ACR 2010: Tools Calculate Fracture Risk, Guide Osteoporosis Treatment

Osteoporosis guidelines and a Web-based tool allow physicians to identify patients for treatment and calculate 10-year fracture risk.

Doctors now have better tools to guide them in targeting patients who should receive treatment for osteoporosis and osteopenia: the National Osteoporosis Foundation (NOF) 2008 guidelines and FRAX®, a Web-based tool to assess 10-year fracture risk. The use of these tools, however, depends on the sound clinical judgment of doctors who use them, said Chad R. Deal, MD, Head of the Center for Osteoporosis and Metabolic Bone Disease at the Cleveland Clinic in Ohio.

Speaking at the 2010 Annual Scientific Sessions of the American College of Rheumatology, Deal said, “Clinical judgment becomes even more important in situations where FRAX and the 2008 guidelines don’t help, such as a patient with very low bone mass on T-score but no other risk factors.”

FRAX is a welcome addition to the specialist’s armamentarium, and it is also useful for primary care physicians. Developed by the World Health Organization, FRAX is now country-specific for 24 different countries. FRAX works best when combined with T-score, a measure of bone mineral density (BMD), Deal said.

The diagnosis of osteoporosis is made by a T-score of < -2.5, but most fractures occur in patients with osteopenia. Deal said several studies have shown that about 54% of patients who sustained a hip fracture have osteopenia, not osteoporosis. “We have to do better than T-score, and that’s where FRAX comes in. FRAX combined with T-score improves the sensitivity of selecting patients who should be treated,” Deal explained.

The 2008 NOF Guidelines include two main updates from the 2003 version. New thresholds for treatment include a T-score of < -2.5 at the femoral neck, total hip, or spine and patients with a T-score between -1.0 and -2.5 or a 10-year risk of hip fracture >3% or of major osteoporotic fracture >20% (as calculated by FRAX). Risk factors incorporated in FRAX -- but not in the 2003 NOF guidelines -- include age, BMD, gender, low Body Mass Index, previous fracture, parental history of hip fracture, glucocorticoid treatment, current smoking, and consumption of more than three glasses of alcohol/day.

The following example shows how FRAX is used. Open up the Web-based tool and enter the following facts: A 65-year-old Caucasian female who is 5’4” tall and weighs 130 lbs. Then click on “yes” for each of the listed risk factors that this patient has. Clicking on the “calculate” button will give you the 10-year absolute risk for major osteoporotic fracture and hip fracture. This can be printed out for the patient. “With FRAX, you can also get an idea of what any given risk factor adds to the risk,” Deal said.

“FRAX is a tool but it is not an all-in-one tool and it does not replace clinical judgment,” he re-iterated. He gave the example of an Asian woman, 55 years old, with no risk factors and a low 10-year fracture risk on FRAX. “But this woman had very low bone mass and if she is likely to be a rapid bone loser in your judgment that would signal treatment.”

Studies have shown that since the introduction of the NOF guidelines in 2008, treatment patterns have changed in the US. Now about four times fewer younger women (age 40 to 60) are treated for osteoporosis, and more people age 80 and older are treated than in 2003.

A major caveat to FRAX is that although it includes major risk factors, several other important risk factors need to be considered, including falls, physical activity level, vitamin D level, and drugs that may affect BMD. “This is where clinical judgment enters the picture,” Deal said.