National Osteoporosis Foundation Guidelines Research Articles

Osteoporosis in Parkinson's disease and the role of lean body mass: a cross-sectional study in a Brazilian tertiary center.

Parkinson's disease (PD) is the second most common neurodegenerative illness and has the highest increase rate in recent years. There is growing evidence to suggest that PD is linked to higher osteoporosis rates and risk of fractures. This study aims to estimate the prevalence and factors associated with osteoporosis as defined by the National Osteoporosis Foundation (NOF) and World Health Organization in patients with mild to moderate PD. We performed a cross-sectional study at a tertiary public hospital in Fortaleza, Brazil, dating from May 2021 until April 2022. The study sample was comprised of patients with mild to moderate PD who were at least 40 years old and who had the ability to walk and stand unassisted. Bone Mineral Density (BMD) of both the hip (neck of the femur) and the lumbar spine were obtained via properly calibrated Dual Energy X-ray Absorptiometry (DXA) scanning. The FRAX (Fracture Risk Assessment Tool) score was used to determine a person's 10-year risk of major osteoporotic fracture. The Revised European Working Group on Sarcopenia in Older People (EWGSOP 2) was used as a basis to confirm a sarcopenia diagnosis with the following parameters: low muscle strength gauged by handgrip strength and low muscle quantity by DXA. Physical performance was carefully evaluated by using the Short Physical Performance Battery test. Osteoporosis and osteopenia were diagnosed following the NOF guidelines and WHO recommendations. We evaluated 107 patients in total, of whom 45 (42%) were women. The group's mean age was 68 ± 9 years, and the mean disease time span was 9.9 ± 6.0 years and mean motor UPDRS was 43 ± 15. We found that 42.1% and 34.6% of the sample had osteopenia and osteoporosis following NOF criteria, respectively, and 43% and 33.6% following the WHO recommendations. Lower lean appendicular mass was associated to osteopenia and osteoporosis in multinomial logistic regression analysis in both diagnostic criteria. Our findings provide additional evidence for the protective role of lean mass against osteoporosis in patients with PD.

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

BackgroundThis is an observational study conducted to determine the prevalence of osteoporosis and osteopenia in patients undergoing elective arthroplasty and spinal procedures in India.MethodsThis 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).ResultsThe 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.ConclusionsRegular preoperative bone health evaluation should be adopted and osteoporosis/osteopenia patients should be adequately managed pharmacologically in India.

ASSESSMENT OF THE FRACTURE RISK THROUGH FRACTURE RISK ASSESSMENT TOOL (FRAX) IN POSTMENOPAUSAL WOMEN

Current National Osteoporosis Foundation (NOF) guidelines recommend treating patients with a 10-year fracture risk (FRAX) of ≥3% for hip fractures or ≥20% for major osteoporotic fractures to reduce the future fracture risk. The present study investigated the distribution of the women in the groups with a FRAX score for major osteoporotic fractures below 20% and for hip fractures below 3%, as well as a FRAX score for major osteoporotic fractures ≥20% and for hip fractures ≥3%. We found that women with a fracture risk corresponding to a FRAX score for major osteoporotic fractures ≥20% and with a FRAX score for hip fractures ≥3% were significantly older (p = 0.000) and had significantly lower weight and height (p = 0.000) compared to women with FRAX score for major osteoporotic fractures below 20% and with a FRAX score for hip fractures below 3%. Regarding the risk factors studied, women with a history of rheumatoid arthritis who currently use corticosteroids have the highest risk of fractures with a FRAX score for major osteoporotic fractures ≥20% and a FRAX score for hip fractures ≥3%.

Protection of bone mineral density in heart failure patients:audit on current clinical practice in a busy tertiary care hospital cardiology department in Ireland

Abstract Background The strong association between heart failure (HF) and osteoporosis is well recognised. Heart failure, due to its multiple risk factors and common pathogenesis with osteoporosis can lead to low bone mineral density (BMD) and increase the risk of fragility fractures. The mortality of HF patients following these fractures is high. Current National Osteoporosis Foundation Guidelines recommend that pharmacological therapy should be reserved for postmenopausal women and men aged 50 years or older who present with a hip or vertebral fracture, where the vertebral fractures may be clinical or identified on a radiograph alone. Methods Most HF patients have frequent chest radiographs over their course years. We aimed to audit the prevalence of osteoporosis and current practice of prescribing BMD-protection in patients attending the HF clinic in a busy tertiary care hospital in Ireland. 100 patients attending the clinic in the last one year were randomly selected and clinical, medication and chest radiograph information on this cohort was collected via the hospital electronic information system. All those patients with Radiologist confirmed vertebral compression fractures (VCF) on their plain chest radiographs were audited regarding osteoporosis screening and bone protection prescription. Results Due to limited penetration,18 out of 100 chest radiographs were inconclusive,reducing the sample size to 82. 9 out of the remaining 82 patients had radiologist confirmed VCF on their plain chest radiographs whereas 2 patients had VCF incidentally picked up on their lumbar spine x-rays. All patients were aged more than 50. 4 were female and 7 male. Median ejection fraction calculated was 35%. 3 out of 11 were smokers,8 had atrial fibrillation and were on anticoagulation,4 had DM-II and 2 had CKD. 10 were on loop diuretics. Of note,4 patients were on calcium and vitamin D supplements but only 1 patient was on antiresorptive therapy for osteoporosis. Conclusion Despite its strong association with heart failure,Osteoporosis remains undertreated in this patient cohort.Due to the significant mortality and morbidity associated with major osteoporotic fractures, doctors should carefully assess and screen heart failure patients for osteoporosis and initiate specific therapy where indicated. Funding Acknowledgement Type of funding sources: None.

FRAX-based osteoporosis treatment guidelines for resource-poor settings in India.

Our study aimed to formulate population-specific intervention thresholds for treatment of osteoporosis in India which can be used even without dual X-ray absorptiometry (DXA). Using the FRAX® model for India, thresholds for different age groups for men and women were calculated without bone mineral density (BMD) measurement. The lower assessment threshold (LAT) was based on the 10-year probability of a major osteoporosis fracture (MOF) or hip fracture (HF) equivalent to patients without clinical risk factors. The intervention threshold (IT) was based on the 10-year probability equivalent to patients with fracture. The upper assessment threshold (UAT) was set at 1.2 times the IT. Probability-based thresholds for no intervention (LAT), treatment initiation (UAT) and BMD assessment (between LAT and UAT) were derived. The thresholds were validated in a cohort of 300 patients who were referred for BMD testing. Graphs for age, gender, BMI and ethnic-specific LAT, IT and UAT for MOF and HF are derived. In the validation cohort, BMD testing to initiate/defer treatment was required in only 32.3% patients. The intervention thresholds derived without BMD testing were valid in 98.7% patients. Use of National Osteoporosis Foundation (NOF) guidelines would have resulted in overtreatment in 56/300 (18.6%) patients. We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis. Adopting these cut-offs will ensure that those requiring osteoporosis treatment will not be denied of it just because of lack of a DXA machine and will also help avoid overtreatment.

Comparison of the NOF and NOGG guidelines for spinal radiographic examination in postmenopausal Chinese women.

To compare the National Osteoporosis Foundation (NOF) and the UK National Osteoporosis Guideline Group (NOGG) guidelines for the detection of vertebral fractures in postmenopausal Chinese women. A cross-sectional study on 255 community-dwelling postmenopausal women was conducted in Hunan province in 2017. Demographic and clinical characteristics and risk factors were recorded through questionnaires. Height and weight were measured using standard methods, and bone mineral density (BMD) was measured with dual-energy X-ray absorptiometry. Vertebral fractures were diagnosed by radiography using semi-quantitative morphometry. The prevalence of vertebral fractures was 9.4%. Women with vertebral fractures were significantly older and shorter, had higher years-since menopause and height loss values and lower BMD and T-scores at the femoral neck and total hip, and were more likely to have a history of previous fractures. The sensitivity and specificity of the NOF guidelines were 91.7% and 39.8%, respectively, while the NOGG guidelines had lower sensitivity (87.5%) and specificity (32.5%). However, a higher percentage had indications for radiography in the 50-64 years age group according to the NOGG guidelines, while a higher percentage had indications for radiography in the ≥ 65 year group according to the NOF guidelines. The NOF guidelines were better than the NOGG guidelines for spinal radiography examination in the Chinese postmenopausal women.

Bone Mineral Density: Clinical Relevance and Quantitative Assessment.

Bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry (DXA) is an internationally accepted standard-of-care screening tool used to assess fragility-fracture risk. Society guidelines have recommended which populations may benefit from DXA screening and the use of the fracture risk assessment tool (FRAX) to guide decisions regarding pharmacologic treatment for osteoporosis. According to the U.S. National Osteoporosis Foundation guidelines, postmenopausal women and men at least 50 y old with osteopenic BMD warrant pharmacologic treatment if they have a FRAX-calculated 10-y probability of at least 3% for hip fracture or at least 20% for major osteoporotic fracture. Patients with osteoporosis defined by a clinical event, namely a fragility fracture, or with an osteoporotic BMD should also be treated. Patients who are treated for osteoporosis should be monitored regularly to track expected gains in BMD by serial DXA scans. With some drug therapies, BMD targets can be reached whereby further improvements in BMD are not associated with further reductions in fracture risk. Although reaching this target might suggest a stopping point for therapy, the reversibility of most treatments for osteoporosis, except for the bisphosphonates, has dampened enthusiasm for this approach. In the case of denosumab, it is now apparent that stopping therapy at any point can lead to an increase in multiple-fracture risk. For patients who do not respond to antiosteoporosis pharmacologic therapy with an improvement in BMD, or who have an incident fragility fracture on therapy, secondary causes of osteoporosis or non-compliance with medical therapy should be considered.

Vertebral fracture assessment (VFA) for osteoporosis screening in US postmenopausal women: is it cost-effective?

To evaluate the cost-effectiveness of VFA as a screening tool to reduce future fracture risk in US community-dwelling women aged ≥ 65years. An individual-level state-transition cost-effectiveness model from a healthcare perspective was constructed using derived data from published literature. The time horizon was lifetime. Five screening strategies were compared, including no screening at all, central dual-energy X-ray absorptiometry (DXA) only, VFA only, central DXA followed by VFA if the femoral neck T-score (FN-T) ≤ - 1.5, or if the FN-T ≤ - 1.0. Various initiation ages and rescreening intervals were evaluated. Oral bisphosphonate treatment for 5-year periods was assumed. Incremental cost-effectiveness ratios (2017 US dollars per quality-adjusted life-year (QALY) gained) were used as the outcome measure. The incorporation of VFA slightly increased life expectancy by 0.1years and reduced the number of subsequent osteoporotic fractures by 3.7% and 7.7% compared with using DXA alone and no screening, respectively, leading to approximately 30 billion dollars saved. Regardless of initiation ages and rescreening intervals, central DXA followed by VFA if the FN-T ≤ - 1.0 was most cost-effective ($40,792 per QALY when the screening is initiated at age 65years and with rescreening every 5years). Results were robust to change in VF incidence and medication costs. In women aged ≥ 65years, VFA is cost-effective when it was incorporated in routine screening for osteoporosis. Our findings support the National Osteoporosis Foundation (NOF) guidelines for the diagnostic use of VFA as an important addition to fracture risk assessment.

SAT-538 A Dedicated Inpatient Bone Health Team Improves Screening Rates for Osteoporosis

BACKGROUND: Published reports continue to indicate osteoporosis is under-diagnosed in the United States and most significantly in men, with published rates of screening in primary care settings repeatedly below 20%; this despite that fact that men have been shown to have higher rates of fracture-related morbidity and mortality when compared to women (Cheng N, Green ME.. We have previously published how an interdisciplinary Bone Health Team (BHT) improves screening rates in the outpatient setting. Here we describe the results of identifying individuals for screening in the inpatient setting. METHODS: Over the course of 3 months, on 5 of 7 days per week, all patients on the inpatient medical wards of our hospital were reviewed for age-based screening eligibility (aged 70 years of over in men, aged 65 or over in women) based upon current National Osteoporosis Foundation and Endocrine Society guidelines. All individuals felt clinically appropriate for DXA and/or treatment recommendations were also earmarked for outpatient BHT follow-up. RESULTS: Of the 203 individuals identified as meeting age-based criteria, 200 (98.5%) were men and 3 (0.015%) were women, with ages ranging from 70 to 98, and with 48 (23.6%) having had dual energy x-ray absorptiometry (DXA) studies in the 2 years prior to identification (28 (58.3%) of which were performed by our outpatient program) and 13 (6.4%) with DXAs >2 years prior (range 3-11 years). Two had previously received recommendations for DXAs but had refused. Charts of all 155 (76.4% of the 203) without recent DXAs were reviewed: DXA was not felt to be clinically useful but treatment recommendations based upon fracture history were made in 7 (4.5% of the 155); 33 (21.2%) did not have DXA recommended related to goals of care; 18 (11.6%) received inpatient DXA recommendations and a post-hospital contact but declined the study; 5 (3.2%) were not local and would not have had follow-up; 4 (2.6%) did not get the recommended DXA for unclear reasons; 1 (0.6%) died during the hospitalization. Notably, of the 155 age-eligible without a DXA in the last 2 years, 87 (56.1% (42.9% of the total age-eligible)) went on to complete a DXA within the next 3 months. CONCLUSION: When compared to published rates for primary care, a dedicated inpatient BHT results in higher rates of DXA screening completion in those meeting age-based criteria.

Performance of FRAX and FRAX-Based Treatment Thresholds in Women Aged 40 Years and Older: The Manitoba BMD Registry

We examined among women aged ≥40 years the performance of the Fracture Risk Assessment Tool (FRAX) and FRAX-based osteoporosis treatment thresholds under the US National Osteoporosis Foundation (NOF) and UK National Osteoporosis Guideline Group (NOGG) guidelines. We used registry data for all women aged ≥40 years in Manitoba, Canada, with baseline bone mineral density (BMD) testing (n = 54,459). Incident major osteoporotic fracture (MOF), hip fracture, and clinical fracture were assessed from population-based health services data (mean follow-up 10.5 years). Age-stratified hazard ratios (HR) were estimated from Cox regression models. We assessed the sensitivity, specificity, positive predictive value (PPV), number needed to screen (NNS), and number needed to treat (NNT) to prevent a fracture (assuming 20% relative risk reduction on treatment) for osteoporosis treatment thresholds under the NOF and NOGG guidelines. Femoral neck T-score and FRAX (with and without BMD) predicted all fracture outcomes at all ages. There was good calibration in FRAX-predicted versus observed 10-year MOF and hip fracture probability. Overall sensitivity (PPV) for incident MOF was 25.7% (24.0%) for femoral neck T-score ≤ -2.5; 20.3% (26.3%) for FRAX (with BMD)-predicted 10-year MOF risk ≥20% (NOF threshold); 27.3% (22.0%) for FRAX-predicted 10-year MOF risk ≥ age-dependent cut-off (NOGG threshold), 59.4% (19.0%) for the NOF treatment algorithm; and 28.5% (18.4%) for the NOGG treatment algorithm. Sensitivity for identifying incident MOF varied by age, ranging from 0.0% to 26.3% in women 40 to 49 years old and from 49.0% to 93.3% in women aged 80+ years. The gradient of risk for fracture prediction from femoral neck T-score and FRAX (with and without BMD) as continuous measures was strong across the age spectrum. The sensitivity and PPV of the strategies based on dichotomous cut-offs are low, especially among women aged 40 to 49 years (who have lowest incidence rates). Threshold-based approaches should be reassessed, particularly in younger women. © 2019 American Society for Bone and Mineral Research.

FRAX 10-yr Fracture Risk in Rheumatoid Arthritis—Assessments With and Without Bone Mineral Density May Lead to Very Different Results in the Individual Patient

Objectives: FRAX is a computer-based algorithm developed by the World Health Organisation for estimation of the 10-yr risk of a hip or major osteoporotic fracture. Inclusion of femoral neck bone mineral density (BMD) in the estimation is optional. The study aimed to investigate the intra-individual agreement between FRAX fracture risk calculated with and without BMD in patients with rheumatoid arthritis (RA). Methods: Clinical data and BMD results from 50 RA patients registered in the Danish rheumatology registry (DANBIO) were used for analysis. Using the Bland–Altman method, lower and upper 95% limits of agreement [LLoA;ULoA] between intraindividual assessments of fracture risk with and without BMD and the bias (mean of individual differences) were calculated. Categorization of patients according to the National Osteoporosis foundation (NOF) treatment thresholds were also assessed with and without BMD. Results: Mean age was 63.6 ± 11.7 yr, mean disease activity score (DAS28-CRP) 3.3 ± 3.5 and mean femoral neck T-score −1.43 ± 1.15. The mean 10-yr risk of a major fracture and a hip fracture calculated with BMD was 22.9 ± 15.8% and 8.5 ± 10.8%, respectively. The LLoA and ULoA [bias] calculated without vs with BMD were −14.5 and 20.4 percent point (pp) [2.9 pp] for major fracture risk and −14.0 and 23.2 pp [4.6 pp] for hip fracture. NOF treatment categorization was only dependent on BMD in 4% of the patients. Conclusion: The FRAX fracture risk estimated with and without BMD may disagree substantially in individual patients with RA but this seems to have only little impact on treatment categorization based on the NOF guidelines.

Postmenopausal Osteoporosis: A Clinical Review

In postmenopausal women, osteoporotic fractures are more common than stroke, myocardial infarction, and breast cancer combined, and fractures can be costly and result in disability or death. Because there are no signs or symptoms of osteoporosis other than fracture, risk assessment is necessary to identify those at higher risk for clinical events. For women, a clinical fracture risk assessment (FRAX) is appropriate at menopause. Bone mineral density (BMD) measurement is recommended for women at age 65, and earlier for those who have risk factors. Adequate calcium, vitamin D, and weight-bearing exercise are important for bone health at all ages, and those at high risk for fracture based on BMD or FRAX should be offered medical therapy to reduce fracture risk after an appropriate medical evaluation. Bisphosphonates can accumulate in bone, so after a period of treatment, lower risk patients may be offered a period off drug therapy. However, the effects of denosumab are not sustained when treatment is discontinued, so there is no "drug holiday" with denosumab. Anabolic therapy can be offered to those with higher risk for fracture. Although rare safety concerns regarding atypical femoral fracture and osteonecrosis of the jaw have received prominent attention, for patients who are appropriately treated according to National Osteoporosis Foundation guidelines, the benefit of hip fracture risk reduction far outweighs the risk of these uncommon side effects. Accurate information for patients and shared decision-making are important for acceptance and persistent with appropriate treatment.

Screening for Osteoporosis in Older Men: Operating Characteristics of Proposed Strategies for Selecting Men for BMD Testing.

The optimal approach for selecting men for bone mineral density (BMD) testing to screen for osteoporosis is uncertain. To compare strategies for selecting older men for screening BMD testing. Prospective cohort study. A total of 4043 community-dwelling men aged ≥70years at four US sites. BMD at the total hip, femoral neck, and lumbar spine using dual-energy x-ray absorptiometry (DXA). Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and area under the receiver operating curve (AUC) of the Osteoporosis Self-Assessment Tool (OST) and Fracture Risk Assessment Tool (FRAX) without BMD to discriminate between those with and without osteoporosis as defined by World Health Organization (WHO) diagnostic criteria, and between those recommended and not recommended for pharmacologic therapy based on the National Osteoporosis Foundation (NOF) guidelines. Among the cohort, 216 (5.3%) had a BMD T-score≤-2.5 at the femoral neck, total hip, or lumbar spine, and 1184 (29.2%) met criteria for consideration of pharmacologic therapy according to NOF guidelines. The OST had better discrimination (AUC 0.68) than the FRAX (AUC 0.62; p=0.004) for identifying T-score-defined osteoporosis. Use of an OST threshold of <2 resulted in sensitivity of 0.83 and specificity of 0.36 for the identification of osteoporosis, compared to sensitivity of 0.59 and specificity of 0.59 for the use of FRAX with a cutoff of 9.3% 10-year risk of major osteoporotic fracture. The OST performs modestly better than the more complex FRAX in selecting older men for BMD testing to screen for osteoporosis; the use of either tool substantially reduces the proportion of men referred for BMD testing compared to universal screening. Of 1000 men aged 70 and older in this community-based cohort, the use of an OST cutoff of <2 to select men for BMD testing would result in 654 men referred for BMD testing, of whom 44 would be identified as having osteoporosis, and nine with osteoporosis would be missed.

Time to Clinically Relevant Fracture Risk Scores in Postmenopausal Women

BackgroundClinical practice guidelines recommend use of fracture risk scores for screening and pharmacologic treatment decisions. The timing of occurrence of treatment-level (according to 2014 National Osteoporosis Foundation guidelines) or screening-level (according to 2011 US Preventive Services Task Force guidelines) fracture risk scores has not been estimated in postmenopausal women. MethodsWe conducted a retrospective competing risk analysis of new occurrence of treatment-level and screening-level fracture risk scores in postmenopausal women aged 50 years and older, prior to receipt of pharmacologic treatment and prior to first hip or clinical vertebral fracture. ResultsIn 54,280 postmenopausal women aged 50 to 64 years without a bone mineral density test, the time for 10% to develop a treatment-level FRAX score could not be estimated accurately because of rare incidence of treatment-level scores. In 6096 women who had FRAX scores calculated with bone mineral density, the estimated unadjusted time to treatment-level FRAX ranged from 7.6 years (95% confidence interval [CI], 6.6-8.7) for those aged 65 to 69, to 5.1 years (95% CI, 3.5-7.5) for those aged 75 to 79 at baseline. Of 17,967 women aged 50 to 64 with a screening-level FRAX at baseline, 100 (0.6%) experienced a hip or clinical vertebral fracture by age 65 years. ConclusionsPostmenopausal women with sub-threshold fracture risk scores at baseline were unlikely to develop a treatment-level FRAX score between ages 50 and 64 years. After age 65, the increased incidence of treatment-level fracture risk scores, osteoporosis, and major osteoporotic fracture supports more frequent consideration of FRAX and bone mineral density testing.

Would FRAX Define the High Fracture Risk if the Patients Were Evaluated the Day before Hip Fracture?

Objective: The aim of this study was to evaluate the 10-year major osteoporotic and hip fracture risks in patients with a recent hip fracture. Material and Methods: The study population comprised 58 patients (32 male and 26 female, mean age 79.1 years) with a recent hip fracture. A bedside questionnaire including fracture risk assessment tool (FRAX®) variables and fall frequency was administered to the patients. The FRAX® 10-year major osteoporotic and hip fracture risks were calculated. Statistical analyses were performed to compare different age groups (60–69 years, 70–79 years, and ≥80 years). Results: The mean 10-year major osteoporotic and hip fracture risks were 13.9% and 78%, respectively. If the National Osteoporosis Foundation guidelines were taken into account according to major osteoporotic and hip fracture risks using FRAX® the day before the fracture, treatment would not be initiated in 75.8% and 18.9% of patients, respectively. There were significant differences between the age groups according to the 10-year major osteoporotic and hip fracture probability and fall frequency (p<0.001, p<0.001, and p=0.005, respectively). Conclusion: In our study group, the FRAX® 10-year major osteoporotic fracture probability had an underestimation in younger patients with a history of frequent falling and did not seem to improve the definition of high-risk patients. The 10-year probability of hip fracture by the FRAX® tool can classify populations at risk more effectively.

Singapore Cancer Network (SCAN) Guidelines for Bisphosphonate Use in the Adjuvant Breast Cancer Setting

The SCAN breast cancer workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines regarding the optimal time-point for initiation of bisphosphonates when using adjuvant aromatase inhibitors (AIs) and provide a consensus for their role in modifying clinical breast cancer outcomes. The workgroup utilised a modified ADAPTE process to calibrate high quality international evidence-based clinical practice guidelines to our local setting. Six international guidelines were evaluated-those developed by the National Cancer Comprehensive Network (2015), the European Society of Medical Oncology (2014), the National Institute for Clinical Evidence (2012), the Scottish Intercollegiate Guidelines Network (2013), the British Columbia Cancer Agency (2013) and the treatment algorithm based on the National Osteoporosis Foundation guidelines (2006). Recommendations on the use of bisphosphonates in postmenopausal women initiating adjuvant AIs in breast cancer to preserve bone health and the use of adjuvant bisphosphonates to improve breast cancer outcomes were developed. These adapted guidelines form the SCAN Guidelines on the use of adjuvant bisphosphonates to influence breast cancer outcomes and maintenance of bone health when on AIs.

Opportunistic Osteoporosis Screening: Addition of Quantitative CT Bone Mineral Density Evaluation to CT Colonography

PurposeFor patients undergoing CT colonography (CTC), the screening presents an opportunity for concurrent osteoporosis screening, without increasing radiation exposure or the time involved for the patient, using proximal femur quantitative CT-CT x-ray absorptiometry (QCT-CTXA). MethodsThis cohort included 129 women and 112 men (mean age: 60.1 ± 8.2 years; range: 50–95 years) who underwent CTC between March 2013 and September 2014. Areal bone mineral density (BMD; g/cm2), and resultant left femoral neck T-score, was prospectively measured on the supine CT series. QCT results were reported with the CTC. Chart review evaluated whether the patients were eligible for BMD screening according to guidelines from the US Preventive Services Task Force and the National Osteoporosis Foundation guidelines; whether they had undergone prior BMD testing; and whether QCT results changed patient management. ResultsOverall, 68.0% (164 of 241) of patients from this cohort had not previously undergone BMD screening. According to the National Osteoporosis Foundation guidelines, 44.0% (106 of 241) of patients were eligible for screening. T-scores within the osteopenic and osteoporotic range were detected in 32.3% (78 of 241) and 5.0% (12 of 241) of patients, respectively. Of these patients with low BMD, 66.7% (60 of 90) either had not previously undergone screening or were eligible for BMD testing. Reporting of QCT-CTXA T-scores altered management in 9 patients (3.7%) who had low BMD. ConclusionsMaximizing the pre-existing value from imaging studies is crucial in the current era of health care reform. We demonstrate that colorectal and osteoporosis screening can be combined at CT examination, adding clinical and likely economic value.

Impact of the NOGG and NOF Guidelines on the Indication of Bone Mineral Density in Routine Clinical Practice

The universal screening for osteoporosis by bone mineral density (BMD) is not feasible because of its unfavorable cost-benefit due to its low sensitivity. The aim of the present study was to estimate the population and economic impact of the diagnostic criteria of the National Osteoporosis Guideline Group (NOGG) and the National Osteoporosis Foundation (NOF) and assess the appropriateness of the BMD tests performed in routine clinical practice. A cross-sectional study was conducted in individuals referred for BMD testing who were not receiving antiresorptive therapy. The absolute risk of major and hip fracture was calculated using the British formula of the Fracture Risk Assessment Tool. NOGG and NOF guidelines diagnostic thresholds interventions were used. A total of 640 individuals were included, of which 95% were women, with a median age of 59.4 years (interquartile range = 14). When applying the NOGG criteria, BMD testing was recommended in 32.3% of the individuals, whereas this percentage increased to 75.6% with the NOF guidelines (p < 0.05). Regarding the appropriateness of the BMD tests performed, 31.9% were deemed appropriate according to both the NOGG and NOF guidelines, whereas 23.9% were considered inappropriate. In conclusion, the application of the NOGG and NOF guidelines led to a decrease in BMD indications, reducing costs and improving efficiency in the diagnostic management of osteoporosis, although variability exists between the guidelines.

Patterns of Pharmacological Treatment for Osteoporosis Among Patients Qualified for Pharmacotherapy According to the National Osteoporosis Foundation Guidelines.

Whereas the National Osteoporosis Foundation (NOF) guidelines suggest pharmacological treatment for patients at high risk of fractures, little is known about the prevalence of osteoporosis treatment among those who met the NOF criteria for pharmacotherapy. To evaluate the prevalence of osteoporosis treatment among patients who met the NOF criteria and to assess factors associated with pharmacological treatment. The 2005-2010 National Health and Nutrition Examination Survey served as the data source. Using the Fracture Risk Assessment Tool, the study included postmenopausal women and men 50 years or older who met the NOF treatment criteria. Andersen's Behavioral Model was used to select predisposing, enabling, and need factors that might predict osteoporosis treatment. A logistic regression was used to assess factors associated with osteoporosis treatment. An estimated 16 million individuals qualified for osteoporosis treatment according to the NOF guidelines. Only 24% of them received pharmacological treatment, and 89% of the patients receiving treatment were women. Only 6% to 12% of men who were at high risk of osteoporosis or fracture received pharmacotherapy. Older age, long-term corticosteroid use, history of fractures, and T-score ≤-2.5 were associated with increased odds of osteoporosis treatment, whereas male gender and lack of a usual source of health care were associated with decreased odds of osteoporosis treatment. Less than one-fourth of the population who should be considered for pharmacotherapy received osteoporosis treatment. Clinicians should be more aware of the unmet need for medication treatment for osteoporosis.

Kyphoplasty versus Conservative Treatment: A Case–Control Study in 110 Postmenopausal Women Population. Is Kyphoplasty Better than Conservative Treatment?

Introduction Osteoporosis is a highly prevalent and one of the most debilitating and costly chronic diseases worldwide and it is also responsible for approximately 1.5 million vertebral fragility fractures (VCFs) a year.1,2,3 Most of the patients experiencing an osteoporotic VCFs remain asymptomatic or minimally symptomatic; however, a large part of these patients do experience significant pain, resulting in decreased quality of life and disability and mortality too.4 The consequences of these fractures include pain and, in many cases, progressive vertebral collapse with resultant spinal kyphosis. Minimally invasive procedures, namely, kyphoplasty and vertebroplasty, represent a recent advance to the treatment of osteoporotic VCFs.5,6,7 The aim of this study is to compare effects in terms of recovery and quality of life and to compare deformity prevention efficacy of kyphoplasty and conservative treatment in postmenopausal women with an osteoporotic VCF. The aim of this study is to provide an efficacy assessment of kyphoplasty as compared with standard conservative treatment in postmenopausal women (bracing immobilization).8,9,10 Patients and Methods We designed a retrospective case–control study on 110 postmenopausal women. Included in this study were patients who were diagnosed with postmenopausal osteoporosis according to National Osteoporosis Foundation (NOF) guidelines, with a recent (&lt; 2 weeks) symptomatic osteoporotic vertebral compression fracture (VCF), no more than two (if any) old VCFs with no resultant kyphotic deformity, and whose treatment starts no later than 15 days from the VCF time. Study population was split in a surgery cohort and a conservative cohort according to the provided treatment. All patients were asked to fill in VAS, SF-12, and Eq. 5D questionnaires at different time points up to 12 months after treatment. Segmental kyphosis at fracture level was also measured for our analysis. Results Kyphoplasty-treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients ( p &lt; 0.05). Eq. 5D questionnaire also showed a better quality of life at 1 month for surgically treated patients ( p &lt; 0.05). As for the SF-12 no significant difference was observed. At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average. Conclusion Kyphoplasty seems to be a safe and effective procedure in reducing back pain due to painful VCF. The kyphosis restoring effect is also extremely interesting and can be achieved only in the first days after fracture time. In conclusion, kyphoplasty is a procedure that offers a fast recovery and a better quality of life at 1 month after treatment, helping restoring segmental kyphosis after VCFs.11,12,13 Acknowledgments There was no external funding source and no funding source played a role in the investigation. References Who are candidates for prevention and treatment for osteoporosis? Osteoporos Int 1997;7(1):1–6 Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17(12):1726–1733 Iqbal MM, Sobhan T. Osteoporosis: a review. Mo Med 2002;99(1):19–24 Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone 1996;18(3, Suppl):185S–189S Jarvik JG, Kallmes DF. Point of view. Efficacy of vertebroplasty and kyphoplasty. Spine 2009;34(6):613–614 Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. 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