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Kanis JA, Harvey NC, Lorentzon M, Liu E, Schini M, Abrahamsen B, Adachi JD, Alokail M, Borgstrom F, Bruyère O, Carey JJ, Clark P, Cooper C, Curtis EM, Dennison EM, Díaz-Curiel M, Dimai HP, Grigorie D, Hiligsmann M, Khashayar P, Lems W, Lewiecki EM, Lorenc RS, Papaioannou A, Reginster JY, Rizzoli R, Shiroma E, Silverman SL, Simonsick E, Sosa-Henríquez M, Szulc P, Ward KA, Yoshimura N, Johansson H, Vandenput L, McCloskey EV. Race-specific FRAX models are evidence-based and support equitable care: a response to the ASBMR Task Force report on Clinical Algorithms for Fracture Risk. Osteoporos Int 2024; 35:1487-1496. [PMID: 38960982 DOI: 10.1007/s00198-024-07162-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/19/2024] [Indexed: 07/05/2024]
Abstract
Task Force on 'Clinical Algorithms for Fracture Risk' commissioned by the American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee has recommended that FRAX® models in the US do not include adjustment for race and ethnicity. This position paper finds that an agnostic model would unfairly discriminate against the Black, Asian and Hispanic communities and recommends the retention of ethnic and race-specific FRAX models for the US, preferably with updated data on fracture and death hazards. In contrast, the use of intervention thresholds based on a fixed bone mineral density unfairly discriminates against the Black, Asian and Hispanic communities in the US. This position of the Working Group on Epidemiology and Quality of Life of the International Osteoporosis Foundation (IOF) is endorsed both by the IOF and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).
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Affiliation(s)
- John A Kanis
- Mary McKillop Institute for Health Research, Catholic University, AustralianMelbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
| | - 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 McKillop Institute for Health Research, Catholic University, AustralianMelbourne, Australia
- Sahlgrenska Osteoporosis Centre, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Enwu Liu
- Mary McKillop Institute for Health Research, Catholic University, AustralianMelbourne, Australia
| | - Marian Schini
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Bo Abrahamsen
- Odense Patient Data Explorative Network, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Majed Alokail
- Biochemistry Department, College of Science, Riyadh, Kingdom of Saudi Arabia
| | | | - Olivier Bruyère
- Research Unit in Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - John J Carey
- School of Medicine, University of Galway, Galway, Ireland
| | - Patricia Clark
- Clinical Epidemiology Research Unit, Hospital Infantil de Mexico "Federico Gomez", Mexico City, Mexico
- Faculty of Medicine of National Autonomous University of Mexico (Universidad, Nacional Autónoma de México), Mexico City, Mexico
| | - 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
| | - Elizabeth M Curtis
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Elaine M Dennison
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- Victoria University of Wellington, Wellington, New Zealand
| | - Manuel Díaz-Curiel
- Metabolic Bone Diseases Unit, Department of Internal Medicine, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma Madrid, Madrid, Spain
| | - Hans P Dimai
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Daniel Grigorie
- Carol Davila University of Medicine, Bucharest, Romania
- Department of Endocrinology & Bone Metabolism, National Institute of Endocrinology, Bucharest, Romania
| | - Mickael Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Patricia Khashayar
- International Institute for Biosensing, University of Minnesota, Minneapolis, USA
| | - Willem Lems
- Department of Rheumatology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Roman S Lorenc
- Multidisciplinary Osteoporosis Forum, Warsaw, Poland, Poland
| | | | - Jean-Yves Reginster
- Protein Research Chair, Biochemistry Dept, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - René Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Eric Shiroma
- Laboratory of Epidemiology and Population Sciences, National Institute On Aging, Baltimore, MD, USA
| | - Stuart L Silverman
- Department of Medicine, Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eleanor Simonsick
- Translational Gerontology Branch, National Institute On Aging Intramural Research Program, Baltimore, MD, USA
| | | | - Pawel Szulc
- INSERM UMR 1033, University of Lyon, Hospital Edouard Herriot, Lyon, France
| | - Kate A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- MRC Unit The Gambia, London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Noriko Yoshimura
- Department of Preventive Medicine for Locomotive Organ Disorders, The University of Tokyo Hospital, Tokyo, Japan
| | - Helena Johansson
- Mary McKillop Institute for Health Research, Catholic University, AustralianMelbourne, Australia
- Sahlgrenska Osteoporosis Centre, Institute of Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Liesbeth Vandenput
- Mary McKillop Institute for Health Research, Catholic University, AustralianMelbourne, Australia
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
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McCloskey E, Tan ATH, Schini M. Update on fracture risk assessment in osteoporosis. Curr Opin Endocrinol Diabetes Obes 2024; 31:141-148. [PMID: 38809256 DOI: 10.1097/med.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW The assessment of fracture risk is playing an ever-increasing role in osteoporosis clinical management and informing international guidelines for osteoporosis. FRAX, a fracture risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used since 2008. In this review, we recap the development and limitations of intervention thresholds and the role of absolute fracture risk. RECENT FINDINGS There is an increasing awareness of disparities and inequities in the setting of intervention thresholds in osteoporosis. The limitations of the simple use of prior fracture or the DXA-derived BMD T -score threshold are increasingly being discussed; one solution is to use fracture risk or probabilities in the setting of such thresholds. This approach also permits more objective assessment of high and very high fracture risk to enable physicians to make choices not just about the need to treat but what agents to use in individual patients. SUMMARY Like all clinical tools, FRAX has limitations that need to be considered, but the use of fracture risk in deciding who to treat, when to treat and what agent to use is a mechanism to target treatment equitably to those at an increased risk of fracture.
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Affiliation(s)
- Eugene McCloskey
- Division of Clinical Medicine, School of Medicine and Population Health
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | - Andre T H Tan
- Fast and Chronic Programmes, Alexandra Hospital, Queenstown
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Marian Schini
- Division of Clinical Medicine, School of Medicine and Population Health
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
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Chanidkul P, Sribenjalak D, Charoenngam N, Pongchaiyakul C. The proportion of Thai postmenopausal women who would be eligible for anti-osteoporosis therapy. PLoS One 2023; 18:e0279829. [PMID: 36735672 PMCID: PMC9897565 DOI: 10.1371/journal.pone.0279829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 12/05/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To determine the proportion of postmenopausal Thai women who would be classified as having high risk of fracture and eligible for anti-osteoporosis therapy according to the National Osteoporosis Foundation (NOF) criteria. METHODS Postmenopausal Thai women aged 40-90 years who had been screened for osteoporosis during 2014-2019 were recruited. Demographic data and osteoporosis risk factors were collected based on the Fracture Risk Assessment Tool (FRAX) questionnaire. Bone mineral density (BMD) at the femoral neck and lumbar spine measured using dual energy X-ray absorptiometry. Ten-year probabilities of hip and major osteoporotic fracture (MOF) were calculated based on the Thai FRAX model with BMD. The study's protocol was approved by the Institutional Ethical Committee (HE581241). RESULTS A total of 3,280 postmenopausal women were included. The mean ± SD age was 63.6 ± 10.1 years. A total of 170 (5.2%) participants had a history of hip and/or vertebral fracture. After excluding these participants with fracture history, 699 (21.3%) had osteoporosis, 355 (10.8%) had osteopenia with high risk of fracture (FRAX 10-year probability of hip fracture ≥ 3% and/or MOF ≥ 20%), 1192 (36.3%) had osteopenia with low risk of fracture (FRAX 10-year probability of hip fracture < 3% and MOF < 20%) and 864 (26.3%) had normal BMD. Taken together, a total of 1,224 (37.3%) participants would be eligible for anti-osteoporosis therapy (prior fracture, osteoporosis or osteopenia with high risk of fracture). CONCLUSION The prevalence of Thai postmenopausal women who would be eligible for anti-osteoporosis therapy was 37.3%.
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Affiliation(s)
- Piyachat Chanidkul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Dueanchonnee Sribenjalak
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nipith Charoenngam
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- * E-mail:
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Silva BC, Madeira M, d'Alva CB, Maeda SS, de Holanda NCP, Ohe MN, Szejnfeld V, Zerbini CAF, de Paula FJA, Bandeira F. Definition and management of very high fracture risk in women with postmenopausal osteoporosis: a position statement from the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Brazilian Association of Bone Assessment and Metabolism (ABRASSO). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:591-603. [PMID: 36191263 PMCID: PMC10118822 DOI: 10.20945/2359-3997000000522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Several drugs are available for the treatment of osteoporosis in postmenopausal women. Over the last decades, most patients requiring pharmacological intervention were offered antiresorptive drugs as first-line therapy, while anabolic agents were considered a last resource for those with therapeutic failure. However, recent randomized trials in patients with severe osteoporosis have shown that anabolic agents reduce fractures to a greater extent than antiresorptive medications. Additionally, evidence indicates that increases in bone mineral density (BMD) are maximized when patients are treated with anabolic agents first, followed by antiresorptive therapy. This evidence is key, considering that greater increases in BMD during osteoporosis treatment are associated with a more pronounced reduction in fracture risk. Thus, international guidelines have recently proposed an individualized approach to osteoporosis treatment based on fracture risk stratification, in which the stratification risk has been refined to include a category of patients at very high risk of fracture who should be managed with anabolic agents as first-line therapy. In this document, the Brazilian Society of Endocrinology and Metabolism and the Brazilian Association of Bone Assessment and Metabolism propose the definition of very high risk of osteoporotic fracture in postmenopausal women, for whom anabolic agents should be considered as first-line therapy. This document also reviews the factors associated with increased fracture risk, trials comparing anabolic versus antiresorptive agents, efficacy of anabolic agents in patients who are treatment naïve versus those previously treated with antiresorptive agents, and safety of anabolic agents.
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Affiliation(s)
- Barbara C Silva
- Unidade de Endocrinologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
- Unidade de Endocrinologia, Hospital Felício Rocho, Belo Horizonte, MG, Brasil
- Departamento de Medicina, Centro Universitário de Belo Horizonte (UNI-BH), Belo Horizonte, MG, Brasil,
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Miguel Madeira
- Divisão de Endocrinologia e Metabolismo, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Catarina Brasil d'Alva
- Departamento de Medicina Clínica, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Sergio Setsuo Maeda
- Unidade de Endocrinologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Narriane Chaves Pereira de Holanda
- Divisão de Endocrinologia e Metabolismo, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Monique Nakayama Ohe
- Unidade de Endocrinologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
| | - Vera Szejnfeld
- Divisão de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Cristiano A F Zerbini
- Centro Paulista de Investigação Clínica, São Paulo, SP, Brasil
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Francisco José Albuquerque de Paula
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
- Member of the Associação Brasileira de Avaliação Óssea e Osteometabolismo (ABRASSO)
| | - Francisco Bandeira
- Divisão de Endocrinologia e Metabolismo, Faculdade de Medicina, Universidade de Pernambuco, Recife, PE, Brasil
- Member of the Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM)
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Gladkova EN, Lesnyak OM, Zakroeva AG, Gaydukova IZ, Grigorieva AL, Safonova YA. The role and place of the FRAX calculator in initiation osteoporosis treatment: an analysis of the osteoporosis center registry. OSTEOPOROSIS AND BONE DISEASES 2022. [DOI: 10.14341/osteo12945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- E. N. Gladkova
- North West State Medical University named after I.I. Mechnikov; City Clinical Rheumatological Hospital N 25, St. Petersburg
| | - O. M. Lesnyak
- North West State Medical University named after I.I. Mechnikov; City Clinical Rheumatological Hospital N 25, St. Petersburg
| | | | - I. Z. Gaydukova
- North West State Medical University named after I.I. Mechnikov; City Clinical Rheumatological Hospital N 25, St. Petersburg
| | | | - Yu. A. Safonova
- North West State Medical University named after I.I. Mechnikov; City Clinical Rheumatological Hospital N 25
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Lesnyak OM, Ershova OB, Belova KY. Efforts of the Russian Association on Osteoporosis in 2021. OSTEOPOROSIS AND BONE DISEASES 2022. [DOI: 10.14341/osteo12958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Russian Association on Osteoporosis was established in 1995 and by now it has regional branches in 53 cities of the Russian Federation with total 116 members. The Association also includes the Society of Patients OSTEORUS (Chairman — OB Ershova). Association and OSTEORUS are full members of the Committee of National Societies of the International Osteoporosis Foundation (IOF).At the general meeting of regional branch delegates, held in September 2020, the following members of the presidium were elected: President prof. OM Lesnyak (St. Petersburg), vice-president prof. OB Ershova (Yaroslavl), members of the presidium: dr. AF Akhatov (Kazan), prof. IA Baranova (Moscow), PhD ZE Belaya (Moscow), IG Belenky (St. Petersburg), KYu Belova (Yaroslavl), LP Evstigneeva (Yekaterinburg), IE Zazerskaya (St. Petersburg), EG Zotkin (Moscow), PhD NA Ibragimova (Omsk), TL Karonova (St. Petersburg), IN Kiseleva (Cheboksary), prof. AYu Kochish (St. Petersburg), fellow of the Russian Academy of Sciences prof. VI Mazurov (St. Petersburg), PhD LA Marchenkova (Moscow), prof. LV Menshikov (Irkutsk), PhD RZ Nurlygayanov (Ufa), prof. EN Otteva (Khabarovsk), prof. SS Rodionova (Moscow), prof. LYa Rozhinskaya (Moscow), IA Skripnikova (Moscow), prof. ON Tkacheva (Moscow), NV Toroptsova (Moscow), prof. SV Yureneva (Moscow). The next meeting of the RAOP Presidium was held on December 18, 2021, at which the results of work in 2021 were summed up and plans for 2022 were outlined.
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Affiliation(s)
- O. M. Lesnyak
- North-Western State Medical University named after I.I. Mechnikov
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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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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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Kanis JA, Johansson H, Harvey NC, Lorentzon M, Liu E, Vandenput L, McCloskey EV. An assessment of intervention thresholds for very high fracture risk applied to the NOGG guidelines : A report for the National Osteoporosis Guideline Group (NOGG). Osteoporos Int 2021; 32:1951-1960. [PMID: 33813622 DOI: 10.1007/s00198-021-05942-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
UNLABELLED The National Osteoporosis Guideline Group (NOGG) has developed intervention thresholds based on FRAX® to characterise patients at high and very high risk of fracture. INTRODUCTION Guidelines for the assessment of fracture risk have begun to categorise patients eligible for treatment into high and very high risk of fracture to inform choice of therapeutic approach. The aim of the present study was to develop intervention thresholds based on the hybrid assessment model of NOGG. METHODS We examined the impact of intervention thresholds in a simulated cross-sectional cohort of women age 50 years or more from the UK with the distribution of baseline characteristics based on that in the FRAX cohorts. The prevalence of very high risk using the hybrid model was compared with age-dependent thresholds used by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (IOF/ESCEO). The appropriateness of thresholds was tested based on the populations treated with anabolic agents. RESULTS With an upper intervention threshold using the IOF/ESCEO criteria, 56% of women age 50 years or more would be characterised at very high risk. This compares with 36% using the IOF/ESCEO criteria and an age-specific intervention threshold over all ages. With an upper intervention threshold of 1.6 times the pre-existing intervention threshold, 10% of women age 50 years or more would be characterised at very high risk. The data from phase 3 studies indicate that most trial participants exposed to romosozumab or teriparatide would fall into the very high-risk category. CONCLUSIONS Proposals for FRAX-based criteria for very high risk for the NOGG hybrid model categorise a small proportion of women age 50 years or more (10%) in this highest risk stratum. The level of risk identified was comparable to that of women enrolled in trials of anabolic agents.
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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, 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, 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
| | - 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 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, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, 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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