Use Of FRAX Research Articles

Osteoporosis as Perceived by Saudi Physicians: A Cross-Sectional Study of Quality of Practice and Current Barriers in Management.

Background Osteoporosis (OP) is a state of abnormal bone quality and architecture that leads to fragility fractures, with lifetime costs reaching 16.27 billion Saudi Arabian Riyal (SAR). Methods An electronic survey was distributed to physicians from July 2020 to May 2021 to assess the quality of the practice of physicians towardOP and barriers in OP management in Saudi Arabia. Specialties included were endocrinology, general medicine, family medicine, primary care, orthopedic surgery, rheumatology, obstetrics and gynecology, and geriatrics. Results A total of 177 surveys were eligible (55.9% female and 44.1% male). The majority were family consultants (42.9%). In terms of knowledge, 18.1% of our sample recognized all risk factors, and 24.9% recognized all indications to assess bone density. A central dual-energy X-ray absorptiometry (DEXA) was accessible to only 49.4% of the sample. Over 80% of the sample performed comprehensive laboratory workup. Although 68.4% of participants were aware of fracture risk assessment (FRAX), 53.7% used it in their practice. The most cited barrier was a lack of physicians' awareness (80.2%), followed by a lack of patients' awareness (63.6%). The specialty was significantly associated with the awareness of the densitometry certificate (P-value < 0.0001) and the use of FRAX (P-value = 0.0001). Conclusion Our results revealed a below-satisfactory quality of practice among Saudi physicians towardOP. Additionally, our results identified many gaps in knowledge and many barriers to optimal care.

FRAX® Adjustment Using Renormalized Trabecular Bone Score (TBS) from L1 Alone may be Optimal for Fracture Prediction: The Manitoba BMD Registry

Lumbar spine trabecular bone score (TBS) used in conjunction with FRAX® improves 10-year fracture prediction. The derived FRAX risk adjustment is based upon TBS measured from L1-L4, designated TBSL1-L4-FRAX. In prior studies, TBS measurements that include L1 and exclude L4 give better fracture stratification than L1-L4. We compared risk stratification from TBS-adjusted FRAX using TBS derived from different combinations of upper lumbar vertebral levels renormalized for level-specific differences in individuals from the Manitoba Bone Density Program aged >40 years with baseline assessment of TBS and FRAX. TBS measurements for L1-L3, L1-L2 and L1 alone were calculated after renormalization for level-specific differences. Corresponding TBS-adjusted FRAX scores designated TBSL1-L3-FRAX, TBSL1-L2-FRAX and TBSL1-FRAX were compared with TBSL1-L4-FRAX for fracture risk stratification. Incident major osteoporotic fractures (MOF) and hip fractures were assessed. The primary outcome was incremental change in area under the curve (ΔAUC). The study population included 71,209 individuals (mean age 64 years, 89.8% female). Before renormalization, mean TBS for L1-3, L1-L2 and L1 was significantly lower and TBS-adjusted FRAX significantly higher than from using TBSL1-L4. These differences were largely eliminated when TBS was renormalized for level-specific differences. During mean follow-up of 8.7 years 6745 individuals sustained incident MOF and 2039 sustained incident hip fractures. Compared with TBSL1-L4-FRAX, use of FRAX without TBS was associated with lower stratification (ΔAUC = −0.009, p < 0.001). There was progressive improvement in MOF stratification using TBSL1-L3-FRAX (ΔAUC = +0.001, p < 0.001), TBSL1-L2-FRAX (ΔAUC = +0.004, p < 0.001) and TBSL1-FRAX (ΔAUC = +0.005, p < 0.001). TBSL1-FRAX was significantly better than all other combinations for MOF prediction (p < 0.001). Incremental improvement in AUC for hip fracture prediction showed a similar but smaller trend. In conclusion, this single large cohort study found that TBS-adjusted FRAX performance for fracture prediction was improved when limited to the upper lumbar vertebral levels and was best using L1 alone.

Ireland DXA-FRAX may differ significantly and substantially to Web-FRAX

SummaryAppropriate use of FRAX reduces the number of people requiring DXA scans, while contemporaneously determining those most at risk. We compared the results of FRAX with and without inclusion of BMD. It suggests clinicians to carefully consider the importance of BMD inclusion in fracture risk estimation or interpretation in individual patients.PurposeFRAX is a widely accepted tool to estimate the 10-year risk of hip and major osteoporotic fracture in adults. Prior calibration studies suggest this works similarly with or without the inclusion of bone mineral density (BMD). The purpose of the study is to compare within-subject differences between FRAX estimations derived using DXA and Web software with and without the inclusion of BMD.MethodA convenience cohort was used for this cross-sectional study, consisting of 1254 men and women aged between 40 and 90 years who had a DXA scan and complete validated data available for analysis. FRAX 10-year estimations for hip and major osteoporotic fracture were calculated using DXA software (DXA-FRAX) and the Web tool (Web-FRAX), with and without BMD. Agreements between estimates within each individual subject were examined using Bland–Altman plots. We performed exploratory analyses of the characteristics of those with very discordant results.ResultsOverall median DXA-FRAX and Web-FRAX 10-year hip and major osteoporotic fracture risk estimations which include BMD are very similar: 2.9% vs. 2.8% and 11.0% vs. 11% respectively. However, both are significantly lower than those obtained without BMD: 4.9% and 14% respectively, P < 0.001. Within-subject differences between hip fracture estimates with and without BMD were < 3% in 57% of cases, between 3 and 6% in 19% of cases, and > 6% in 24% of cases, while for major osteoporotic fractures such differences are < 10% in 82% of cases, between 10 and 20% in 15% of cases, and > 20% in 3% of cases.ConclusionsAlthough there is excellent agreement between the Web-FRAX and DXA-FRAX tools when BMD is incorporated, sometimes there are very large differences for individuals between results obtained with and without BMD. Clinicians should carefully consider the importance of BMD inclusion in FRAX estimations when assessing individual patients.

The effectiveness of screening to identify patients with osteoporosis/high risk of fractures in primary health care

Background. The organization of screening for osteoporosis is an actual problem due to the need for early detection of patients with high risk of fractures and initiation of their treatment.Aim. The aim of our study was to study the effectiveness of screening for osteoporosis (high risk of fractures) in postmenopausal men and women 40 years and older.Materials and methods. Screening was performed by outpatient doctors for all people aged 40 years and older who applied for various reasons. The doctor asked standard questions included in the FRAX questionnaire.Results. In 2017– 2020, 11,013 people were screened by outpatient doctors — 31.7% of the total attached population aged 40 years and older. According to the screening results, 21.9% people were identified with a high risk of fractures. The average 10-year probability of major osteoporotic fractures in these patients (19.0±7.9%) was statistically significantly higher compared to the rest of the screened (7.6±3.3%), p=0.0001. 60% (1,450 people) of the group of individuals with an identified high risk of fractures were patients with FRAX in the area of therapeutic intervention. Among them were patients with indications of a fracture and without a history of fractures. In the remaining 40%, the high risk was determined only on the basis of the fact of a previously suffered fracture (their FRAX index was below the intervention threshold). In general, using only the FRAX calculator, 40 men and 1410 women were identified as having a high risk of fractures, which accounted for 1.3% of the male and 17.7% of the female screened population, respectively. With the simultaneous use of FRAX and anamnestic data on a previous fracture, 13.3% of men and 25.3% of women in the screening population had a high risk of fractures.Conclusion. Screening in primary health care has allowed us to identify 21.9% of the screened population of men and women aged 40 years and older (postmenopausal women) as having a high risk of fractures. Screening with simultaneous calculation of the 10-year risk of fractures according to FRAX and clarification of the presence of a history of fractures was the most effective.

Hospital-Wide Surveillance of Fracture Risk Assessment by Both FRAX and Medication Patterns in Acute Care Hospital.

To identify patients at a high risk for primary and secondary osteoporotic fractures using fracture risk assessments performed using the current method and the proposed method, in an acute care hospital and to identify departments where high-risk patients are admitted. This retrospective study included patients aged 40-90 years who were hospitalized at Fujita Health University Hospital. We collated the clinical data and prescriptions of all study participants. We also gathered data pertaining to risk factors according to Fracture Risk Assessment Tool (FRAX). Of the 1595 patients, the mean number of major osteoporotic fracture risk predicted using FRAX was 11.73%. The department of rheumatology showed the highest fracture risk (18.55 ± 16.81) and had the highest number of patients on medications that resulted in reduced bone mineral density (1.07 ± 0.98 medication). Based on the FRAX, the proportion of patients in the high-risk group in this department was significantly higher compared with those in the remaining departments with respect to glucocorticoid administration, rheumatoid arthritis, and secondary osteoporosis. However, the departments included in the high-risk group were not necessarily the same as the departments included in the top group, based on the administered medications. FRAX score is calculated based on various risk factors; however, only glucocorticoid corresponds to medications. We should focus on medication prescription patterns in addition to FRAX to improve fracture risk assessment in hospital-wide surveillance. Therefore, we recommend the use of FRAX along with the prescribed medications to identify departments that admit high-risk patients.

BONE MINERAL DENSITY AND PROBABILITY OF OSTEOPOROTIC FRACTURES IN WOMEN WITH TYPE II DIABETES MELLITUS.

The aim: To assess bone mineral density and 10-year probability of major osteoporotic and hip fractures using the Ukrainian FRAX® version for postmenopausal women with Type II diabetes mellitus and to determine the need for OP treatment according to the algorithm FRAX and BMD. Materials and methods: 690 females aged 50-89 years (mean age 67.0±7.7 years) were divided into two groups: Group I (n=345) was made of mostly healthy women, Group II (n=345) - patients with Type II diabetes mellitus. Bone mineral density was measured using dual-energy X-ray absorptiometry, 10-year probability of major osteoporotic and hip fractures was calculated using the Ukrainian FRAX® model. Results: Bone mineral density and 10-year risk of major osteoporotic and hip fractures did not differ depending on the Type II diabetes mellitus presence, however the frequencies of low-energy, vertebral and all previous fractures were higher in Group II. 19% of women with diabetes mellitus and 38% of healthy ones required antiosteoporotic treatment according to dual-energy X-ray absorptiometry and only 8% and 2%, respectively, according to the FRAX. These indices became higher after recalculation of FRAX taking into account bone mineral density, however they were lower in patients with diabetes mellitus compared to the corresponding rate in the Group I (FRAX (high risk) + bone mineral density: 26% and 41%; χ2 = 18.2; p<0.001). Conclusions: The use of FRAX in combination with bone mineral density resulted in an increased necessity for antiosteoporotic treatment, indicating the urgency of using both indices for osteoporotic fractures prediction in patients with Type II diabetes mellitus.

44 BONE HEALTH AND FRACTURE RISK: KNOWLEDGE, OPINION AND PRACTICE OF PHYSIOTHERAPISTS

Abstract Background Osteoporotic-related fractures are responsible for excess mortality, morbidity, chronic pain, reduction in quality of life, admission to long-term care and health and social care costs (Papaioannou et al, 2010). Evidence for using Fracture Risk Assessment Tool (FRAX®) based community-screening in older people is increasing (Kanis et al, 2020). There is no published evidence on the use of FRAX® by Physiotherapists. Methods A questionnaire was sent to South Eastern Branch members of the Irish Society of Chartered Physiotherapists (ISCP). Survey themes were: participant characteristics, knowledge and opinion in the areas of Bone Health and Fracture Risk. Responses were downloaded from Survey Monkey and analysed using descriptive statistics. Results The response rate was 27% (n = 56). 72% (n = 40) of those surveyed had at least 10 years clinical experience. For 65% (n = 37) of participants, older people made up more than half of their clinical caseload. 96% (n = 54) of participants treated people with frailty and other bone health risk factors; falls (93%), osteoporosis (89%), fracture or reduced mobility (87%). On a scale of 1–10 (1 = least confident, 10 = most confident) 49% of respondents rated confidence in prescribing Bone Health Physiotherapy interventions at ≤5. When interpreting results of a DEXA scan; 80% reported confidence to be ≤5. Half (49%) of participants had never heard of FRAX®. 95% of respondents felt fracture risk was under addressed in clinical practice. All felt it was within their professional responsibility to discuss fracture risk with patients. Conclusion This is the first evaluation of bone health and fracture risk knowledge, opinion and practice of physiotherapists. The need for more knowledge of DEXA, FRAX® and bone health was highlighted. The use of FRAX® may improve fracture risk assessment in patients attending Physiotherapy. Based on these results, FRAX® has been introduced into a Rehabilitation Unit by Physiotherapists as part of Quality Improvement Project.

FRAX assessment in people ageing with HIV.

Current British HIV Association (BHIVA) guidelines recommend the use of FRAX for the routine assessment of bone fracture risk in people living with HIV over 50years of age every 3years. Bone mineral density measurement with dual-energy X-ray absorptiometry (DXA) scan is recommended for those with increased fracture risk (FRAX major >10%). Our objectives were to estimate the prevalence of and risk factors for osteoporosis in a population of PLWH aged>50years and assess the utility of FRAX in predicting the presence of DXA-proven osteoporosis in this cohort. This was a cross-sectional study of a cohort of PLWH aged >50years attending the Chelsea and Westminster Hospital and who had a DXA scan between January 2009 and December 2018. FRAX scores were calculated using the Sheffield algorithm. Multiple regression models and Cohen's kappa values were used to assess risk factors for osteoporosis and agreement between FRAX and DXA scan results, respectively. In all, 744 patients were included (92.9% male, mean age 56±5years). The prevalence rates of osteoporosis (at DXA scans) and osteopenia were 12.2% and 63.7%, respectively. FRAX major was >10% in only two patients, while 90/91 (98.9%) patients with osteoporosis had a normal FRAX score. The presence of osteoporosis was significantly associated with low body mass index and estimated glomerular filtration rate (p<0.05). Our results indicate that FRAX scores did not predict the presence of osteoporosis in our population of PLWH over 50years of age and therefore FRAX scores may not be the appropriate tool to define eligibility to perform DXA scans in PLWH.

Fracture risk assessment (FRAX) without BMD and risk of major osteoporotic fractures in adults with type 1 diabetes.

To evaluate the association between Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) and risk for major osteoporotic fractures (MOF) in type 1 diabetes. Subjects with type 1 diabetes and without diabetes from the 'Coronary Artery Calcification in Type 1 Diabetes' study were included. Risk for MOF was calculated using FRAX-based clinical risk factors and without BMD at visit 3 (2006-2008). Incident fractures were defined as fractures that occurred between visit 3 and visit 4 (2013-2017). Survival models were used to study the predictability of new MOF by diabetes status. 346 type 1 diabetes (mean age 43.3±9, BMI 26.4±5, diabetes duration 29.4±8.6years, A1c 7.8±1.1) and 411 controls (mean age 46.9±9years, BMI 26.3±5kg/m2, A1c 5.5±0.4) were analyzed in this study. In unadjusted survival analysis, the FRAX score without BMD was significantly associated with MOF (HR 1.08, 95% CI: 1.04-1.13, p<0.0001), and remained significantly associated after adjustment for age and sex (HR 1.09, 95% CI: 1.04-1.15, p=0.0007) and type 1 diabetes (HR 1.08, 95% CI: 1.04-1.12, p=0.0002). In the fully adjusted model (adjusted for age, sex and type 1 diabetes), the FRAX score without BMD was the only variable significantly associated with risk of MOF (HR 1.08, 95% CI: 1.02-1.14, p=0.006). Clinical use of FRAX without BMD is useful tool in identifying adults with type 1 diabetes at higher risk for MOF risk and may help clinicians to guide therapeutic decision-making in this high fracture risk population.

The Use of FRAX in Identifying Women Less Than 65 Years Needing Bone Mineral Density Testing

The purpose of this study is to determine if the United States Preventive Services Task Force (USPSTF) screening guideline for osteoporosis identifies women under the age of 65 with osteoporosis needing bone mineral density (BMD) testing. If the Fracture Risk Assessment Tool (FRAX) tool fails to identify women under the age of 65 with undiagnosed osteoporosis, then diagnosis and treatment are delayed, potentially leading to increased fractures and morbidity. Another aim of this study is to characterize women under the age of 65 with osteoporosis that FRAX fails to identify and provide descriptive data on our study population. A retrospective chart review was completed between 2012 and 2018. We extracted data for 113 women ≤ 65-years with osteoporosis confirmed by BMD or fractures. Major osteoporotic fracture (MOF) risk calculation without BMD by FRAX of 9.3% or greater (high risk group) was found in 51 (45.1%) of patients. Osteoporosis by T-score < 2.5 was evident in 102 (90%) of patients. Previous osteoporotic fractures were noted in 29 (25.7%) of patients. The average age of women in the high-risk group was 58 years and 55 years in the low-risk group. The sensitivity of FRAX for identifying women with a T-score <−2.5 was 40%. The sensitivity of FRAX for identifying women with a history of fracture was 32%. The sensitivity of FRAX for identifying women with a T-score <−2.5 or identifying women with a history of fracture was 32%. These results demonstrate that the FRAX tool alone (USPSTF recommendation) fails to identify many women under the age of 65 with osteoporosis in need of BMD testing. Over half of women would not have had a BMD performed based on guidelines for screening BMD in women <65. Further study is needed to characterize women under the age of 65 with osteoporosis with a FRAX MOF risk less than 9.3%.

People living with HIV and fracture risk.

PLHIV have an increased risk of osteoporosis and fractures when compared with people of the same age and sex. In this review, we address the epidemiology and the pathophysiology of bone disease and fractures in PLHIV. The assessment of fracture risk and fracture prevention in these subjects is also discussed. The spectrum of HIV-associated disease has changed dramatically since the introduction of potent antiretroviral drugs. Today, the survival of people living with HIV (PLHIV) is close to that of the general population. However, the longer life-span in PLHIV is accompanied by an increased prevalence of chronic diseases. Detrimental effects on bone health are well recognised, with an increased risk of osteoporosis and fractures, including vertebral fractures, compared to the general population. The causes of bone disease in PLHIV are not fully understood, but include HIV-specific risk factors such as use of antiretrovirals and the presence of chronic inflammation, as well as traditional risk factors for fracture. Current guidelines recommend the use of FRAX to assess fracture probability in PLHIV age ≥ 40years and measurement of bone mineral density in those at increased fracture risk. Vitamin D deficiency, if present, should be treated. Bisphosphonates have been shown to increase bone density in PLHIV although fracture outcomes are not available.

Possibilities of using a FRAX® risk calculator for 10-year probability of fractures assessment in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) and glucocorticoid use are the most common causes of secondary osteoporosis (OP). Early detection of individuals at high risk for osteoporotic fractures among RA patients allows timely prevention of OP and its complications.Objective: to evaluate the diagnostic possibilities of using a FRAX® calculator without introducing femoral neck bone mineral density (BMD) into the algorithm, as well as different therapeutic intervention thresholds to identify RA patients who need anti-osteoporotic therapy.Subjects and methods. The investigation enrolled 97 RA patients aged over 50 years. A questionnaire survey and axial skeletal densitometry were made; the 10-year fracture risk was calculated using the FRAX® calculator with and without femoral neck BMD. The diagnostic characteristics (sensitivity, specificity, ROC-curves) of different therapeutic intervention thresholds (Russian and European age-dependent intervention thresholds; 20% and 10%) for FRAX) were studied.Results and discussion. The capabilities of the Russian FRAX® model with and without femoral neck BMD to identify patients requiring treatment for OP were very good (AUC=0.878±0.036 and AUC=0.872±0.040, respectively). Lumbar spine dual-energy X-ray absorptiometry also identified very well RA patients who should undergo prophylaxis against OP and related fractures (AUC=0.837±0.063), while femoral neck and whole hip BMD values showed lower accuracy in detecting these patients (AUC=0.587±0.102 and AUC=0.625±0.092, respectively). The Russian age-dependent threshold showed 79.7% sensitivity and 63.7% specificity in evaluating the FRAX® algorithm without BMD; these figures for FRAX® with BMD were 82.2 and 65.2%, respectively. The use of FRAX® without and with BMD revealed no significant differences in the identification of persons in need of treatment (χ2=0.22; p=0.64). The sensitivity and specificity of other therapeutic intervention thresholds in determining the fracture risk with and without BMD were as follows: 90.4-94.6 and 17.4-21.7% for the European threshold; 58.8 and 93.8% for 20%, and 96.5% and 0 for 10%, respectively.Conclusion. The FRAX® calculator can be used to assess a fracture risk without entering the femoral neck BMD data into the algorithm for RA patients aged 50 years and older. Fracture risk should be assessed using the Russian agedependent threshold that adequately identifies those who need OP treatment among RA patients.

Cost-Effectiveness of the Screening for the Primary Prevention of Fragility Hip Fracture in Spain Using FRAX®.

To assess the cost-effectiveness of the primary prevention of fragility hip fractures through opportunistic risk-based screening using FRAX® among women aged 70 to 89years, and the subsequent treatment with alendronate in women at high-risk, from the Spanish national health system perspective. We performed a discrete-event simulation model. Women were categorized in low, intermediate and high-risk of fragility hip fracture through screening based on the FRAX® risk assessment tool score (Spanish version). Low-risk women received lifestyle recommendations whereas the high-risk group was assigned to alendronate treatment. For women at intermediate-risk, treatment decision was based on a recalculated score considering bone mineral density (BMD). The cost-effectiveness analysis tested six scenarios defined by different FRAX® cut-off values assessing the incremental costs per averted fracture in 20years. Deterministic sensitivity analysis was performed. We included a random sample of 5146 women obtained from a Spanish cohort of women referred for BMD. The most cost-effective intervention had an Incremental Cost-effectiveness Ratio (ICER) of 57,390 € per averted hip fracture and consisted of using the FRAX® score without BMD and treating women with a score higher than 5%. The ICER exceeded the acceptability threshold of 25,000 € in all the scenarios. Sensitivity analysis based on time to fracture, treatment efficacy, adherence to treatment and cost of dependence resulted in ICERs ranging from 39,216 € to 254,400 €. An ICER of 24,970 € was obtained when alendronate cost was reduced to 1.13 € per month. The use of FRAX® as screening tool followed by alendronate treatment is not cost-effective in senior women in Spain. Other primary preventions strategies are advisable.

SAT-523 The Use of FRAX in Identifying Women Less Than 65 Years Needing Bone Mineral Density Testing

The United States Preventive Service Task Force (USPSTF) recommends bone mineral density (BMD) screening for osteoporosis in women under the age of 65 by dual-energy x-ray absorptiometry (DXA) if their risk of a major osteoporotic fracture (MOF) is greater or equal to that of an average 65-year-old woman without risk factors for osteoporosis.(1) The absolute risk of a MOF is calculated using the FRAX ®, a tool that incorporates various risk factors to calculate risk with or without the addition of BMD of the femoral neck as a variable. Those, without the BMD variable, having a calculated 10-year risk of a MOF of 9.3% or greater are recommended for BMD testing. A retrospective chart review was completed for patients between 2012 to 2018. We identified 128 charts and analyzed the extracted data for 113 women < 65-years with osteoporosis confirmed by BMD or fractures. MOF fracture risk calculation without BMD by FRAX of 9.3% or greater were found in 51 (45.1%) patients. Osteoporosis by T-score <-2.5 at the spine, total hip, femoral neck or distal radius was evident in 102 (90%) patients. Previous osteoporotic fractures were noted in 29 (25.7%) patients. Demographics were stratified in terms of high-risk (FRAX >= 9.3%) and low-risk (FRAX< 9.3%). The average age of women in the high-risk group was 58 years and 55 years in the low-risk group. In the high-risk group, 88.2% were Caucasian, 11.8% Hispanic, 0% African American, 0% Asian. In the low risk group, 59.7% were Caucasian, 32.3% Hispanic, 3.2% African American, 4.8% Asian. Women with MOF >9.3% were older, had more years post menopause, and had more risk factors (average 2.18 factors vs 0.61) than women with MOF <9.3%. Total hip T-score was lower in the high-risk group. The sensitivity of FRAX for identifying women with a T-score < -2.5 was 40%. The sensitivity of FRAX for identifying women with a history of fracture was 32%. The sensitivity of FRAX for identifying women with a T-score < -2.5 or identifying women with a history of fracture was 32%. These results demonstrate that the FRAX tool alone, according to USPSTF recommendation, fails to identify many women under the age of 65 with osteoporosis in need of BMD testing. Over half of women would not have had a BMD performed based on guidelines for screening BMD in women < 65. Further study is needed to characterize women under the age of 65 with osteoporosis with FRAX MOF less than 9.3%. Reference: 1. U.S. Preventive Services Task Force (2011). Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2011;154:356-64. Research Support: Grant to support statistical analysis from the University of Texas Health San Antonio School of Medicine Office of the Dean.

The Fracture Risk Assessment Tool (FRAX®) predicts fracture risk in patients with chronic kidney disease

The Fracture Risk Assessment Tool (FRAX®) was developed to predict fracture risk in the general population, but its applicability to patients with chronic kidney disease (CKD) is unknown. Using the Manitoba Bone Mineral Density (BMD) Database, we identified adults not receiving dialysis with available serum creatinine measurements and bone densitometry within 1 year. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Incident major osteoporotic fractures and hip fractures were ascertained from population-based health care databases. The performance of FRAX, derived without and with BMD, was studied in relation to CKD stage. Among 10,099 subjects (mean age 64 ± 13 years, 13.0% male), 2,154 had eGFR 30-60 mL/min/1.73 m2 (CKD stage 3) and 590 had eGFR<30 mL/min/1.73 m2 (CKD stages 4-5). During a 5-year observation period, 772 individuals experienced a major osteoporotic fracture and 226 had a hip fracture. FRAX predicted risk for major osteoporotic fracture and hip fracture in all eGFR strata. For every standard deviation increase in FRAX score derived with BMD, the hazard ratio (HR) for hip fracture was 4.54 (95% confidence interval [CI] 3.57-5.77) in individuals with eGFR≥ 60 mL/min/1.73m2, 4.52 (95% CI 3.15-6.49) in individuals with eGFR 30-60 mL/min/1.73m2, and3.10 (95% CI 1.80-5.33) in individuals with eGFR <30mL/min/1.73m2.The relationship between FRAX and major osteoporotic fracture was stronger in those with CKD compared to those with preserved eGFR. These findings support the use of FRAX to risk stratify patients with non-dialysis CKD for major osteoporotic fractures and hip fractures.

Type 2 diabetes mellitus and bone.

Type 2 diabetes (T2DM) is a rapidly growing public health problem. It is associated with an increased risk of fracture, particularly of the hip, despite normal or high bone mineral density. Longer duration of disease and poor glycaemic control are both associated with higher fracture risk. The factors underlying increased fracture risk have not been clearly established, but increased falls risk, obesity, sarcopenia and co-morbidities are likely to contribute. The basis for reduced bone strength despite higher bone mineral density remains to be fully elucidated. Bone turnover is reduced in individuals with T2DM, with evidence of impaired bone formation. Most studies indicate normal or superior trabecular bone structure although reduced lumbar spine trabecular bone score (TBS) has been reported. Deficits in cortical bone structure have been demonstrated in some, but not all, studies whilst reduced bone material strength index (BMSi), as assessed by microindentation, has been a consistent finding. Accumulation of advanced glycation end products in bone may also contribute to reduced bone strength. The use of FRAX in individuals with T2DM underestimates fracture probability. Clinical management should focus on falls prevention strategies, avoidance of known risk factors, maintenance of good glycaemic control and bone protective intervention in individuals at high risk of fracture. Dietary and surgical strategies to reduce weight have beneficial effects on diabetes but may have adverse effects on skeletal health. Future research priorities include better definition of the mechanisms underlying increased fracture risk in T2DM and optimal strategies for identifying and treating those at high risk.

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.

Agreement of Mexican FRAX with and without the value of bone mineral density in assessing the risk of fracture in daily clinical practice

IntroductionThe use of FRAX without the inclusion of bone mineral density (FRAX-BMI) may be useful in clinical practice to identify patients at high risk of fracture and inform treatment decisions, but its usefulness is debated. The aim of the study is to evaluate the agreement between the risk of fracture calculated by FRAX with or without bone mineral density (BMD). Patients and methodsA cross-sectional study was conducted with 431 women (40–90 years) without treatment. The concordance of the probability of fracture was assessed by the concordance correlation coefficient (CCC), and by Bland–Altman method. The kappa index was used to evaluate the agreement between treatment indications. ResultsThe difference between the risks of a major osteoporosis fracture (MOFR) was 1.02±1.40% (95% CI −2 to 1.90) and −0.03±0.51% (95% CI −1.18 to 1.32) for the hip fracture risk (HFR). Agreement between MOFR and HFR FRAX scores was good (CCC 0.879, 95% CI 0.85–0.90 and CCC 0.821, 95% CI 0.79–0.85, respectively). The correlation between BMD of the femoral neck and fracture risk calculated by FRAX-BMI was a moderate, MOFR (r=−0.55, p<0.001) and HFR (r=−0.54, p<0.001). The agreement between the recommendations of treatment was 87% (kappa 0.61). ConclusionsThe good agreement between the risk of fracture obtained suggests that FRAX-BMI allows us to provide an estimate of risk in most cases.

Abstract #728: Primary Care Use of Frax: to Assess Osteoporosis Risk Score Among Bangladeshi Male & Female Subjects.

Abstract #728: Primary Care Use of Frax: to Assess Osteoporosis Risk Score Among Bangladeshi Male & Female Subjects.

Concordancia del FRAX México con y sin el valor de la densidad mineral ósea en la evaluación del riesgo de fractura en la práctica clínica diaria

IntroductionThe use of FRAX without the inclusion of bone mineral density (FRAX-BMI) may be useful in clinical practice to identify patients at high risk of fracture and inform treatment decisions, but its usefulness is debated. The aim of the study is to evaluate the agreement between the risk of fracture calculated by FRAX with or without bone mineral density (BMD). Patients and methodsA cross-sectional study was conducted with 431 women (40-90 years) without treatment. The concordance of the probability of fracture was assessed by the concordance correlation coefficient (CCC), and by Bland-Altman method. The kappa index was used to evaluate the agreement between treatment indications. ResultsThe difference between the risks of a major osteoporosis fracture (MOFR) was 1.02±1.40% (95% CI −2 to 1.90) and −0.03±0.51% (95% CI −1.18 to 1.32) for the hip fracture risk (HFR). Agreement between MOFR and HFR FRAX scores was good (CCC 0.879, 95% CI 0.85-0.90 and CCC 0.821, 95% CI 0.79-0.85, respectively). The correlation between BMD of the femoral neck and fracture risk calculated by FRAX-BMI was a moderate, MOFR (r=−0.55, P<.001) and HFR (r=−0.54, P<.001). The agreement between the recommendations of treatment was 87% (kappa 0.61). ConclusionsThe good agreement between the risk of fracture obtained suggests that FRAX-BMI allows us to provide an estimate of risk in most cases.