Osteoporosis

Assessments, recommendations and scoring criteria

• WHO FRAX (Fracture Risk Assessment) tool – provides fracture probability based on patient’s risk (eg, clinical risk factors, BMI)
  • Benefits
    • Useful in estimating fracture risk over 10-year period
    • Country-specific
  • Limitations
    • Not validated in treated patients or in individuals outside the age range (≤40 years or ≥90 years)
    • Not validated for use of lumbar spine BMD
    • Calculations available for only four ethnic groups (Caucasian, African American, Hispanic, Asian)
    • Other important risk factors not included (eg, falls, high rate of bone loss)
• National Osteoporosis Foundation (NOF) clinical assessment criteria for Osteoporosis in Postmenopausal Women and Men ≥50 Years

  • Obtain a detailed patient history pertaining to clinical risk factors for osteoporosis-related fractures and falls
  • Perform physical exam and diagnostic studies to evaluated the signs of osteoporosis and its secondary causes
  • Modify diet/supplements and other clinical risk factors for fracture
  • Estimate patient’s 10-year probability of hip and/or any major osteoporosis-related fracture using the U.S.-adapted WHO algorithm
  • Decisions on whom to treat and how to treat should be based on clinical judgment using the NOF guide and all available clinical information
  • Consider FDA-approved medical therapies based on the following
    • Vertebral or hip fracture
    • DXA hip (femoral neck or total site) or lumbar spine T score ≤-2.5
    • Low bone mass and a U.S.-adapted WHO 10-year probability of a hip fracture ≥3% or probability of any major osteoporosis-related fracture ≥20%
    • Patient preferences may indicate treatment for people with 10-year fracture probabilities below these levels
  • Consider non-medical therapeutic interventions
    • Modify risk factors related to falling
    • Consider physical and occupational therapy, including walking aids and hip-pad protectors
    • Perform weight-bearing activities daily
  • Patients not requiring medical therapies at time of initial evaluation should be clinically reevaluated when medically appropriate
  • Patients taking FDA-approved medications should have laboratory and bone density reevaluation after 2 years or when medically appropriate
  • Vertebral imaging should be repeated if there is documented height loss, new back pain, postural change or suspicious finding on chest x-ray, following the last (or first) vertebral imaging test
  • Regularly, and at least annually, assess compliance and persistence with the therapeutic regimen
• Guidelines for bone density screening

  Indications for Bone Density Screening – Summary of Society Recommendations
  	ISCD 2010	ACP 2011	NOF 2013	AACE 2010, 2012	USPSTF 2011	ACOG 2012
  Women
  ≥65 years Recommended regardless of clinical risk factors	YES	YES	YES	YES	YES	YES
  <65 years Postmenopausal Meets clinical risk profile* for increased risk of fracture Discontinuing estrogen therapy Menopausal transition Specific clinical risk factors for fracture (eg, prior low-trauma fracture, low body weight, medications associated with bone loss, medical condition associated with bone loss)	YES	YES	YES	YES		YES
  10 year probability of major fracture ≥9.3%, which is equal to 10-year fracture risk in a 65-year-old white woman without additional risk factors					YES	YES
  Men
  ≥70 years Recommended regardless of clinical risk factors	YES	YES	YES	YES	No recommendation for men without previous known fractures of secondary causes of osteoporosis	N/A
  <70 years If clinical risk profile* indicates risk for fracture	YES	YES	YES (50-69 years)	YES (50-69 years)	No recommendation for men without previous known fractures of secondary causes of osteoporosis	N/A
  *Clinical risk profile (one or more of the following) Fragility fracture after 50 Medications associated with bone loss Diseases or condition associated with bone loss (eg, rheumatoid arthritis, alcoholism) May be considered for pharmacologic therapy for osteoporosis Low body weight Parental medical history of hip fracture
  Organizations ISCD – The International Society for Clinical Densitometry ACP – American College of Physicians NOF – National Osteoporosis Foundation AACE – American Association of Clinical Endocrinologists USPSTF – U.S. Preventive Services Task Force ACOG – American Congress of Obstetrics and Gynecology
• QFracture scoring calculator – newest scoring system (non-validated)