Revised FRAX®-based intervention thresholds for the management of osteoporosis among postmenopausal women in Sri Lanka

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.

Age-dependent assessment thresholds to optimize patient care in a resource-limited setting: an analysis based on the Sri Lankan FRAX model

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.

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.

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.

Ability of FRAX Sri Lanka adjusted for trabecular bone score to discriminate between postmenopausal women with a recent fracture and without a fracture

Objectives

We evaluated the ability of fracture risk assessment tool (FRAX) Sri Lanka to discriminate between women with a recent fracture and without a fracture, when trabecular bone score (TBS) is added to the calculation.

Methods

We studied 394 women without previous fractures and 87 women who underwent dual energy X-ray absorptiometry within 3 months after the first fragility fracture. Fracture probabilities (FP) were estimated with and without TBS using Sri Lankan FRAX model and their ability to discriminate those with and without fracture was tested.

Results

Women without fractures had higher bone mineral densities (BMDs) and lower FPs, compared to those with a recent fracture. Area under curves of receiver operating characteristic for FPs unadjusted were not different from those adjusted for TBS. The odd ratios of FPs unadjusted were not different from those of adjusted. The FPs estimated with TBS were higher, hence the intervention thresholds (ITs) were higher compared to FPs estimated without TBS. Thirty-two percent of women without previous fracture were above the ITs and the inclusion of TBS increased this to 36%. The integrated discriminatory index analysis showed a 8% increase in the discriminatory slope.

Conclusions

The inclusion of TBS to Sri Lankan FRAX did not show an added advantage in discriminating between postmenopausal women with a recent fracture and without a fracture. TBS inclusion in fracture risk calculation among those without previous fractures, however, showed a marginal increase in the number of women above ITs.

[Study on adsorption of microRNA-124 by long chain non-coding RNA MALAT1 regulates osteogenic differentiation of mesenchymal stem cells]

OBJECTIVE

To investigate the regulatory effect of long chain non-coding RNA (lncRNA) metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) adsorbing microRNA-124 (miR-124) on osteogenic differentiation of mesenchymal stem cells (MSCs).

METHODS

C3H10T1/2 cells derived from mouse embryos were cultured in vitro, then randomly divided into control group (group A), lncRNA MALAT1 no-load plasmid group (group B), lncRNA MALAT1 overexpression plasmid group (group C), lncRNA MALAT1 small interfering RNA (siRNA) group (group D), and lncRNA MALAT1 siRNA negative control group (group E). The cells were transfected into plasmids and siRNA, then induced to differentiate into osteoblasts. Alkaline phosphatase (ALP) and alizarin red staining were used to detect the osteogenic differentiation of cells in each group, real-time fluorescence quantitative (qRT-PCR) analysis was used to detect the expressions of lncRNA MALAT, miR-124, and osteogenesis-related genes such as Runt-related transcription factor 2 (Runx2), osteopontin (OPN), and osteocalcin (OCN) in each group. Double luciferase reporter gene was used to detect the targeting regulation of lncRNA MALAT1 to miR-124.

RESULTS

The relative contents of ALP positive cells, mineralized nodule, and the relative mRNA expressions of lncRNA MALAT1, Runx2, OPN, and OCN in group C were significantly higher than those in other groups ( P<0.05), while in group D significantly lower than in other groups ( P<0.05); the relative expression of miR-124 in group C was significantly lower than that in other groups( P<0.05), while in group D significantly higher than in other groups ( P<0.05). There was no significant difference in these indexes between groups A, B, and E ( P>0.05). The results of double luciferase reporter gene assay showed that lncRNA MALAT1 targeting down-regulated the expression of miR-124.

CONCLUSION

LncRNA MALAT1 can targeting down-regulate the expression of miR-124 and promote the osteogenic differentiation of MSCs.

The diversity of Fracture Risk Assessment Tool (FRAX)-based intervention thresholds in Asia

Fracture Risk Assessment Tool (FRAX), introduced in 2008, is the most frequently used fracture risk calculator. Many Asian countries have developed own FRAX models to suit their country needs. Only a few Asian countries, however, have developed country-specific intervention thresholds to demarcate high-risk patients. A wide variation is seen in these intervention thresholds partly due to the different approaches used in developing the cutoff values. This paper discusses the diversity of the intervention thresholds in Asian countries and possible reasons. It also discusses the future directions for the countries in the Asian region.