Utility of FRAX (fracture risk assessment tool) in primary care and family practice setting in India

Screening and early treatment for osteoporosis: Who are we missing under age 65?

For women under age 65, varying recommendations and the need to apply clinical risk calculators can lead to underscreening for osteoporosis. The resulting undertreatment may lead to a risk of osteoporotic fractures with significant morbidity and impact on functional status. Factors that must be considered when deciding to screen a woman under age 65 include a history of fragility fractures, race, family history, body mass index, smoking, high alcohol use, and secondary causes of osteoporosis. Secondary causes of osteoporosis are much more common in younger women. These include common conditions such as glucocorticoid use, hyperthyroidism, hypogonadism, chronic kidney disease, diabetes, anticonvulsant use, rheumatoid arthritis, malabsorption, and a history of anorexia nervosa. The reasons why these conditions confer an increased risk of osteoporosis are discussed. Recommendations are provided for the clinician to be aware of when screening women under age 65 for osteoporosis and initiating treatment when indicated.

Prevalence and predictors of low bone mineral density among adults aged 50 years and above in Chandigarh, India

Background

Osteoporosis, defined as skeletal disorder characterized by reduced bone density and strength, is prevalent in both developing and developed countries. Dual energy X-ray absorptiometry (DEXA) is an effective tool to diagnose low bone mineral density (BMD).

Objective

This study objective was to know the prevalence and predictors of low BMD in a community-based screening program among the adult population using DEXA scan.

Methods

In this community-based study conducted between January and June 2016, a population-based screening program was offered to both males and females of age 50 years and above. BMD was measured to derive T-scores and classify as normal, osteopenic, and osteoporotic individuals.

Results

A total of 455 subjects were enrolled where 62.4% proportion was women; 42.6% subjects were in the age group of 50 to 59 years. The prevalence of osteoporosis and osteopenia was 20.9% and 48.1%, respectively. Hypertension (23.7%) and diabetes (8.4%) were common comorbidities. Age and gender (female) were independent predictors of low BMD.

Conclusion

Osteoporosis/osteopenia is present in both genders with increasing trend with age advancement. Institution of timely screening will prevent the morbidity associated with fractures due to low BMD.

Osteoporosis in Indian Patients Undergoing Elective Arthroplasty and Spinal Procedures: An Observational Study

Background This is an observational study conducted to determine the prevalence of osteoporosis and osteopenia in patients undergoing elective arthroplasty and spinal procedures in India. Methods This observational, multicentre study included both male and female patients. Their bone mineral density and fracture risk were measured using dual-energy x-ray absorptiometry (DEXA) and Fracture Risk Assessment Tool (FRAX®: Centre for Metabolic Bone Diseases, University of Sheffield, UK), respectively, in compliance with the guidelines for Good Epidemiological Practice (ISRCTN: 14543098). Results The study revealed that majority (76.4%; 97/127) of the patients had low BMD; over one-third had osteoporosis (39.4%; 50/127) or osteopenia (37%; 47/127). Among those undergoing total knee replacement (TKR)/total hip replacement (THR), majority (75.6%; 59/78) had low BMD (osteoporosis: 38.5% {30/78}; osteopenia: 37.2% {29/78}). Among the patients undergoing spinal procedures, all except two (93.10%; 27/29) had low BMD, two-thirds had osteoporosis (65.5%; 19/29), and around one-fourth had osteopenia (27.6%; 8/29). Radial BMD measurements showed higher prevalence of osteoporosis and osteopenia. Based on FRAX score, nearly 30% of patients were at a high risk of hip fracture in the next 10 years. As per National Osteoporosis Foundation (NOF) guidelines, most (59.79%; 58/97) patients with osteoporosis/osteopenia met criteria for pharmacological treatment. Conclusions Regular preoperative bone health evaluation should be adopted and osteoporosis/osteopenia patients should be adequately managed pharmacologically in India.

Risk of osteoporotic fracture in women using the FRAX tool with and without bone mineral density score in patients followed at a tertiary outpatient clinic ‒ An observational study

OBJECTIVES

Fragility fractures increase morbidity and mortality. Adding assessment of clinical risk factors independently or as a previous step to Bone Densitometry (BD) should provide better accuracy in fracture risk prediction. FRAX tool might be used to stratify patients in order to rationalize the need for BD and risk classification. The primary objective of this study is to describe and perform comparisons between the estimated risk of fractures in 10 years using the FRAX calculator based on clinical factors with and without BD results for women aged 40 or more with clinical diseases monitored in tertiary care service in internal medicine.

METHODS

Cross-sectional. Women over 40 years with BD in the previous year. After medical chart review, identification of risk factors and risk estimations using FRAX-BRAZIL with (FRAX BDI) and without (FRAX BDNI) the inclusion of T-score.

RESULTS

239 women. Age 65 ± 10.35 years. BMI 29.68 ± 6.27kg/m2.

RISK FACTORS

32(13.4%) previous fractures; 23 (9.6%) current smoking; 78 (32.6%) corticosteroids use; 44 (18.4%) rheumatoid arthritis; 38 (15.9%) secondary causes; FRAX scores were higher when BD was not included. Spearman correlation coefficients between FRAX BDNI and FRAX BDI for major fractures r = 0.793 (95% CI 0.7388‒0.836). For hip fractures r = 0.6922 (95% CI 0.6174‒0.75446) CONCLUSION: Using FRAX to estimate 10-year fracture risk without BD data might be a reliable tool for screening, even for patients with a high prevalence of risk factors, improving accessibility and equity in health systems. The present study's data suggest an overestimation of fracture risk with FRAX BDNI, suggesting that it is safe to be widely used as a screening tool.

A surrogate FRAX model for Pakistan

A surrogate FRAX® model for Pakistan has been constructed using age-specific hip fracture rates for Indians living in Singapore and age-specific mortality rates from Pakistan.

INTRODUCTION

FRAX models are frequently requested for countries with little or no data on the incidence of hip fracture. In such circumstances, the International Society for Clinical Densitometry and International Osteoporosis Foundation have recommended the development of a surrogate FRAX model, based on country-specific mortality data but using fracture data from a country, usually within the region, where fracture rates are considered to be representative of the index country.

OBJECTIVE

This paper describes the development and characteristics of a surrogate FRAX model for Pakistan.

METHODS

The FRAX model used the ethnic-specific incidence of hip fracture in Indian men and women living in Singapore, combined with the death risk for Pakistan.

RESULTS

The surrogate model gave somewhat lower 10-year fracture probabilities for men and women at all ages compared to the model for Indians from Singapore, reflecting a higher mortality risk in Pakistan. There were very close correlations in fracture probabilities between the surrogate and authentic models (r ≥ 0.998) so that the use of the Pakistan model had little impact on the rank order of risk. It was estimated that 36,524 hip fractures arose in 2015 in individuals over the age of 50 years in Pakistan, with a predicted increase by 214% to 114,820 in 2050.

CONCLUSION

The surrogate FRAX model for Pakistan provides an opportunity to determine fracture probability within the Pakistan population and help guide decisions about treatment.

FRAX® with or without BMD and TBS predicts fragility fractures in community-dwelling rural southern Indian postmenopausal women

This study from southern India showed that FRAX® with or without BMD or TBS predicted fragility vertebral fractures at a cut-off of ≥ 9% for major osteoporotic fracture and ≥ 2.5% for hip fracture with sensitivities of 77-88% and specificities of 55-72%.

PURPOSE

There is limited information available with regard to utility of Fracture Risk Assessment Tool (FRAX® tool) in predicting fragility fractures in Indian postmenopausal women. We studied the performance of 3 categories: FRAX® (without BMD), FRAX® (with BMD), and FRAX® (with BMD and TBS) in predicting fragility vertebral fractures in rural postmenopausal women.

MATERIAL AND METHODS

It was a cross-sectional study conducted at a south Indian tertiary care center. Rural postmenopausal women (n = 301) were recruited by simple random sampling. The risk for major osteoporotic fracture (MOF) and hip fracture (HF) was calculated individually for the 3 categories. The BMD (at lumbar spine and femoral neck) and vertebral fractures were assessed by a DXA (dual energy X-ray absorptiometry) scanner and TBS by TBS iNsight software. ROC curves were constructed, and area under curve (AUC), sensitivity and specificity of FRAX® scores, which would best predict prevalent vertebral fractures (moderate to severe), was computed.

RESULTS

The mean (SD) age was 65.6(5.1) years. The prevalence of osteoporosis at spine was 45%, and femoral neck was 32.6%. Moderate to severe vertebral fractures was seen in 29.2% of subjects. The performance of all 3 categories for FRAX® (MOF) and FRAX® (HF) were good (AUC was 0.798, 0.806, and 0.800, respectively, for MOF) at a cut-off score of ≥ 9, and at a cut-off of ≥ 2.5 for HF, it was 0.818, 0.775, and 0.770, respectively. At these cut-offs, sensitivities were 77-89%, and specificities were 55-72% for predicting prevalent vertebral fractures.

CONCLUSION

All three categories of FRAX® showed good performance in predicting fractures in Indian postmenopausal women. Thus, it may be utilized for decision regarding treatment and referral for osteoporosis.