Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA

The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report

Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.

Balancing fracture risk versus risk of mortality before fracture among women aged 80 years or older

BACKGROUND

Most fractures occur in women aged ≥80 years but competing mortality unrelated to fracture may limit the benefit of osteoporosis drug therapy for some women in late life. Our primary aim was to develop separate prediction models for non-spine fracture (NSF) and mortality before fracture to identify subsets of women with varying fracture versus mortality risks.

METHODS

Separate prediction models were developed for NSF and mortality before NSF for 4895 women aged ≥80 years enrolled in the Study of Osteoporotic Fractures (SOF) or the Health Aging and Body Composition (HABC) study. Proportional hazards models modified to account for competing mortality were used to identify candidate risk factors for each outcome. Predictors associated with NSF or mortality (p < 0.2) were included in separate competing risk models to estimate the cumulative incidence of NSF and mortality before NSF during 5 years of follow-up. This process was repeated to develop separate prediction models for hip fracture and mortality before hip fracture.

RESULTS

Significant predictors of NSF (race, total hip BMD, grip strength, prior fracture, falls, and use of selective serotonin reuptake inhibitors, benzodiazepines, or oral/transdermal estrogen) differed from predictors of mortality before NSF (age, walking speed, multimorbidity, weight change, shrinking, smoking, self-rated health, dementia, and use of warfarin). Within nine subsets of women defined by tertiles of risk, 5-year outcomes varied from 28% NSF and 8% mortality in the high-risk NSF/low-risk mortality subset, to 9% NSF and 22% mortality in the low-risk NSF/high-risk mortality subset. Similar results were seen for predictors of hip fracture and mortality before hip fracture.

CONCLUSION

Considerable variation in 5-year competing mortality risk is present among women in late life with similar 5-year NSF risk. Both fracture risk and life expectancy should inform shared clinical decision-making regarding initiation or continuation of osteoporosis drug therapy for women aged ≥80 years.

Effect of Race/Ethnicity on United States FRAX Calculations and Treatment Qualification: A Registry-Based Study

Since 2008. the United States has had four race/ethnic fracture risk assessment tool (FRAX) calculators: White ("Caucasian"), Black, Asian, and Hispanic. The American Society for Bone and Mineral Research Task Force on Clinical Algorithms for Fracture Risk has been examining the implications of retaining race/ethnicity in the US FRAX calculators. To inform the Task Force, we computed FRAX scores according to each US calculator in 114,942 White, 485 Black, and 2816 Asian women (self-reported race/ethnicity) aged 50 years and older. We estimated treatment qualification based upon FRAX thresholds (3% for hip fracture, 20% for major osteoporotic fracture [MOF]). Finally, we examined measures for a hypothetical population-based FRAX calculator derived as the weighted mean for the US population based upon US Census Bureau statistics. With identical inputs, the highest FRAX measurements were found with the White FRAX calculator, lowest measurements with the Black calculator, and intermediate measurements for the Asian and Hispanic calculators. The percentage of women with FRAX scores exceeding the hip fracture treatment threshold was 32.0% for White, 1.9% for Black, and 19.7% for Asian women; the MOF treatment threshold was exceeded for 14.9% of White, 0.0% of Black, and 3.5% of Asian women. Disparities in treatment qualification were reduced after considering additional criteria (fracture history and dual-energy X-ray absorptiometry [DXA] T-score -2.5 or lower). When fracture risk was recalculated for non-White women using the White FRAX calculator, mean values for Asian women slightly exceeded those for White women but for Black women remained substantially below those for White women. When using a single population-based FRAX calculator, the mean probability of fracture and treatment qualification increased for non-White women across the age range. In summary, use of a single population-based FRAX calculator, rather than existing US race/ethnic FRAX calculators, will reduce differences in treatment qualification and may ultimately enhance equity and access to osteoporosis treatment. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Osteoporosis and Vertebral Column

Background

Osteoporosis is an age-related metabolic disease which has a significant impact on bone health and overall quality of life. It is gaining importance as a major medical consideration with the rapid increase in geriatric population globally. It increases the risk of vertebral fractures, progressive spinal deformities and neurological complications, contributing significantly to morbidity and mortality. Increase in life expectancy and advancement of medical technology has led to an increase in the proportion of geriatric patients undergoing orthopaedic procedures. It is becoming vital to adequately evaluate, investigate and treat osteoporosis before planning spinal surgery, especially spinal fusions and instrumentation.

Content

Historically, osteoporosis was considered a contraindication to spine surgery adding to the burden of Disability Adjusted Life Years (DALYs) and mortality. Conversely, osteoporotic patients who underwent spine surgery were not adequately optimized, leading to an increase in failure and complication rates. Better understanding of the pathophysiology of osteoporosis and the biomechanics of an osteoporotic spine with knowledge of current standards of treatment of osteoporosis facilitate the timely and adequate management of this disease. Advances in surgical and anaesthetic techniques facilitate successful surgeries on high-risk elderly and osteoporotic patients with multiple comorbidities allowing for a significantly high predictability for long-term positive outcomes.This article discusses the biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal disease, and the new treatments, recommendations, surgical indications, strategies and advances in instrumentation in patients with osteoporosis who require spinal surgery.

Implications

In this article, the authors aim to provide a generalized overview for better understanding of the pathophysiological processes underlying osteoporosis in the vertebral column. This review provides a comprehensive set of guidelines for overall health and management of spine patients with pathologies, either caused by or compounded with osteoporosis. An overview of current techniques, strategies and technologies designed to address the challenges associated with spine surgery in osteoporotic patients is also outlined.

Sources

Content for this article has been sourced from routinely cited articles available via PubMed, from National Institute of Health consensus development conference, from the recommendations by World Health Organization technical report series, from previous articles by the authors and from the protocols established by the authors in their clinical practice based on experience and detailed case reviews.

Rib Fragility Fractures and Chest Wall Hematoma After Cardiopulmonary Resuscitation Training: A Case Report

Fragility fractures commonly manifest as complications in individuals with diminished bone mineral density and other risk factors. The hip, vertebral body, and wrist are the most documented locations of fragility fractures among patients with osteoporosis or osteopenia. This report presents a rare case of multiple fragility fractures of the right ribs accompanied by an adjacent right chest wall hematoma in an otherwise healthy 60-year-old woman after participating in cardiopulmonary resuscitation (CPR) training. Upon further workup, a diagnosis of osteopenia was established. This report aims to underscore a potential complication in those performing CPR and outline the clinicoradiological presentations, diagnostic workup, and treatment of fragility fractures in patients with no history of prior underlying skeletal conditions or malignancy.

Osteoporosis and Fracture Risk among Older US Asian Adults

PURPOSE OF REVIEW

This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults.

RECENT FINDINGS

Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.

Threshold based on bone mineral density for therapeutic decision-making in postmenopausal women and men over 50 years old under glucocorticoid therapy

INTRODUCTION AND AIM

T-score bone mineral density (BMD) thresholds may influence guidance for treatment in patients under glucocorticoid (GC) therapy. Different BMD thresholds have been described but there is no international consensus. The aim of this study was to find a threshold to help in treatment decision-making in the population under GC therapy.

METHODS

A working group representing three scientific societies from Argentina was convened. The first team was formed by specialists with expertise in glucocorticoid-induced osteoporosis (GIO) who voted according to summary of evidence. The second team was constituted by a methodology group who coordinated and supervised each stage. We conducted two systematic reviews to synthesize the evidence. The first included trials of drugs used in GIO to analyze the BMD cut-off used as inclusion criteria. In the second, we analyzed the evidence regarding the densitometric thresholds to discriminate between fractured and non-fractured patients under GC treatment.

RESULTS

In the first review, 31 articles were included for qualitative synthesis and more than 90% of the trials included patients regardless of their densitometric T-score or range of osteopenia. In the second review, 4 articles were included and more than 80% of the T-scores were in the range -1.6 to -2.0. The summary of findings was analyzed and put to a vote.

CONCLUSIONS

With more than 80% agreement of the voting expert panel, a T-score≤-1.7 was considered the most appropriate for treatment in postmenopausal women and men over 50 years of age under GC therapy. This study could help in treatment decision-making in patients under GC therapy without fractures but other fracture risk factors should certainly be considered.

Bone Metastases and Health in Prostate Cancer: From Pathophysiology to Clinical Implications

Clinically relevant bone metastases are a major cause of morbidity and mortality for prostate cancer patients. Distinct phenotypes are described: osteoblastic, the more common osteolytic and mixed. A molecular classification has been also proposed. Bone metastases start with the tropism of cancer cells to the bone through different multi-step tumor-host interactions, as described by the "metastatic cascade" model. Understanding these mechanisms, although far from being fully elucidated, could offer several potential targets for prevention and therapy. Moreover, the prognosis of patients is markedly influenced by skeletal-related events. They can be correlated not only with bone metastases, but also with "bad" bone health. There is a close correlation between osteoporosis-a skeletal disorder with decreased bone mass and qualitative alterations-and prostate cancer, in particular when treated with androgen deprivation therapy, a milestone in its treatment. Systemic treatments for prostate cancer, especially with the newest options, have improved the survival and quality of life of patients with respect to skeletal-related events; however, all patients should be evaluated for "bone health" and osteoporotic risk, both in the presence and in the absence of bone metastases. Treatment with bone-targeted therapies should be evaluated even in the absence of bone metastases, as described in special guidelines and according to a multidisciplinary evaluation.

Chronic airway disease as a major risk factor for fractures in osteopenic women: Nationwide cohort study

INTRODUCTION

The study aimed to demonstrate the risk factors for fractures and to develop prediction models for major osteoporotic and hip fractures in osteopenic patients using the nationwide cohort study in South Korea.

METHODS

The study was a retrospective nationwide study using the national screening program for transitional ages from the National Health Insurance Services database in Korea from 2008 to 2019. Primary outcomes were incident fracture events of major osteoporotic and hip fractures. Major osteoporotic and hip fracture events were defined as diagnostic and procedural codes. Patients were followed until the fragility fractures, death, or 2019, whichever came first.

RESULTS

All participants were 66-year-old females, with a mean body mass index was 25.0 ± 3.1 kg/m². During a median follow-up of 10.5 years, 26.9% and 6.7% of participants experienced major osteoporotic and hip fractures. In multivariate analysis, a history of fracture, chronic airway disease, falls, diabetes mellitus and cerebrovascular diseases were significant risk factors for major osteoporotic (hazard ratio [HR] 2.35 for a history of fracture; 1.17 for chronic airway disease; 1.10 for falls; 1.12 for diabetes mellitus; 1.11 for cerebrovascular disease) and hip fractures (HR 1.75 for a history of fracture; 1.54 for diabetes mellitus; 1.27 for cerebrovascular disease; 1.17 for fall; 1.15 for chronic airway disease). The performances of the prediction models were area under the receiver operating curve of 0.73 and 0.75 for major osteoporotic and hip fractures.

CONCLUSION

The study presented prediction models of major osteoporotic and hip fractures for osteopenia patients using simple clinical features.

Calcium status assessment at the population level: Candidate approaches and challenges

Inadequate dietary calcium intake is a global public health problem that disproportionately affects low- and middle-income countries. However, the calcium status of a population is challenging to measure, and there are no standard methods to identify high-risk communities even in settings with an elevated prevalence of a disease caused or exacerbated by low calcium intake (e.g., rickets). The calcium status of a population depends on numerous factors, including intake of calcium-rich foods; the bioavailability of the types of calcium consumed in foods and supplements; and population characteristics, including age, sex, vitamin D status, and genetic attributes that influence calcium retention and absorption. The aim of this narrative review was to assess candidate indicators of population-level calcium status based on a range of biomarkers and measurement methods, including dietary assessment, calcium balance studies, hormonal factors related to calcium, and health outcomes associated with low calcium status. Several promising approaches were identified, but there was insufficient evidence of the suitability of any single indicator to assess population calcium status. Further research is required to develop and validate specific indicators of calcium status that could be derived from the analysis of data or samples that are feasibly collected in population-based surveys.

EXTENSIVE EXPERTISE IN ENDOCRINOLOGY: Osteoporosis management

Fractures occur in about half of older White women, and almost a third of older White men. However, 80% of the older individuals who have fractures do not meet the bone density definition of osteoporosis, suggesting that this definition is not an appropriate threshold for offering treatment. Fracture risk can be estimated based on clinical risk factors with or without bone density. A combination of calculated risk, fracture history, and bone density is used in treatment decisions. Medications available for reducing fracture risk act either to inhibit bone resorption or to promote bone formation. Romosozumab is unique in that it has both activities. Bisphosphonates are the most widely used interventions because of their efficacy, safety, and low cost. Continuous use of oral bisphosphonates for >5 years increases the risk of atypical femoral fractures, so is usually punctuated with drug holidays of 6-24 months. Denosumab is a further potent anti-resorptive agent given as 6-monthly s.c. injections. It is comparable to the bisphosphonates in efficacy and safety but has a rapid offset of effect after discontinuation so must be followed by an alternative drug, usually a bisphosphonate. Teriparatide stimulates both bone formation and resorption, substantially increases spine density, and reduces vertebral and non-vertebral fracture rates, though data for hip fractures are scant. Treatment is usually limited to 18-24 months, followed by the transition to an anti-resorptive. Romosozumab is given as monthly s.c. injections for 1 year, followed by an anti-resorptive. This sequence prevents more fractures than anti-resorptive therapy alone. Because of cost, anabolic drugs are usually reserved for those at very high fracture risk. 25-hydroxyvitamin D levels should be maintained above 30 nmol/L, using supplements if sunlight exposure is limited. Calcium intake has little effect on bone density and fracture risk but should be maintained above 500 mg/day using dietary sources.

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.

Circulating serum microRNAs including senescent miR-31-5p are associated with incident fragility fractures in older postmenopausal women with type 2 diabetes mellitus

Fragility fractures are an important hallmark of aging and an increasingly recognized complication of Type 2 diabetes (T2D). T2D individuals have been found to exhibit an increased fracture risk despite elevated bone mineral density (BMD) by dual x-ray absorptiometry (DXA). However, BMD and FRAX-scores tend to underestimate fracture risk in T2D. New, reliable biomarkers are therefore needed. MicroRNAs (miRNAs) are secreted into the circulation from cells of various tissues proportional to local disease severity. Serum miRNA-classifiers were recently found to discriminate T2D women with and without prevalent fragility fractures with high specificity and sensitivity (AUC > 0.90). However, the association of circulating miRNAs with incident fractures in T2D has not been examined yet. In 168 T2D postmenopausal women in the AGES-Reykjavik cohort, miRNAs were extracted from baseline serum and a panel of 10 circulating miRNAs known to be involved in diabetic bone disease and aging was quantified by qPCR and Ct-values extracted. Unadjusted and adjusted Cox proportional hazard models assessed the associations between serum miRNAs and incident fragility fracture. Additionally, Receiver operating curve (ROC) analyses were performed. Of the included 168 T2D postmenopausal women who were on average 77.2 ± 5.6 years old, 70 experienced at least one incident fragility fracture during the mean follow-up of 5.8 ± 2.7 years. We found that 3 serum miRNAs were significantly associated with incident diabetic fragility fracture: while low expression of miR-19b-1-5p was associated with significantly lower risk of incident fragility fracture (HR 0.84 (95% CI: 0.71-0.99, p = 0.0323)), low expression of miR-203a and miR-31-5p was each significantly associated with a higher risk of incident fragility fracture per unit increase in Ct-value (miR-203a: HR 1.29 (95% CI: 1.12-1.49), p = 0.0004, miR-31-5p HR 1.27 (95% CI: 1.06-1.52), p = 0.009). Hazard ratios of the latter two miRNAs remained significant after adjustments for age, body mass index (BMI), areal bone mineral density (aBMD), clinical FRAX or FRAXaBMD. Women with miR-203a and miR-31-5p serum levels in the lowest expression quartiles exhibited a 2.4-3.4-fold larger fracture risk than women with miR-31-5p and miR-203a serum expressions in the highest expression quartile (0.002 ≤ p ≤ 0.039). Women with both miR-203a and miR-31-5p serum levels below the median had a significantly increased fracture risk (Unadjusted HR 3.26 (95% CI: 1.57-6.78, p = 0.001) compared to those with both expression levels above the median, stable to adjustments. We next built a diabetic fragility signature consisting of the 3 miRNAs that showed the largest associations with incident fracture (miR-203a, miR-31-5p, miR-19b-1-5p). This 3-miRNA signature showed with an AUC of 0.722 comparable diagnostic accuracy in identifying incident fractures to any of the clinical parameters such as aBMD, Clinical FRAX or FRAXaBMD alone. When the 3 miRNAs were combined with aBMD, this combined 4-feature signature performed with an AUC of 0.756 (95% CI: 0.680, 0.823) significantly better than aBMD alone (AUC 0.666, 95% CI: 0.585, 0.741) (p = 0.009). Our data indicate that specific serum microRNAs including senescent miR-31-5p are associated with incident fragility fracture in older diabetic women and can significantly improve fracture risk prediction in diabetics when combined with aBMD measurements of the femoral neck.

Role of Fracture Risk Assessment Tool and Bone Turnover Markers in Predicting All-Cause and Cardiovascular Mortality in Hemodialysis Patients

Background

Fracture Risk Assessment Tool (FRAX) and bone turnover markers (BTMs) predict fractures in the general population. However, the role of FRAX and BTMs in predicting mortality remains uncertain in hemodialysis (HD) patients.

Methods

One hundred and sixty-four HD patients stratified by low or high risk of 10-year fracture probability using FRAX. High risk of fracture was defined as 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20%. The association of high risk of fracture and BTMs with all-cause mortality and cardiovascular (CV) mortality were evaluated using multivariate-adjusted Cox regression analysis.

Results

Eighty-five (51.8%) patients were classified as high risk of fracture based on FRAX among 164 HD patients. During a mean follow-up period of 3.5 ± 1.0 years, there were 39 all-cause deaths and 23 CV deaths. In multivariate-adjusted Cox regression, high risk of fracture based on FRAX was independently associated with all-cause mortality [hazard ratio (HR): 2.493, 95% confidence interval (CI): 1.026–6.056, p = 0.044) but not with CV mortality (HR: 2.129, 95% CI: 0.677–6.700, p = 0.196). There were no associations between BTMs and mortality risk. Furthermore, lower geriatric nutritional risk index (GNRI) was significantly associated with increased CV mortality (HR: 0.888, 95% CI: 0.802–0.983, p = 0.022) after adjusting by confounding variables.

Conclusion

High risk of fracture using FRAX was an independent predictor of all-cause mortality in patients undergoing HD. FRAX, rather than BTMs, has an important role of prognostic significance in HD patients.

Racial Disparities and Inequalities in the Management of Patients With Osteoporosis

Osteoporosis is a skeletal disease characterized by low bone density and poor bone quality that weakens bones and increases the risk of fractures. Serious consequences of fractures include disability, loss of independence, and death. Despite the availability of clinical tools to evaluate fracture risk and medications to reduce fracture risk, many or most patients at risk, even those with a recent fracture, are not being treated. This represents a large osteoporosis treatment gap that has reached a crisis level. Importantly, the treatment gap is not evenly distributed among populations of different race/ethnicity. Black women are less likely to have bone density testing when indicated, are less likely to be treated, and have worse outcomes after a fracture than White women. This is a review and update of race-based disparities and inequalities, with suggestions for interventions to optimize patient care.

Evaluation of fracture risk in Egyptian rheumatoid arthritis patients by the Fracture Risk Assessment Tool

Background

Rheumatoid arthritis (RA) patients have a risk of fractures due to secondary osteoporosis. This study aimed to evaluate the probability of fractures in the next 10 years in Egyptian RA patients by the Fracture Risk Assessment Tool (FRAX).

Results

The study was a case–control study. It included a hundred RA patients as well as 51 apparently healthy volunteers. Bone mineral density (BMD) means of lumbar vertebra, femoral neck, and total femur were significantly lower in the RA patient group. Additionally, FRAX of the major osteoporotic and hip fractures means were significantly higher in the RA group than in the control group. It was also found that age, body mass index (BMI), Health Assessment Questionnaire Disability Index (HAQ-DI), and BMD of the femoral neck were significant predictors of FRAX of major osteoporotic and hip fractures (P ≤ 0.05). The cumulative dose of steroids was a significant predictor for FRAX of major osteoporotic fractures; however, the 28 joints disease activity score calculated with erythrocyte sedimentation rate (ESR) (DAS28-ESR) was a significant predictor for FRAX of hip fractures.

Conclusions

RA patients have a high fracture risk probability. Regular annual screening for BMD and FRAX of major osteoporotic and hip fractures is necessary for those patients.

A patent review on cathepsin K inhibitors to treat osteoporosis (2011 - 2021)

INTRODUCTION

Cathepsin K (CatK) is a lysosomal cysteine protease and the predominant cathepsin expressed in osteoclasts, where it degrades the bone matrix. Hence, CatK is an attractive therapeutic target related to diseases characterized by bone resorption, like osteoporosis.

AREAS COVERED

This review summarizes the patent literature from 2011 to 2021 on CatK inhibitors and their potential use as new treatments for osteoporosis. The inhibitors were classified by their warheads, with the most explored nitrile-based inhibitors. Promising in vivo results have also been disclosed.

EXPERT OPINION

As one of the most potent lysosomal proteins whose primary function is to mediate bone resorption, cathepsin K remains an excellent target for therapeutic intervention. Nevertheless, there is no record of any approved drug that targets CatK. The most notable cases of drug candidates targeting CatK were balicatib and odanacatib, which reached Phase II and III clinical trials, respectively, but did not enter the market. Further developments include exploring new chemical entities beyond the nitrile-based chemical space, with improved ADME and safety profiles. In addition, CatK's role in cancer immunoexpression and its involvement in the pathophysiology of osteo- and rheumatoid arthritis have raised the race to develop activity-based probes with excellent potency and selectivity.

Performance of the Fracture Risk Assessment Tool Associated with Muscle Mass Measurements and Handgrip to Screen for the Risk of Osteoporosis in Young Postmenopausal Women

OBJECTIVE

 To evaluate the improvement in screening accuracy of the Fracture Risk Assessment Tool (FRAX) for the risk of developing osteoporosis among young postmenopausal women by associating with it clinical muscle mass measures.

METHODS

 A sample of postmenopausal women was submitted to calcaneal quantitative ultrasound (QUS), application of the FRAX questionnaire, and screening for the risk of developing sarcopenia at a health fair held in the city of São Bernardo do Campo in 2019. The sample also underwent anthropometric measurements, muscle mass, walking speed and handgrip tests. A major osteoporotic fracture (MOF) risk ≥ 8.5% on the FRAX, a classification of medium risk on the clinical guideline of the National Osteoporosis Guideline Group (NOGG), and a QUS T-score ≤ -1.8 sd were considered risks of having low bone mass, and QUS T-score ≤ -2.5sd, risk of having fractures.

RESULTS

 In total, 198 women were evaluated, with a median age of 64 ±  7.7 years, median body mass index (BMI) of 27.3 ±  5.3 kg/m² and median QUS T-score of -1.3 ±  1.3 sd. The accuracy of the FRAX with a MOF risk ≥ 8.5% to identify women with T-scores ≤ -1.8 sd was poor, with an area under the curve (AUC) of 0.604 (95% confidence interval [95%CI]: 0.509-0.694) for women under 65 years of age, and of 0.642 (95%CI: 0.571-0.709) when age was not considered. Including data on muscle mass in the statistical analysis led to a significant improvement for the group of women under 65 years of age, with an AUC of 0,705 (95%CI: 0.612-0.786). The ability of the high-risk NOGG tool to identify T-scores ≤ -1.8 sd was limited.

CONCLUSION

 Clinical muscle mass measurements increased the accuracy of the FRAX to screen for osteoporosis in women aged under 65 years.

Disparities in osteoporosis care among postmenopausal women in the United States

Osteoporosis and fragility fractures result in significant morbidity and mortality and contribute to substantial healthcare costs. Despite being a treatable disease, osteoporosis remains both underdiagnosed and undertreated in the US general population, with significant disparities in care between non-White and White women. These disparities are evident from screening to post-fracture treatment. Non-White women are less likely to be screened for osteoporosis, to be prescribed pharmacotherapy, or to receive treatment post-fracture; furthermore, the mortality rate after fracture is higher in non-White women. Given existing diagnostic and treatment disparities, additional studies and interventions are needed to optimize the bone health of Asian, Black, Hispanic, and Native American women, and to reduce morbidity and mortality from osteoporosis and fragility fractures.

Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk: An Update

Quantitative ultrasound (QUS) presents a low cost and readily available alternative to DXA measurements of bone mineral density (BMD) for osteoporotic fracture risk assessment. It is performed in a variety of skeletal sites, among which the most widely investigated and clinically used are first the calcaneus and then the radius. Nevertheless, there is still uncertainty in the incorporation of QUS in the clinical management of osteoporosis as the level of clinical validation differs substantially upon the QUS models available. In fact, results from a given QUS device can unlikely be extrapolated to another one, given the technological differences between QUS devices. The use of QUS in clinical routine to identify individuals at low or high risk of fracture could be considered primarily when central DXA is not easily available. In this later case, it is recommended that QUS bone parameters are used in combination with established clinical risk factors for fracture. Currently, stand-alone QUS is not recommended for treatment initiation decision making or follow-up. As WHO classification of osteoporosis thresholds cannot apply to QUS, thresholds specific for given QUS devices and parameters need to be determined and cross-validated widely to have a well-defined and certain use of QUS in osteoporosis clinical workflow. Despite the acknowledged current clinical limitations for QUS to be used more widely in daily routine, substantial progresses have been made and new results are promising.

Machine Learning Can Improve Clinical Detection of Low BMD: The DXA-HIP Study

BACKGROUND

Identification of those at high risk before a fracture occurs is an essential part of osteoporosis management. This topic remains a significant challenge for researchers in the field, and clinicians worldwide. Although many algorithms have been developed to either identify those with a diagnosis of osteoporosis or predict their risk of fracture, concern remains regarding their accuracy and application. Scientific advances including machine learning methods are rapidly gaining appreciation as alternative techniques to develop or enhance risk assessment and current practice. Recent evidence suggests that these methods could play an important role in the assessment of osteoporosis and fracture risk.

METHODS

Data used for this study included Dual-energy X-ray Absorptiometry (DXA) bone mineral density and T-scores, and multiple clinical variables drawn from a convenience cohort of adult patients scanned on one of 4 DXA machines across three hospitals in the West of Ireland between January 2000 and November 2018 (the DXA-Heath Informatics Prediction Cohort). The dataset was cleaned, validated and anonymized, and then split into an exploratory group (80%) and a development group (20%) using the stratified sampling method. We first established the validity of a simple tool, the Osteoporosis Self-assessment Tool Index (OSTi) to identify those classified as osteoporotic by the modified International Society for Clinical Densitometry DXA criteria. We then compared these results to seven machine learning techniques (MLTs): CatBoost, eXtreme Gradient Boosting, Neural network, Bagged flexible discriminant analysis, Random forest, Logistic regression and Support vector machine to enhance the discrimination of those classified as osteoporotic or not. The performance of each prediction model was measured by calculating the area under the curve (AUC) with 95% confidence interval (CI), and was compared against the OSTi.

RESULTS

A cohort of 13,577 adults aged ≥40 yr at the age of their first scan was identified including 11,594 women and 1983 men. 2102 (18.13%) females and 356 (17.95%) males were identified with osteoporosis based on their lowest T-score. The OSTi performed well in our cohort in both men (AUC 0.723, 95% CI 0.659-0.788) and women (AUC 0.810, 95% CI 0.787-0.833). Four MLTs improved discrimination in both men and women, though the incremental benefit was small. eXtreme Gradient Boosting showed the most promising results: +4.5% (AUC 0.768, 95% CI 0.706-0.829) for men and +2.3% (AUC 0.833, 95% CI 0.812-0.853) for women. Similarly MLTs outperformed OSTi in sensitivity analyses-which excluded those subjects taking osteoporosis medications-though the absolute improvements differed.

CONCLUSION

The OSTi retains an important role in identifying older men and women most likely to have osteoporosis by bone mineral density classification. MLTs could improve DXA detection of osteoporosis classification in older men and women. Further exploration of MLTs is warranted in other populations, and with additional data.

The Impact of Observation Versus Parathyroidectomy on Bone Mineral Density and Fracture Risk Determined by FRAX Tool in Patients With Primary Hyperparathyroidism

To study impact of observation (OBV) vs parathyroidectomy (PTX) on biochemistry, bone mineral density (BMD) and fracture risk calculated by Fracture Risk Assessment (FRAX) tool in primary hyperparathyroidism (PHPT). Retrospective study of 60 patients (OBV - 26; PTX - 34 patients). Mean adjusted calcium improved in both groups [OBV - 2.76 ± 0.07 vs 2.51 ± 0.20 mmol/L; p < 0.00001, PTX - 2.87 ± 0.21 vs 2.36 ± 0.12 mmol/L; p < 0.00001]. Mean parathyroid hormone level declined in both but more in PTX group [OBV - 11.4 ± 5.2 vs. 9.7 ± 5.6 pmol/L; p = 0.04, PTX - 14.3 ± 8.2 vs 4.6 ± 2.2 pmol/L; p < 0.00001]. In OBV group, BMD and T scores declined at all sites. Mean percentage change of BMD was -5.8 % at femoral neck (FN), -4.9 % at total hip (TH), -6.2 % at lumbar spine (LS) and -10.0 % at lower 1/3^rd radius (LR). PTX led to stabilization of BMD at FN (3.0 %), TH (-0.6 %) and LS (2.2 %) but significant improvement at LR (13.9 %; p = 0.0005). In OBV group, 10 year risk of hip fracture (HF) (7.5 ± 9.0 % vs. 8.6 ± 9.0; p = 0.01) and major osteoporotic fracture (OF) (16.6 ± 10.9 % vs 18.3 ± 10.8 %; p = 0.002) worsened with time whereas in PTX group, risk of both type of fractures remained stable (HF; p = 0.48 and OF; p = 0.43). Comparison between groups showed greater improvement in median % change of fracture risk for both HF and OF in PTX group. OBV in PHPT lead to greater decline in BMD at all skeletal sites and imparted significant risk of HF and major OF. PTX offered stabilization of BMD at most sites but improvement at LR with unchanged fracture risk. FRAX tool should be used more frequently and universally.

Automated bone mineral density prediction and fracture risk assessment using plain radiographs via deep learning

Dual-energy X-ray absorptiometry (DXA) is underutilized to measure bone mineral density (BMD) and evaluate fracture risk. We present an automated tool to identify fractures, predict BMD, and evaluate fracture risk using plain radiographs. The tool performance is evaluated on 5164 and 18175 patients with pelvis/lumbar spine radiographs and Hologic DXA. The model is well calibrated with minimal bias in the hip (slope = 0.982, calibration-in-the-large = -0.003) and the lumbar spine BMD (slope = 0.978, calibration-in-the-large = 0.003). The area under the precision-recall curve and accuracy are 0.89 and 91.7% for hip osteoporosis, 0.89 and 86.2% for spine osteoporosis, 0.83 and 95.0% for high 10-year major fracture risk, and 0.96 and 90.0% for high hip fracture risk. The tool classifies 5206 (84.8%) patients with 95% positive or negative predictive value for osteoporosis, compared to 3008 DXA conducted at the same study period. This automated tool may help identify high-risk patients for osteoporosis.

Osteoporosis and Spine Surgery: A Critical Analysis Review

Despite being part of the aging process, early and adequate management of osteoporosis mitigates adverse outcomes associated with low bone mineral density. Although the health-care burden of osteoporosis is on the rise, screening and management of osteoporosis are not yet an integral part of preoperative patient evaluation in spine surgery. Patients with osteoporosis should undergo multidisciplinary evaluation and management, including lifestyle modifications and initiation of multiple therapeutic modalities. Integrating osteoporosis in preoperative optimization and surgical planning for patients undergoing spine surgery has the potential to mitigate osteoporosis-related postoperative complications.

Sex-specific associations of serum insulin-like growth factor-1 with bone density and risk of fractures in Chinese patients with type 2 diabetes

We evaluated the associations of serum insulin-like growth factor-1 (IGF-1) with bone mineral density (BMD) and risk of fractures in Chinese patients with type 2 diabetes (T2D). We found positive associations between IGF-I and BMD and negative associations between IGF-I and all three modified 10-year probabilities of MOFs and HFs in men, but not in women.

INTRODUCTION

The objective was to investigate the associations of serum insulin-like growth factor-1 (IGF-1) with bone mineral density (BMD) and risk of fractures in Chinese patients with type 2 diabetes (T2D) in each gender.

METHODS

This was a cross-sectional, retrospective study that included men over 50 years and postmenopausal women with T2D without medical conditions or medications known to significantly affect BMD or serum IGF-I levels. Data of IGF-1, bone metabolism markers, lumbar spine (LS), femoral neck (FN), and total hip (TH) BMD were obtained; 10-year probability of major osteoporotic fractures (MOFs) and hip fractures (HFs) was calculated and modified with rheumatoid arthritis, femoral neck T-score, and age. Correlations of IGF-1 levels with bone metabolism and risk of fractures were statistically analyzed in men and women, respectively.

RESULTS

A total of 391 patients, including 226 men and 165 women, were included. The age, serum fasting C-peptide, glycosylated hemoglobin (HbA1c), bone formation marker, and all three modified 10-year probabilities of MOFs and HFs were higher in women than those in men (all p < 0.05). The levels of 25 hydroxyvitamin D (25OHD), IGF-1, and BMD were lower in women than those in men (all p < 0.05). In men, IGF-1 was positively correlated with FN and TH BMD (FN BMD: r = 0.267, p < 0.001; TH BMD: r = 0.235, p < 0.001) and negatively correlated with all three modified 10-year probabilities of MOFs (RA-modified MOFs: r = - 0.289, p < 0.001; age-modified MOFs: r = - 0.237, p < 0.001; FN T-score-modified MOFs: r = - 0.280, p < 0.001) and HFs (RA-modified HFs: r = - 0.291, p < 0.001; age-modified HFs: r = - 0.271, p < 0.001; FN T-score-modified HFs: r = - 0.270, p < 0.001), while no significant correlations were found between serum IGF-I and BMD and three modified 10-year probability in women.

CONCLUSIONS

According to this study, we found sex differences in the associations of serum IGF-1 with BMD and risk of fractures in Chinese patients with T2D. These results suggested that increasing serum IGF-1 might be a clinical target for protecting fractures in T2D, especially in men.

Bone densitometry categories as a salient distracting feature in the modern clinical pathways of osteoporosis care: A retrospective 20-year cohort study

BACKGROUND

It is unknown as to what factors typically drive osteoporosis therapy decisions in real-world practice.

METHODS

Retrospective, 20-year cohort study within the government health system of Manitoba including all women having bone densitometry (BMD) tests between 1996 and 2017. Osteoporosis prescription data was linked to registry data on fractures, clinical risk factors and BMD tests. We defined 6 possible treatment decisions by prescription data: no treatment, starting, stopping, continuing, drug hiatus and re-starting. For each decision, we tested the association between salient patient factors (age, glucocorticoid use, recent fracture, BMD hip or spine T-score ≤ -2.5, FRAX major osteoporotic fracture probability ≥20%) using multivariable logistic regression. The factors were rank-ordered by decreasing Wald χ² statistic to determine the relative importance.

RESULTS

There were 64,181 women, 33.8% of whom started osteoporosis therapy. For patients who begin therapy after a first BMD, the rank-ordered multivariable logistic regression factor most strongly associated was the T-score ≤ -2.5 [OR of 7.59(95%CI 7.19-8.01, p < 0.001)]. This was followed by glucocorticoid use [OR 2.89(95%CI 2.59-3.22, p < 0.001)]. Increasing age and recent fracture (within 2 years) were weak predictors of therapy and high FRAX score associated with reduced odds of therapy [OR 0.80 (95%CI 0.74-0.88, p < 0.001)]. T-scores were the strongest factor predicting therapy stop/continuation/re-starting; age and prior fracture had weak or no associations.

CONCLUSIONS

Despite recommendations for fracture-risk-based approach to osteoporosis therapy, BMD T-score continues to be the dominant factor in actual practice. Age, prior fracture or global fracture risk are much less associated; it is possible that BMD T-score categories are therefore acting as a clinically salient distracting factor.

Awareness of osteoporosis risk assessment tools and screening recommendations among community pharmacists in Malaysia

Background The incidence of osteoporosis in Malaysia is increasing due to a fast-ageing population. Because of its silent nature, various osteoporosis risk assessment tools exist to detect high-risk patients and facilitate referrals for bone mineral density measurements. As an accessible point of contact, community pharmacists would benefit from the utilization of these tools and familiarity with guideline recommendations for osteoporosis screening. Aim This study aimed to investigate the awareness of osteoporosis risk assessment tools, practice behaviour towards osteoporosis, and knowledge of guideline recommendations among community pharmacists in the Klang Valley, Malaysia. Setting Community pharmacies. Methods This study was a cross-sectional study which sampled 284 community pharmacists practicing in the Klang Valley, using a stratified sampling approach. The study was conducted using a self-administered questionnaire which was divided into three sections: demographic data, knowledge of osteoporosis risk assessment tools and guideline recommendations, and practice behaviour towards osteoporosis. Practice behaviour was assessed with 15 items using a 5-point Likert scale. Main outcome measure. Proportion of respondents aware of osteoporosis risk assessment tools and respondent knowledge on guideline recommendations for osteoporosis screening. Results A total of 284 community pharmacists participated in the study. 84.1% of the respondents were aware of at least one risk assessment tool. However, only a small proportion of pharmacists (14.9%) regularly used these tools in their practice. Respondents perceived these tools to be relevant and beneficial, but perception towards their accessibility, ease-of-use, and administration time was mixed, suggesting unfamiliarity. Respondents preferred to conduct clinical assessments based on risk factors, with respondents identifying a mean of 10.1 ± 3.4 out of 15 risk factors. However, several clinically relevant risk factors were frequently unidentified. Knowledge of guideline recommendations among respondents was low. Conclusion There is some awareness of osteoporosis risk assessment tools but use in practice remains low among community pharmacists in Malaysia. There is potential to increase the use of these tools and knowledge of recommendations for osteoporosis screening and referral among community pharmacists.

Status of fracture risk assessment and osteoporosis treatment in Japanese patients with rheumatoid arthritis

OBJECTIVES

This study aimed to investigate the prevalence of patients with rheumatoid arthritis (RA) at a high risk of major osteoporosis (OP)-related fractures and the status of OP-related medical treatment for these patients.

METHODS

We enrolled 120 patients aged ≥40 years (average, 69.1 years) with RA. The Fracture Risk Assessment Tool (FRAX^®) was used to evaluate the fracture risk. Of the 120 patients, the femoral neck bone mineral density (BMD) was evaluated in 102 patients, and their FRAX^® scores were calculated alongside the BMD values. Patients observed to be at a high risk of a major OP-related fracture (10-year probability >20% or hip fracture risk >3%), according to FRAX^®, were identified as those requiring OP treatment; medication ratio for OP (percentage of patients actually receiving medication among patients requiring OP treatment) was assessed.

RESULTS

OP treatment was indicated in 75 (63%) patients; the medication ratio for OP was 49%. The use of biological disease-modifying anti-rheumatic drugs and corticosteroids showed a positive effect; however, the use of methotrexate showed a negative effect on the medication ratio.

CONCLUSION

The number of potential patients requiring OP treatment is underestimated. All patients with RA should be assessed to determine their eligibility for OP treatment.

Ten-year fracture risk predicted by proximal femur Hounsfield units

Colon cancer screening occurs at younger ages than osteoporosis screening. Bone density measurements using virtual colonoscopy performed for colon cancer screening can provide an early warning sign of patients at potential risk for osteoporosis-related fractures. Earlier identification may improve treatment and potentially fracture prevention.

INTRODUCTION

Opportunistic osteoporosis screening with computed tomography colonography (CTC) offers an opportunity to capitalize on earlier colorectal cancer screening to identify patients at risk of future fractures. The purpose of this study is to evaluate 10-year fracture and specifically hip fracture risk based on Hounsfield units (HU) obtained from CTC.

METHODS

We identified all CTC scans between 2004 and 2007 of patients 40 years and older with 10 years minimum follow-up. Hounsfield units were measured within the proximal femur and fractures identified via worldwide military records. Patients were stratified into two cohorts based on the presence or lack of a fracture in the wrist, spine, hip, or proximal humerus. Hounsfield unit measurements were compared between groups using Student's t test and the HU threshold was calculated that best approximated an 80% sensitivity to optimally screen patients for fracture risk. The odds ratio, negative predictive value, 10-year incidence of fracture, and survival curves were calculated.

RESULTS

We identified 3711 patients with 183 fractures over 10 years. The HU threshold that corresponded with an 80% sensitivity to identify fractures was 112 HU. The negative predictive value (NPV) for overall fractures and hip fractures was over 97%. The 10-year fracture incidence was higher in patients below 112 HU compared to those above for both overall fractures (6.3% vs 1.7%) and hip fractures (2.7% vs 0.07%). The 112 HU threshold corresponds with an odds ratio for overall fracture and hip fractures of 2.5 (95% confidence interval (CI), 1.7-3.6) and 24.5 (95% CI, 3.3-175.5), respectively.

CONCLUSION

In the 10 years following CTC, patients who experienced a fracture had lower hip HU. Decreasing HU on CTC may be an early warning sign of fracture potential.

Effects of bisphosphonates on osteoporosis: Focus on zoledronate

Osteoporosis is a bone disease that mainly affects older people and postmenopausal women. Lack of proper treatment for this disease gives rise to many problems in patients and occasionally leads to death. Many drugs have been utilized to treat osteoporosis but the most effective one is the bisphosphonates (BPs) family. This family has several positive effects on bone tissue, including promoting bone healing, enhancing bone mineral density, reducing bone resorption, preventing pathologic fractures, suppressing bone turnover, and modulating bone remodeling. On the other hand, there have also been inconclusive reports that BPs might have a desirable or even adverse impact on osteoporotic patients. Therefore, we set out to examine the positive and negative effects of this family, with a focus on the most potent one that is zoledronate (Zol), in clinical usage. Zoledronate is an amino-BPs and nitrogen-containing drug which is the most powerful BPs on osteoporosis treatment or prevention. Many studies showed its effectiveness in the treatment of osteoporosis and bone healing. As Zol enjoys a considerable potential in treating and preventing osteoporosis, it can be used as one of the effective treatments in this field.

Hepatic osteodystrophy and fracture risk prediction using FRAX tool in Indian patients with cirrhosis

Background and Aim

The main clinical relevance of hepatic osteodystrophy is the increased risk of fractures. Dual‐energy X ray absorptiometry (DEXA)‐based assessment of bone mineral density, the current gold standard for diagnosing osteoporosis, is not the sole determinant of fracture risk. Other clinical risk factors also play an important role. This study was carried out to assess the prevalence and risk factors of hepatic osteodystrophy and estimate the entailed fracture risk by using the FRAX tool in a cohort of Indian cirrhotics.

Methods

Consecutive patients with cirrhosis (n = 120) were recruited. Etiologic workup, liver function tests, serum calcium, phosphate, 25(OH)D, HbA1c, and DEXA scan were performed. Hepatic osteodystrophy was defined as a T score of < −1. FRAX scores were calculated using the Indian calculator.

Results

The study cohort was predominantly male (86.7%) with a median age of 49 (40–65) years. Alcohol was the most common etiology (80%). All patients had Child‐Turcotte‐Pugh class B (63.3%) or class B (36.7%) cirrhosis. Hepatic osteodystrophy was present in 83.3% patients. On multivariate analysis, smoking (odds ratio [OR]: 3.1 [1.76–4.7], P < 0.001) and serum 25(OH)D (OR: 0.23 [0.09–0.94]; P = 0.03) showed significant association with hepatic osteodystrophy. The 10‐year probability of major osteoporotic fracture and hip fracture was 5.7% (2.1–28.9) and 2.5% (1.4–7.4), respectively. Using a FRAX probability cut‐off of 20% for major osteoporotic fracture and 3% for hip fracture, 30% patients qualified for osteoporosis treatment.

Conclusion

Hepatic osteodystrophy is widely prevalent among Indian patients with cirrhosis and entails a high risk of fractures. Approximately one‐third of patients with cirrhosis need treatment to reduce the risk of osteoporotic fractures.

Assessment of fracture risk tools in care home residents: a multi-centre observational pilot study

BACKGROUND

Fragility fractures are common in care home residents but established tools have not been tested in this population.

AIM

To identify the most practicable tool for use.

METHODS

DESIGN: Multicentre prospective observational cohort pilot study.

SETTING

18 care homes in Boston, UK.

ASSESSMENTS

fragility risk score at baseline with FRAX, QFractureScore, Garvan nomogram, body mass index and TUGT for each participant.

OUTCOMES

falls, fractures, combined falls & fractures. Follow-up; 12 months.

RESULTS

217/618 (35%) residents in the 18 care homes were enrolled. 147 (68%) had mental capacity,70 (32%) did not. There were 325 falls and 10 fractures in participants during the study. At the same time there were 1671 falls and 103 fractures in residents not participating in the study. Multiple regression analyses showed that only age had a statistically significant association with falls (χ²(1) = 5.7775, p = 0.0162), fractures (χ²(1) = 4.7269, p = 0.0297) and combined falls & fractures (χ²(1) = 4.7269, p = 0.0297). C-statistics were: falls; FRAX 0.544, BMI 0.610, QFractureScore 0.554, Garvan nomogram 0.579, TUGT 0.656, fractures; FRAX 0.655, BMI 0.708, QFractureScore 0.736, Garvan nomogram 0.712, TUGT 0.590, combined falls and fractures, c-statistics were same as for fractures. Fifty-four participants (25%) died during follow-up. Charlson comorbidity index predicted mortality, R² = 0.021 (p = 0.034).

CONCLUSIONS

QFractureScore, BMI and Garvan nomogram were good predictors of fractures and combined falls and fractures Only age had statistically significant association with the outcomes. No tool was good predictor of falls.

Determinants of Bone Material Strength and Cortical Porosity in Patients with Type 2 Diabetes Mellitus

CONTEXT

Reduced bone material strength index (BMSi) and increased cortical porosity (CtPo) have emerged as potentially contributing to fracture risk in type 2 diabetes mellitus (T2DM) patients.

OBJECTIVE

To determine whether BMSi or CtPo are related to other diabetic complications.

DESIGN

Cross-sectional observational study.

SETTING

Subjects recruited from a random sample of southeast Minnesota residents.

PARTICIPANTS

A total of 171 T2DM patients (mean age, 68.8 years) and 108 age-matched nondiabetic controls (mean age, 67.3 years).

MAIN MEASURES

Bone material strength index was measured using microindentation, skin advanced glycation end-products (AGEs) measured using autofluorescence, high-resolution peripheral quantitative computed tomography at the distal radius and tibia, assessment of diabetic microvascular complications including urine microalbuminuria, retinopathy, neuropathy, and vascular disease (ankle brachial index and transcutaneous oxygen tension [TcPO2]). All analyses were adjusted for age, sex, and body mass index.

RESULTS

Skin AGEs were negatively correlated with the BMSi in both T2DM (r = -0.30, P < 0.001) and control (r = -0.23, P = 0.020) subjects. In relating diabetic complications to CtPo, we found that T2DM patients with clinically significant peripheral vascular disease (TcPO2 ≤ 40 mm Hg) had higher (+21.0%, P = 0.031) CtPo at the distal tibia as compared to controls; in these subjects, CtPo was negatively correlated with TcPO2 at both the distal tibia (r = -0.39, P = 0.041) and radius (r = -0.41, P = 0.029).

CONCLUSIONS

Our findings demonstrate that bone material properties are related to AGE accumulation regardless of diabetes status, while CtPo in T2DM patients is linked to TcPO2, a measure of microvascular blood flow.

Osteoporosis in Africa-where are we now

Africa is experiencing an exponential increase in the number of older persons. The number of persons surviving with human immunodeficiency virus is simultaneously increasing due to improved availability of anti-retroviral therapy. The burden of non-communicable diseases, in particular, osteoporosis and its consequent fragility fractures, is also predicted to increase. Osteoporosis, however, remains a neglected disease and there are no age-standardized reference data available to accurately screen and diagnose individuals with osteoporosis. Epidemiological studies reporting the incidence of hip fracture or vertebral fractures are limited from Africa, especially Sub-Saharan Africa. The studies are usually limited as they are based on a retrospective data and small study numbers and often from a single study site. However, compared with early initial studies, the more recent studies show that osteoporosis and fractures are increasing across the continent. The overall incidence rates for osteoporosis and fractures still vary greatly between different regions in Africa and ethnic groups. Predisposing factors are similar with those in developed countries, but awareness of osteoporosis is sorely lacking. There is a lack of awareness among the population as well as health authorities, making it extremely difficult to quantify the burden of disease. There is great potential for research into the need and availability of preventive strategies. The FRAX® tool needs to be developed for African populations and may circumvent the shortage of bone densitometry.

The Risk of Osteoporotic Forearm Fractures in Postmenopausal Women in a Siberian Population Sample

The reduction in bone and muscle mass increases in menopausal women and poses a threat to the loss of self-dependence in the elderly. The aim of the study was to assess the frequency of osteoporotic forearm fractures (OFF) in postmenopausal women and to study their association with risk factors for chronic non-communicable diseases (NCD). The study was based on the Russian arm of the Health, Alcohol and Psychosocial Factors In Eastern Europe (HAPIEE) project (Novosibirsk). In a subsample of postmenopausal women aged 55–84 years old (n = 2005), we assessed the history of OFF during the last 3 years and risk factors for fracture and common NCD/. Cross-sectional associations between OFF history and potential determinants were analyzed using multivariable-adjusted logistic regression. A history of OFF in the last 3 years was found in 3.9% women. In a multivariable-adjusted model, the risk of OFF was directly associated with smoking in the past (OR = 2.23; 95% Cl 1.10–4.55), total cholesterol level higher than 200 mg/dL (OR = 1.98; 95% Cl 1.19–3.29), and it was inversely associated with body mass index (OR = 0.91; 95% Cl 0.86–0.96). In studied population sample of postmenopausal women the cross-sectional determinants of osteoporotic forearm fractures were smoking in the past and high total cholesterol value; body mass index protectively related to the risk of osteoporotic fractures. These findings might have implications for fracture prevention in postmenopausal women.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE

Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.

Rheumatoid arthritis in tight disease control is no longer risk of bone mineral density loss

Objectives

Rheumatoid arthritis (RA) is an independent risk factor of osteoporosis. However, if disease activity is successfully controlled using the treat-to-target (T2T) strategy, the risk of bone mineral density (BMD) loss can be diminished. We evaluated if RA is a risk factor even when the T2T is applied in clinical cases.

Methods

From September 2017 to August 2019, 741 patients were examined using dual-energy X-ray absorptiometry; of these, 279 were diagnosed with RA who attained clinical remission within 6 months (RA-rem) and 53 could not attain clinical remission (RA-nonrem), while 409 were not diagnosed with RA (non-RA). The following characteristics between RA-rem and non-RA were matched using the propensity score matching (PSM) technique: age, sex, past bone fragility fracture experience, osteoporosis drug intervention ratio, glucocorticoid administration ratio, mean dose, Barthel Index score, body mass index, serum-creatinine-to-cystatin C ratio, and the number of comorbidities. The BMDs and changes of the lumbar spine, femoral neck, total hip, and greater trochanter were statistically compared between the RA-rem and the non-RA after PSM, and between RA-nonrem and RA-rem after PSM using the Mann-Whitney U test.

Results

In total, 107 patients of RA-rem and 108 of non-RA were recruited. BMDs and changes of every part demonstrated no significant differences between the 2 groups. BMDs in every part of RA-rem after PSM were significantly greater than those in every part of RA-nonrem, while no significant difference in change during follow-up.

Conclusions

If disease activity is controlled in clinical remission, RA will not contribute to BMD reduction.

Practical management of fracture risk among peri- and postmenopausal women

Fractures and their consequences are the clinically important manifestation of osteoporosis; preventing fractures is the primary goal of management. Effective management is achievable given present knowledge and tools but is seldom prescribed. This review will cover the individual and social burden of fracture, essential information about fracture risk and its estimation, an approach to patient care emphasizing specific information to elicit and therapeutic strategies to pursue, and existing gaps in knowledge and important questions for future research.

A decade of FRAX: how has it changed the management of osteoporosis?

The fracture risk assessment tool, FRAX^®, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, 71 models have been made available for 66 countries covering more than 80% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. The application of FRAX in assessment guidelines has been heterogeneous with the adoption of several different approaches in setting intervention thresholds. Whereas most guidelines adopt a case-finding strategy, the case for FRAX-based community screening in the elderly is increasing. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future.

Performance of FRAX in Predicting Fractures in US Postmenopausal Women with Varied Race and Genetic Profiles

BACKGROUND

Whether the Fracture Risk Assessment Tool (FRAX) performed differently in estimating the 10-year fracture probability in women of different genetic profiling and race remained unclear.

METHODS

The genomic data in the Women's Health Initiative (WHI) study was analyzed (n = 23,981). The genetic risk score (GRS) was calculated from 14 fracture-associated single nucleotide polymorphisms (SNPs) for each participant. FRAX without bone mineral density (BMD) was used to estimate fracture probability.

RESULTS

FRAX significantly overestimated the risk of major osteoporotic fracture (MOF) in the WHI study. The most significant overestimation was observed in women with low GRS (predicted/observed ratio (POR): 1.61, 95% CI: 1.45-1.79) specifically Asian women (POR: 3.5, 95% CI 2.48-4.81) and in African American women (POR: 2.59, 95% CI: 2.33-2.87). Compared to the low GRS group, the 10-year probability of MOF adjusted for the FRAX score was 21% and 30% higher in the median GRS group and high GRS group, respectively. Asian, African American, and Hispanic women respectively had a 78%, 76%, and 56% lower hazard than Caucasian women after the FRAX score was adjusted. The results were similar for hip fractures.

CONCLUSIONS

Our study suggested the FRAX performance varies significantly by both genetic profile and race in postmenopausal women.

Efficacy of zoledronic acid in older prostate cancer patients undergoing androgen deprivation therapy

Objectives

The purpose of this study is to evaluate the efficacy of annual zoledronic acid treatment in Japanese patients with nonmetastatic prostate cancer during androgen deprivation therapy (ADT).

Methods

This is a single institution 12-month study. Between 2016 and 2019, patients aged 70 years or older on ADT for nonmetastatic prostate cancer had bone mineral density (BMD) measured and 10-year probability of fracture calculated using fracture risk assessment tool (FRAX). Patients who showed osteopenia or had a 10-year hip fracture risk ≥ 3% or a 10-year probability of major osteoporotic fracture ≥ 20% were offered treatment with zoledronic acid 5 mg intravenously (ZA group). The patients who did not receive treatment were set as the control group. Lumbar and hip BMD were measured 6 and 12 months after treatment in the ZA group and 12 months after baseline in the control group. The yearly BMD change of both groups was compared.

Results

The mean ages of the ZA group (n = 26) and control group (n = 12) were 80.5 ± 9.1 and 76.1 ± 6.7 years, respectively. In the ZA group, lumbar and hip BMD changes at 12 months were +2.1% and +0.8%, respectively. In the control group, lumbar and hip BMD changes were -0.9% and -4.9%, respectively. There were statistically significant differences between the 2 groups in BMD percent changes (P < 0.05).

Conclusions

Without intervention, BMD tends to continue to decrease during ADT. Our findings suggest that administration of zoledronic acid enables maintenance of BMD in the older adults.

[10-year risk of fractures (FRAX) in people with diabetes type 2]

AIM

To study indicators of bone mineral densit (BMD) and trabecular bone score (TBS) and to reveal the 10-year fracture risk (FRAX®) taking into account the data obtained in persons with type 2 diabetes (DM2).

MATERIALS AND METHODS

A clinical study of the type of case - control. The study included 122 people with and without DM2. All persons were: questionnaires, anthropometry, densitometry, determination of TBS and fracture risk on the FRAX®.

RESULTS AND DISCUSSION

Persons with DM2 who underwent a fracture had lower T-score values in all areas except the spine, unlike those with DM2, but without fracture. However, persons with DM2 had a fracture at high values of T-score in vertebrae and hips in comparison with persons without DM. Using the TBS, we did not get a significant difference in any of the examined groups. We also found no differences in the risk of recurrent fractures among women with and without DM2 using FRAX® without densitometry and FRAX® adjusted for TBS. The values of FRAX® by T-score in the group of persons with DM with fractures were significantly lower (p=0.029 for major fractures, p=0.024 for hip fractures) than in persons without DM with fractures.

CONCLUSION

Persons with DM2 and fractures have higher BMD values, lower than the FRAX fracture risk values adjusted for the T-score, do not differ significantly in TBS, which determines the difficulties in diagnosis, the need to find additional methods for early diagnosis of increased fracture risk in patients with DM2.

Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review

PURPOSE

To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making.

METHODS

A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force.

DISCUSSION

Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.

Can Classification and Regression Tree Analysis Help Identify Clinically Meaningful Risk Groups for Hip Fracture Prediction in Older American Men (The MrOS Cohort Study)?

Although the WHO fracture risk algorithm (FRAX) is used to predict fracture, the utility of some simple machine‐learning methods, such as classification and regression trees (CARTs) should be evaluated to determine their efficacy in fracture prediction. Follow‐up time for the hip fracture analyses of 5977 community‐dwelling American men aged ≥65 years old was truncated to 10 years. There were 172 (2.9%) men who had an incident nontraumatic hip fracture. The CARTs were developed using hip BMD and common clinical risk factors as follows: model 1 = using classification with continuous variables of age, total hip BMD, and femoral neck BMD, or together with common clinical risk factors; and model 2 = using classification with continuous variables of age, total hip BMD, femoral neck BMD, FRAX score, osteoporosis by T‐score at the hip, and common clinical risk factors. The predictive performance of risk models derived from CARTs was compared with the basic classification of FRAX at 3% (basic model). From model 1, discriminators selected by CART were total hip BMD, age, and femoral neck BMD; no other clinical risk factors were selected. From model 2, discriminators selected by CART were FRAX score, femoral neck BMD, and age. Compared with the basic model using only a high‐risk group by FRAX ≥3%, no significantly improved predictive performance was demonstrated by model 1 or model 2 as identified by CART with the area under the receiver‐operating characteristic curve for each model of 0.714 (95% CI, 0.676 to 0.751) or 0.726 (95% CI, 0.690 to 0.762) versus 0.703 (95% CI, 0.667 to 0.740), respectively. The improved overall net reclassification improvement index was 0.02 (95% CI, –0.04 to 0.08) and 0.05 (95% CI, –0.01 to 0.10), respectively. Although a FRAX category is a good clinical indicator for hip fracture risk, a simple classification by age and BMD may provide an alternative way to estimate a clinical risk level of 3.0%. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Comparison of strategies for setting intervention thresholds for Chinese postmenopausal women using the FRAX model

PURPOSE

The two main strategies for managing osteoporosis using the Fracture Risk Assessment (FRAX®) are the fixed-probability threshold of the National Osteoporosis Foundation (NOF) and the age-dependent-probability threshold of the National Osteoporosis Guideline Group (NOGG), but there are no FRAX® Chinese-specific thresholds. This study examined the NOF and NOGG strategies for intervention thresholds using the Chinese FRAX® model for their appropriateness for Chinese postmenopausal women, and explored Chinese-specific thresholds.

METHODS

Postmenopausal women (N = 264) >50 years old from community-medical centers in China were randomly selected. They completed a self-report questionnaire and underwent bone mineral density measurements and spinal X-rays. The 10-year risks for a major osteoporosis fracture and hip fracture were calculated using the Chinese FRAX® model. Using an osteoporosis diagnosis as the gold standard, we compared the abilities of the NOF and NOGG thresholds to detect osteoporosis by analyzing their sensitivity, specificity, accuracy, and positive and negative likelihood ratios.

RESULTS

The 10-year risks for hip fracture and a major osteoporotic fracture increased with age. The NOF's accuracy in detecting osteoporosis was 83.33% and the NOGG's was 74.24%. The NOF thresholds showed higher accuracy and specificity than the NOGG thresholds.

CONCLUSION

NOF thresholds are more appropriate for Chinese menopausal women.

Automated quantitative morphometry of vertebral heights on spinal radiographs: comparison of a clinical workflow tool with standard 6-point morphometry

A workflow tool for measurements of vertebral heights on lateral spine radiographs based on automated placements of 6 points per vertebra was evaluated. The tool helps to standardize point placement among operators. Its success rate is very good in normal vertebrae but lower in vertebrae with more severe fractures. Manual corrections were required in 192 of 1257 analyzed vertebrae.

INTRODUCTION

To evaluate a new workflow tool (SA) for the automated measurements of vertebral heights on lateral spine radiographs.

METHODOLOGY

Lateral radiographs from 200 postmenopausal women were evaluated at two visits. Genant's semi-quantitative fracture assessment (SQ) and manual quantitative morphometry (QM) results were available from prior analyses. Vertebral heights from point placements using SA were compared with manual 6-point placement QM. Differences were quantified as RMS coefficient of variations (rmsCV) and standard deviations (rmsSD).

RESULTS AND CONCLUSIONS

SA required manual corrections in 192 of 1257 vertebrae. SA heights were larger than QM ones by 2.2-3.6%. Correlations (r² > 0.92) between SA and QM were very high. Differences between QM and SA were higher for fractured (SQ = 2; rmsCV% 14.5%) than for unfractured vertebrae (rmsCV% 4.2-4.7%). rmsCV% for QM varied between 3 and 6% and for SA between 2.5 and 7.5%. For SA, highest rmsCV% was obtained for T4 and L4. Manual correction mostly affected the end vertebrae T4 and L4. SA helps to standardize point placement among operators. The algorithm success rate is very good in normal vertebrae but lower in vertebrae with more severe fractures, which are of greater clinical interest but are more readily recognized without morphometric measurements.