavilanez
- AECE Research Group, The Association of Clinical Endocrinologists of Ecuador, Guayaquil, Ecuador
- Hospital Docente de La Policía Nacional Guayaquil #2, Guayaquil, Ecuador
| | - Imaicela N Luis
- AECE Research Group, The Association of Clinical Endocrinologists of Ecuador, Guayaquil, Ecuador
| | - Navarro G Mario
- AECE Research Group, The Association of Clinical Endocrinologists of Ecuador, Guayaquil, Ecuador
| | - Helena Johansson
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mattias Lorentzon
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Enwu Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Liesbeth Vandenput
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Department of Oncology and Metabolism, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - John A Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
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Chotiyarnwong P, McCloskey EV, Harvey NC, Lorentzon M, Prieto-Alhambra D, Abrahamsen B, Adachi JD, Borgström F, Bruyere O, Carey JJ, Clark P, Cooper C, Curtis EM, Dennison E, Diaz-Curiel M, Dimai HP, Grigorie D, Hiligsmann M, Khashayar P, Lewiecki EM, Lips P, Lorenc RS, Ortolani S, Papaioannou A, Silverman S, Sosa M, Szulc P, Ward KA, Yoshimura N, Kanis JA. Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group. Arch Osteoporos 2022; 17:87. [PMID: 35763133 PMCID: PMC9239944 DOI: 10.1007/s11657-022-01117-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.
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Affiliation(s)
- P Chotiyarnwong
- Department of Oncology & Metabolism, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - E V McCloskey
- Department of Oncology & Metabolism, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Bone Diseases, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK.
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Lorentzon
- University of Gothenburg, Gothenburg, Sweden
- Australian Catholic University, Melbourne, Australia
| | - D Prieto-Alhambra
- Oxford NIHR Biomedical Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
- GREMPAL (Grup de Recerca en Malalties Prevalents de L'Aparell Locomotor) Research Group, CIBERFes and Idiap Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Gran Via de Les Corts Catalanes, 591 Atico, 08007, Barcelona, Spain
| | - B Abrahamsen
- Department of Clinical Research, Odense Patient Data Exploratory Network, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - J D Adachi
- Department of Medicine, Michael G DeGroote School of Medicine, St Joseph's Healthcare-McMaster University, Hamilton, ON, Canada
| | - F Borgström
- Quantify Research, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - O Bruyere
- 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
| | - J J Carey
- School of Medicine, National University of Ireland Galway, Galway, Ireland
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - P Clark
- Clinical Epidemiology Unit of Hospital Infantil de México Federico Gómez-Faculty of Medicine, Universidad Nacional Autónoma de México, UNAM, Mexico City, Mexico
| | - C Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - E M Curtis
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - E Dennison
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Diaz-Curiel
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - H P Dimai
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - D Grigorie
- Carol Davila University of Medicine, Bucharest, Romania
- Department of Endocrinology & Bone Metabolism, National Institute of Endocrinology, Bucharest, Romania
| | - M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - P Khashayar
- Center for Microsystems Technology, Imec and Ghent University, 9050, Ghent, Belgium
| | - E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - P Lips
- Department of Internal Medicine, Endocrine Section & Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R S Lorenc
- Multidisciplinary Osteoporosis Forum, SOMED, Warsaw, Poland
| | - S Ortolani
- IRCCS Istituto Auxologico, UO Endocrinologia E Malattie del Metabolismo, Milano, Italy
| | - A Papaioannou
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- GERAS Centre for Aging Research, Hamilton, ON, Canada
| | - S Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M Sosa
- Bone Metabolic Unit, University of Las Palmas de Gran Canaria, Hospital University Insular, Las Palmas, Gran Canaria, Spain
| | - P Szulc
- INSERM UMR 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - K A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - N Yoshimura
- Department of Preventive Medicine for Locomotive Organ Disorders, 22Nd Century Medical and Research Center, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - J A Kanis
- Centre for Metabolic Bone Diseases, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK
- Australian Catholic University, Melbourne, Australia
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Lekamwasam S, Abeygunasekara T, Rathnayake N, Liyanage G, Subasinghe S. Age-dependent assessment thresholds to optimize patient care in a resource-limited setting: an analysis based on the Sri Lankan FRAX model. Arch Osteoporos 2022; 17:77. [PMID: 35553258 DOI: 10.1007/s11657-022-01118-5] [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: 12/08/2021] [Accepted: 05/04/2022] [Indexed: 02/03/2023]
Abstract
Age-dependent upper and lower assessment thresholds help categorizing women aged 40 years or more according to their fracture risk, independent of BMD information. INTRODUCTION Age-dependent assessment thresholds of the FRAX algorithm help stratifying men and women aged 40 years or more according to their fracture risk. This allows clinicians to decide on those who require interventions without BMD assessment and those who require BMD input for further assessment. METHODS Intervention thresholds were defined by 10-year probabilities of a major osteoporotic fracture (MOF) and hip fracture (HF) considering a woman with a BMI of 25.0 kg/m2 having a prior fragility fracture but no other clinical risk factors. The lower assessment thresholds (LAT) were set at 0.8 times the 10-year probabilities of a MOF and HF in a woman with a BMI of 25.0 kg/m2, without previous fracture or other clinical risk factors. The upper assessment thresholds (UAT) were set at 1.2 times the intervention thresholds of MOF and HF. Fracture probabilities were estimated for the age range of 40-80 years, without BMD input. These values were applied to a group of women who underwent DXA for clinical reasons in a single center. RESULTS The LATs of MOF and HF varied from 0.7 to 8.8% and 0.1 to 3.7%, from 40 to 80 years, respectively. The corresponding values for UATs were 2.5 to 21.6% and 0.3 to 8.4%. ITs of MOF and HF varied from 2.1 to 18% and 0.2 to 7%, respectively. When applied to a group of 315 postmenopausal women who underwent DXA for clinical indications, 22.9% of women were above the UATs (high-risk category) while 8.6% were below the LATs (low-risk category). The proportion of women in the intermediate category who require BMD for further assessment was 68.6% (95% CI 59.7 to 77.5%). CONCLUSIONS In nearly one-third of women aged 40 years or more, the decision to treat or not to treat can be achieved without BMD estimation. The remaining two-thirds will require a BMD assessment for further evaluation.
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Affiliation(s)
- Sarath Lekamwasam
- Department of Medicine, Faculty of Medicine, Population Health Research Center, University of Ruhuna, Matara, Sri Lanka.
| | - Thilina Abeygunasekara
- Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Matara, Sri Lanka
| | - Nirmala Rathnayake
- Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Matara, Sri Lanka
| | - Gayani Liyanage
- Department of Pharmacology, Faculty of Medicine, University of Ruhuna, Matara, Sri Lanka
| | - Sewwandi Subasinghe
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Ruhuna, Matara, Sri Lanka
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Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2022; 17:58. [PMID: 35378630 PMCID: PMC8979902 DOI: 10.1007/s11657-022-01061-5] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management. INTRODUCTION The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.
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Affiliation(s)
- Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Royal United Hospital NHS Foundation Trust, Bath, UK.
| | - David J Armstrong
- Western Health and Social Care Trust (NI), Nutrition Innovation Centre for Food and Health, Ulster University, and Visiting Professor, Belfast, Northern Ireland
| | - Jean Bowden
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John Edwards
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, and Wolstanton Medical Centre, Newcastle under Lyme, UK
| | - Neil J L Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital, University Hospitals Birmingham & University of Birmingham, Birmingham, UK
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia and Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | | | - Rebecca Low
- Abingdon and Specialty Doctor in Metabolic Bone Disease, Marcham Road Health Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - Eugene McCloskey
- Department of Oncology & Metabolism, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - Katie Moss
- St George's University Hospital, London, UK
| | - Jane Parker
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Zoe Paskins
- School of Medicine, Keele University, Keele, Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | - Kenneth Poole
- Department of Medicine, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Mike Stone
- University Hospital Llandough, Cardiff and Vale University Health Board, Llandough, UK
| | | | - Nic Vine
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Juliet Compston
- University of Cambridge, School of Clinical Medicine, Cambridge, UK
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8
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Johansson H, Naureen G, Iqbal R, Jafri L, Khan AH, Umer M, Liu E, Vandenput L, Lorentzon M, McCloskey EV, Kanis JA, Harvey NC. FRAX-based intervention thresholds for Pakistan. Osteoporos Int 2022; 33:105-112. [PMID: 34414463 DOI: 10.1007/s00198-021-06087-y] [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: 05/18/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
We compared, for women in Pakistan, the utility of intervention thresholds either at a T-score ≤ - 2.5 or based on a FRAX probability equivalent to women of average body mass index (BMI) with a prior fragility fracture. Whereas the FRAX-based intervention threshold identified women at high fracture probability, the T-score threshold was less sensitive, and the associated fracture risk decreased markedly with age. PURPOSE The fracture risk assessment algorithm FRAX® has been recently calibrated for Pakistan, but guidance is needed on how to apply fracture probabilities to clinical practice. METHODS The age-specific 10-year probabilities of a major osteoporotic fracture were calculated in women with average BMI to determine fracture probabilities at two potential intervention thresholds. The first comprised the age-specific fracture probabilities associated with a femoral neck T-score of - 2.5. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without bone mineral density (BMD). The parsimonious use of BMD was additionally explored by the computation of upper and lower assessment thresholds for BMD testing. RESULTS When a BMD T-score ≤ - 2.5 was used as an intervention threshold, FRAX probabilities in women aged 50 years were approximately two-fold higher than in women of the same age but with no risk factors and average BMD. The relative increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of - 2.5 was actually protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to women with a previous fracture, rose with age from 2.1% at the age of 40 years to 17%, at the age of 90 years, and identified women at increased risk at all ages. CONCLUSION Intervention thresholds based on BMD alone do not effectively target women at high fracture risk, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a 'fracture threshold' target women at high fracture risk.
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Affiliation(s)
- H Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - G Naureen
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, Melbourne, Australia
| | - R Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - L Jafri
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - A H Khan
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - M Umer
- Department of Orthopaedics, Aga Khan University, Karachi, Pakistan
| | - E Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - L Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK
- Department of Oncology and Metabolism, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - J A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, 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
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9
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Al-Daghri NM, Sabico S, Al-Saleh Y, Sulimani R, Aljohani NJ, Sheshah E, Alodhayani A, Harvey NC, Liu E, Lorentzon M, McCloskey EV, Vandenput L, Johansson H, Kanis JA. The application of FRAX in Saudi Arabia. Arch Osteoporos 2021; 16:166. [PMID: 34739604 DOI: 10.1007/s11657-021-01024-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/06/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Assessment and treatment pathways based on age-specific intervention thresholds in Saudi Arabi can be used to identify patients at high risk of fracture and avoid unnecessary treatment in those at low fracture risk. PURPOSE Intervention thresholds for the treatment of osteoporosis have historically been based on the measurement of bone mineral density. The aim of the present study was to explore treatment paths and characteristics of women eligible for treatment in Saudi Arabia based on fracture probabilities derived from FRAX®. METHODS The approach to the setting of intervention and assessment thresholds used the methodology adopted by the National Osteoporosis Guideline Group for FRAX-based guidelines in the UK but based on the epidemiology of fracture and death in Saudi Arabia. The methodology was applied to women age 40 years or more drawn from a tertiary referral population for skeletal assessment. Missing data for the calculation of FRAX was simulated using data from the referral and FRAX derivation cohorts. RESULTS Intervention thresholds expressed as a 10-year probability of a major osteoporotic fracture ranged from 2.0% at the age of 50 years increasing to 7.6% at the age of 70 years. A total of 163 of 1365 women (11.9%) had a prior fragility fracture and would be eligible for treatment for this reason. An additional 5 women were eligible for treatment in that MOF probabilities lay above the upper assessment threshold. A BMD test would be recommended for 593 women (43.4%) so that FRAX could be recalculated with the inclusion of femoral neck BMD. Of these, 220 individuals would be eligible for treatment after a BMD test and 373 women categorised at low risk after a BMD test. CONCLUSION Probability-based assessment of fracture risk using age-specific intervention thresholds was developed for Saudi Arabia to help guide decisions about treatment.
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Affiliation(s)
- Nasser M Al-Daghri
- Biochemistry Department, College of Science, King Saud University, 11451, Riyadh, Kingdom of Saudi Arabia.
| | - Shaun Sabico
- Biochemistry Department, College of Science, King Saud University, 11451, Riyadh, Kingdom of Saudi Arabia
| | - Yousef Al-Saleh
- Biochemistry Department, College of Science, King Saud University, 11451, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Riad Sulimani
- Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Naji J Aljohani
- Biochemistry Department, College of Science, King Saud University, 11451, Riyadh, Kingdom of Saudi Arabia.,Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Eman Sheshah
- Diabetes Care Center, King Salman Bin Abdulaziz Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Alodhayani
- Department of Family Medicine and Community, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Enwu Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Mattias Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.,Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.,MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Liesbeth Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.,Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia. .,Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
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10
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Harvey NC, Kanis JA, Liu E, Vandenput L, Lorentzon M, Cooper C, McCloskey E, Johansson H. Impact of population-based or targeted BMD interventions on fracture incidence. Osteoporos Int 2021; 32:1973-1979. [PMID: 33758991 DOI: 10.1007/s00198-021-05917-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
In a simulated population of older women, we demonstrate that an upward shift in the population distribution of BMD by approximately 0.3SD may decrease the risk of incident fractures to the same extent as an intervention targeted to those with T-score less than -2.5. INTRODUCTION To investigate the impact of population level or targeted alterations to BMD on the incidence of fractures. METHODS We used a simulated cohort of 49,242 women with age and body mass index distribution from the UK, and prevalence of other clinical risk factors based on European FRAX® cohorts. Using FRAX probabilities of major osteoporotic fracture (MOF: hip, clinical vertebral, distal forearm, proximal humerus) and hip fracture, calculated with femoral neck BMD, we determined the expected number of fractures over 10 years, stratified by 10-year age band from 50 years. We then investigated the effect of (i) uplifting all individuals with T-score below -2.5 to be exactly -2.5 (high-risk strategy) and (ii) shifting the entire BMD distribution upwards (population strategy). RESULTS Overall, the high-risk strategy prevented 573 MOF including 465 hip fractures. Moving the BMD T-score distribution upward by 0.27SD gave an equivalent reduction in numbers of MOF; for hip fractures prevented, this was 0.35SD. A global upward 0.25SD BMD shift prevented 524 MOF including 354 hip fractures, with corresponding figures for an increase of 0.5SD being 973 MOF prevented and 640 hip fractures prevented. The ratio of hip fracture to MOF prevented differed by the two approaches, such that for the high-risk strategy, the ratio was 0.81, and for the population strategy was 0.68 (0.25SD BMD uplift) and 0.66 (0.5SD BMD uplift). The numbers of fractures prevented by the high-risk strategy increased with age. In contrast, the age-related increase in numbers of fractures prevented with the population strategy rose with age, but peaked in the 70-79-year age band and declined thereafter. CONCLUSIONS Both strategies reduced the numbers of expected incident fractures, with contrasting relative impacts by age and fracture site. Whilst the current analysis used UK/European anthropometric/risk factor distributions, further analyses calibrated to the distributions in other settings globally may be readily undertaken. Overall, these findings support the investigation of both population level interventions and those targeted at high fracture risk groups.
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Affiliation(s)
- N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK.
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - E Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - L Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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11
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FRAX-Based Intervention Thresholds for Osteoporosis Treatment in Ukraine. J Osteoporos 2021; 2021:2043479. [PMID: 34194719 PMCID: PMC8214495 DOI: 10.1155/2021/2043479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 05/29/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Osteoporosis, in addition to its consequent fracture burden, is a common and costly condition. FRAX® is a well-established, validated, web-based tool which calculates the 10-year probability of fragility fractures. A FRAX model for Ukraine has been available since 2016 but its output has not yet been translated into intervention thresholds for the treatment of osteoporosis in Ukraine; we aimed to address this unmet need in this analysis. METHODS In a referral population sample of 3790 Ukrainian women, 10-year probabilities of major osteoporotic fracture (MOF) and hip fracture separately were calculated using the Ukrainian FRAX model, with and without femoral neck bone mineral density (BMD). We used a similar approach to that first proposed by the UK National Osteoporosis Guideline Group, whereby treatment is indicated if the probability equals or exceeds that of a woman of the same age with a prior fracture. RESULTS The MOF intervention threshold in females (the age-specific 10-year fracture probability) increased with age from 5.5% at the age of 40 years to 11% at the age of 75 years where it plateaued and then decreased slightly at age 90 (10%). Lower and upper thresholds were also defined to determine the need for BMD, if not already measured; the approach targets BMD measurements to those at or near the intervention threshold. The proportion of the referral populations eligible for treatment, based on prior fracture or similar or greater probability, ranged from 44% to 69% depending on age. The prevalence of the previous fracture rose with age, as did the proportion eligible for treatment. In contrast, the requirement for BMD testing decreased with age. CONCLUSIONS The present study describes the development and application of FRAX-based assessment guidelines in Ukraine. The thresholds can be used in the presence or absence of access to BMD and optimize the use of BMD where access is restricted.
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12
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McCloskey EV, Harvey NC, Johansson H, Lorentzon M, Vandenput L, Liu E, Kanis JA. Global impact of COVID-19 on non-communicable disease management: descriptive analysis of access to FRAX fracture risk online tool for prevention of osteoporotic fractures. Osteoporos Int 2021; 32:39-46. [PMID: 33057738 PMCID: PMC7556595 DOI: 10.1007/s00198-020-05542-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/07/2020] [Indexed: 12/31/2022]
Abstract
The COVID-19 pandemic, and its management, is markedly impacting the management of osteoporosis as judged by access to online FRAX fracture risk assessments. Globally, access was 58% lower in April than in February 2020. Strategies to improve osteoporosis care, with greater use of fracture risk assessments, offer a partial solution. INTRODUCTION The COVID-19 pandemic is having a significant detrimental impact on the management of chronic diseases including osteoporosis. We have quantified the global impact by examining changes in the usage of online FRAX fracture risk assessments before and after the declaration of the pandemic (11 March 2020). METHODS The study comprised a retrospective analysis using GoogleAnalytics data on daily sessions on the FRAX® website ( www.sheffield.ac.uk/FRAX ) from November 2019 to April 2020 (main analysis period February-April 2020), and the geographical source of that activity. RESULTS Over February-April 2020, the FRAX website recorded 460,495 sessions from 184 countries, with 210,656 sessions in February alone. In March and April, the number of sessions fell by 23.1% and 58.3% respectively, a pattern not observed over the same period in 2019. There were smaller reductions in Asia than elsewhere, partly related to earlier and less-marked nadirs in some countries (China, Taiwan, Hong Kong, South Korea and Vietnam). In Europe, the majority of countries (24/31, 77.4%) reduced usage by at least 50% in April. Seven countries showed smaller reductions (range - 2.85 to - 44.1%) including Poland, Slovakia, Czech Republic, Germany, Norway, Sweden and Finland. There was no significant relationship between the reduction in FRAX usage and measures of disease burden such as COVID-attributed deaths per million of the population. CONCLUSION This study documents a marked global impact of the COVID-19 pandemic on the management of osteoporosis as reflected by FRAX online fracture risk assessments. The analysis suggests that impact may relate to the societal and healthcare measures taken to ameliorate the pandemic.
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Affiliation(s)
- E V McCloskey
- Department of Oncology and Metabolism, Academic Unit of Bone Metabolism, Metabolic Bone Centre, Northern General Hospital, Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, S5 7AU, UK.
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - M Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital Mölndal, Gothenburg, Sweden
| | - L Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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13
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Kanis JA, Johansson H, Harvey NC, Gudnason V, Sigurdsson G, Siggeirsdottir K, Lorentzon M, Liu E, Vandenput L, McCloskey EV. Adjusting conventional FRAX estimates of fracture probability according to the recency of sentinel fractures. Osteoporos Int 2020; 31:1817-1828. [PMID: 32613411 PMCID: PMC7116089 DOI: 10.1007/s00198-020-05517-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/01/2020] [Indexed: 11/27/2022]
Abstract
The risk of a recurrent fragility fracture is particularly high immediately following the fracture. This study provides adjustments to FRAX-based fracture probabilities accounting for the site of a recent fracture. INTRODUCTION The recency of prior fractures affects subsequent fracture risk. The aim of this study was to quantify the effect of a recent sentinel fracture, by site, on the 10-year probability of fracture determined with FRAX. METHODS The study used data from the Reykjavik Study fracture register that documented prospectively all fractures at all skeletal sites in a large sample of the population of Iceland. Fracture probabilities were determined after a sentinel fracture (humeral, clinical vertebral, forearm and hip fracture) from the hazards of death and fracture. Fracture probabilities were computed on the one hand for sentinel fractures occurring within the previous 2 years and on the other hand, probabilities for a prior osteoporotic fracture irrespective of recency. The probability ratios provided adjustments to conventional FRAX estimates of fracture probability for recent sentinel fractures. RESULTS Probability ratios to adjust 10-year FRAX probabilities of a major osteoporotic fracture for recent sentinel fractures were age dependent, decreasing with age in both men and women. Probability ratios varied according to the site of sentinel fracture with higher ratios for hip and vertebral fracture than for humerus or forearm fracture. Probability ratios to adjust 10-year FRAX probabilities of a hip fracture for recent sentinel fractures were also age dependent, decreasing with age in both men and women with the exception of forearm fractures. CONCLUSION The probability ratios provide adjustments to conventional FRAX estimates of fracture probability for recent sentinel fractures.
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Affiliation(s)
- J A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
| | - H Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, 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
| | - V Gudnason
- Icelandic Heart Association Research Institute, Kopavogur, Iceland
- University of Iceland, Reykjavik, Iceland
| | - G Sigurdsson
- Icelandic Heart Association Research Institute, Kopavogur, Iceland
| | - K Siggeirsdottir
- Icelandic Heart Association Research Institute, Kopavogur, Iceland
| | - M Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Geriatric Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - E Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - L Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Mellanby Centre for bone research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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14
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Forgetta V, Keller-Baruch J, Forest M, Durand A, Bhatnagar S, Kemp JP, Nethander M, Evans D, Morris JA, Kiel DP, Rivadeneira F, Johansson H, Harvey NC, Mellström D, Karlsson M, Cooper C, Evans DM, Clarke R, Kanis JA, Orwoll E, McCloskey EV, Ohlsson C, Pineau J, Leslie WD, Greenwood CMT, Richards JB. Development of a polygenic risk score to improve screening for fracture risk: A genetic risk prediction study. PLoS Med 2020; 17:e1003152. [PMID: 32614825 PMCID: PMC7331983 DOI: 10.1371/journal.pmed.1003152] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Since screening programs identify only a small proportion of the population as eligible for an intervention, genomic prediction of heritable risk factors could decrease the number needing to be screened by removing individuals at low genetic risk. We therefore tested whether a polygenic risk score for heel quantitative ultrasound speed of sound (SOS)-a heritable risk factor for osteoporotic fracture-can identify low-risk individuals who can safely be excluded from a fracture risk screening program. METHODS AND FINDINGS A polygenic risk score for SOS was trained and selected in 2 separate subsets of UK Biobank (comprising 341,449 and 5,335 individuals). The top-performing prediction model was termed "gSOS", and its utility in fracture risk screening was tested in 5 validation cohorts using the National Osteoporosis Guideline Group clinical guidelines (N = 10,522 eligible participants). All individuals were genome-wide genotyped and had measured fracture risk factors. Across the 5 cohorts, the average age ranged from 57 to 75 years, and 54% of studied individuals were women. The main outcomes were the sensitivity and specificity to correctly identify individuals requiring treatment with and without genetic prescreening. The reference standard was a bone mineral density (BMD)-based Fracture Risk Assessment Tool (FRAX) score. The secondary outcomes were the proportions of the screened population requiring clinical-risk-factor-based FRAX (CRF-FRAX) screening and BMD-based FRAX (BMD-FRAX) screening. gSOS was strongly correlated with measured SOS (r2 = 23.2%, 95% CI 22.7% to 23.7%). Without genetic prescreening, guideline recommendations achieved a sensitivity and specificity for correct treatment assignment of 99.6% and 97.1%, respectively, in the validation cohorts. However, 81% of the population required CRF-FRAX tests, and 37% required BMD-FRAX tests to achieve this accuracy. Using gSOS in prescreening and limiting further assessment to those with a low gSOS resulted in small changes to the sensitivity and specificity (93.4% and 98.5%, respectively), but the proportions of individuals requiring CRF-FRAX tests and BMD-FRAX tests were reduced by 37% and 41%, respectively. Study limitations include a reliance on cohorts of predominantly European ethnicity and use of a proxy of fracture risk. CONCLUSIONS Our results suggest that the use of a polygenic risk score in fracture risk screening could decrease the number of individuals requiring screening tests, including BMD measurement, while maintaining a high sensitivity and specificity to identify individuals who should be recommended an intervention.
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Affiliation(s)
- Vincenzo Forgetta
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | | | - Marie Forest
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Audrey Durand
- School of Computer Science, McGill University, Montréal, Québec, Canada
| | - Sahir Bhatnagar
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - John P. Kemp
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Maria Nethander
- Bioinformatics Core Facility, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Evans
- California Pacific Medical Center Research Institute, San Francisco, California, United States of America
| | - John A. Morris
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Douglas P. Kiel
- Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Broad Institute of MIT & Harvard University, Boston, Massachusetts, United States of America
| | | | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, United Kingdom
- Australian Catholic University, Melbourne, Victoria, Australia
| | - Nicholas C. Harvey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Dan Mellström
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Karlsson
- Department of Orthopaedics and Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - David M. Evans
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom
| | - John A. Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, United Kingdom
- Australian Catholic University, Melbourne, Victoria, Australia
| | - Eric Orwoll
- Bone and Mineral Unit, Oregon Health & Science University, Portland, Oregon, United States of America
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Eugene V. McCloskey
- Mellanby Centre for Bone Research, Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield and Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute for Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joelle Pineau
- School of Computer Science, McGill University, Montréal, Québec, Canada
| | - William D. Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Celia M. T. Greenwood
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Human Genetics, McGill University, Montréal, Québec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montréal, Québec, Canada
| | - J. Brent Richards
- Centre for Clinical Epidemiology, Department of Medicine, Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Department of Human Genetics, McGill University, Montréal, Québec, Canada
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, United Kingdom
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15
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A decade of FRAX: how has it changed the management of osteoporosis? Aging Clin Exp Res 2020; 32:187-196. [PMID: 32043227 DOI: 10.1007/s40520-019-01432-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/21/2019] [Indexed: 01/14/2023]
Abstract
The fracture risk assessment tool, FRAX®, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, 71 models have been made available for 66 countries covering more than 80% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. The application of FRAX in assessment guidelines has been heterogeneous with the adoption of several different approaches in setting intervention thresholds. Whereas most guidelines adopt a case-finding strategy, the case for FRAX-based community screening in the elderly is increasing. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future.
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Kanis JA, Chandran M, Chionh SB, Ganeson G, Harvey NC, Koh WP, Kwok T, Lau TC, Liu E, Lorentzon M, McCloskey EV, Tan KB, Vandenput L, Johansson H. Use of age-dependent FRAX-based intervention thresholds for Singapore. Arch Osteoporos 2020; 15:104. [PMID: 32700118 PMCID: PMC7376084 DOI: 10.1007/s11657-020-00782-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Assessment and treatment pathways based on age-specific intervention thresholds in Singapore using FRAX paths can be used to identify patients at high risk of fracture and avoid unnecessary treatment in those at low risk. PURPOSE Intervention thresholds for the treatment of osteoporosis have been based historically on the measurement of bone mineral density. The development of FRAX® has permitted a more accurate assessment of fracture risk. The aim of the present study was to explore treatment paths and characteristics of women selected for treatment in Singapore based on FRAX. METHODS The approach to the setting of intervention and assessment thresholds used the methodology adopted by the National Osteoporosis Guideline Group for FRAX-based guidelines in the UK but based on the epidemiology of fracture and death in Singapore. The methodology was applied to women age 50 years or more drawn from the population-based Singapore Chinese Health Study (SCHS) cohort. Missing data for the calculation of FRAX was simulated using data from Chinese cohorts from Hong Kong. RESULTS Intervention thresholds expressed as a 10-year probability of a major osteoporotic fracture ranged from 2.9% at the age of 50 years increasing to 32% at the age of 90 years. A total of 1927 of 29,323 women (7%) had a prior fragility fracture and would be eligible for treatment for this reason. An additional 3019 women (10.3%) would be eligible for treatment on the basis of age-dependent thresholds. The mean BMD T-score of women so selected was -2.94. CONCLUSION Probability-based assessment of fracture risk using age-specific intervention thresholds was developed for Singapore to help guide decisions about treatment.
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Affiliation(s)
- John A. Kanis
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Manju Chandran
- grid.163555.10000 0000 9486 5048Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore, Singapore
| | - Siok Bee Chionh
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ganga Ganeson
- grid.415698.70000 0004 0622 8735Division of Policy, Research and Evaluation, Ministry of Health, Singapore, Singapore
| | - Nicholas C Harvey
- grid.5491.90000 0004 1936 9297MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Woon-Puay Koh
- grid.428397.30000 0004 0385 0924Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore ,grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Singapore, 117549 Singapore
| | - Timothy Kwok
- grid.415197.f0000 0004 1764 7206Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China ,grid.10784.3a0000 0004 1937 0482Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Tang Ching Lau
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Enwu Liu
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Mattias Lorentzon
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,grid.8761.80000 0000 9919 9582Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V McCloskey
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.11835.3e0000 0004 1936 9262MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Kelvin Bryan Tan
- grid.415698.70000 0004 0622 8735Ministry of Health Singapore, Singapore, Singapore
| | - Liesbeth Vandenput
- grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia ,grid.8761.80000 0000 9919 9582Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- grid.11835.3e0000 0004 1936 9262Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.411958.00000 0001 2194 1270Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Assessing the risk of osteoporotic fractures: the Ecuadorian FRAX model. Arch Osteoporos 2019; 14:93. [PMID: 31440846 DOI: 10.1007/s11657-019-0644-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/12/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED The FRAX tool incorporates data on the incidence of fractures and mortality in each country. The epidemiology of fractures changes over time, this makes it necessary to update the specific FRAX model of each population. It is shown that there are differences between old and new FRAX models in older individuals. PURPOSE A new FRAX® model for Ecuador was released online in April 2019. This paper describes the data used to build the revised model, its characteristics, and how intervention and assessment thresholds were constructed. METHODS The national rates of hip fracture incidence standardized by age and sex from the age of 40 years for 2016 were used to synthesize a FRAX model for Ecuador. For other major fractures, Ecuadorian incidence rates were calculated using ratios obtained in Malmö, Sweden, for other major osteoporotic fractures. The new FRAX model was compared with the previous model released in 2012. Assessment and intervention thresholds were based on age-specific probabilities of a major osteoporotic fracture equivalent to women with a previous fracture. RESULTS Fracture incidence rates increase with age. The probability of hip or major fractures at 10 years increased in patients with a clinical risk factor, lower BMI, female sex, a higher age, and a lower BMD T-score. Compared to the previous model, the new FRAX model gave similar 10-year fracture probabilities in men and women age less than70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the two models (> 0.99) so that the revision had little impact on the rank order of risk. CONCLUSIONS The FRAX tool provides a country-specific fracture prediction model for Ecuador. This update of the model is based on the original FRAX methodology, which has been validated externally in several independent cohorts. The FRAX model is an evolving tool that is being continuously refined, as the databases of each country are updated with more epidemiological information.
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The ability of calcaneal and multisite quantitative ultrasound variables in the identification of osteoporosis in women and men. Turk J Phys Med Rehabil 2019; 65:203-215. [PMID: 31663068 DOI: 10.5606/tftrd.2019.1894] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/10/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives The aim of this study was to assess the ability of calcaneal and multisite quantitative ultrasound (QUS) parameters in the identification of osteoporosis in women and men. Patients and methods A total of 131 women (mean age 53.7±11.9 years; range, 21 to 79 years) and 109 men (mean age 57.8±13.7 years; range, 24 to 85 years) whose bone mineral density (BMD) at the spine and proximal femur was measured between January 2010 and January 2012, using dual-energy X-ray absorptiometry (DXA) were included. Acoustic bone properties were also examined using both a calcaneal and a multisite QUS. The receiver operating characteristic analysis with the calculation of areas under the curve (AUCs) to evaluate the ability of both QUS devices for the identification of osteoporosis. We also calculated a lower and an upper threshold at a specificity of 90% and at a sensitivity of 90%, respectively, for the identification of osteoporosis along with a threshold/cut-off value with the best compromise between sensitivity and specificity. Results All calcaneal QUS parameters showed significant AUCs within the range of 0.712 (for Broadband Ultrasound Attenuation [BUA]) and 0.764 (for Speed of Sound [SOS]) in women and ranging from 0.661 (for BUA) to 0.735 (for SOS) in men, while only radial SOS of the multisite QUS demonstrated a significant AUC value of 0.661 for identifying osteoporosis in women. A Quantitative Ultrasound Index T-score of -1.53 for women and -1.68 for men showed sensitivity and specificities around 70%. Conclusion Based on the results of this study, all calcaneal QUS parameters in both women and men and possibly radial SOS measurements of the multisite QUS in women may be helpful for the identification of osteoporosis.
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Kanis JA, Cooper C, Rizzoli R, Reginster JY. Review of the guideline of the American College of Physicians on the treatment of osteoporosis. Osteoporos Int 2018; 29:1505-1510. [PMID: 29869039 PMCID: PMC6037298 DOI: 10.1007/s00198-018-4504-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/11/2018] [Indexed: 10/14/2022]
Abstract
This review, endorsed by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, summarizes several failings of the recent guidelines of the American College of Physicians (ACP) on the treatment of low bone density or osteoporosis to prevent fractures. INTRODUCTION The ACP recently issued guidelines for the treatment of low bone density or osteoporosis to prevent fractures. METHODS Literature review and critical review of the ACP guidelines. RESULTS The guideline is lacking in scope due to the endorsement of treatment based on T-scores rather than fracture risk assessment and in failure to adequately consider anabolic therapies. CONCLUSIONS The ACP guideline appears outdated.
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Affiliation(s)
- J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia.
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - R Rizzoli
- Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium
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Clark P, Denova-Gutiérrez E, Zerbini C, Sanchez A, Messina O, Jaller JJ, Campusano C, Orces CH, Riera G, Johansson H, Kanis JA. FRAX-based intervention and assessment thresholds in seven Latin American countries. Osteoporos Int 2018; 29:707-715. [PMID: 29273826 DOI: 10.1007/s00198-017-4341-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
UNLABELLED Age-specific intervention and assessment thresholds were developed for seven Latin American countries. The intervention threshold ranged from 1.2% (Ecuador) to 27.5% (Argentina) at the age of 50 and 90 years, respectively. In the Latin American countries, FRAX offers a substantial advance for the detection of subjects at high fracture risk. INTRODUCTION Intervention thresholds are proposed using the Fracture Risk Assessment (FRAX) tool. We recommended their use to calculate the ten-year probability of fragility fracture (FF) in both, men and women with or without the inclusion of bone mineral density (BMD). The purpose of this study is to compute FRAX-based intervention and BMD assessment thresholds for seven Latin American countries in men and women ≥ 40 years. METHODS The intervention threshold (IT) was set at a 10-year probability of a major osteoporotic fracture (MOF) equivalent to a woman with a prior FF and a body mass index (BMI) equal to 25.0 kg/m2 without BMD or other clinical risk factors. The lower assessment threshold was set at a 10-year probability of a MOF in women with BMI equal to 25.0 kg/m2, no previous fracture and no clinical risk factors. The upper assessment threshold was set at 1.2 times the IT. RESULTS For the seven LA countries, the age-specific IT varied from 1.5 to 27.5% in Argentina, 3.8 to 25.2% in Brazil, 1.6 up to 20.0% in Chile, 0.6 to 10.2% in Colombia, 0.9 up to 13.6% in Ecuador, 2.6 to 20.0% in Mexico, and 0.7 up to 22.0% in Venezuela at the age of 40 and 90 years, respectively. CONCLUSIONS In the LA countries, FRAX-based IT offers a substantial advance for the detection of men and women at high fracture risk, particularly in the elderly. The heterogeneity of IT between the LA countries indicates that country-specific FRAX models are appropriate rather than a global LA model.
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Affiliation(s)
- P Clark
- Clinical Epidemiology Research Unit, Hospital Infantil de México Federico Gomez, Dr. Márquez #164, Col. Doctores, Mexico City, Mexico
- School of Medicine, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico
| | - E Denova-Gutiérrez
- Clinical Epidemiology Research Unit, Hospital Infantil de México Federico Gomez, Dr. Márquez #164, Col. Doctores, Mexico City, Mexico.
- School of Medicine, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico.
| | - C Zerbini
- Centro Paulista de Investigação Clinica, São Paulo, Brazil
| | - A Sanchez
- Centro de Endocrinología, Rosario, Argentina
| | - O Messina
- Servicio de Reumatología, Hospital Argerich, Buenos Aires, Argentina
- Unidad de Postgrado en Reumatología, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - J J Jaller
- Centro de Reumatología y Ortopedia, Barranquilla, Colombia
| | - C Campusano
- Clínica de la Universidad de los Andes, Santiago, Chile
| | - C H Orces
- Department of Medicine, Laredo Medical Center, Laredo, TX, USA
| | - G Riera
- Unidad Metabolica, Universidad de Carabobo, Valencia, Venezuela
| | - H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
- Medical School, Sheffield, UK Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, England
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Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017; 12:43. [PMID: 28425085 PMCID: PMC5397452 DOI: 10.1007/s11657-017-0324-5] [Citation(s) in RCA: 500] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In 2008, the UK National Osteoporosis Guideline Group (NOGG) produced a guideline on the prevention and treatment of osteoporosis, with an update in 2013. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment, lifestyle measures and pharmacological interventions, duration and monitoring of bisphosphonate therapy, glucocorticoid-induced osteoporosis, osteoporosis in men, postfracture care and intervention thresholds. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management.
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Affiliation(s)
- J. Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - A. Cooper
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - N. Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
| | - C. Gregson
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
| | - N. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - S. Hope
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
| | - J. A. Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
| | | | - K. E. S. Poole
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - D. M. Reid
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
| | - P. Selby
- Metabolic Bone Disease, University of Manchester, Manchester, UK
| | | | | | - N. Vine
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - The National Osteoporosis Guideline Group (NOGG)
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Crawley Fracture Liaison Service, Crawley, Sussex, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- University Hospitals Birmingham NHS Foundation Trust, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham & Birmingham Health Partners, Birmingham, UK
- Musculoskeletal Research Unit, University of Bristol and Royal United Hospital NHS Foundation Trust, Bath, UK
- Metabolic Bone, Nuffield Orthopaedic Hospital, Oxford, UK
- Centre for Metabolic Diseases, University of Sheffield Medical School, Sheffield, UK
- Metabolic Bone, University of Sheffield, Sheffield, UK
- Emeritus Professor of Rheumatology, University of Aberdeen, Aberdeen, UK
- Metabolic Bone Disease, University of Manchester, Manchester, UK
- National Osteoporosis Society, Camerton, UK
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Johansson H, Azizieh F, Al Ali N, Alessa T, Harvey NC, McCloskey E, Kanis JA. FRAX- vs. T-score-based intervention thresholds for osteoporosis. Osteoporos Int 2017; 28:3099-3105. [PMID: 28782072 PMCID: PMC5881885 DOI: 10.1007/s00198-017-4160-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Many current guidelines for the assessment of osteoporosis, including those in Kuwait, initiate fracture risk assessment in men and women using BMD T-score thresholds. We compared the Kuwaiti guidelines with FRAX-based age-dependent intervention thresholds equivalent to that in women with a prior fragility fracture. FRAX-based intervention thresholds identified women at higher fracture probability than fixed T-score thresholds, particularly in the elderly. PURPOSE A FRAX® model been recently calibrated for Kuwait, but guidance is needed on how to utilise fracture probabilities in the assessment and treatment of patients. METHODS We compared age-specific fracture probabilities, equivalent to women with no clinical risk factors and a prior fragility fracture (without BMD), with the age-specific fracture probabilities associated with femoral neck T-scores of -2.5 and -1.5 SD, in line with current guidelines in Kuwait. Upper and lower assessment thresholds for BMD testing were additionally explored using FRAX. RESULTS When a BMD T-score of -2.5 SD was used as an intervention threshold, FRAX probabilities of a major osteoporotic fracture in women aged 50 years were approximately twofold higher than those in women of the same age but with an average BMD. The increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 83 years or more, a T-score of -2.5 SD was associated with a lower probability of fracture than that of the age-matched general population with no clinical risk factors. The same phenomenon was observed from the age of 66 years at a T-score of -1.5 SD. A FRAX-based intervention threshold, defined as the 10-year probability of a major osteoporotic fracture in a woman of average BMI with a previous fracture, rose with age from 4.3% at the age of 50 years to 23%, at the age of 90 years, and identified women at increased risk at all ages. Qualitatively comparable findings were observed in the case of hip fracture probability and in men. CONCLUSION Intervention thresholds based on BMD alone do not optimally target women at higher fracture risk than those on age-matched individuals without clinical risk factors, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a 'fracture threshold' consistently target women at higher fracture risk, irrespective of age.
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Affiliation(s)
- H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - F Azizieh
- Department of Mathematics and Natural Sciences, Gulf University for Science and Technology, Mubarak Al-Abdullah, Kuwait City, Kuwait
| | - N Al Ali
- Unit of Endocrinology & Metabolism, Al-Amiri Hospital, Kuwait City, Kuwait
| | - T Alessa
- Endocrinology, Diabetes & Metabolism, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
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Abstract
The characterization of risk factors for fracture that contribute significantly to fracture risk, over and above that provided by the bone mineral density, has stimulated the development of risk assessment tools. The more adequately evaluated tools, all available online, include the FRAX® tool, the Garvan fracture risk calculator and, in the United Kingdom only, QFracture®. Differences in the input variables, output, and model construct give rise to marked differences in the computed risks from each calculator. Reasons for the differences include the derivation of fracture probability (FRAX) rather than incidence (Garvan and QFracture), limited calibration (Garvan), and inappropriate source information (QFracture). These differences need to be taken into account in the evaluation of assessment guidelines.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK; Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia; MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
| | - Nicholas C Harvey
- Centre for Bone and Arthritis Research (CBAR), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK; Centre for Bone and Arthritis Research (CBAR), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Odén
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Abstract
The fracture risk assessment tool, FRAX, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, models are now available for 63 countries, covering 79% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. However, the application of FRAX in guidelines has been heterogeneous with the adoption of several different approaches to setting intervention thresholds. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future. A more unified approach to setting intervention thresholds with FRAX is a research priority.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK; Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia.
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK; Centre for Bone and Arthritis Research (CBAR), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Odén
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
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Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, McCloskey EV. A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 2016; 11:25. [PMID: 27465509 PMCID: PMC4978487 DOI: 10.1007/s11657-016-0278-z] [Citation(s) in RCA: 254] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/16/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific. INTRODUCTION In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation. METHODS We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds. RESULTS Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the 'fracture threshold') should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity. CONCLUSION The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia.
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Helena Johansson
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Anders Odén
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Eugene V McCloskey
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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Kanis JA, Compston J, Cooper C, Harvey NC, Johansson H, Odén A, McCloskey EV. SIGN Guidelines for Scotland: BMD Versus FRAX Versus QFracture. Calcif Tissue Int 2016; 98:417-25. [PMID: 26650822 DOI: 10.1007/s00223-015-0092-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/21/2015] [Indexed: 11/26/2022]
Abstract
Scottish Intercollegiate Guidelines Network (SIGN) recently issued guidance on the management of osteoporosis and the prevention of fragility fractures. The aim of this paper was to critically review the guidance. The SIGN guidance utilises risk factors for fracture as an initial step for assessment, but recommends treatment only in individuals with a T-score of -2.5. There are many problems with the sole use of BMD as the sole gateway to treatment. Moreover, the assessment tools to determine risk (FRAX or QFracture) are not designed to detect osteoporosis but rather fracture risk. Whereas SIGN assumes that FRAX overestimates fracture probability, there are compelling reasons to believe that the disparity is related to the inadequate calibration of QFracture. The disparities make the use of a single threshold for BMD testing problematic. The SIGN guidance for men at high risk of fracture provides a set of confused and inconsistent recommendations that are in direct conflict with regulatory authorizations and is likely to increase further the large treatment gap in men. For women, the number of women eligible for treatment (i.e. with osteoporosis) is 81,700 with the use of FRAX but only 12,300 with QFracture representing 8.2 and 1.2 % of the total population at risk, respectively. We conclude that serious problems with the SIGN guidance preclude its implementation.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
| | | | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Helena Johansson
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Anders Odén
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Eugene V McCloskey
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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Kanis JA, Harvey NC, Johansson H, Odén A, Leslie WD, McCloskey EV. FRAX and fracture prediction without bone mineral density. Climacteric 2015; 18 Suppl 2:2-9. [PMID: 26489076 DOI: 10.3109/13697137.2015.1092342] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The major application of FRAX in osteoporosis is to direct pharmacological interventions to those at high risk of fracture. Whereas the efficacy of osteoporosis treatment, with the possible exception of alendronate, is largely independent of baseline bone mineral density (BMD), it remains a widely held perception that osteoporosis therapies are only effective in the presence of low BMD. Thus, the use of FRAX in the absence of BMD to identify individuals requiring therapy remains the subject of some debate and is the focus of this review. The clinical risk factors used in FRAX have high evidence-based validity to identify a risk responsive to intervention. The selection of high-risk individuals with FRAX, without knowledge of BMD, preferentially selects for low BMD and thus identifies a risk that is responsive to pharmacological intervention. The prediction of fractures with the use of clinical risk factors alone in FRAX is comparable to the use of BMD alone to predict fractures and is suitable, therefore, in the many countries where facilities for BMD testing are sparse. In countries where access to BMD is greater, FRAX can be used without BMD in the majority of cases and BMD tests reserved for those close to a probability-based intervention threshold. Thus concerns surrounding the use of FRAX in clinical practice without information on BMD are largely misplaced.
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Affiliation(s)
- J A Kanis
- a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK
| | - N C Harvey
- b MRC Lifecourse Epidemiology Unit, University of Southampton , Southampton , UK
| | - H Johansson
- a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK ;,c Centre for Bone and Arthritis Research, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - A Odén
- a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK
| | - W D Leslie
- d University of Manitoba , Winnipeg , Canada
| | - E V McCloskey
- a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK
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Odén A, McCloskey EV, Kanis JA, Harvey NC, Johansson H. Burden of high fracture probability worldwide: secular increases 2010-2040. Osteoporos Int 2015; 26:2243-8. [PMID: 26018089 DOI: 10.1007/s00198-015-3154-6] [Citation(s) in RCA: 320] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/26/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED The number of individuals aged 50 years or more at high risk of osteoporotic fracture worldwide in 2010 was estimated at 158 million and is set to double by 2040. INTRODUCTION The aim of this study was to quantify the number of individuals worldwide aged 50 years or more at high risk of osteoporotic fracture in 2010 and 2040. METHODS A threshold of high fracture probability was set at the age-specific 10-year probability of a major fracture (clinical vertebral, forearm, humeral or hip fracture) which was equivalent to that of a woman with a BMI of 24 kg/m(2) and a prior fragility fracture but no other clinical risk factors. The prevalence of high risk was determined worldwide and by continent using all available country-specific FRAX models and applied the population demography for each country. RESULTS Twenty-one million men and 137 million women had a fracture probability at or above the threshold in the world for the year 2010. The greatest number of men and women at high risk were from Asia (55 %). Worldwide, the number of high-risk individuals is expected to double over the next 40 years. CONCLUSION We conclude that individuals with high probability of osteoporotic fractures comprise a very significant disease burden to society, particularly in Asia, and that this burden is set to increase markedly in the future. These analyses provide a platform for the evaluation of risk assessment and intervention strategies.
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Affiliation(s)
- A Odén
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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McCloskey E, Kanis JA, Johansson H, Harvey N, Odén A, Cooper A, Cooper C, Francis RM, Reid DM, Marsh D, Selby P, Thompson F, Hewitt S, Compston J. FRAX-based assessment and intervention thresholds--an exploration of thresholds in women aged 50 years and older in the UK. Osteoporos Int 2015; 26:2091-9. [PMID: 26077380 DOI: 10.1007/s00198-015-3176-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/13/2015] [Indexed: 01/22/2023]
Abstract
UNLABELLED Under current guidelines, based on prior fracture probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold (a fixed threshold from the age of 70 years) reduces this disparity, increases treatment access and decreases the need for bone densitometry. INTRODUCTION Several international guidelines set age-specific intervention thresholds at the 10-year probability of fracture equivalent to a woman of average BMI with a prior fracture. At older ages (≥70 years), women with prior fracture selected for treatment are at lower average absolute risk than those selected for treatment in the absence of prior fracture, prompting consideration of alternative thresholds in this age group. METHODS Using a simulated population of 50,633 women aged 50-90 years in the UK, with a distribution of risk factors similar to that in the European FRAX derivation cohorts and a UK-matched age distribution, the current NOGG intervention and assessment thresholds were compared to one where the thresholds remained constant from 70 years upwards. RESULTS Under current thresholds, 45.1% of women aged ≥70 years would be eligible for therapy, comprising 37.5% with prior fracture, 2.2% with high risk but no prior fracture and 5.4% selected for treatment after bone mineral density (BMD) measurement. Mean hip fracture probability was 11.3, 23.3 and 17.6%, respectively, in these groups. Under the alternative thresholds, the overall proportion of women treated increased from 45.1 to 52.9%, with 8.4% at high risk but no prior fracture and 7.0% selected for treatment after BMD measurement. In the latter group, the mean probability of hip fracture was identical to that observed in women with prior fracture (11.3%). The alternative threshold also reduced the need for BMD measurement, particularly at older ages (>80 years). CONCLUSIONS The alternative thresholds equilibrate fracture risk, particularly hip fracture risk, in those with or without prior fracture selected for treatment and reduce BMD usage at older ages.
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Affiliation(s)
- E McCloskey
- Academic Unit of Bone Metabolism and Mellanby Centre for Bone Research, University of Sheffield, Metabolic Bone Centre, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
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Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2013; 24:23-57. [PMID: 23079689 PMCID: PMC3587294 DOI: 10.1007/s00198-012-2074-y] [Citation(s) in RCA: 877] [Impact Index Per Article: 79.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 12/12/2022]
Abstract
UNLABELLED Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk of fractures due to osteoporosis. INTRODUCTION The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2008. This manuscript updates these in a European setting. METHODS Systematic literature reviews. RESULTS The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk, general and pharmacological management of osteoporosis, monitoring of treatment, assessment of fracture risk, case finding strategies, investigation of patients and health economics of treatment. CONCLUSIONS A platform is provided on which specific guidelines can be developed for national use.
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Affiliation(s)
- J A Kanis
- WHO Collaborating Centre, UK University of Sheffield Medical School, Sheffield, UK.
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Abstract
The diagnosis and management of osteoporosis have been improved by the development of new quantitative methods of skeletal assessment and by the availability of an increasing number of therapeutic options, respectively. A number of imaging methods exist and all have advantages and disadvantages. Dual-energy X-ray absorptiometry (DXA) is the most widely available and commonly utilized method for clinical diagnosis of osteoporosis and will remain so for the foreseeable future. The WHO 10-year fracture risk assessment tool (FRAX(®)) will improve clinical use of DXA and the cost-effectiveness of therapeutic intervention. Improved reporting of radiographic features that suggest osteoporosis and the presence of vertebral fracture, which are powerful predictors of future fractures, could increase the frequency of appropriate DXA referrals. Quantitative CT remains predominantly a research tool, but has advantages over DXA--allowing measurement of volumetric density, separate measures of cortical and trabecular bone density, and evaluation of bone shape and size. High resolution imaging, using both CT and MRI, has been introduced to measure trabecular and cortical bone microstructure. Although these methods provide detailed insights into the effects of disease and therapies on bone, they are technically challenging and not widely available, so they are unlikely to be used in clinical practice.
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Affiliation(s)
- Judith E Adams
- Manchester Academic Health Science Centre, The Royal Infirmary and University of Manchester, Department of Radiology, The Royal Infirmary, Manchester M13 9WL, UK.
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The impact of a FRAX-based intervention threshold in Turkey: the FRAX-TURK study. Arch Osteoporos 2012; 7:229-35. [PMID: 23060308 DOI: 10.1007/s11657-012-0101-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/30/2012] [Indexed: 02/03/2023]
Abstract
INTRODUCTION With the development of country-specific FRAX® tools to estimate fracture probability, guidance is required on the fracture probability at which treatment can be recommended. OBJECTIVES The aim of the present study was to determine FRAX-based intervention thresholds in men and women from Turkey and determine their population impact. PATIENTS AND METHODS Intervention thresholds for treatment and assessment thresholds for measuring BMD were devised using the strategy adopted by the National Osteoporosis Guideline Group of the UK but applied to the fracture probabilities in Turkey. The number of men and women potentially eligible for treatment was determined from the distribution of FRAX-based probabilities of a major fracture (Turkish model, version 3.6) in a representative sample of 26,394 men and women aged 50 years or more. RESULTS Intervention thresholds, set at the probability equivalents of a woman with a prior fragility fracture rose with age from 7.0 % at the age of 50 years to 31 % at the age of 90 years. Approximately 8.6 % of the female Turkish population aged 50 years or more had a prior fragility fracture and would be eligible for treatment. A further 13.6 % without a prior fracture would be eligible for treatment. In contrast, the number of men aged 50 years or more eligible for treatment was 3.1 %. CONCLUSIONS FRAX-based guidelines can be developed and are expected to avoid unnecessary treatment of individuals at low fracture risk and direct treatments to those at high risk. The adoption of FRAX-based intervention thresholds will demand a reappraisal of the criteria for reimbursement of interventions and health economic assessment.
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Lekamwasam S, Adachi JD, Agnusdei D, Bilezikian J, Boonen S, Borgström F, Cooper C, Diez Perez A, Eastell R, Hofbauer LC, Kanis JA, Langdahl BL, Lesnyak O, Lorenc R, McCloskey E, Messina OD, Napoli N, Obermayer-Pietsch B, Ralston SH, Sambrook PN, Silverman S, Sosa M, Stepan J, Suppan G, Wahl DA, Compston JE. A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. Osteoporos Int 2012; 23:2257-76. [PMID: 22434203 DOI: 10.1007/s00198-012-1958-1] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 02/13/2012] [Indexed: 01/13/2023]
Abstract
UNLABELLED This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer. INTRODUCTION The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010. METHODS AND RESULTS The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review. CONCLUSIONS Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.
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Affiliation(s)
- S Lekamwasam
- Department of Medicine, Faculty of Medicine, Centre for Metabolic Bone Diseases, Galle, Sri Lanka
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Kanis JA, McCloskey E, Johansson H, Oden A, Leslie WD. FRAX(®) with and without bone mineral density. Calcif Tissue Int 2012; 90:1-13. [PMID: 22057815 DOI: 10.1007/s00223-011-9544-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 08/23/2011] [Indexed: 12/31/2022]
Abstract
The use of FRAX, particularly in the absence of BMD, has been the subject of some debate and is the focus of this review. The clinical risk factors used in FRAX have high validity as judged from an evidence-based assessment and identify a risk that is responsive to pharmaceutical intervention. Moreover, treatment effects, with the possible exception of alendronate, are not dependent on baseline BMD and strongly suggest that FRAX identifies high-risk patients who respond to pharmaceutical interventions. In addition, the selection of high-risk individuals with FRAX, without knowledge of BMD, preferentially selects for low BMD. The prediction of fractures with the use of clinical risk factors alone in FRAX is comparable to the use of BMD alone to predict fractures and is suitable, therefore, in the many countries where DXA facilities are sparse. In countries where access to BMD is greater, FRAX can be used without BMD in the majority of cases and BMD tests reserved for those close to a probability-based intervention threshold. Whereas the efficacy for agents to reduce fracture risk has not been tested prospectively in randomized controlled trials in patients selected on the basis of FRAX probabilities, there is compelling evidence that FRAX with or without the use of BMD provides a well-validated instrument for targeting patients most likely to benefit from an intervention.
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Affiliation(s)
- John A Kanis
- WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, UK.
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