FRAX- vs. T-score-based intervention thresholds for osteoporosis

FRAX-derived intervention and assessment thresholds for osteoporosis in ten Middle Eastern countries

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.

Guidelines for fracture risk assessment and management of osteoporosis in postmenopausal women and men above the age of 50 in Qatar

We present comprehensive guidelines for osteoporosis management in Qatar. Formulated by the Qatar Osteoporosis Association, the guidelines recommend the age-dependent Qatar fracture risk assessment tool for screening, emphasizing risk-based treatment strategies and discouraging routine dual-energy X-ray scans. They offer a vital resource for physicians managing osteoporosis and fragility fractures nationwide.

PURPOSE

Osteoporosis and related fragility fractures are a growing public health issue with an impact on individuals and the healthcare system. We aimed to present guidelines providing unified guidance to all healthcare professionals in Qatar regarding the management of osteoporosis.

METHODS

The Qatar Osteoporosis Association formulated guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men above the age of 50. A panel of six local rheumatologists who are experts in the field of osteoporosis met together and conducted an extensive review of published articles and local and international guidelines to formulate guidance for the screening and management of postmenopausal women and men older than 50 years in Qatar.

RESULTS

The guidelines emphasize the use of the age-dependent hybrid model of the Qatar fracture risk assessment tool for screening osteoporosis and risk categorization. The guidelines include screening, risk stratification, investigations, treatment, and monitoring of patients with osteoporosis. The use of a dual-energy X-ray absorptiometry scan without any risk factors is discouraged. Treatment options are recommended based on risk stratification.

CONCLUSION

Guidance is provided to all physicians across the country who are involved in the care of patients with osteoporosis and fragility fractures.

Two-sample Mendelian randomization analysis evaluates causal associations between inflammatory bowel disease and osteoporosis

Introduction

Over the past few years, multiple observational studies have speculated a potential association between inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn's disease (CD), and osteoporosis. However, no consensus has been reached regarding their interdependence and pathogenesis. Herein, we sought to further explore the causal associations between them.

Methods

We validated the association between IBD and reduced bone mineral density in humans based on genome-wide association studies (GWAS) data. To investigate the causal relationship between IBD and osteoporosis, we performed a two-sample Mendelian randomization study using training and validation sets. Genetic variation data for IBD, CD, UC, and osteoporosis were derived from published genome-wide association studies in individuals of European ancestry. After a series of robust quality control steps, we included eligible instrumental variables (SNPs) significantly associated with exposure (IBD/CD/UC). We adopted five algorithms, including MR Egger, Weighted median, Inverse variance weighted, Simple mode, and Weighted mode, to infer the causal association between IBD and osteoporosis. In addition, we evaluated the robustness of Mendelian randomization analysis by heterogeneity test, pleiotropy test, leave-one-out sensitivity test, and multivariate Mendelian randomization.

Results

Genetically predicted CD was positively associated with osteoporosis risk, with ORs of 1.060 (95% CIs 1.016, 1.106; p = 0.007) and 1.044 (95% CIs 1.002, 1.088; p = 0.039) for CD in the training and validation sets, respectively. However, Mendelian randomization analysis did not reveal a significant causal relationship between UC and osteoporosis (p > 0.05). Furthermore, we found that overall IBD was associated with osteoporosis prediction, with ORs of 1.050 (95% CIs 0.999, 1.103; p = 0.055) and 1.063 (95% CIs 1.019, 1.109; p = 0.005) in the training and validation sets, respectively.

Conclusion

We demonstrated the causal association between CD and osteoporosis, complementing the framework for genetic variants that predispose to autoimmune disease.

The role and place of the FRAX calculator in initiation osteoporosis treatment: an analysis of the osteoporosis center registry

Background: The growing frequency of fractures associated with osteoporosis, the significant costs of their treatment, disability and increased mortality make it an important and urgent task to optimize the diagnosis and treatment of osteoporosis in the Russian Federation.

Aim: The aim of this study was analyzed of using modern diagnostic criteria for osteoporosis by specialists when they making a clinical decision to initiate treatment for osteoporosis, including an estimate of the 10-year probability of fractures according to FRAX.

Materials and methods: The study was conducted in the city consultative and diagnostic center for the prevention of osteoporosis, St. Petersburg. The register of the osteoporosis center for 2018–2021 was used to select patients for the study. Based on the analysis of registry data, a sample of 362 patients with newly diagnosed osteoporosis was obtained. In the resulting sample, the existing FRAX value was assessed on the therapeutic intervention threshold graph, all of them analyzed the primary medical documentation, as well as the available DXA densitometry data.

Results: In this study, we assessed the place of FRAX 10-year risk of major osteoporotic fractures in the clinical decision of an osteoporosis specialist to start anti-osteoporosis therapy, in this case taken as the «gold standard». The study found that a positive FRAX score had a high predictive value of 100%. In contrast, the negative predictive value was very low (19.5%): a FRAX value below the intervention threshold did not guarantee a truly low fracture risk and no need to start osteoporosis treatment.

Conclusion: Despite the fact that both densitometry and FRAX have significant limitations in use, and cannot identify all patients with a high risk of fractures, their combined use increases the prognostic value of the methods. FRAX technology in routine practice allows, in addition to clinical and instrumental methods for diagnosing high-risk fractures, to identify candidates for the treatment of osteoporosis, and should be used in accordance with clinical recommendations.

Reverse engineering the FRAX algorithm: Clinical insights and systematic analysis of fracture risk

The Fracture Risk Assessment Tool (FRAX) is a computational tool developed to predict the 10-year probability of hip fracture and major osteoporotic fracture based on inputs of patient characteristics, bone mineral density (BMD), and a set of seven clinical risk factors. While the FRAX tool is widely available and clinically validated, its underlying algorithm is not public. The relative contribution and necessity of each input parameter to the final FRAX score is unknown. We systematically collected hip fracture risk scores from the online FRAX calculator for osteopenic Caucasian women across 473,088 unique inputs. This dataset was used to dissect the FRAX algorithm and construct a reverse-engineered fracture risk model to assess the relative contribution of each input variable. Within the reverse-engineered model, age and T-Score were the strongest contributors to hip fracture risk, while BMI had marginal contribution. Of the clinical risk factors, parent history of fracture and ongoing glucocorticoid treatment had the largest additive effect on risk score. A generalized linear model largely recapitulated the FRAX tool with an R2 of 0.91. Observed effect sizes were then compared to a true patient population by creating a logistic regression model of the Study of Osteoporotic Fractures (SOF) cohort, which closely paralleled the effect sizes seen in the reverse-engineered fracture risk model. Analysis identified several clinically relevant observations of interest to FRAX users. The role of major osteoporotic fracture risk prediction in contributing to an indication of treatment need is very narrow, as the hip fracture risk prediction accounted for 98% of treatment indications for the SOF cohort. Removing any risk factor from the model substantially decreased its accuracy and confirmed that more parsimonious models are not ideal for fracture prediction. For women 65 years and older with a previous fracture, 98% of FRAX combinations exceeded the treatment threshold, regardless of T-score or other factors. For women age 70+ with a parent history of fracture, 99% of FRAX combinations exceed the treatment threshold. Based on these analyses, we re-affirm the efficacy of the FRAX as the best tool for fracture risk assessment and provide deep insight into the interplay between risk factors.

Prevalence and Factors of Osteoporosis and High Risk of Osteoporotic Fracture in Patients with Ankylosing Spondylitis: A Multicenter Comparative Study of Bone Mineral Density and the Fracture Risk Assessment Tool

Background: We investigated the prevalence of and the factors associated with a high risk of osteoporotic fractures in Korean patients with ankylosing spondylitis (AS). Methods: This was a multicenter, retrospective study including 219 AS patients from five university hospitals; the control group was selected by matching age and sex with those of the AS patients. The fracture risk was evaluated based on bone mineral density (BMD) measured by dual-energy X-ray absorptiometry and the fracture risk assessment tool (FRAX) with/without BMD. Results: The mean age of the patients was 47.6 years, and 144 (65.8%) patients were men. According to the WHO criteria and FRAX with/without BMD, the candidates for pharmacological treatment were 44 (20.1%), 20 (13.2%), and 23 (15.1%) patients, respectively, significantly more than those in the healthy control group. Among them, the proportion of patients receiving osteoporosis treatment was 39.1–75%. In logistic regression analysis, menopause was an independent factor for the high risk of fracture according to the WHO criteria and FRAX with/without BMD. C-reactive protein level (odds ratio (OR) 3.8 and OR 6) and glucocorticoid use (OR 1.5 and OR 1.7) were associated with a high risk of osteoporotic fracture based on FRAX without BMD and osteoporosis diagnosed according to the WHO criteria. Conclusions: Our study suggests that both FRAX and WHO criteria may be complementary for treatment decisions to reduce osteoporotic fractures in patients with AS.

An optimal intervention threshold of FRAX in postmenopausal Thai women

This study was designed to determine a FRAX intervention threshold in postmenopausal Thais, based on a history of hip fracture. The optimal FRAX thresholds for hip fracture were 4.9% (without BMD) and 4% (with BMD), while the thresholds for major osteoporotic fracture were 9.8% (without BMD) and 8.9% (with BMD).

INTRODUCTION

Fracture Risk Assessment Tool (FRAX) has been widely used as an intervention threshold for initiating osteoporosis treatment. However, there is a lack of data to validate the threshold in Thai population.

METHODS

A cross-sectional study was conducted from January 2014 to February 2019. Postmenopausal women in the Northeast of Thailand whom has bone mineral density (BMD) measured using dual-energy X-ray absorptiometry (DXA) in the study period were recruited. Participants who had previously received anti-osteoporotic treatment were not eligible. FRAX score, both with and without BMD, was calculated using a Thai reference. Prevalent hip fracture was identified by reviewing the ICD-10 diagnosis from the hospital database during the study period. The receiver operating characteristic (ROC) curve and Youden index were used to determine the FRAX threshold in predicting hip fracture, based on the rationale that women with a prevalent hip fracture would be eligible for treatment.

RESULTS

A total of 2872 postmenopausal Thai women were recruited, with 45 sustained a recent hip fracture. In association with hip fracture, the optimal FRAX thresholds for hip fracture without and with BMD were 4.9% and 4%, respectively, with 71.1% sensitivity and 83.3% specificity, and 82.2% sensitivity and 78.6% specificity, while the optimal FRAX thresholds for major osteoporotic fracture (MOF) without and with BMD were 9.8% and 8.9%, respectively, with 75.6% sensitivity and 77.0% specificity, and 86.7% sensitivity and 70.9% specificity.

CONCLUSION

An optimal intervention threshold based on FRAX of hip fracture and MOF in postmenopausal Thai women is slightly different from the standard recommendation, which confirmed the marked variations of thresholds across ethnicities. The proposed threshold should be considered as new cutoff for initiating osteoporosis treatment in postmenopausal Thais.

Comparison between real-world practice and application of the FRAX algorithm in the treatment of osteoporosis

BACKGROUND AND AIMS

The most recent guidelines suggest treating patients whose FRAX 10-year fracture risk scores are ≥ 20%. However, this method of evaluation does not take into account parameters that are nonetheless relevant to the therapeutic choice. Our aim was to compare the therapeutic choices for treatment based on a wider assessment (real-world practice) with those based on FRAX scores, taking 20% as the cut-off score.

METHODS

We obtained the medical history, bone mineral density (BMD) values, and the presence of major fragility fractures in a sample of 856 postmenopausal women. The 10-year FRAX risk of major osteoporotic fracture was calculated, and patients were grouped into risk classes ("FRAX < 20%" = low, "FRAX ≥ 20%" = high); we then compared the treated and untreated patients in each class. After an average interval of 2.5 years, changes in lumbar and femoral BMD and appearances of new fragility fractures were recorded.

RESULTS

83% of high-risk patients and 57% of low-risk patients were treated. The therapeutic decision was based mainly on densitometric values and the presence of vertebral fractures. At the 2.5 year follow-up, lumbar spine and femur BMD had decreased in the untreated group; 9.9% of the treated patients developed new vertebral fragility fractures, compared with 5.3% of the untreated patients.

DISCUSSION AND CONCLUSIONS

Our wider assessment designated as at high fracture risk a group of patients who had not been identified by the FRAX assessment. FRAX could underestimate the risk of fracture in older people, for which the therapeutic choice should consider a broader approach, also based on individual patient's needs.

FRAX-based intervention thresholds for Pakistan

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.

Prevalence of Osteopenia in Drug-Naive Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Monocentric Study

OBJECTIVES

To examine the bone mineral density and prevalence of osteoporosis and osteopenia in glucocorticoid- and immunosuppressive drug-naive patients younger than 55 years with antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

This was a cross-sectional study. We reviewed the medical records of 35 AAV patients and 35 age-, sex-, and body mass index (BMI)-matched control subjects. We collected clinical data such as AAV-related variables and conventional risk factors for osteoporosis and assessed bone mineral density and the prevalence of osteoporosis and osteopenia in both groups. Categorical and continuous variables were compared between the 2 groups using the χ2 or Fisher exact test and Mann-Whitney U test, respectively. Multivariate logistic regression analysis was used to calculate the odds ratio (OR).

RESULTS

There were no statistically significant differences between the demographical data of AAV patients and control subjects. Patients with AAV showed significantly higher frequencies of conventional risk factors for osteoporosis than the control subjects, except for hyperthyroidism. Osteopenia was found more commonly in AAV patients than in control subjects (57.1% vs. 31.4%, p = 0.030). In the univariate logistic regression analysis, BMI (OR, 0.813) and AAV (OR, 2.620) were associated with osteopenia in all participants. In the multivariate analysis, both BMI and AAV were associated with osteopenia, but this was not statistically significant. In contrast, when analyzing AAV patients only, neither conventional risk factors nor AAV-related variables were associated with the prevalence of osteopenia.

CONCLUSIONS

Antineutrophil cytoplasmic antibody-associated vasculitis and BMI were both associated with osteopenia.

Intervention thresholds to identify postmenopausal women with high fracture risk: A single center study based on the Philippines FRAX model

Objectives

This study is designed to estimate appropriate intervention thresholds for the Philippines Fracture Risk Assessment Tool (FRAX) model to identify postmenopausal women with high fracture risk.

Methods

Age dependent intervention thresholds were calculated for a woman of body mass index 25 kg/m² aged 50-80 years with a previous fragility fracture without other clinical risk factors. Fixed thresholds were developed using a database of 1546 postmenopausal women who underwent dual-energy X-ray absorptiometry for clinical reasons. Major and hip fracture risks were estimated using clinical risk factors with and without bone mineral density (BMD) input. Women were categorized to high risk and low risk groups according to the age dependent thresholds. The best cut-points were determined considering the optimum sensitivity and specificity using receiver operating characteristic analysis.

Results

The age dependent intervention thresholds of major fracture risk ranged from 2.8 to 6.9% while hip fracture risk ranged from 0.4 to 3.0% between 50 and 80 years of age. Major fracture threshold of 3.75% and hip fracture threshold of 1.25% were the best fixed thresholds observed and non-inclusion BMD in the fracture risk estimations did not change the values. As a hybrid method, 3% major fracture and 1% hip fracture risks for those < 70 years old and age-dependent thresholds for those aged 70 years and above can be recommended.

Conclusions

The intervention thresholds estimated in the current study can be applied to identify Filipino postmenopausal women with a high fracture risk. Clinicians should decide on the type of thresholds most appropriate.

Treatment indications and thresholds of intervention: consensus and controversies in osteoporosis

A few indications for treatment and thresholds for intervention in osteoporosis have been propounded in the literature and recommended in guidelines. These include a bone mineral density (BMD) T-score ≤ -2.5, fracture probability-based scores and the presence of a fragility fracture. A low BMD is associated with an increased risk of fracture. However, a BMD T-score of ≤ -2.5 on its own does not capture fracture risk in its entirety. Fracture risk assessment tools that are based on clinical risk factors arose from the misgivings about using BMD T-scores in isolation to assess fracture risk. Algorithms such as FRAX, Garvan etc, integrate various clinical risk factors with or without BMD to compute the probability of a hip fracture or a major osteoporotic fracture over a finite period. These probabilities do not yield distinctive thresholds by themselves and need to be interpreted wisely and adopted by consensus. Evidence exists to show that treatment can decrease the risk of sustaining a second fracture. Therefore, patients with a fragility fracture should be considered for treatment. In this narrative interview, we will explore the strengths and limitations of some of these indications for treatment and will discuss the various points of contention surrounding them.

Beijing Friendship Hospital Osteoporosis Self-Assessment Tool for Elderly Male (BFH-OSTM) vs Fracture Risk Assessment Tool (FRAX) for identifying painful new osteoporotic vertebral fractures in older Chinese men: a cross-sectional study

Background

To compare the validation of four tools for identifying painful new osteoporotic vertebral compression fractures (PNOVCFs) in older Chinese men: bone mineral density (BMD), Asian osteoporosis self-assessment tool (OSTA), World Health Organization fracture risk assessment tool (FRAX) (without BMD) and Beijing Friendship Hospital Osteoporosis Self-Assessment Tool (BFH-OSTM).

Methods

A cross sectional study was conducted from 2013 to 2019. A total of 846 men aged ≥50 were included and were divided into two groups: Fracture Group (patients with PNOVCFs underwent percutaneous vertebroplasty surgery) and Non-Fracture Group (community dwelled subjects for healthy examination). All subjects accepted a dual-energy X-ray BMD test and a structured questionnaire. The results of BMD, OSTA, FRAX and BFH-OSTM scores were assessed and receiver-operating characteristic (ROC) curves were generated to compare the validity of four tools for identifying PNOVCFs. Optimal cutoff points, sensitivity, specificity, and areas under the ROC curves (AUCs) were determined.

Results

There were significant differences including BMD T score (femoral neck, total hip and L1-L4), OSTA, FRAX and BFH-OSTM scores between Fracture group and Non-fracture group. Compared to BMD and OSTA, BFH-OSTM and FRAX had better predictive value, the sensitivity, specificity and AUC value are 0.841, 81.29%, 70.67% and 0.796, 74.85%, 78.52%, respectively. Compared with FRAX, the BFH-OSTM has a better AUC value.

Conclusions

Both BFH-OSTM and FRAX can be used to identify POVCFs, However, BFH-OSTM model may be a more simple and effective tool to identify the risk of POVCFs in Chinese elderly men.

FRAX-based osteoporosis treatment guidelines for resource-poor settings in India

Using the FRAX® model for India, thresholds for osteoporosis evaluation and treatment without bone mineral density measurement were derived and were validated in a cohort of 300 patients. We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis in India.

PURPOSE

Our study aimed to formulate population-specific intervention thresholds for treatment of osteoporosis in India which can be used even without dual X-ray absorptiometry (DXA).

METHODS

Using the FRAX® model for India, thresholds for different age groups for men and women were calculated without bone mineral density (BMD) measurement. The lower assessment threshold (LAT) was based on the 10-year probability of a major osteoporosis fracture (MOF) or hip fracture (HF) equivalent to patients without clinical risk factors. The intervention threshold (IT) was based on the 10-year probability equivalent to patients with fracture. The upper assessment threshold (UAT) was set at 1.2 times the IT. Probability-based thresholds for no intervention (LAT), treatment initiation (UAT) and BMD assessment (between LAT and UAT) were derived. The thresholds were validated in a cohort of 300 patients who were referred for BMD testing.

RESULTS

Graphs for age, gender, BMI and ethnic-specific LAT, IT and UAT for MOF and HF are derived. In the validation cohort, BMD testing to initiate/defer treatment was required in only 32.3% patients. The intervention thresholds derived without BMD testing were valid in 98.7% patients. Use of National Osteoporosis Foundation (NOF) guidelines would have resulted in overtreatment in 56/300 (18.6%) patients.

CONCLUSION

We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis. Adopting these cut-offs will ensure that those requiring osteoporosis treatment will not be denied of it just because of lack of a DXA machine and will also help avoid overtreatment.

Effectiveness of Prophylactic Preoperative Antibiotics in Mandible Fracture Repair: A National Database Study

OBJECTIVE

This is the first database study to assess the effectiveness of prophylactic preoperative antibiotics (PPAs) in mandible fracture repair.

STUDY DESIGN

Retrospective cohort.

SETTING

Database study using US inpatient and outpatient insurance claims submitted from July 2006 to March 2015.

METHODS

The IBM MarketScan Commercial Database was queried for adults aged 18 to 64 years who had undergone first-time mandible fracture repair according to Current Procedural Terminology codes for open and closed repair. Primary outcomes included surgical revision, local infection, and osteomyelitis. Rates were compared between cohorts based on whether or not patients had filled antibiotic prescriptions during the preoperative period alone. The effects of drug abuse and type of mandible repair (open vs closed) were explored. Multivariate Poisson regression models were used to calculate adjusted relative risk estimates, and 95% CIs were used to determine statistically significant differences.

RESULTS

A total of 2676 patients were included, with 847 (31.7%) filling PPAs and 1829 (68.3%) filling no antibiotics. Rates were 38.9% for revision, 5.8% for local infection, and 2.1% for osteomyelitis. After multivariate analysis, exposure to PPAs was not associated with surgical revision (adjusted relative risk, 1.04; 95% CI, 0.94-1.15), local infection (1.16; 0.82-1.64), or osteomyelitis (1.21; 0.68-2.14). Patients were more likely to fill PPAs if they underwent open repair (35.3%) versus closed (26.6%) (proportion difference, 8.7%; 95% CI, 5.2%-12.2%), but exposure to antibiotics did not predict outcomes on subgroup analysis.

CONCLUSION

PPAs do not improve mandible repair outcomes, regardless of repair type.

Recent developments towards closing the gap in osteoporosis management

Background

A fracture that occurs in people with low bone mass in the setting of minimal trauma—such as a fall from standing height—meets the criteria for the clinical diagnosis of osteoporosis and qualifies this particular individual for being at high risk of further fractures, particularly in the first 2 years after the index fracture. Therefore, it is vital to identify those individuals at very high and high fracture risk with the potential of instantly starting osteoporosis therapy.

Main body

Currently, there are unmet needs in the management of bone fragility and fracture prevention. Therefore, re-stratification of the people according to their risk of fracture, and, also, identify what is and is not achievable using different osteoporosis therapies, represent a major step forward. In 2020, the dichotomisation of high risk into high and very high-risk categories, which represent a new concept in osteoporosis assessment, was published by the IOF and the ESCEO. This coincided with proliferation of the available therapies with different modes of action and new therapeutic targets for treating osteoporosis. Fear of complications, even though rare, associated with long-term bisphosphonates and the positive impact of osteoanabolic agents on fracture reduction and bone quality, have changed the prescribing patterns and paved the way for sequential and combined therapy.

Conclusion

The incorporation of recent concepts in osteoporosis and the development of new interventional thresholds have positive implication on strategies for osteoporotic patients’ diagnosis and management.

FRAX-based fracture probabilities in South Africa

The hip fracture rates in South Africa were used to create ethnic-specific FRAX® models to facilitate fracture risk assessment.

INTRODUCTION

The aim of this study was to develop FRAX models to compute the 10-year probability of hip fracture and major osteoporotic fracture and assess their potential clinical application.

METHODS

Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for the White, Black African, Coloured and Indian population of South Africa. Age-specific 10-year probabilities of a major osteoporotic fracture were calculated in women to determine fracture probabilities at a femoral neck T score of -2.5 SD, or those equivalent to a woman with a prior fragility fracture. Fracture probabilities were compared with those from selected countries.

RESULTS

Probabilities were consistently higher in Indian than in Coloured men and women, in turn, higher than in Black South Africans. For White South Africans, probabilities were lower than in Indians at young ages up to the age of about 80 years. When a BMD T score of -2.5 SD was used as an intervention threshold, FRAX probabilities in women age 50 years were approximately 2-fold higher than in women of the same age but with an average BMD and no risk factors. The increment in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T score of -2.5 SD was no longer a risk factor. Probabilities equivalent to women with a previous fracture rose with age and identified women at increased risk at all ages.

CONCLUSIONS

These FRAX models should enhance accuracy of determining fracture probability amongst the South African population and help guide decisions about treatment.

Fracture risk among treatment-naïve postmenopausal women with osteopenia in Greece: results from the "ACROSS" study

Use of the FRAX (Fracture Risk Assessment Tool) tool to assess fracture risk is the most common practice worldwide. Our findings suggest that in treatment-naïve women with osteopenia treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75 years, according to the Greek-specific FRAX-based thresholds.

INTRODUCTION

When evaluating a patient with low bone mineral density (BMD), fracture risk estimation is of paramount importance. Fracture risk assessment using the FRAX tool is the most common and most studied practice worldwide.

PATIENTS-METHODS

The primary aim of the "ACROSS" study was to record the 10-year probability of major osteoporotic fractures and hip fractures, using the Greek version of the FRAX tool, in a rather representative population of 230 postmenopausal treatment-naïve women with osteopenia. Secondary aims of the study were to identify (1) the risk for fractures according to age and the years from menopause, (2) the proportion of patients qualifying for treatment according to the Greek cost-effective FRAX thresholds, and (3) the perception of both the patient and the treating physician regarding the estimated fracture risk.

RESULTS

The mean 10-year risk was 10.7% ± 6.6 for major osteoporotic fractures and 3.4% ± 4.2 for hip fractures. For women up to 75 years of age, the 10-year risk for major osteoporotic and hip fractures was 8.8% and 2.1%, respectively, while for women over 75 years, the risk was 15.2% and 6.6%, respectively. Patients generally believed that they had low fracture risk independently of age, while the physicians considered that the risk increases with advancing age.

CONCLUSIONS

According to the Greek-specific FRAX-based thresholds, the administration of osteoporosis treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75 years. Patients are not fully aware of their fracture risk.

Diagnosis and management of osteoporosis in postmenopausal women in Gulf Cooperation Council (GCC) countries: consensus statement of the GCC countries' osteoporosis societies under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

A consensus platform is provided by the experts of the Gulf Cooperation Council (GCC) countries' respective osteoporosis societies, on which specific guidelines can be developed further for regional use on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

Guidance is provided in a Gulf Cooperation Council (GCC) country setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis, which is an adaptation of the European guidance by Kanis et al., jointly published by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). The respective osteoporosis societies of the Gulf Cooperation Council (GCC) countries assembled for a unifying consensus on the diagnosis and management of osteoporosis in postmenopausal women for the region.

METHODS

The Chair for Biomarkers of Chronic Diseases (CBCD) in King Saud University (KSU), Riyadh, Kingdom of Saudi Arabia (KSA), in cooperation with the Saudi Osteoporosis Society (SOS), hosted regional experts and respective leaders from different GCC osteoporosis societies, together with an adviser from the ESCEO. An assembly of experts representing the different osteoporosis societies from Saudi Arabia, the UAE, Bahrain, Oman, and Kuwait gathered on February 15-16, 2019 in Riyadh, KSA for the formulation of a general osteoporosis consensus for the region.

RESULTS

The following areas were covered: diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; and hip fractures, vitamin D, recommendation on which FRAX tool to follow, and the importance of country-specific FRAX® and fracture liaison services for secondary fracture prevention.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for regional use in GCC.

Targeted bone density testing for optimizing fracture prevention in Canada

The Canadian FRAX® tool used without bone mineral density (BMD) is highly sensitive for identifying individuals qualifying for pharmacotherapy based upon an intervention threshold of 20% for major osteoporotic fracture risk (MOF) computed with BMD.

INTRODUCTION

This analysis was performed to inform initial BMD testing as part of Osteoporosis Canada's Guidelines Update for women and men at average risk, assuming a pharmacotherapy intervention threshold of 20% for FRAX® MOF computed with BMD.

METHODS

Women and men age 50 + without previous low-trauma fracture or high-risk medication use were identified in a BMD registry for the province of Manitoba, Canada. Fracture probability assessments with the Canadian FRAX® tool were computed without and with BMD (denoted MOF-clinical and MOF-BMD, respectively).

RESULTS

The study population consisted of 50,700 women (mean age 65.5 ± 9.4 years) and 4152 men (69.2 ± 10.0 years). FRAX MOF-clinical score was > 10% in 33.8% of women and 13.3% of men (P < 0.001). The median (interquartile range [IQR]) age for MOF-clinical to reach 10% in women was 70 (69-72) and 65 years (62-67) years in the absence and presence of additional FRAX clinical risk factors, respectively. In men, comparable ages were 83 years [82-86] and 76 [70-78] years. Using MOF-BMD of 20% as the intervention threshold, 4.3% of women and 0.7% of men qualified for treatment. MOF-clinical > 10% had high sensitivity to identify those qualifying for treatment (99.3% in women and 99.1% in men). An age-based rule ("BMD testing is indicated at age 70 if no additional FRAX clinical risk factors are present, or at age 65 if one or more clinical risk factors exists") gave similarly high sensitivity (women 99.9% and men > 99.9%).

CONCLUSIONS

FRAX without BMD offers an effective strategy to identify individuals meeting the current Canadian treatment threshold based upon FRAX® with BMD (≥ 20%). Moreover, this can be operationalized using simple age cutoffs of 70 years in the absence of additional clinical risk factors and 65 years in the presence of additional clinical risk factors.

Practical guidance for the use of bisphosphonates in osteoporosis

Bisphosphonates are widely used in the treatment of osteoporosis in postmenopausal women and older men. In clinical trials they have been shown to reduce fractures in women with osteoporosis and there is increasing evidence that they are also effective in women with osteopenia, in whom the majority of fractures occur. In addition to their role as initial therapy in individuals at increased risk of fracture, bisphosphonates are used as sequential therapy after treatment with anabolic drugs. There are no head-to head studies to compare the anti-fracture efficacy of different bisphosphonates, but there is limited evidence that zoledronate treatment results in greater increases in BMD than risedronate or alendronate. This, together with the need for less frequent administration of zoledronate, supports its wider use in clinical practice, particularly if longer dosing intervals than those currently recommended are shown to be effective.

Underestimated fracture risk in postmenopausal women-application of the hybrid intervention threshold

This study evaluated the fragility fracture risk of Taiwanese postmenopausal women with osteopenia. With the incorporation of FRAX and hybrid intervention threshold (HIT), 25% of the participants had high fracture risk. We suggest intervention for fragility fracture for postmenopausal women should be guided by FRAX and HIT instead of bone mineral density alone.

INTRODUCTION

To explore the risk of fragility fracture in Taiwanese postmenopausal women with osteopenia using the hybrid intervention threshold (HIT) and Fracture Risk Assessment tool (FRAX).

METHODS

The Taiwan Osteoporosis Association (TOA) conducted a nationwide bone mineral density (BMD) survey between 2008 and 2011 using a bus equipped with a dual-energy X-ray absorptiometry (DXA) machine. All participants completed a structured questionnaire, which included the elements in the FRAX. Based on the results, the group made up of postmenopausal women with osteopenia was identified. In order to explore the risk of fragility fracture by HIT and FRAX among Taiwan postmenopausal women with osteopenia, the 10-year probability of fracture (FRAX score) and individual intervention threshold (IIT) in this group were calculated. If the FRAX score of a participant was higher than or equal to the IIT or fixed intervention threshold (FIT), the participant was considered as above the HIT (HIT could be reached by being over a threshold at either major osteoporotic fracture or hip fracture) and categorized as having a high FRAX fracture risk.

RESULTS

A total of 13,068 postmenopausal women were enrolled in the program. A total of 5743 (43.9%) participants had osteopenia, of which 1434 (25.0%) had high FRAX fracture risk.

CONCLUSIONS

One quarter of Taiwanese postmenopausal women with osteopenia had high fragility fracture risk evaluated by FRAX and HIT. Due to the poor sensitivity of BMD for fragility fracture, we suggest that intervention for fragility fracture for postmenopausal women should also be guided by FRAX and HIT instead of BMD alone.

A decade of FRAX: how has it changed the management of osteoporosis?

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.

FRAX: re-adjust or re-think

Since its development in 2008, FRAX has booked its place in the standard day to day management of osteoporosis. The FRAX tool has been appreciated for its simplicity and applicability for use in primary care, but criticised for the same reason, as it does not take into account exposure response. To address some of these limitations, relatively simple arithmetic procedures have been proposed to be applied to the conventional FRAX estimates of hip and major fracture probabilities aiming at adjustment of the probability assessment. However, as the list of these adjustments got longer, this has reflected on its implementation in the standard practice and gave FRAX a patchy look. Consequently, raises the need to re-think of the current FRAX and whether a second generation of the tool is required to address the perceived limitations of the original FRAX. This article will discuss both point of views of re-adjustment and re-thinking.

Comparison of treatment strategies and thresholds for optimizing fracture prevention in Canada: a simulation analysis

This comparison of osteoporosis treatment strategies and intervention thresholds highlights tradeoffs in terms of number of individuals qualifying for treatment and estimated fractures prevented.

PURPOSE

The current analysis was performed to inform the following key question as part of the Osteoporosis Canada's Osteoporosis Guidelines Update: "What is the best strategy to identify those at high fracture risk for pharmacotherapy in order to prevent the most fractures, considering both population and patient perspectives?"

METHODS

The study population consisted of 66,878 women age 50 years and older (mean age 66.0 ± 9.7 years) with documented fracture probability assessment (FRAX) and fracture outcomes. Fractures over the next 5 years were identified through linked administrative healthcare data. We estimated the fraction of the population that would warrant treatment and the number of fractures avoided per 1000 person-years according to multiple strategies and thresholds. Strategies were then rank ordered using 19 metrics.

RESULTS

During mean 4.4 years, 863 (3.5%) sustained one or more major osteoporotic fractures (MOF), 212 (0.8%) sustained a hip fracture, and 1210 (4.9%) sustained any incident fracture. For woman age 50-64 years, the highest ranked strategy was treatment based upon total hip T score ≤ -2.5, but several other strategies fell within 0.5 overall ranking. For women age 65 years and older, MOF > 20% was the highest ranked strategy with no closely ranked strategies. Pooling both age subgroups gave MOF > 20% as the highest ranked strategy, with several other strategies within 0.5 overall ranking.

CONCLUSIONS

Choice of treatment strategy and threshold for osteoporosis management strongly influences the number of individuals for whom pharmacologic treatment would be recommended and on estimated fracture rates in the population. This evidence-based approach to comparing these strategies will help to inform guidelines development in Canada and may be on interest elsewhere.

Clinical Characteristics of Primary and Secondary Osteoporotic Fractures: Data from Single Referral Center Emergency Department

Background

To investigate the characteristics of patients with osteoporotic fractures (OF) who visited the emergency room, we analyzed the frequency and distribution of primary and secondary OF.

Methods

From March 2015 to April 2017, 406 patients with OF were assigned to wrist (W; n=132), spine (S; n=78), and hip (H; n=196) according to the site. All subjects were classified as having primary fracture or secondary fracture. Age, fracture site, the risk of future fracture using Fracture Risk Assessment Tool (FRAX) were compared.

Results

The mean age at fracture site was significantly different among the 3 groups, groups W (66.57±10.03), S (73.50±9.07), and H (78.50±7.72). The most common site of OF were in the order of wrist, spine, and hip with the increase of age. The FRAX scores significantly increased (P<0.001) in the order of W (8.35±5.67), S (10.74±6.99), and H (13.88±7.98) in total patient, and same in primary fracture group (W, 7.50±4.18; S, 9.76±5.91; H, 11.93±6.61; P<0.001). The main site of prior fractures in secondary fracture was same lesion, which means that the prior fracture of secondary wrist fracture was wrist fracture such as spine for spine, hip for hip.

Conclusions

We determined that as age increasing, the major sites of OF were different and FRAX scores increased. The most common site for secondary fracture was the same one. Hence, the risk of subsequent fracture in same site should be noted after patient suffered OF.

FRAX-based intervention and assessment thresholds for osteoporosis in Iran

We compared the utility of the current Iranian guidelines that recommend treatment in women with a T-score ≤ - 2.5 SD with a FRAX-based intervention threshold equivalent to women of average BMI with a prior fragility fracture. Whereas the FRAX-based intervention threshold identified women at high fracture probability, the T-score threshold was less sensitive, and the associated fracture risk decreased markedly with age.

INTRODUCTION

The fracture risk assessment algorithm FRAX® has been recently calibrated for Iran, but guidance is needed on how to apply fracture probabilities to clinical practice.

METHODS

The age-specific ten-year probabilities of a major osteoporotic fracture were calculated in women with average BMI to determine fracture probabilities at two potential intervention thresholds. The first comprised the age-specific fracture probabilities associated with a femoral neck T-score of - 2.5 SD, in line with current guidelines in Iran. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without BMD. The parsimonious use of BMD was additionally explored by the computation of upper and lower assessment thresholds for BMD testing.

RESULTS

When a BMD T-score ≤ - 2.5 SD was used as an intervention threshold, FRAX probabilities in women aged 50 years was approximately two-fold higher than in women of the same age but with an average BMD and no risk factors. The relative increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of - 2.5 SD was actually protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to women with a previous fracture rose with age from 4.9% at the age of 50 years to 17%, at the age of 80 years, and identified women at increased risk at all ages.

CONCLUSION

Intervention thresholds based on BMD alone do not effectively target women at high fracture risk, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a "fracture threshold" target women at high fracture risk.

The role of bone mineral density in therapeutic decision-making using the Fracture Risk Assessment Tool (FRAX): a sub-study of the Taiwan OsteoPorosis Survey (TOPS)

Fracture Risk Assessment Tool (FRAX)-based intervention threshold (IT) is widely applied for treatment decision-making; however, an IT based on FRAX without the measurement of bone mass density (BMD) has not been validated. The study demonstrated that estimates of fracture risk by FRAX without BMD were higher than those by FRAX with BMD in women with old age.

INTRODUCTION

BMD is an integral component for bone strength assessment, but age-specific impacts of BMD on fracture risk assessment and therapeutic decision-making remained unclear. We aimed to investigate whether using BMD measurement changed the interpretation of the FRAX-based fracture probability assessment and treatment decision.

METHODOLOGY

The database was provided by the Taiwanese Osteoporosis Association (TOA) which conducted a nationwide survey of BMD. We calculated the 10-year major and hip fracture probabilities using the FRAX for each participant, either with (FRAX + BMD) or without BMD (FRAX - BMD). Age-specific individual intervention thresholds (IITs) were established using the FRAX-based fracture risk, equivalent to a woman with a prior fracture. Participants whose FRAX scores of major fracture were greater than or equal to their IITs were deemed suitable for therapeutic intervention.

RESULTS

A total of 14,007 postmenopausal women were enrolled. Compared with FRAX + BMD, FRAX - BMD predicted lower FRAX scores in major and hip fractures in subjects aged 40-60 years; however, FRAX - BMD estimated higher risks for those aged 61-90 years. The therapeutic decision using FRAX - BMD was concordant to that using FRAX + BMD in 90.5% of the subjects, especially in the younger age group (40-70 years). FRAX - BMD identified more treatment candidates (7.7-16.4%) among those aged 71-90 years.

CONCLUSIONS

The FRAX scores are influenced by age, irrespective of the consideration of BMD. FRAX - BMD is able to identify more subjects for therapeutic intervention in the elderly population. We should reconsider the role of BMD at different ages for therapeutic decision-making.

Adherence to the Mediterranean Diet and Bone Fracture Risk in Middle-Aged Women: A Case Control Study

The prevention of bone mass loss and related complications associated with osteoporosis is a significant public health issue. The Mediterranean diet (MD) is favorably associated with bone health, a potentially modifiable risk factor. The objective of this research was to determine MD adherence in a sample of women with and without osteoporosis. In this observational case-control study of 139 women (64 women with and 75 without osteoporosis) conducted in a primary-care health center in Girona (Spain), MD adherence, lifestyle, physical exercise, tobacco and alcohol consumption, pathological antecedents, and FRAX index scores were analyzed. Logistic multilinear regression modeling to explore the relationship between the MD and bone fracture risk indicated that better MD adherence was associated with a lower bone risk fracture. Non-pharmacological preventive strategies to reduce bone fracture risk were also reviewed to explore the role of lifestyle and diet in bone mass maintenance and bone fracture prevention.

Comparison of FRAX in postmenopausal Asian women with and without type 2 diabetes mellitus: a retrospective observational study

Objective

To compare the fracture risk in postmenopausal Asian women with or without type 2 diabetes mellitus (T2DM).

Methods

The study cohort comprised data from consecutive postmenopausal women with T2DM that were retrieved from a prospectively maintained institutional database from 2001 to 2009. Postmenopausal women without DM from the Medical Examination Center from 2001 to 2009 formed the control cohort. The primary endpoint was the World Health Organization Fracture Risk Algorithm (FRAX, revised 2013) score. The secondary endpoint was bone mineral density (BMD).

Results

There were 1014 individuals included for the assessment (T2DM, n=500 and non-DM, n=514). Based on the FRAX model, the risk of major osteoporotic fractures and hip fractures over the next 10 years was higher in the T2DM group compared with the non-DM group. Compared with the T2DM group, the non-DM group had a lower BMD. After adjusting for age, gender, history of alcohol consumption, smoking status, body mass index, and low-density lipoprotein, the differences were statistically significant.

Conclusions

Compared with postmenopausal women without DM, postmenopausal women with T2DM had a significantly higher fracture risk calculated using the FRAX model. Early intervention for postmenopausal women with T2DM may be necessary, although T2DM is associated with a high BMD.

Clinical Impact of the Fracture Risk Assessment Tool on the Treatment Decision for Osteoporosis in Patients with Knee Osteoarthritis: A Multicenter Comparative Study of the Fracture Risk Assessment Tool and World Health Organization Criteria

Background: To compare the frequency of high-risk osteoporotic fracture in patients with knee OA (OA) using the fracture risk assessment tool (FRAX) and the bone mineral density (BMD). Methods: We retrospectively assessed 282 Korean patients with knee OA who visited five medical centers and 1165 healthy controls (HCs) aged ≥50 years without knee OA. After matching for age, sex, and body mass index, 478 subjects (239 patients with knee OA and 239 HCs) were included. Results: Based on the BMD, the frequency of osteoporosis was 40.2% in patients with knee OA and 36.4% in HCs. The predicted mean FRAX major osteoporotic fracture probabilities calculated with or without femur neck BMD differed significantly between the knee OA and HCs (6.9 ± 3.8% versus 6.1 ± 2.8%, p = 0.000 and 8 ± 3.6% versus 6.8 ± 2.3%, p < 0.001, respectively). The mean FRAX hip fracture probabilities calculated with or without femur neck BMD differed significantly in the knee OA and HCs (2.1 ± 2.4% versus 1.7 ± 1.8%, p = 0.006 and 3 ± 2.3% versus 2.4 ± 1.6%, p < 0.001, respectively). Conclusion: Our study suggests that FRAX may have a clinical impact on treatment decisions to reduce osteoporotic facture in patients with knee OA.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

Prevalence and Fracture Risk of Osteoporosis in Patients with Rheumatoid Arthritis: A Multicenter Comparative Study of the FRAX and WHO Criteria

(1) Background: We evaluated the prevalence and fracture risk of osteoporosis in patients with rheumatoid arthritis (RA), and compared the fracture risk assessment tool (FRAX) criteria and bone mineral density (BMD) criteria established by the World Health Organization (WHO). (2) Methods: This retrospective cross-sectional study, which included 479 RA patients in 5 hospitals, was conducted between January 2012 and December 2016. The FRAX criteria for high-risk osteoporotic fractures were calculated including and excluding the BMD values, respectively. The definition of high risk for fracture by FRAX criteria and BMD criteria by WHO was 10-year probability of ≥ 20% for major osteoporotic fracture or ≥ 3% for hip fracture, and T score ≤ −2.5 or Z score ≤ −2.0, respectively. (3) Results: The mean age was 61.7 ± 11.9 years. The study included 426 female patients (88.9%), 353 (82.9%) of whom were postmenopausal. Osteoporotic fractures were detected in 81 (16.9%) patients. The numbers of candidates for pharmacological intervention using the FRAX criteria with and without BMD and the WHO criteria were 226 (47.2%), 292 (61%), and 160 (33.4%), respectively. Only 69.2%–77% of the patients in the high-risk group using the FRAX criteria were receiving osteoporosis treatments. The following were significant using the WHO criteria: female (OR 3.55, 95% CI 1.46–8.63), age (OR 1.1, 95% CI 1.08–1.13), and BMI (OR 0.8, 95% CI 0.75–0.87). Glucocorticoid dose (OR 1.09, 95% CI 1.01–1.17), age (OR 1.09, 95% CI 1.06–1.12), and disease duration (OR 1.01, 95% CI 1–1.01) were independent risk factors for fracture. (4) Conclusions: The proportion of RA patients with a high risk of osteoporotic fractures was 33.4%–61%. Only 69.2%–77% of candidate patients were receiving osteoporotic treatments while applying FRAX criteria. Independent risk factors for osteoporotic fractures in RA patients were age, the dose of glucocorticoid, and disease duration.

A brief history of FRAX

This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008.

INTRODUCTION

Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments.

METHODS

The method used in this paper is literature review.

RESULTS

FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population.

CONCLUSION

FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.

The Effectiveness of Osteoporosis Screening and Treatment in the Midwest

Introduction:

With osteoporosis on the rise across the United States, the goal of this prospective study is to determine the effectiveness of our Midwest level-1 trauma center in diagnosing, treating, and educating osteoporosis patients after fracture with the use of questionnaires. Secondarily, we aimed to identify barriers that prevent our patients from complying with bone health recommendations.

Methods:

One hundred participants (≥55 years) were given 2 questionnaires (Fracture Risk Assessment Tool and a study-specific questionnaire) that were administered during the patient’s visit to the orthopedic trauma clinic. A group of patients diagnosed with osteoporosis was compared to a group of patients not diagnosed with osteoporosis. Statistical analyses were performed using SPSS 24 (IBM Corp, Chicago, Illinois).

Results:

Patients who had been diagnosed with osteoporosis were significantly older (72.7 vs 66.5, P = .009) and more were women (86.2% vs 66.2%, P = .043). Significantly, fewer patients without the diagnosis of osteoporosis had a history of fragility fracture (56.3%) compared to 92.9% of those diagnosed with osteoporosis (P < .001). Of those with dual-energy X-ray absorptiometry (DXA) recommended by a healthcare provider, 20 (55.6%) of those without the diagnosis of osteoporosis and 13 (52%) of those with the diagnosis of osteoporosis had DXA screening before their fragility fracture (P = .499). More patients diagnosed with osteoporosis (93.1%) were taking calcium and vitamin D supplementation compared to 66.2% of those without the diagnosis of osteoporosis (P = .005). Only 37.9% of patients with the diagnosis of osteoporosis were receiving US Food and Drug Administration–approved medications for the management of their disease.

Discussion:

In patients without previous osteoporosis diagnosis, 59 (83.1%) of the 71 claimed that they did not receive any preventative education about osteoporosis, while 21 (72.4%) of the 29 patients with the diagnosis of osteoporosis claimed that they did not receive a preventative education (P = .165). Both groups lacked optimum diagnosis, treatment, and education of osteoporosis.

Conclusion:

Our study highlights the need for a deliberate effort of a multidisciplinary team to focus efforts in all stages of osteoporosis management.

FRAX-based intervention and assessment thresholds in seven Latin American countries

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.