Osteoporosis is a systemic skeletal disorder that remains underdiagnosed and undertreated, although we now have a better understanding of the disease and better tools to manage it. Osteoporosis is the most common metabolic bone disease, affecting 10 million Americans, with an additional 33.6 million having reduced bone mineral density (BMD) of the hip.1 One in 2 Caucasian women and 1 in 5 men will experience an osteoporosisrelated fracture over their lifetime, responsible for more than 1.5 million fractures every year.
When an osteoporosisrelated fracture occurs, it can have a debilitating effect on patients. In women with hip fractures related to osteoporosis, less than 50% will regain their ability to participate in activities of daily living. Nearly 20% will require longterm care in a nursing home. Hip fractures result in a substantial incidence of mortality, with about 20% to 24% of patients dying within the first year after fracture.1
Because osteoporosis occurs without signs and symptoms until a fracture occurs, clinicians should attempt to identify those patients at risk for fractures in order to initiate lifestyle changes and offer medication.
As the population ages and the activity level for mature adults continues to increase, fracture rates also increase. This stems from several sources, including an insufficient understanding of fracture risk assessment by physicians, osteoporosis treatment options that can function as preventive therapy, and low levels of patient adherence to treatment. This activity is designed to help you address these areas of your practice to maximize your patient care and minimize patient risk.
The purpose of this activity is to enhance the learner’s osteoporosis screening rates, fracture risk assessment, decisionmaking about therapeutic options, and skills to overcome barriers to osteoporosis therapy adherence.
At the conclusion of this initiative, participants will do the following:
Appropriately identify all patients who are at risk for osteoporotic fractures in his/her practice and provide/refer them for appropriate diagnostic workup
Compute a patient’s risk of fracture using the WHO FRAX® risk assessment tool
Implement implications of therapeutic options into a treatment model for improving the care of the patient at risk for osteoporotic fracture
Select an osteoporosis therapy that takes into account the patient’s clinical situation, preferences, and risk of nonadherence
Accurately assess and address in a meaningful way a patient’s risk of nonadherence to increase optimal adherence to treatment goals
A Newer Diagnostic Tool
Clinicians now have more than dualenergy xray absorptiometry (DXA) technology to contribute to their diagnosis and evaluation of reduced bone density and osteoporosis. While DXA has been widely available for the diagnosis of osteoporosis – and is, in fact, still the gold standard for diagnosis – a newer fracture risk prediction tool is increasingly in use. Called FRAX® (Fracture Risk Assessment tool), it was developed by the World Health Organization, and can be utilized in conjunction with femoral neck bone mineral density (BMD) along with clinical risk factors to provide better individualized prediction of fracture risk.4,5 Particularly for patients with a personal history of fracture, or a family history of fracture – plus the presence of other risk factors (such as increasing age: women 65 years and older, and men 70 and older) – the use of FRAX is an option worth considering.13 Specifically, it predicts:
A patient’s 10year probability of having a hip fracture
A patient’s 10year probability of sustaining any major osteoporotic fracture (clinical spine, hip, forearm, shoulder)
This information may be particularly useful when there is uncertainty surrounding whether or not to treat. Using the findings of the FRAX tool, clinicians and patients can make more clearcut decisions in the face of osteopenia (low bone mass) because the FRAX tool goes beyond Tscore alone. With the help of FRAX, physicians can identify patients at high risk for fractures so treatment can be offered to reduce risk. It also helps to avoid prescribing medication to those at low risk and who have little to gain from treatment.
While FRAX is wellvalidated, research related to additional risk factors continues in order to further improve this instrument.
In using the FRAX tool in the United States, clinicians should keep a number of factors in mind:
FRAX applies solely to patients who have not previously been treated.
FRAX is designed for postmenopausal women and men who are 50 years of age or older. It should not be used in younger individuals.
FRAX can utilize total hip BMD if femoral neck BMD is not available.
FRAX has therapeutic thresholds that should be considered as guidance, not inflexible rules. In patients who do not meet the cutoff points associated with FRAX, clinical interventions can still be considered.
Limitations of FRAX
Because the validation of FRAX has not yet occurred for the use of spine BMD,1 clinical judgment is needed in patients with disproportionate reductions in spine BMD, for whom FRAX may underestimate the risk of fracture.1 In fact, the FRAX assessment does not specifically provide recommendations about whom to treat and whom not to treat.
The FRAX algorithm has been shown to underestimate the fracture risk in a number of scenarios. Some risk factors are dosedependent – such as glucocorticoids, smoking, alcohol, and fractures; however, FRAX does not consider the dose. FRAX also does not include some risk factors – such as bone turnover level – that have been identified as important in certain prospective trials, nor does it account for the severity of risk factors. Thus, clinical judgment is again needed to interpret fracture risk in particular patients.4
Some risk factors and other criteria may increase the risk of fractures independently of their effect on BMD, and they are not incorporated into FRAX. These include certain medical conditions (diabetes, immobilization) and medications (SSRIs, anticonvulsants). Except for in the FRAX algorithm used in the US, where there is enough epidemiologic data to adjust for ethnic groups, ethnic minorities are not taken into account by the tool.4 Some known risk factors such as falls are not included in FRAX because the cohort evidence on falls has been collected in varying ways, preventing the creation of a standardized metric.