Frax tools for osteoporosis

By Chad Deal, MD. Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy. She had been treated with a bisphosphonate for three years immediately following menopause ages 52 to She had a lumbar spine T-score of —2.

Her current bone density showed a significant decline of 8. Laboratory tests did not reveal a secondary cause for low bone mass and bone loss. She was taking adequate calcium and vitamin D and walked for exercise four times a week. Current National Osteoporosis Foundation guidelines recommend treatment if the year fracture risk is 3 percent or greater for the hip or 20 percent or greater for a major osteoporotic fracture hip, spine, wrist or humerus.

Even though B. The appropriate use of FRAX as a tool for guiding treatment decisions is important in the clinic. With FRAX, as with all tools, understanding its strengths as well as its limitations is essential to making appropriate treatment decisions. The limitations are often called FRAX caveats.

In the case of B. When deciding whether to screen for osteoporosis to prevent osteoporotic fractures in men, clinicians should consider the following factors. The prevalence of osteoporosis in men is generally lower than in women 4. Older age in men is an important risk factor for osteoporotic fracture. In the absence of other risk factors, it is not until age 80 years that the prevalence of osteoporosis in white men starts to reach that of white women at age 65 years.

Similar to women, risk factors for fractures in men include low body mass index, excessive alcohol consumption, current smoking, long-term corticosteroid use, previous fractures, and history of falls within the past year. A recent systematic review of risk factors for osteoporosis in men also found that hypogonadism, history of cerebrovascular accident, and history of diabetes are associated with an increased risk of fractures, although their clinical use in identifying men who need further bone measurement testing is unclear.

Although clinical risk assessment tools and imaging tests to diagnose osteoporosis seem to perform as well in men as in women, evidence on the effectiveness of medications to treat osteoporosis in men is lacking.

The review identified limited evidence on the effect of treatment of men with osteoporosis on the prevention of fractures. Potential harms of screening in men are likely to be similar to those in women. Evidence on harms of drug therapies in men is very limited.

Data on how frequently men are screened for osteoporosis are limited. Several organizations have issued statements on screening in men at increased risk. Progress toward the Healthy People objectives for osteoporosis have shown little change in the number of hip fracture hospitalizations among men According to the Centers for Disease Control and Prevention, engaging in to minutes of at least moderate-intensity aerobic activity each week can reduce the risk of hip fractures, and performing balance and muscle-strengthening activities each week along with moderate-intensity aerobic activity can help prevent falls in older adults.

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years and older at increased risk of falls and selectively offering multifactorial interventions based on circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences; it recommends against vitamin D supplementation to prevent falls. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. This recommendation statement was first published in JAMA.

Department of Health and Human Services, or the U. Public Health Service. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. Incidence and mortality of hip fractures in the United States. Incidence and economic burden of osteoporosis-related fractures in the United States, — Screening to prevent osteoporotic fractures: an evidence review for the U. Preventive Services Task Force: evidence synthesis no.

AHRQ publication no. Rockville, Md. Screening to prevent osteoporotic fractures: updated evidence report and systematic review for the US Preventive Services Task Force. Anthropometric reference data for children and adults: United States, — Vital Health Stat 3. University of Sheffield. Accessed May 15, ACOG practice bulletin n.

Obstet Gynecol. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis——executive summary [published correction appears in Endocr Pract. Endocr Pract. Management of osteoporosis in postmenopausal women: position statement of the North American Menopause Society.

Screening for osteoporosis: an update for the U. Ann Intern Med. The clinical epidemiology of male osteoporosis: a review of the recent literature. Clin Epidemiol. Clinical review. Risk factors for low bone mass-related fractures in men: a systematic review and meta-analysis. J Clin Endocrinol Metab. Fracture risk and zoledronic acid therapy in men with osteoporosis. N Engl J Med. The effect of teriparatide [human parathyroid hormone ] therapy on bone density in men with osteoporosis.

Pyridinoline cross-links are light-sensitive and degrade under the influence of intense ultraviolet irradiation Currently the best-established clinical use of bone marker analysis is for monitoring treatment efficacy.

After antiresorptive therapy, there is a substantial reduction in levels of bone resorption markers within four to six weeks and in levels of bone formation markers within two to three months 76 , After treatment, the nadir in bone marker levels generally occurs after two to three months and remains constant as long as the patient continues to receive therapy Therefore, failure to show the expected reduction in levels of bone resorption markers could indicate poor compliance with treatment or an improper use of antiresorptive agents.

The objective of treatment should be the return of bone marker levels to the premenopausal range. However, some patients with osteoporosis present with normal bone marker values because the diagnosis was made at a late stage of their disease. In this instance, the goal should be a decrease in bone marker levels to the least significant change. After treatment with an anabolic agent, levels of bone formation markers increase substantially within four weeks and levels of bone resorption markers increase later, approximately three months following the initial therapy 84 , Prediction of fracture risk is probably the most important potential use of bone marker measurements because turnover alters bone geometry and material properties and thus may affect the susceptibility to fracture.

Several studies have shown that bone turnover may be an independent predictor of fracture risk 86 - In a study of postmenopausal women, of whom had fractures, high levels of the bone turnover marker bone-specific alkaline phosphatase were independently associated with an increased fracture risk, with an age-adjusted hazard ratio of 2.

In the Os des Femmes de Lyon OFELY study, a comparison between baseline bone marker levels in fifty-five women who had a fracture and bone marker levels in women who did not have a fracture within five years before the time of follow-up showed that women with levels of bone resorption markers in the highest quartile had an approximately twofold increased risk of fracture compared with women with levels in the three lowest quartiles.

After adjustment for bone mineral density, bone marker levels were still predictive of fracture risk, with similar relative risks of 1. This finding indicates that bone turnover markers and bone mineral density predict fracture risk independently. When both factors are altered, the fracture risk is compounded Although bone markers are independent predictors of fracture risk, the optimal use of bone marker measurements alone or in combination with bone mineral density in predicting absolute fracture risk has not yet been established.

Several studies indicate that individuals with the highest levels of bone turnover seem to have the best response to antiresorptive therapy 83 , The relationship between bone marker levels and the response to antiresorptive agents, however, is controversial 93 - The authors of a pharmacoeconomic study concluded that measurement of bone marker levels has the potential to identify a subset of postmenopausal women with bone marker levels within the highest quartile, but who do not have osteoporosis as defined by the World Health Organization, for whom alendronate treatment to prevent fracture is cost-effective In a study assessing the efficacy of risedronate in the treatment of postmenopausal osteoporosis in women, the reduction in the incidence of vertebral fractures was independent of the baseline measurement of the urinary deoxypyridinoline level.

However, the number needed to treat to avoid one vertebral fracture at twelve months was fifteen with high urinary deoxypyridinoline levels and twenty-five with low urinary deoxypyridinoline levels Therefore, from a pharmacoeconomic standpoint, it may be useful to stratify patients by the pretreatment bone resorption rate 93 , With regard to anabolic therapy, a recent post hoc analysis of the data from the Fracture Prevention Trial study, in which teriparatide was used to treat osteoporosis, showed a strong positive correlation between the baseline bone markers PINP, NTX, PICP, bone-specific alkaline phosphatase, and deoxypyridinoline and subsequent increases in lumbar spine bone mineral density at eighteen months Therefore, even patients with high bone turnover rates at baseline could have a robust bone mineral density response to teriparatide treatment Osteoporotic fracture is a common and debilitating problem in the elderly.

However, if physicians can identify patients at risk for fracture, prevention programs may be initiated to reduce the number of fractures sustained. Although bone mineral density is used for the diagnosis of osteoporosis and to assess fracture risk, it has become increasingly apparent that bone mineral density reflects only one component of bone strength. Recently, FRAX was developed to calculate age-specific fracture probabilities in men and women on the basis of clinical risk factors and the bone mineral density at the femoral neck.

Measurements of biochemical bone marker levels can be used not only to monitor treatment efficacy but also to assess fracture risk and help select patients for therapy. Antiresorptive medications are most appropriate for patients with high bone turnover, while anabolic agents demonstrate efficacy in both low and high-turnover conditions.

It is anticipated that the development of new imaging tools to evaluate bone quality will improve the assessment of a patient's fracture risk and response to treatment in the future. In the meantime, bone strength should be assessed with the use of clinical risk factors as identified in FRAX and measurement of bone turnover marker levels as a supplement to the measurement of bone mineral density to enhance patient evaluation and improve osteoporosis diagnosis and treatment.

National Center for Biotechnology Information , U. J Bone Joint Surg Am. Lane , MD 1. Brian P. Joseph M. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Bone mineral density is considered to be the standard measure for the diagnosis of osteoporosis and the assessment of fracture risk.

Assessment of Bone Quantity: Bone Mineral Density In , the World Health Organization developed a definition of osteoporosis on the basis of studies of women of various ages Open in a separate window.

FRAX Model Because of the limitations of dual x-ray absorptiometry, efforts have been made to formulate a system to better predict fracture risk. Clinical Guidelines The application of FRAX includes selecting an appropriate group of patients for osteoporosis treatment. Assessment of Bone Turnover Bone turnover is the principal factor that controls both the quality and the quantity of bone in the adult skeleton.

Bone Resorption Markers When osteoclasts resorb bone, they degrade the extracellular matrix and release a variety of collagen breakdown products into the circulation that are further metabolized by the liver and kidneys. Bone Formation Markers During bone formation, osteoblasts produce type-I collagen, which is their major synthetic product. Factors Affecting Levels of Bone Formation and Bone Resorption Markers There are multiple factors that may cause variations in the levels of biochemical bone markers.

Biological Factors Analytical Factors Circadian rhythm, seasonal variation, bed rest, exercise, fracture-healing, medical conditions diabetes mellitus, thyroid diseases, etc. Technical variability, sample conservation. Potential Clinical Uses of Measurements of Bone Formation and Resorption Marker Levels Monitoring Effectiveness of Treatment Currently the best-established clinical use of bone marker analysis is for monitoring treatment efficacy.

Prediction of Fracture Risk Prediction of fracture risk is probably the most important potential use of bone marker measurements because turnover alters bone geometry and material properties and thus may affect the susceptibility to fracture. Selection of Patients for Treatment Several studies indicate that individuals with the highest levels of bone turnover seem to have the best response to antiresorptive therapy 83 , Overview Osteoporotic fracture is a common and debilitating problem in the elderly.

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Relationship between changes in bone mineral density and vertebral fracture risk associated with risedronate: greater increases in bone mineral density do not relate to greater decreases in fracture risk.

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Predicting fracture risk: tougher than it looks.