National Osteoporosis Foundation 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.

THU421 Utility Of Forearm DXA As A Tool For Identification Of Osteoporosis: A Cleveland Clinic Experience

Abstract Disclosure: A.F. Ishola: None. K. Alsibai: None. A. Iqbal: None. A. Elsherif: None. P. Rao: None. L.Z. Khan: None. Background: Osteoporosis is a preventable and treatable condition with a significant impact on the quality of life. According to the National Osteoporosis Foundation, 10.2 million Americans have osteoporosis. In addition, more than 2 million osteoporosis-related fractures occur annually in the US and >70% of these occur in women. Unfortunately, most individuals at risk do not undergo appropriate assessment or treatment. Clinically osteoporosis may be diagnosed if there is a fragility fracture, independent of bone mineral density (BMD) T-score value. Diagnosis based on BMD can also be made with a T-score of − 2.5 or below in the lumbar spine, femoral neck, total proximal femur, or distal 1/3 radius. Due to the limitations in interpreting BMD values in patients with degenerative joint disease (DJD), using the forearm (distal 33% radius) as an alternative skeletal site could serve as a more sensitive screening test. Our study primary aims were to assess the frequency at which females age ≥ 65 undergoing BMD testing had DJD of the spine, to determine the frequency at which BMD testing of the forearm was performed in patients with DJD of the spine, and to assess skeletal site-specific rates of osteoporosis. Methods: This is a large, single-center, retrospective, IRB- approved study conducted at Cleveland Clinic Foundation. Postmenopausal female patients above the age of 65 who underwent DXA scans between January 2018 and December 2019 were identified. Manual chart reviews were performed. Patients receiving osteoporosis treatment and those with hyperparathyroidism were excluded. Results: 195 patients were eligible for the study. The mean age was 73.4 ± 8.2 years. DJD of spine and osteoarthritis were present in 74.5% and 58.2% of patients respectively. Forearm BMD testing was only performed in 18.9% of patients with DJD of the spine. Osteoporosis was diagnosed in 39.1 % at the femoral neck, 35.4% of patients at the lumbar spine, 9.3 % at the distal 1/3 radius, and 6.8% at the total hip. Conclusion: DJD of the spine and hip osteoarthritis often lead to falsely elevated T-scores resulting in under-diagnosis and under-treatment of osteoporosis. Although there is a higher sensitivity of using forearm BMD values to diagnose osteoporosis in patients with DJD of spine and/or osteoporosis, our preliminary data show that the forearm DXA scan is an under-utilized clinical tool in cases of DJD of spine, osteoarthritis, and hip replacement. Presentation: Thursday, June 15, 2023

The antifracture efficacy of vitamin D in adults - are we assessing it reliably? A systematic review.

The antifracture efficacy of vitamin D is still controversial. The aim of this systematic review was to examine if the vitamin D trials were designed adequately to reliably assess its antifracture activity. The electronic databases PubMed, Medline, Embase, Web of Science, and Cochrane Library were searched to identify clinical trials evaluating the antifracture efficacy of vitamin D in adults. We compared the protocols of the trials against the opinions of the American Society for Bone and Mineral Research (ASBMR), International Society for Clinical Densitometry (ISCD), National Osteoporosis Foundation (NOF), European Medicines Agency (EMEA) experts, and the consensus statement from the 2nd International Conference on Controversies in Vitamin D, and against the protocols of the trials of the medications with proven antifracture efficacy (bisphosphonates, teriparatide, abaloparatide, raloxifene, denosumab, romosozumab). We assessed the prospective character, study design, group description, number of patients, study duration, and vitamin D (serum examination and dosage) supplementation. A description of the desired characteristics of the study protocol was presented. Thirteen eligible trials were identified. All but 2 were conducted in the elderly population only. Nine trials were included in the final analysis. Serum 25-hydroxy vitamin D (25OHD) was not measured in a representative number of subjects before (except in 2 studies), during, or after treatment in any study. The analysed studies did not conclusively assess the vitamin D antifracture efficacy in patients with prestudy low serum vitamin levels, due to the lack of assessment of whether sufficient doses of vitamin D were used. They informed about the relevant doses and preparations of vitamin D in particular groups (specific fracture risk, age, place of residence) only.

The proportion of Thai postmenopausal women who would be eligible for anti-osteoporosis therapy.

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. 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). 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). The prevalence of Thai postmenopausal women who would be eligible for anti-osteoporosis therapy was 37.3%.

LBSAT139 Osteoporosis Screening In Men As Per Endocrine Society Clinical Practice Guidelines: A Cross-sectional Study

Abstract Introduction With the aging of the population, osteoporosis in men is a significant public health problem. Both hip and vertebral fractures are associated with increased mortality in men, as compared to women. One out of every five men experiences fragility fractures at least once in their lifetime. Declining sex steroid levels and bioavailable estradiol levels contributes to age-related bone loss in men. The objective of this study was to identify the underdiagnosis and the lack of guideline-based screening for osteoporosis in men. Method: Endocrine Society Clinical Practice Guidelines published in June 2012 recommends screening for osteoporosis in all men aged ≥70y, and all men aged between 50-69y who have risk factors including delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, chronic obstructive pulmonary disease; drugs such as glucocorticoids or GnRH agonists; life choices such as alcohol abuse or smoking; or other causes of secondary osteoporosis, using a dual-energy x-ray absorptiometry (DXA) of the spine and hip. The National Osteoporosis Foundation has similar recommendations. | Using a cross-sectional study design, charts of male patients eligible for osteoporosis screening, between the period of September 2020 to December 2021, were reviewed. Patients seen in the internal medicine residents’ clinic, family medicine residents’ clinic and endocrinology clinic were included in the study. Results A total of 90 out of the 1120 male patients aged ≥70y had ever undergone a DXA scan. Of these 90 patients, on reviewing their problem list from the electronic health record, 15 had osteoporosis listed and 9 had fragility fracture/compression fracture/fracture listed. Of the 135 patients aged ≥50y with ho HIV, only 21 received a DXA scan. Additionally, it was observed that only 20% (23/120) of the patients on testosterone therapy were screened for osteoporosis. As compared to this, almost 40% (1012 out of 2479) of all women aged ≥65y received screening DXA scan. Conclusion This project highlighted the inconsistencies in ordering screening DXA scans for male patients at risk for osteoporosis. Fewer than 10% of the at-risk males had a DXA. Additionally, 10% of the patients who underwent DXA had already suffered from a fracture, further emphasizing the burden of this disease. Although osteoporosis is appreciated in post-menopausal women, we must not overlook our male patients, who have 2-3 times higher morbidity and mortality associated with a hip fracture. Based on this data, we plan to initiate a quality improvement project with an aim to improve guideline directed screening for osteoporosis. Enhanced DXA screening for at risk patients will not only reduce rates of fragility fracture but will also help reduce healthcare cost. For a sustainable and broader impact, we are working further on EPIC Best Practice Alert to prompt providers to order DXA scans for these patients. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

ODP092 Guideline Adherence for Age-based Screening of Osteoporosis in Men at a Veterans Affairs Medical Center

Abstract Background Osteoporosis is one of the leading causes of morbidity and mortality in older women and men. Men with osteoporosis have higher fracture-related morbidity and mortality rates compared to women, but screening rates in men remain much lower. Moreover, there is limited veteran-specific data despite the suggestion that veterans may be at higher risk for osteoporosis. (1) Objective: To assess current dual energy X-ray absorptiometry (DEXA) ordering practices within a veteran cohort. Design: A retrospective cohort study of male veterans aged71-75 years who were evaluated by a primary care provider (PCP) within the last 5 years (n = 13,174). Results DEXAs wereordered for ∼7% of the population (920/13,174), and 91.6% were completed (843/920). Over 60% of completed DEXAs were ordered due to the presence of risk factors (308/843, 36.5%), history of fractures (60/843, 7%), known osteopenia or osteoporosis (59/843, 7%), or osteopenia mentioned on another imaging modality (78/843, 9.3%), while only 33.5% (282/843) were ordered for screening purposes. Of those with DEXA results reported (838/843, 99.4%), 34.5% (289/838) were normal, 51% (427/838) were in the osteopenia range and 14.5% (122/838) were in the osteoporosis range. Regarding DEXAs obtained for screening purposes, 42% (118/282) were normal, 48% (136/282) were in the osteopenia range, and 10% (28/282) were in the osteoporosis range. Conclusions Despite the Endocrine Society and National Osteoporosis Foundation recommending screening men aged ≥70 years, less than 10% of male veterans eligible for osteoporosis screening based on age alone had a DEXA scan. Of those male veterans who received a DEXA for screening purposes, almost 60% were found to have an abnormal result. The lack of screening for osteoporosis in this population has the potential to worsen the disparity in bone health between men and women, and between veterans and non-veterans, making it difficult to determine the scope of a problem which has the potential to cause significant morbidity and mortality.

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.

The clinician’s guide to prevention and treatment of osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) – formerly the National Osteoporosis Foundation – first published the Clinician’s Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician’s Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued—sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above − 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Effect of Bone Health Optimization on Osteoporosis Screening and Treatment Before Thoracolumbar Fusion

Objective:Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized, and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population.Methods:This retrospective case series includes adults older than 30 years who underwent elective thoracolumbar spine fusion at a single tertiary care center before and after creation of a BHO referral clinic. Data collected included preoperative osteoporosis risk factors, prior dual-energy radiograph absorptiometry testing, and prior osteoporosis pharmacotherapy. Fracture risk was estimated using the fracture risk assessment tool with and without bone mineral density (BMD), and the US National Osteoporosis Foundation criteria for screening and treatment were applied.Results:Ninety patients were included in the pre-BHO group; 53 patients met criteria for BMD measurement, but only 10 were tested within 2 years preoperatively. Sixteen patients (18%) met criteria for osteoporosis pharmacotherapy, but only 5 of the 16 (31%) received osteoporosis medication within 6 months of surgery. There were 87 patients in the post-BHO group, and 19 were referred to the BHO clinic. BMD measurement was done in 17 of the patients (89%) referred to the BHO clinic compared with 10% for those not referred. All patients (n = 7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of the patients not referred received treatment.Discussion:Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13% to 18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment.

Editorial introductions

Current Opinion in Rheumatology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of Rheumatology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Kenneth G. SaagKenneth G. SaagKenneth G. Saag, MD, MSc, is Jane Knight Lowe Professor of Medicine, Division of Clinical Immunology and Rheumatology, at the University of Alabama at Birmingham (UAB) in Birmingham, Alabama, USA and Professor of Epidemiology, at the UAB School of Public Health. Dr Saag is a native of Chicago, and following studies in engineering at the University of Michigan, USA, he returned to Chicago for medical school and Internal Medicine Residency at Northwestern University, USA. He then traveled to the University of Iowa, USA, for his rheumatology and epidemiology training and remained on the faculty there until moving to UAB in 1998. Dr Saag is the founding Director of the Agency for Health Care Research and Quality Deep South Center for Education and Research on Therapeutics, the UAB Center of Research Translation in Gout and Hyperuricemia, and the UAB Outcomes Research Center. He also serves as a Vice Chair for the UAB Department of Medicine. He has published over 300 peer reviewed manuscripts; has also authored more than 100 reviews, editorials, and book chapters. Recently he published the first edition of the clinical handbook Diagnosis and Management of Osteoporosis. Dr Saag is the Secretary of the American College of Rheumatology (ACR) and Past President of the Board of Trustees of the National Osteoporosis Foundation. Sara K. TedeschiSara K. TedeschiDr Tedeschi is a Rheumatologist at Brigham and Women's Hospital and an Assistant Professor of Medicine at Harvard Medical School, both in Boston, Massachusetts, USA. She completed medical school at Vanderbilt University School of Medicine in Nashville, Tennessee, USA. Dr Tedeschi then completed both her internal medicine residency and rheumatology fellowship training at Brigham and Women's Hospital and received her MPH from the Harvard T.H. Chan School of Public Health. Her clinical research focuses on risk factors for and outcomes in rheumatic diseases. Dr Tedeschi's current work which focuses on calcium pyrophosphate crystal deposition disease is funded by the National Institutes of Health. She is Co-Chair of the OMERACT CPPD Working Group and serves on the leadership team of the ACR/EULAR CPPD Classification Criteria working group. George C. TsokosGeorge C. TsokosDr George C. Tsokos, MD is Professor of Medicine at Harvard Medical School and Chief, Rheumatology Division, Beth Israel Deaconess Medical Center in Boston, USA. He trained in Rheumatology at the National Institutes of Health, USA. He has served various leadership positions including President of the Clinical Immunology Society, Chair of the Council of the University of Athens and Member or Chair of multiple federal study sections and Editor or Member of editorial boards of scientific journals. Dr Tsokos holds a MERIT Award from the National Institutes of Health and has received several prestigious awards including the Kirkland, Howley, Evelyn Hess awards and the Distinguished Basic Investigator Award from the American College of Rheumatology, the Lupus Insight Award, the Carol Nachman International Prize in Rheumatology and the Marian Ropes Physician Achievement Award. Dr Tsokos’ laboratory has opened and led the field of molecular abnormalities on immune cells in patients with SLE and identified previously unknown pathways which have served as the basis for novel treatments which are currently in various phases of development.

A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization.

IntroductionOsteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA.Materials/MethodsThis retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ −2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ −2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD].ResultsThe study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.).Discussion/ConclusionA simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.

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.

P60. Bone health optimization improves osteoporosis screening and treatment prior to thoracolumbar fusion

BACKGROUND CONTEXT Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population. PURPOSE The purpose of the study is to determine the proportion of patients receiving appropriate osteoporosis screening and treatment before and after initiation of a BHO clinic. STUDY DESIGN/SETTING Retrospective case series. PATIENT SAMPLE Adults age 30+ who underwent elective thoracolumbar spine fusion at a single tertiary care center prior to and after creation of a BHO referral clinic OUTCOME MEASURES Osteoporosis screening rates (ie, dual-energy X-ray absorptiometry (DXA) testing). METHODS Preoperative osteoporosis risk factors, prior DXA testing, and prior osteoporosis pharmacotherapy were collected from the electronic medical record. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density (BMD) and the U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. RESULTS Ninety patients were included in the pre-BHO group; 53 met criteria for BMD measurement but only 10 were tested within two years preoperatively. Sixteen (18%) met criteria for osteoporosis pharmacotherapy but only 5 of the 16 (31%) received osteoporosis medication within six months of surgery. There were 87 patients in the postBHO group and 19 were referred to the BHO clinic. BMD measurement was performed in 17 (89%) of patients referred to BHO clinic compared to 10% for those not referred. All patients (n=7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of patients not referred received treatment. CONCLUSIONS Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13-18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population. The purpose of the study is to determine the proportion of patients receiving appropriate osteoporosis screening and treatment before and after initiation of a BHO clinic. Retrospective case series. Adults age 30+ who underwent elective thoracolumbar spine fusion at a single tertiary care center prior to and after creation of a BHO referral clinic Osteoporosis screening rates (ie, dual-energy X-ray absorptiometry (DXA) testing). Preoperative osteoporosis risk factors, prior DXA testing, and prior osteoporosis pharmacotherapy were collected from the electronic medical record. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density (BMD) and the U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Ninety patients were included in the pre-BHO group; 53 met criteria for BMD measurement but only 10 were tested within two years preoperatively. Sixteen (18%) met criteria for osteoporosis pharmacotherapy but only 5 of the 16 (31%) received osteoporosis medication within six months of surgery. There were 87 patients in the postBHO group and 19 were referred to the BHO clinic. BMD measurement was performed in 17 (89%) of patients referred to BHO clinic compared to 10% for those not referred. All patients (n=7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of patients not referred received treatment. Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13-18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment.

Burden of osteoporosis in Vietnam: An analysis of population risk.

PurposeTo estimate the proportion of men and women aged 50 years and older who would be classified as "high risk" for fracture and eligible for anti-fracture treatment.MethodsThe study involved 1421 women and 652 men aged 50 years and older, who were recruited from the general population in Ho Chi Minh City, Vietnam. Fracture history was ascertained from each individual. Bone mineral density (BMD) was measured at the lumbar spine and femoral neck by DXA (Hologic Horizon). The diagnosis of osteoporosis was based on the T-scores ≤ -2.50 derived from either femoral neck or lumbar spine BMD. The 10-year risks of major fractureand hip fracture were estimated from FRAX version for Thai population. The criteria for recommended treatment were based on the US National Osteoporosis Foundation (NOF).ResultsThe average age of women and men was ~60 yr (SD 7.8). Approximately 11% (n = 152) of women and 14% (n = 92) of men had a prior fracture. The prevalence of osteoporosis was 27% (n = 381; 95% CI, 25 to 29%) in women and 13% (n = 87; 95% CI, 11 to 16%) in men. Only 1% (n = 11) of women and 0.1% (n = 1) of men had 10-year risk of major fracture ≥ 20%. However, 23% (n = 327) of women and 9.5% (n = 62) of men had 10-year risk of hip fracture ≥ 3%. Using the NOF recommended criteria, 49% (n = 702; 95% CI, 47 to 52%) of women and 35% (n = 228; 95% CI, 31 to 39%) of men would be eligible for therapy.ConclusionAlmost half of women and just over one-third of men aged 50 years and older in Vietnam meet the NOF criteria for osteoporosis treatment. This finding can help develop guidelines for osteoporosis treatment in Vietnam.

P113 How has COVID-19 affected the treatment of osteoporosis? The answers from a global survey

Background/Aims The COVID-19 pandemic has had profound effects on the health of the global population both directly, via the sequelae of the infection, and indirectly, including the relative neglect of chronic disease management. Together the International Osteoporosis Federation and National Osteoporosis Foundation sought to ascertain the impact on osteoporosis management. Methods Questionnaires were electronically circulated to a sample of members of both learned bodies and included information regarding the location and specialty of respondents, current extent of face to face consultations, alterations in osteoporosis risk assessment, telemedicine experience, alterations to medication ascertainment and delivery, and electronic health record (EHR) utilisation. Responses were collected, quantitative data analysed, and qualitative data assessed for recurring themes. Results Responses were received from 209 healthcare workers from 53 countries, including 28% from Europe, 24% from North America, 19% from the Asia Pacific region, 17% from the Middle East, and 12% from Latin America. Most respondents were physicians (85%) with physician assistants, physical therapists and nurses/nurse practitioners represented in the sample. The main three specialties represented included rheumatology (40%), endocrinology (22%) and orthopaedics (15%).In terms of the type of patient contact, 33% of respondents conducted telephone consultations and 21% video consultations. Bone mineral density assessment by dual-energy x-ray absorptiometry (DXA) usage was affected with only 29% able to obtain a scan as recommended. The majority of clinicians (60%) had systems in place to identify patients receiving subcutaneous or intravenous medication, and 43% of clinicians reported difficulty in arranging appropriate osteoporosis medications during the COVID-19 crisis. Conclusion To conclude through surveying a global sample of osteoporosis healthcare professionals, we have observed an increase in telemedicine consultations, delays in DXA scanning, interrupted supply of medications and reductions in intravenous medication delivery. Disclosure N.R. Fuggle: None. A. Singer: None. N. Harvey: None. J. Reginster: None. C. Cooper: None. S. Greenspan: 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.

Osteoporosis Screening Is Often Indicated but Overlooked Prior to Rotator Cuff Repair

PurposeTo (1) report the percentage of patients undergoing rotator cuff repair (RCR) who were appropriately screened with dual-energy X-ray absorptiometry testing prior to surgery, if indicated, and (2) determine the percentage of patients properly prescribed osteoporosis medications within 6 months of surgery.MethodsConsecutive patients aged 50 years or older who underwent elective RCR at a single tertiary-care center over a 1-year period were reviewed. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density. The U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Patients with acute fractures or revision surgery were excluded.ResultsOf the 218 patients included, 129 were women (58.1%). The mean age was 61.5 ± 7.2 years. One hundred thirty-one RCRs (60.1%) occurred within 3 months of injury. A total of 69 patients (31.7%) met the NOF criteria for bone mineral density screening. Of these patients, 23 (33.3%) were appropriately screened with a dual-energy X-ray absorptiometry scan. Primary care providers initiated bone health assessment in 18 of the 23 appropriately screened patients, with orthopaedic providers initiating the workup in 3 patients (13.0%). Thirty-two patients (14.7%) met the NOF criteria for pharmacologic management of osteoporosis. Of these patients, 5 (15.6%) were treated. Patients meeting the medication criteria were older (69.1 ± 7.7 years vs 60.2 ± 6.3 years, P < .001), had a lower body mass index (28.8 ± 6.1 vs 31.5 ± 6.5, P = .028), and had chronic rotator cuff tears (P = .015).ConclusionsPatients aged 50 years or older undergoing RCR are often not appropriately screened for osteoporosis. Even when appropriately screened, only 15.6% of patients meeting the indications for pharmacologic intervention for bone health optimization were prescribed appropriate medications. Although bone health optimization may or may not affect surgical timing, patient encounters related to rotator cuff tears can be used as an opportunity for providers to initiate osteoporosis screening and treatment protocols.Level of EvidenceLevel IV, therapeutic case series.

How has COVID-19 affected the treatment of osteoporosis? An IOF-NOF-ESCEO global survey

SummaryThe effects of COVID-19 have the potential to impact on the management of chronic diseases including osteoporosis. A global survey has demonstrated that these impacts include an increase in telemedicine consultations, delays in DXA scanning, interruptions in the supply of medications and reductions in parenteral medication delivery.IntroductionThe COVID-19 pandemic has had profound effects on the health of the global population both directly, via the sequelae of the infection, and indirectly, including the relative neglect of chronic disease management. Together the International Osteoporosis Foundation and National Osteoporosis Foundation sought to ascertain the impact on osteoporosis management.MethodsQuestionnaires were electronically circulated to a sample of members of both learned bodies and included information regarding the location and specialty of respondents, current extent of face to face consultations, alterations in osteoporosis risk assessment, telemedicine experience, alterations to medication ascertainment and delivery and electronic health record (EHR) utilisation. Responses were collected, quantitative data analysed, and qualitative data assessed for recurring themes.ResultsResponses were received from 209 healthcare workers from 53 countries, including 28% from Europe, 24% from North America, 19% from the Asia Pacific region, 17% from the Middle East and 12% from Latin America. Most respondents were physicians (85%) with physician assistants, physical therapists and nurses/nurse practitioners represented in the sample. The main three specialties represented included rheumatology (40%), endocrinology (22%) and orthopaedics (15%). In terms of the type of patient contact, 33% of respondents conducted telephone consultations and 21% video consultations. Bone mineral density assessment by dual-energy X-ray absorptiometry (DXA) usage was affected with only 29% able to obtain a scan as recommended. The majority of clinicians (60%) had systems in place to identify patients receiving parenteral medication, and 43% of clinicians reported difficulty in arranging appropriate osteoporosis medications during the COVID-19 crisis.ConclusionsTo conclude through surveying a global sample of osteoporosis healthcare professionals, we have observed an increase in telemedicine consultations, delays in DXA scanning, interrupted supply of medications and reductions in parenteral medication delivery.

COVID-19 and effects on osteoporosis management: the patient perspective from a National Osteoporosis Foundation survey

COVID-19 and effects on osteoporosis management: the patient perspective from a National Osteoporosis Foundation survey